Day case surgery
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 development of day surgery
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
Submandibular gland excision
Wide excision of breast lump with axillary clearance
Bladder neck incision
Transcervical resection of endometrium
Arthroscopic shoulder decompression
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
Inguinal hernia repair
Excision of breast lump
Anal fissure dilatation or excision
Varicose vein stripping or ligation
Transurethral resection of bladder tumour
Excision of Dupuytren's contracture
Carpal tunnel decompression
Excision of ganglion
Removal of metalware
Extraction of cataract with or without implant
Correction of squint
Reduction of nasal fracture
Operation for bat ears
Dilatation and curettage/hysteroscopy
Termination of pregnancy
How does it work for the patient?
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.
The Day Surgery Cycle
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/m2) 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.19The 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.
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
Adaptation of the American Society of Anesthesiologists' classification of physical status
A healthy patient
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
Severe systemic disease with some functional limitation plus diabetes with complications, severe asthma, myocardial infarction > 6 months
Severe systemic disease that is a constant threat to life plus unstable angina, severe cardiac, pulmonary, renal, hepatic or endocrine insufficiency
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 (HbA1c) 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.26Well-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.
The admission, operation and discharge of a patient within a day requires accurate forward planning, with the procedure occurring on a scheduled day at a scheduled time. Day surgery pioneered the role of preoperative assessment, performed up to 6 weeks prior to surgery. As a result nursing, anaesthetic and surgical assessment on the day of admission is both rapid and minimal. Pre-assessment of patients also ensures that ‘on the day’ cancellation for clinical reasons is rare. Cancellations not only waste hospital resources but cause distress to patients and their families and often disrupt work commitments.
To maximise day surgery throughput, pre-assessment may be accomplished by:
Successful pre-assessment should focus on educating the patient and their carers about their condition, identifying any preoperative risk factors and optimising the patient's condition. All three aspects need to be performed well in order to maximise success on the day of surgery. Strict assessment criteria ensure patient safety, and identifying any anomalies at pre-assessment allows for timely correction of these factors. Day surgery pre-assessment is best performed by trained nurses in nurse-based pre-assessment clinics. The availability of a consultant anaesthetist to deal immediately with some queries and concerns further improves efficiency. The most common treatable exclusion factors are hypertension and identifying an overnight carer for patients living on their own.
Pre-assessment clinics use a patient questionnaire to screen for social and medical problems. Most questionnaires follow a standard format to screen and triage the suitability of patients for day surgery. Questionnaires should address the generic status of the health of the patient, but additional questions may be added for specific surgical specialities.
Patient information leaflets should also be available covering both general day surgery information and information specific to the proposed operation. These may have been issued at the outpatient consultation where first-stage consent is usually obtained. The later pre-assessment visit allows the patient to ask questions that may have arisen since their consultation, and subsequent discussion leads to better understanding by the patient and family, and may reduce anxiety levels.29 Involvement of the patient at this stage permits flexibility and choice regarding their operating date and improves non-attendance rates.
Investigations: Routine investigations are unnecessary in the a symptomatic day surgery patient30 and preoperative testing should be limited to circumstances in which the results will affect patient treatment and outcomes. Investigations should not be prescriptive but should be tailored to the individual's needs because most investigations required can be predicted from the history alone. Even when minor abnormalities are found they rarely entail cancellation. A full blood count is only required if there is a risk of anaemia, chronic renal disease, rectal bleeding or haemorrhage. Similarly, analysis for urea and electrolytes is only indicated if the patient has renal disease or is taking diuretics. Urinalysis is often routinely performed as part of the preoperative routine but, again, unsuspected disease is more likely to be picked up on history alone. In Oxford, routine urine testing of more than 30 000 day case admissions resulted in only one cancellation, caused by unsuspected diabetes mellitus.19
The incidence of electrocardiographic (ECG) abnormalities increases with age but minor preoperative ECG abnormalities do not predict adverse cardiovascular perioperative events in day surgery.31 The only indications for preoperative ECG include chest pain, palpitations and dyspnoea, but these patients have often already been excluded from day surgery by other comorbidity. A chest X-ray examination is also unnecessary. If required, then the patient is probably unsuitable for day surgery in the first place.
