British Association of Day Surgery The Future of Day Surgery: The Ambulatory Pathway Ian Smith, MD, FRCA Senior Lecturer in Anaesthesia University Hospital of North Staffordshire President, British Association of Day Surgery

British Association of Day Surgery Benefits of Day Surgery Quality care –early & better recovery –minimal disruption –comfort of own home PATIENT PATHWAY Better care, Safer care

British Association of Day Surgery Surgical Length of Stay Cascade InpatientOutpatientDay Surg23 hour

British Association of Day Surgery Referral from GP Outpatient review Diagnostics Further review Decision to operate Typical Surgical Pathway Inpatient Waiting list Preop assessment Surgery (if suitable) Day case Waiting list Preop assessment Surgery (if suitable)

British Association of Day Surgery Key Pathway Areas 1.Referral & outpatients 2.Preassessment & selection criteria 3.Booking 4.Patient admission 5.Operating lists & recovery 6.Discharge, documentation & support

British Association of Day Surgery Patient Referral Fit to proceed to surgery? Info on longterm conditions Understands referral may  surgery Understands timescale Diagnostic tests –with results Potential for day surgery

British Association of Day Surgery Surgical Outpatients Surgery possible / worthwhile? Discuss risks & benefits –inform consent Day surgery possible? –in this case –surgical factors

British Association of Day Surgery Preoperative Assessment Nurse performed –clinician supervised

British Association of Day Surgery Preoperative Assessment Nurse performed –clinician supervised Various models –centralised –DSU –telephone Lewis, et al. — J One-day Surg 19: 32, 2009

British Association of Day Surgery Preoperative Assessment Nurse performed –clinician supervised Various models –centralised, DSU, telephone Information –procedure & day of surgery –fasting & medication –recovery & pain management

British Association of Day Surgery Default to Day Surgery Suitability for day surgeryPathway Clearly suitable Unsure Clearly unsuitable Day surgery Home if ok Inpatient care ? Home if ok Inpatient care Hospital stay 20–30% 5–20% 40–65%

British Association of Day Surgery Booking Offer choice of dates –early as possible Mechanisms to allow booking clerks to –offer choice of dates –allow for leave –allow for teaching –allow for complexity

British Association of Day Surgery Operating Lists Dedicated day surgery lists Mix of day and short stay surgery –efficient –flexible Mix of day and inpatient surgery –tension –conflicting needs

British Association of Day Surgery Pooled Lists Maximise day case capacity –full list –reduce waiting times surgeon may have to alternate weeks Maximise day case expertise –surgery by day case enthusiasts Greater flexibility

British Association of Day Surgery Optimising List Order Major cases first –appropriate observation & recovery time Diabetics early –minimal disruption to routine Minor cases later LA cases can go last –need less recovery time

British Association of Day Surgery Recovery Facilities Fully equipped to usual standard –trained staff Potential for rapid turnover –staffing levels Second stage recovery –nurse led discharge

British Association of Day Surgery Patient Discharge Nurse led Supported by –documentation –information

British Association of Day Surgery Safety Mechanisms Defined pathway Review by experienced nurse –recognition of early signs of bleeding Mechanism for recall –24 h telephone no –surgical area (early review) –NOT GP / NHS Direct Patient self-caring –symptoms earlier; no assumptions

Post-discharge support Documentation Patient discharge Recovery facilities Operating lists Admission Booking Selection criteria Preoperative assessment Surgical outpatients Patient referral The Streamlined Pathway

British Association of Day Surgery Future of Day Surgery Aging population Obesity time bomb Increasing surgical complexity Therefore many challenges

British Association of Day Surgery Variation in Practice Day surgery rates vary considerably –between hospitals –within hospitals –within departments Applying pathway principles –can dramatically increase day surgery Smith, et al. — J One-day Surg 20: 80, 2010

British Association of Day Surgery Incentivising Best Practice Orthopaedic subacromial decompression bunions Dupuytren’s Breast mastectomy sentinel node ENT tonsillectomy septoplasty Gynae female incontinence Urology TUR & laser prostate General lap chole hernia repair Best Practice Tariffs

British Association of Day Surgery The Near Future? True day surgery –≈85% Overnight stay –≈5% Longer stay –≈10%

British Association of Day Surgery