1. An Anaesthetist’s perspective on Same Day Surgery
Dr. Rowan Thomas
St. Vincent’s Health

2. Same day concepts Sameday – not listed in English dictionary.
Day surgery – admission, surgery and discharge on the one day. (US <23hr 59min)
Ambulatory surgery – Day surgery, not 23hr
Day of surgery admission (DOSA) – can include day surgery and multiple day stay surgery. (Sometimes called Same day admission.)
23 hour stay and ‘medi-hotel’ – developments extending the capacity of day surgical units.

3. Anaesthetic issues Pre-operative assessment and management
Management of post-operative pain, nausea and vomiting
Neurologic, respiratory and cardiovascular recovery from anaesthesia.

4. Day anaesthesia (& surgery)
Multidisciplinary team approach
Appropriate patient selection and education – medical and social aspects
Routine surgery, without blood loss
Routine pain management
Adequate recovery and home support
Are anaesthetic techniques modified?
Greater use of local anaesthesia

5. Flexible care
Often surgery varies and patients can have significant co-morbidities
An individual approach requires judicious preoperative assessment and tailored hospital or home support.
Pre-operative assessment is the key to safe post-operative planning. Discharge on the day of surgery, depends on careful patient selection.

6. Preadmission at St. Vincent’s
% DOSA. One third of patients seen in preadmission. Random selection
Day surgery rates not recorded
High cancellation rate due to failure to attend
Screening tests ordered routinely
No anaesthetic involvement
PIER (Preoperative Investigation, Education and Research) centre established

7. Preadmission at St. Vincent’s
Triage questionnaire to improve selection of patients for preoperative consultation.
Resident staff run the clinics with anaesthetic consultation. Unusual design, but involves the residents.
Most patients complete a questionnaire when placed on the waiting list. (Reviewed six monthly)
Patients attend clinic about two weeks prior to surgery.

8. Triage for preadmission
Two page questionnaire. Designed to be completed by the patient and assessed according to protocol.
Dual purpose. Clinical information available in the history. Well or stable younger ASA II patients not needing investigation, having surgery without blood loss can avoid preadmission.
One third now ‘fast-tracked’.

9. Triage for preadmission
Very effective method for eliminating costly & unnecessary ‘screening’ investigations
Only 300 (5%) elective patients per year involve anaesthetic consultation
Anaesthetists not taken from theatre where their skills are probably of greater use.

10. DOSA & Day surgery August snapshot (419 elective admissions)
89% Overall DOSA. (Lowest - vascular 62%)
121 (29%) Discharged on the day of surgery. Plastic surgery accounts for nearly half.
Some ‘cross-over’ between intended and actual stay.
Many units perform complex surgery not suitable for day surgery.
Lap. cholecystectomy has been tried unsuccessfully as a day surgery procedure.

11. Cancellations
Of 50 cancellations in August, 10% (5) due to inadequate preoperative investigation or information.
Compare with 20% - lack of time, 10% - no bed, 10% - emergency case, 10% - unexpectedly unwell, 20% - cancelled by patient.
Cancellation need not always be regarded as a failure. It can be a learning opportunity, but is also an important barrier for trapping errors.

12. DOSA at St. Vincent’s
Most elective patients now come through DOSA. Originally designed for 10% - 20% of elective surgery. Discharge is a separate event and is based on surgical and patient factors.
Patients are seen by anaesthetist in DOSA or in the anaesthetic induction room.
Staggered arrival in the morning – needs only one nurse.
Afternoon staff call the next day’s patients to check that they are ready.

13. Benefits of DOSA
Patients generally prefer to be at home prior to surgery.
Preadmission clinics become integral to the system. Timely investigation. Preoperative education & discussion. Involvement of resident staff in the management of elective surgical preparation
Eliminates the night-time preoperative round.
Hospital bed available for emergency or post-operative care.

14. Disadvantages Dilutes the responsibility for preoperative care.
Despite good education, patients regularly arrive un-fasted or not having taken usual medication
Many patients have not had the benefit of a prior discussion with an anaesthetist.
Rushed preoperative morning visit by anaesthetist. Not all clinical decisions can be predicted by other clinicians. Complex cases - need time to consider anaesthetic options.

15. Disadvantages
Rushed arrival and transfer to theatre for the first patient. Heightened patient anxiety.
‘Consent’ is a bureaucratic charade.
Interpreters not easily available at 0700.
Late starts to surgical lists or long breaks between cases.
Patients are now very aware of the waiting time prior to surgery.

16. Is day surgery safe? VCCAMM 1997 – 1999
32 deaths wholly or partly related to anaesthesia. 12 involved inadequate preoperative assessment or management.
6 Elective. 4 Semi-urgent. 2 Emergency
“Of concern were the deaths of two day-stay patients undergoing minor procedures”

17. Future challenges
Better systems for the provision of information about the surgery and anaesthetic.
Better systems for ‘two-way’ communication between the clinician in the preadmission clinic and the anaesthetist and surgeon doing the procedure.
Ideally the anaesthetist and surgeon performing the procedure could use the opportunity provided by preadmission to consult with the patient.

18. Conclusion
Safety, provided by thorough preoperative assessment and flexible pathways for post-operative care must always have a high priority.
Information management and informatics systems will contribute to better communication.