Testing for sickle cell disease is more controversial. Patients with sickle cell disease usually present in childhood with chronic haemolytic anaemia. Preoperative screening in adults is unlikely to identify a patient with previously unknown sickle cell disease but will, of course, identify those with sickle cell trait. However, the ‘at-risk’ population (those of African, Asian and Mediterranean origin) is often difficult to define in Britain today as a result of ethnic mixing. Furthermore, those factors that precipitate sickling (hypotension, hypoxaemia and acidosis) are unlikely to occur during day case surgery.
Day of surgery admission
On arrival at the day unit on the prearranged day of operation, most documentation is already complete and bureaucracy is minimised. Any change of circumstance, either social or medical, should be noted since the time of pre-assessment, and the preoperative surgical visit by the person performing the operation need only consist of verification of the consent and marking the appropriate operation site. The final anaesthetic assessment is performed at this time and not in the anaesthetic room, where levels of anxiety are already high. Many day surgery units have successfully introduced staggered admission times for patients, which is more convenient for both patient and the day unit. In most centres, the 12-hour fasting ritual has now been replaced by regimens of no solids (including milk) within 4–6 hours and up to 300 mL of clear fluid within 2 hours of surgery.
Discharge after inpatient surgery for procedures suitable for day surgery usually occurs at least 24 hours after its completion. By then, there is little concern regarding postoperative complications or the adverse effects of the anaesthetic. In contrast, discharge on the day of surgery must address strict discharge criteria if complications are to be avoided. Before returning home, patients may be seen by the surgeon and anaesthetist involved in their care, but the final decision to discharge is usually nurse initiated, based on clear and agreed discharge guidelines. Some units adhere to strict scoring systems that address vital signs, patient activity, postoperative nausea and vomiting (PONV), pain and bleeding,32 but whether such regimented protocols offer any advantage over the checklist of criteria outlined in Box 3.3 is debatable. Generic criteria have their limitations. For example, the criterion of being able to ‘walk unaided’ from the day unit may be inappropriate following orthopaedic surgery to the foot. Common sense in such situations is clearly required and the individual surgical procedure or type of surgery undertaken may prompt additional specific criteria.33
Box 3.3 Discharge criteria
Vital signs stable for at least 1 hour
Correct orientation as to time, place and person
Adequate pain control and supply of oral analgesia
Understanding the use of oral analgesia supplied, supported by written information
Ability to dress, walk (if appropriate)
Minimal nausea, vomiting or dizziness
Oral fluids taken
Minimal bleeding (or wound drainage)
Has passed urine (if appropriate)
Has a responsible escort for the homeward journey
Has a carer at home for next 24 hours
Written and verbal instructions given about postoperative care
Knows when to return for follow-up (if appropriate)
Emergency contact number supplied
How do we do it?
Developing and maintaining good practice in day surgery requires attention to detail in all aspects of anaesthetic and surgical care. Special considerations apply to management of children in the day unit.
Day surgery may be performed under four basic anaesthetic techniques: sedation, local, regional or general anaesthesia, with or without premedication. Where local or regional anaesthetic techniques can be applied safely, advantages arise both for the patient and for the efficient running of the service.
In day surgery, premedication relates to any drugs administered in the day unit before the patient leaves for surgery and they are usually administered orally or rectally. There is a widely held belief that premedication sedatives for anxiety are unnecessary in day surgery and, if given, recovery time may be prolonged. In most cases this is true, but up to 19% of patients suffer significant anxiety and these may benefit from sedative premedication.34
Other premedication drugs commonly used in day surgery include oral ranitidine 150 mg for known acid reflux and NSAIDs for postoperative pain if the procedure is of short duration. In addition, the patient's normal drug therapy, including antihypertensive agents, should be given as normal.
Sedation: Sedation, commonly used in dental and endoscopy practice, may be defined as ‘a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained’.35 Standards of monitoring for sedation in gastrointestinal endoscopy were published in 1991 and address safety issues such as the availability of resuscitation equipment and the safe use and administration of benzodiazepines.36 Patient responses to sedative agents vary considerably and they should be titrated to the desired clinical effect to minimise overdose. Ideally, the sedationist should be an experienced anaesthetist. Monitoring during the procedure is mandatory and consists of pulse oximetry to measure oxygen saturation, an assessment of the patient's level of consciousness, and ECG and blood pressure monitoring, especially for patients with a history of ischaemic heart disease or cardiac arrhythmias. Oxygen supplementation is provided by oxygen mask or nasal cannulae.
