Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (13 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Paul Baskerville
One of the main aims of surgery is to return the postoperative patient to their home environment, in a safe and timely fashion. If, following a surgical procedure, the patient does not spend a few days in hospital, but returns home the same day, we describe that process as day case surgery. Why should this obvious and rather banal variation in length of hospital stay deserve a chapter of its own in a surgical textbook? The reason is that the development of successful day surgery practice, and the knowledge gained from studying its component parts, have been instrumental in improving the delivery of all surgical care in the last 30 years. It has helped all parties responsible for that delivery to understand how to introduce, create and then manage surgical developments in a timely, safe, efficient and cost-effective manner.
Understanding how day surgery works, how traditional inpatient care can be successfully transferred to the day unit, and what is required to enable that to happen is a fundamental requirement for all those involved in the care of the surgical patient, be they surgeon or anaesthetist, nurse or manager, health purchaser or provider.
Day surgery has been described as the planned admission of a patient to hospital for a surgical procedure which, while requiring recovery from a bed or trolley, allows the patient to return home the same day. As a consequence, procedures not requiring full operating theatre facilities and/or general anaesthesia, procedures which can be performed in outpatient or endoscopic suites, are no longer called true ‘day surgery’.
Successful and well-managed day surgery has the potential to improve the quality of care for patients by separating their elective treatment from the bustle of emergency surgical care, both of which are traditionally managed on the same wards. Most people would rather not stay in hospital longer than necessary, and short stays reduce the risks of hospital-acquired infections. Reducing length of stay also reduces costs and can improve efficiency, reasons that make day surgery attractive to all healthcare systems worldwide.
In the UK, the NHS plan proposed by the government in 2001 set the patient firmly at the centre of a framework for modernising the NHS.
1
The idea was to reduce waiting times, implement booking systems and introduce patient choice. However, the government was faced with capacity constraints and one solution to increase patient throughput was to reduce the length of patients' stay by focusing on increasing national day surgery rates by implementing a National Day Surgery Programme.
The day surgery strategy was launched in 2002 with the broad aim of achieving 75% of all elective surgery in the UK to be performed on a day case basis by the year 2005.
2
Day surgery now comprises over 70% of all elective surgery in the UK, over 80% in the USA and is likely to become the default method of treating most surgical patients in the next two decades. This growth has occurred over the last 30 years, most of it in the last 15. How has this come about? What are the main driving forces behind it? What are its strengths and weaknesses? This chapter covers those aspects of day surgery that are essential to good practice, and highlights some areas of current controversy.
The concept of day surgery is not new. In 1909, James Nicholl, a surgeon working at the Royal Hospital for Sick Children in Glasgow, reported on nearly 9000 children undergoing operations for conditions such as hernia and harelip, all of whom went home on the day of surgery.
3
He described the benefits for parent and child of returning home the same day, but stressed the importance of suitable home conditions in the success of day surgery. A decade later, in 1919, Ralph Waters, an anaesthetist in Sioux City, Iowa, reported on the ‘downtown anaesthesia clinic’ where adults underwent minor surgical procedures, returning home within a few hours.
4
The modern era of day surgery began in the years following World War II with the realisation that prolonged bed rest was associated with high rates of postoperative complications such as deep vein thrombosis.
5
The move towards early ambulation led to earlier discharge and, for the first time, the economic benefits of day surgery were noted.
6
In 1955, Eric Farquharson of Edinburgh described a series of 458 consecutive inguinal hernia repairs performed on a day case basis at a time when the average length of postoperative stay was approximately 2 weeks.
7
The medical benefits of early ambulation were recorded and the potential impact on surgical waiting times was considered.
Further development of day surgery occurred not in the UK but in North America, where cost savings associated with day surgery in privately run healthcare systems led to the early development of day units within hospitals, and by 1969 the first free-standing ambulatory surgical centre in Phoenix, Arizona. The huge commercial success of such units led to a significant shift in surgical care out of hospital inpatient beds, and forced surgeons, anaesthetists and hospital managers to study and improve the safety and efficiency of surgical care.
The UK, with its state-run NHS, was much slower to introduce day surgery. The few existing units were poorly utilised and there was little support for the expansion seen in the USA. In 1980 Paul Jarrett, in the day unit at Kingston Hospital, demonstrated once again the benefits of dedicated day surgery lists for hernias, including the rapid reduction of waiting times from 3 years to 3 months.
8
This time the government was quick to see the advantages, and supported day surgery expansion throughout the UK for a decade. In 1985 the Royal College of Surgeons of England published a report (revised in 1992) entitled
Guidelines for day case surgery
.