In surgical practice, intravenous sedation should be kept simple and consists in adults of midazolam at a titrated dose of 0.07 mg/kg. Dosage is reduced in the elderly patient because hypotension and respiratory depression can occur. It is a better amnesic drug than diazepam and its solubility has reduced the incidence of pain on injection or phlebitis. As it has a short half-life of 2–4 hours, ‘hangover’ effects are reduced. If overdose occurs, the competitive benzodiazepine antagonist flumazenil is given, but as its half-life is only approximately 1 hour, it is important to recognise that re-sedation may occur and premature discharge of the patient must be avoided.
Sedo-analgesia is a combination of a benzodiazepine and an analgesic agent such as pethidine (meperidine) or morphine. It is often used in the more painful endoscopic procedures such as colonoscopy. The longer-acting traditional opioids are often now replaced by the more rapid onset short-acting agents such as fentanyl (50–200 μg i.v.), alfentanil and remifentanil, which act within several minutes.
Local and regional anaesthesia
As with sedation, perioperative monitoring is required and should include pulse oximetry, with ECG and blood pressure monitoring in the elderly or cardiovascularly unfit. Several local anaesthetic agents are available (Table 3.2) but toxic reactions can occur in overdosage. Toxic blood levels lead to circumoral tingling, tinnitus and dizziness. Serious overdosage is reflected in loss of consciousness, convulsions or cardiac dysrhythmia. Dosage levels therefore need to be controlled. Higher dosage can be administered if it is given with adrenaline (epinephrine; 1:200 000), which causes vasoconstriction. This assists haemostasis, slow absorption and prolongs anaesthesia. The administration of adrenaline is contraindicated, however, in end-artery procedures such as in the penis or in the digits of the hand or feet.
Dosage and application of local anaesthetic agents
Local or regional anaesthesia may be used alone, with sedation or with general anaesthesia to prolong pain relief after completion of the procedure. Cocaine, which also has vasoconstrictor properties, may be topically applied to the nasal mucosa prior to nasal surgery. Amethocaine (tetracaine), which is systemically toxic, is mainly used for topical anaesthesia in ophthalmology. Prilocaine is short acting, has less toxic levels in the blood and is useful in intravenous regional anaesthesia such as Bier's block. Field infiltration with local anaesthetic and adrenaline may be used for the removal of minor ‘lumps and bumps’. Bupivacaine (and the newer ropivacaine) has a long duration of action, lasting several hours, but can take up to 30 minutes to achieve simple nerve block. It is therefore a useful adjunct for wound infiltration or nerve block in association with general anaesthesia.
Spinal anaesthesia is not widespread in UK day surgery practice, in contrast to many other parts of the world. The main advantage of spinal anaesthesia is for operations below the waist such as arthroscopic surgery on the knee, foot surgery, haemorrhoidectomy or other rectal surgery, neurological surgery and inguinal hernia repair. The principal reasons for selecting spinal anaesthesia are in the obese or those with cardiorespiratory disease who would otherwise be excluded from day surgery.37
The techniques and drugs used in general anaesthesia today permit up to 90 minutes of anaesthetic time for day surgery. The use of the laryngeal mask rather than the endotracheal tube has changed anaesthetic practice in day surgery since its introduction in 1988. Muscle relaxants are not required with its insertion, which is quicker and easier, and it is tolerated in light anaesthesia, allowing rapid patient turnaround. The introduction of total intravenous anaesthesia using propofol for induction and maintenance of anaesthesia has major advantages over inhalation agents; these include reduced PONV, early recovery and rapid control of the depth of anaesthesia, making it ideal for day case surgery. PONV after surgery is best prevented rather than treated, but is more likely if surgery lasts more than 1 hour or involves laparoscopy, dental procedures, squint surgery or correction of bat ears.
Adequate hydration reduces PONV and intravenous fluid should be administered during longer procedures. Intravenous fluids at a dose of 20 mL/kg significantly reduce the incidence of postoperative drowsiness and dizziness.38
Pain management during anaesthesia is based on a concept of multimodal analgesia, which is a combination of two or more analgesic agents or analgesic techniques to minimise side-effects. A common strategy is to use an NSAID or short-acting opioid in combination with regional or local anaesthesia. The administration of stronger opiates such as morphine and pethidine at this stage is to be avoided as its longer-lasting effects may lead to unplanned overnight admission. Administration of analgesia in recovery and on the day ward before discharge should be given before ‘breakthrough’ pain occurs and is based on the accurate measurement of pain by the patients themselves.
The safe, effective and efficient surgery required for a day case procedure demands the competence of a trained surgeon, a consultant or an experienced specialist registrar. In the past, the day surgery list of intermediate procedures was delegated to the most junior surgical trainee to perform without supervision. Not surprisingly, this led to prolonged operating times, patient cancellations, increased complications and an inevitable rise in the unplanned overnight admission rate. As surgical trainees may no longer work unsupervised, such poor-quality practices should be features of the past. Nevertheless, some consultant surgeons' attitudes towards day surgery remain lukewarm, mainly because many have never considered the importance of their role in the overall delivery of patient care and the need for them to be more actively involved in the process of care through the hospital system. A frequent excuse was that the surgery itself was mundane and lacked the technical challenge of complex major procedures. With the introduction of more major minimal access procedures into the field of day surgery, this excuse no longer holds true. Indeed, many day surgery experts would contend that any intermediate or major surgery performed on a day case basis is a true surgical challenge if morbidity is to be maintained at near zero levels.
Day surgery rates for specific procedures still vary between individual surgeons, between hospitals and even between regions. In November 2011, there was still a 17% variation in day case rates for inguinal hernia repair and varicose vein surgery between the best and the worst performing Strategic Health Authorities (SHAs) in England, whilst the rates for day case laparoscopic cholecystectomy in all SHAs ranged from 23% to 56%!13 The reasons for such variations are complex and remain largely unexplained, but often reflect an inability to organise healthcare effectively and follow guidelines.39–42
Whilst these variations were understandable in the development phase of day surgery, they become increasingly difficult to justify as we move to a genuine National Healthcare system, with equal access to treatment for all. A new generation of surgeons and anaesthetists who are more familiar with the skills and techniques necessary to provide high-quality day surgery should ensure that most of these extreme variations disappear over the next few years.
Surgical practice: controversies
Laparoscopic Cholecystectomy: The day case rate for laparoscopic cholecystectomy in the UK is just under 40% and still shows large variations between surgeons, trusts and regions.13 The reasons for this relate to fears about reactionary haemorrhage, delayed haemorrhage and bile leak. Reactionary haemorrhage occurs within 4–6 hours after surgery and can be addressed within the ordinary working day if the surgery is performed before noon. Delayed haemorrhage usually occurs 3–4 days after cholecystectomy and even if the patient had undergone their operation as an inpatient, they would still have gone home before the secondary haemorrhage was apparent. Bile leaks rarely become apparent before 48 hours after surgery: accessory duct injury is often insidious, diathermy injury to the biliary tree may take days to leak and cystic duct stump leakage likewise. Again, if the patient had undergone inpatient surgery the likelihood is that they would already have been discharged home. It is therefore more important to warn these patients of possible delayed complications and that they should seek medical review in the first few days after discharge if alarm symptoms such as abdominal pain, nausea and vomiting occur. The NHS Institute published a clinical pathway in 2007 which noted that 70% of laparoscopic cholecystectomies could be safely performed as day cases40 and this target has been recommended to NHS commissioners as part of the 18-week programme.43
Successful day case laparoscopic cholecystectomy relies on rigorous patient selection, accepting only well-motivated and non-obese patients, and attention to detailed surgical technique. Patients require approximately 6 hours of recovery time and the procedure is best performed early in the operating day.
Age greater than 50 and ASA class II and III are poor prognostic indicators.44,45
Good operative technique is also relevant when creating the pneumoperitoneum, as carbon dioxide inadvertently placed in the extraperitoneal space can cause considerable discomfort. Shoulder tip pain from diaphragmatic irritation has been related to the size of the gas bubble under the diaphragm46 and attempts should therefore be made to expel as much gas as possible at the end of the procedure. Blood in the peritoneal cavity is an irritant, and liver bed haemostasis and peritoneal lavage before exiting the abdomen are worthwhile. While much of the postoperative pain in laparoscopic cholecystectomy is deep in nature, laparoscopy port sites should always be infiltrated with a long-acting local anaesthetic (such as bupivacaine). There appears to be little difference between infiltration at the beginning or the end of the procedure.47
Prostatectomy: For benign prostatic disease, the current national day case rate for laser ablation is 10% and for transurethral resection is just over 1%, although the rates are 30% in London and 10% in south central England.13 Patients requiring prostatectomy tend to be older and less fit and many have previously been excluded from day surgery by their comorbidity. Conventional transurethral resection of the prostate (TURP) can be performed as a day case but postoperative haemorrhage remains a problem. Over the last decade, laser prostatectomy day case programmes have been developed,48,49 with the patients discharged with a catheter in situ, returning to the day unit approximately 1 week later for trial without catheter. Some units now perform over 90% of prostatectomies as day cases.50
Head And Neck:
In the UK, 6% of tonsillectomies are performed on a day case basis due to worries about reactionary haemorrhage. This risk is small and in a series of 668 adults and children undergoing day case tonsillectomy in Salisbury, the reactionary haemorrhage rate was 0.3%, each occurring within the first 6–8 hours after the operation while the patient was still on the day unit.51
Secondary haemorrhage occurs in approximately 1% of post-tonsillectomy patients and occurs several days after discharge, but may cause rapid airway obstruction at home with fatal consequences. The Salisbury Unit has a high readmission rate of 6% that reflects their policy of readmitting even minor bleeds for 24 hours in case they herald a more major bleed.