9
At that time, it was estimated that only 15% of elective surgery was performed on a day case basis and the report suggested 50% as an appropriate target. In 1989, the gathering momentum of day surgery demonstrated a need for a professional body to promote the speciality and set quality standards of care. The result was the British Association of Day Surgery (BADS) encompassing surgeons, anaesthetists, nurses and managers involved in day surgery. The same year the NHS Management Executive's value-for-money unit demonstrated that the cost of treating patients as day cases was significantly less than as inpatients.
10
By 1990, the Audit Commission had taken over the role of external auditors within the NHS and it introduced the concept of a ‘basket’ of 20 surgical procedures suitable for day case surgery to allow benchmarking between health authorities.
11
The audit figures also demonstrated wide variations between hospitals.
By 1991, the Audit Commission Report
Measuring quality: the patient's view of day surgery
found that 80% of day case patients preferred this mode of treatment to traditional inpatient treatment, adding further impetus to the development of day surgery.
12
By the end of the decade, the introduction of newer surgical and anaesthetic techniques to the day unit and the loss of others to the outpatient department forced a reassessment of the surgical basket to reflect modern-day case activity, as many day units were already performing more complex procedures on a day surgery basis. In 1999, continuing the supermarket analogy, the BADS recommended an additional 20 operations to form a ‘trolley’ of procedures suitable for day surgery in the more experienced day unit (
Box 3.1
). The trolley included major operations such as laparoscopic cholecystectomy, thoracoscopic sympathectomy, partial thyroidectomy and laser prostatectomy. The concept of the trolley was that a target of 50% of these procedures on a day case basis would be realistic.
Box 3.1
British Association of Day Surgery ‘trolley’ of procedures 1999, of which 50% should be suitable for day case surgery
Laparoscopic hernia repair
Thoracoscopic sympathectomy
Submandibular gland excision
Partial thyroidectomy
Superficial parotidectomy
Wide excision of breast lump with axillary clearance
Haemorrhoidectomy
Urethrotomy
Bladder neck incision
Laser prostatectomy
Transcervical resection of endometrium
Eyelid surgery
Arthroscopic meniscectomy
Arthroscopic shoulder decompression
Subcutaneous mastectomy
Rhinoplasty
Dentoalveolar surgery
Tympanoplasty
Laparoscopic cholecystectomy
Bunion operations
Following this lead by the professions, the Audit Commission updated its own basket of procedures (
Box 3.2
) and this was incorporated into the Department of Health's
Day surgery: operational guide
published to support the National Day Surgery Programme to achieve a 75% day case rate for elective surgery by 2005.
2
Although this tool is still used as a comparator in assessing output by Trusts and Health Authorities,
13
for development purposes it has now been superseded by the introduction of a regularly updated Directory of Procedures by the BADS.
14
The Directory, which was first introduced in 2007 and is regularly updated, lists over 200 procedures by speciality, including their OPCS and HRG codes, and provides a breakdown of how each procedure might be treated within four areas: procedure room, day surgery, 24-hour stay or under 72-hour stay. It therefore allows for the planning and development of day surgery practice within a Unit or Trust.
Box 3.2
Audit Commission basket of 25 procedures 2001
Orchidopexy
Circumcision
Inguinal hernia repair
Excision of breast lump
Anal fissure dilatation or excision
Haemorrhoidectomy
Laparoscopic cholecystectomy
Varicose vein stripping or ligation
Transurethral resection of bladder tumour
Excision of Dupuytren's contracture
Carpal tunnel decompression
Excision of ganglion
Arthroscopy
Bunion operations
Removal of metalware
Extraction of cataract with or without implant
Correction of squint
Myringotomy
Tonsillectomy
Submucous resection
Reduction of nasal fracture
Operation for bat ears
Dilatation and curettage/hysteroscopy
Laparoscopy
Termination of pregnancy
Facilities for day surgery
The organisation of day surgery services differs from traditional inpatient surgery. Patients arrive at the hospital on the day of surgery, fully assessed, with the results of investigations already checked. Following operation, patients recover in the day unit and are discharged home, accompanied by their carer. The entire admission episode is preplanned and the routine nature of the hospital visit ensures quality care. Any error in the system results in an unnecessary overnight admission and it is therefore not surprising that the facilities for day surgery differ from inpatient surgery.