Similarly, parathyroid surgery has not been deemed suitable for day case surgery because of the risk of haemorrhage and hypocalcaemia. Nevertheless, McLaren and colleagues have demonstrated high and safe day surgery rates in patients with positive preoperative localisation.52
Bariatric And Other Surgery: Bariatric or weight loss surgery is increasingly performed in the UK, as a result of the growing number of morbidly obese in the population who fail to respond to dietary methods or exercise. Obesity is a risk factor for any surgery,17 but shorter, minimal access procedures such as laparoscopic gastric banding have been performed successfully as day case procedures,53 the limiting criteria being the 150-kg weight limit of most operating trolleys. Of greater significance is perhaps the implied message that BMI should no longer be seen as a limiting factor in the delivery of day surgery generally.
Other areas of surgery are developing fast-track or short-stay admissions as a preferred clinical pathway for their patients, for the same reasons surgeons applied day surgery techniques 30 years ago for hernia and paediatric surgery: when delivered to a high standard, safely and efficiently, patients and providers benefit. Kehlet described his experience in developing enhanced recovery programmes in colorectal surgery a decade ago and the principles have been extended to broader aspects of surgery.54,55 Clinicians using techniques as diverse as abdominoplasty, colorectal cancer surgery, thoracic surgery and even endovascular aortic grafting are now using these techniques to shorten lengths of stay while enhancing patient care.56–59
Upon completion of anaesthesia at the end of a surgical procedure, the patient is transferred to the operating theatre recovery area known as ‘first-stage recovery’. Formerly, patients remained here for a predetermined period, commonly 30 or 60 minutes. However, the development of short-acting anaesthetic agents, the introduction of minimally invasive surgical techniques and individual patient variability meant that patients were often ready for transfer to ‘second-stage recovery’ before their predetermined time. Therefore, ‘time-based recovery’ is no longer necessary and has in many units been superseded by ‘criteria-based recovery’, where discharge is determined by the observations of stable vital signs, return of protective reflexes and the ability to obey commands.60 ‘Second-stage recovery’ occurs back in the ward or trolley area of the day unit itself, where patients recover sufficiently to allow safe discharge home. Certain patients may be suitable for direct transfer to second-stage recovery from the operating theatre itself (Fig. 3.3) and include patients who have received local or regional anaesthesia with or without minimal sedation.
FIGURE 3.3 Staged patient recovery.
Postoperative instructions and discharge
Before leaving the day unit, patients require specific information regarding their medication, wound care and when they are able to bath or shower, arrangements for suture removal or dressing renewal, when they can resume normal activities and arrangements for follow-up (if appropriate). It is also important to offer a contact telephone number for emergency purposes on the night of discharge. In addition, patients must be clearly instructed not to drive a motor vehicle for at least 24 hours.61 Appropriate preoperative information may also have a beneficial effect on return to work after surgery.62
The most common reason for a patient visiting their general practitioner after day surgery is to obtain certification for time off work. The second commonest reason, usually in an unplanned manner, relates to worries about their wound. After discharge, many day surgery units therefore offer outreach or telephone follow-up for their patients 24 hours later. This can be an effective evaluation tool, where any identified actual or potential problems can be highlighted to the day surgery team for action. This may only be necessary after specialised surgery (e.g. cataract surgery, where a change of dressing can be combined with outreach follow-up) or after the introduction of an unfamiliar procedure to the unit.
Precise patient selection should ensure that postoperative morbidity is minimised, but complications do occur and can be classified into major and minor problems.63 Major complications occur less often than anticipated in the day surgery patient population with an incidence of 1 in 145564 and are independent of ASA status. Mortality is low and varies between 1 in 66 500 and 1 in 11 273.