Initially, day surgery was attempted from the inpatient ward, but this environment is a mixture of emergency admissions, unwell elective surgery patients and the ‘well’ elective day surgery patient. Quality of care for the day case patient suffered as busy ward staff naturally concentrated on the acutely ill. There was also no incentive to ensure the day patient was able to go home the same evening. In the UK, the patient's procedure was often cancelled on the day of admission as their projected bed had been occupied overnight by an emergency admission.
Self-contained day units or dedicated day wards were therefore developed and unplanned overnight admission rates dropped dramatically from 14% on an inpatient ward to 2.4% in a dedicated day unit.
2
These units may be free-standing or integrated within the main hospital, where they benefit from the full range of available support services. The self-contained unit should have its own day surgery theatre within the day surgery suite, performing dedicated day case lists.
Dedicated lists require appropriate staffing levels to be allocated as there is a greater intensity of work for theatre staff if several day cases are to be treated rather than a single major case. Experience has shown that the most effective units unite all managerial as well as nursing and operative functions under the same roof. Further efficiencies are made if the day unit can be accessed directly from the street or car park, and if day patients have their own dedicated car parking facilities.
In traditional inpatient surgery, the patient is admitted either from the waiting list or directly from the surgical outpatient clinic if the patient is classified as urgent. In day surgery, the processes are different (
Fig. 3.1
). In many hospitals the patient is seen in the outpatient clinic and then sent directly for pre-assessment. While this has the advantage of a single hospital visit, some patients become overwhelmed with the amount of information they are given in a short space of time. Therefore, some patients find it convenient to come back for pre-assessment at a later date.
Figure 3.1
The day surgery cycle.
A few hospitals accept fast tracking by general practitioners, who refer patients directly for pre-assessment to the day unit. In this case, the surgeon will not see the patient until the morning of operation and, for obvious reasons, the process is only suitable for the young, fit patient with a straightforward surgical problem.
Patient selection addresses the suitability of the patient for day surgery. The majority of patients will be suitable unless an overnight stay would be of particular benefit. Factors that may also influence selection include the risk of major complications, social conditions and medical fitness. There should be no upper limits on age or body mass index (BMI), although each patient is judged on an individual basis, and American Society of Anesthesiologists (ASA) class III patients are routinely accepted. In any hospital, over 75% of traditional inpatient procedures can therefore be performed safely on a day case basis.
2
UK guidelines have recently been published by BADS and the Association of GB and Ireland.
15
Social factors:
The effects of general anaesthesia on cerebral function, affecting judgment and coordination, are well recognised. After day surgery, all patients must be accompanied home by a responsible and physically able adult, who should be available for the first 24 hours following operation. Patients themselves must not drive home and preferably should avoid public transport. Greater travelling times are associated with increased discomfort and nausea,
16
and patients should reside within an hour's journey from the hospital in case of emergency. The patient's home conditions should be sufficient to allow them to recover in comfort. In general, they should have access to a telephone in case of emergency, there should be adequate toilet facilities and household stairs should be minimal, but each set of circumstances requires individual judgment.
Age:
Biological age is more important than chronological age, although some day units arbitrarily and illogically apply upper limits of 65 or 70 years of age. Whilst the older patient is more likely to suffer from respiratory and cardiovascular disease and the carer may also be in an elderly age group, with careful preoperative evaluation the elderly patient can benefit from day surgery through a rapid return to familiar home circumstances and less postoperative confusion.
Body mass index:
Obesity is measured by BMI (in kg/m
2
) and height–weight charts are used as ‘ready reckoners’ to calculate it (
Fig. 3.2
). Obesity is defined as a BMI equal to or greater than 30.
17
The prevalence of obesity has doubled since the 1990s, with 24% of adults in England now fulfilling the definition.
18
The very obese were excluded from day surgery because of delayed recovery related to the absorption of volatile anaesthetic agents into body fat, but this is less of a problem with modern total intravenous anaesthetic agents such as propofol.
19
The problems that do occur with the obese patient are related to comorbidity, the surgical procedure and the anaesthetic. Obesity is associated with cardiac disease, diabetes mellitus, hiatus hernia, hypertension and sleep apnoea, and it may be the comorbidity factor that excludes an obese patient from day surgery rather than the obesity itself. Operating on the obese patient is often more technically demanding and the complication rate is often higher, with increased rates of postoperative haematoma formation and pain as a result of the need for greater surgical access. Anaesthetic problems include problems of venous access, intubation and airway control. Operating on patients early in the day is advisable to ensure that any minor postoperative complications can be corrected and do not prevent the patient from returning home.
Figure 3.2
Assessment chart for body mass index (BMI).
The upper safe BMI limit for day surgery remains controversial. While some day units still remain at a restrictive BMI of 30, others have safely increased this upper limit to 35, 37 and even 40.
20
Smoking:
Smokers undergoing surgery have increased intraoperative complications such as impaired gas exchange and increased secretions, with postoperative problems consisting of an increased incidence of bronchospasm, chest infection and wound complications.
21
Advice at pre-assessment regarding cessation of smoking depends on whether the patient would like to stop permanently or else temporarily suspend their habit in the perioperative period. For those attempting permanent cessation, this should commence 6–8 weeks before surgery since this is the minimum time required for lung function to improve significantly.
22
The least effective time of smoking cessation is in the week before surgery, when the effects of withdrawal are maximal.
23
For those who intend continuing their habit, temporary cessation 12 hours before surgery confers a reduction in circulating carboxyhaemoglobin, thereby improving perioperative lung function.
Medical factors:
In 1991 the ASA classified surgical patients into five classes of physical fitness (
Table 3.1
), which has provided a framework for patient selection in day surgery.
24
Table 3.1
Adaptation of the American Society of Anesthesiologists' classification of physical status
| Class I | A healthy patient |
| Class II | Mild-to-moderate systemic disease caused by the surgical condition to be treated or by another disease process, with no functional limitation, controlled hypertension, mild diabetes, mild asthma |
| Class III | Severe systemic disease with some functional limitation plus diabetes with complications, severe asthma, myocardial infarction > 6 months |
| Class IV | Severe systemic disease that is a constant threat to life plus unstable angina, severe cardiac, pulmonary, renal, hepatic or endocrine insufficiency |
| Class V | Moribund patient not expected to survive 24 hours even with surgical intervention |
While ASA class I or class II patients are generally accepted for day surgery, the suitability of patients in the ASA class III group is less clear. While hypertension,
Stable ASA class III patients have the same risk of unplanned overnight admissions as lower ASA status patients,
25
and any increase in complications with ASA class III patients is related to the surgical procedure rather than comorbidity.
chronic lung disease and symptomatic heart disease increase the risk of complications, this is not evident with asthma or insulin-dependent diabetes mellitus.
Diabetes mellitus:
Patients with stable diabetes mellitus are usually best managed as day cases as this interferes least with their routine. Nevertheless, type I diabetic patients are more difficult to manage in the perioperative period than type II patients and are more liable to unplanned admission. Stability of the disease in the months before surgery is therefore central to success of the admission, especially in the type I patient. A glycosylated haemoglobin (HbA
1c
) result of less than 8% suggests that the patient is suitable for day surgery. Most intermediate surgical procedures, such as those in the Audit Commission basket of 25 (
Box 3.2
), can be safely undertaken in adult diabetic patients with the occasional exception of laparoscopic cholecystectomy due to the increased risk of postoperative nausea and vomiting.
Where possible, the patient should be managed with local or regional anaesthesia as this may remove the need for the patient to starve preoperatively. However, if general anaesthesia is required, diabetic medication is omitted on the morning of surgery, the procedure is scheduled as early as possible on the list and the normal regimen is resumed as soon as possible.
26
Well-controlled non-insulin- dependent diabetics present few problems but insulin-dependent diabetics require intensive monitoring throughout the day surgery process.
Cardiac disease:
The risk of myocardial ischaemia during anaesthesia is increased in the hypertensive patient, and elevated blood pressure is one of the most common reasons for ‘on the day’ cancellation: the blood pressure has either not been accurately measured at preoperative assessment or it has not been adequately treated (see ‘Preoperative assessment’). Preoperative sedation can lower a marginally elevated blood pressure but the underlying cause requires further investigation. Many patients with significant cardiovascular disease can still undergo day surgery procedures provided exercise tolerance is good.
The specific blood pressure that is unsafe for the patient undergoing day surgery remains unclear, but a systematic review and meta-analysis of 30 observational studies found little evidence for an association between admission arterial pressure and perioperative complications if systolic and diastolic pressures are less than 180 and 110 mmHg, respectively.
27
Asthma:
The stable asthmatic using an inhaler and with good exercise tolerance is suitable for day surgery. Only those with unstable or steroid-controlled asthma require investigation before proceeding and may require exclusion. Non-steroidal anti-inflammatory drugs (NSAIDs) can be administered safely for pain relief to 95% of asthmatics.
28
A history of previous administration without bronchial spasm, usually from over-the-counter preparations, is often available.