Minor complications are more common and may precipitate unplanned overnight admission; these range from 0.1% to 5% depending on case mix.65 Postoperative morbidity is usually related to the procedure undertaken and the anaesthetic agent used rather than the ASA status, which predicts complications in major inpatient surgery but not in day surgery patients. Surgical causes account for 60–70% of unplanned admissions and are usually the result of the surgeon embarking on a more extensive procedure than planned rather than surgical misadventure. Day surgery lists require careful planning, with the more major surgical procedures performed earlier in the day to allow adequate recovery time. Failure to adhere to this policy often leads to unplanned admissions.66 The more lengthy and invasive surgical procedures tend to increase postoperative pain, PONV and drowsiness, and preclude safe discharge. Even once the patient has returned home, PONV may return and last up to 5 days in 35% of patients67 and is often severe. Readmission rates are similar to unplanned admission rates (0.7–3.1%) and again are most often from surgically related causes.
Paediatric Day Surgery
Children find surgery and hospital visits a daunting and stressful prospect, and are therefore treated both separately and differently from adults. In 1991, the National Association for the Welfare of Children in Hospital published quality standards for care of paediatric day cases and suggested that children should be managed by staff trained in their care, in a child-safe and child-friendly environment with open access to the conscious child for the parents.68 As a result, excellent results have been reported from non-specialised District General Hospitals as long as regular auditing of quality is practised.69
Most children are fit and healthy ASA class I patients. ASA class II and III patients are not excluded but an anaesthetist with paediatric expertise is recommended.15 Procedures for children with respiratory infections should be postponed for 2–4 weeks depending on severity, but after measles or whooping cough this should be extended to 6 weeks because of irritability of the respiratory tract.70 In many units, children under the age of 6 months are considered unsuitable for day surgery, but if specialist facilities are available, full-term neonates are acceptable provided inpatient neonatal care is available. Premature babies are excluded up to 60 weeks after conception because of the risk of postoperative apnoea.71 Many units also exclude children who are less than 5 kg because of the risk of hypothermia or hypoglycaemia associated with their physical status.
Psychosocial factors also determine a child's suitability for day surgery, and may limit access to day surgery especially in single parents with many children and little support, or very timid children with overly anxious parents.
Therefore, while the range of surgical procedures undertaken is similar to adult day surgery, in children it is often confined to a more restricted list (Box 3.4). In the anaesthetic room, venous access is obtained after the application of topical local anaesthetic 1 hour before; parental presence in the anaesthetic room is useful, especially in the preschool group. Postoperative pain relief is obtained first through adjunctive local or regional anaesthesia. NSAIDs cannot be given to children under 1 year of age or 10 kg in weight because of their immature kidneys, but paracetamol is effective if given in a premedication dose of 20 mg/kg. Before discharge, the parents require clear instructions regarding pain control, wound care, mobilisation and resumption of normal activities.
Box 3.4 Paediatric day surgery procedures
Herniotomy, hydrocele excision, examination under anaesthesia, anal stretch, excision of minor lumps and bumps, ingrowing toenail treatment, endoscopy, biopsy (rectal, skin, lymph node)
Circumcision and associated procedures, orchidopexy
Myringotomy/grommets, adenoidectomy, tonsillectomy
Correction of squint
Change of plaster cast
What will happen next?
The shift of elective surgery from the inpatient setting to short stay and eventually day care is now inexorable and will continue to be driven by three factors. The first and most important is the natural dislike in most people of in-hospital stays, accelerated by the growing fear of hospital-acquired infections; most people prefer to be at home, and as soon as a day surgery procedure can be shown to be performed as safely and effectively as in the traditional inpatient setting, most of us will opt for the former.
The second drive for change is the continued growth of minimal access techniques, including the use of robotics and the development of natural orifice transluminal endoscopic surgery (NOTES).72 These techniques are associated with less surgical trauma and reduced postoperative pain both in the short and medium term, and have led to the concept of ‘fast-track’ surgery for inpatient procedures.54 The concomitant development of better anaesthetic and pain-relieving techniques will further reduce the need for inpatient postoperative care.
The third and greatest factor currently driving change is that of healthcare costs. By dispensing with inpatient hotel costs including staffing, procedures performed as day cases offer significant cost savings to healthcare providers and purchasers, and the impact of this can be seen in many areas: