Day-case surgery is defined as when the patient is admitted and discharged on the same calendar day as their surgery. It is an important part of NHS surgical provision, with many planning documents promoting it as being the norm because of the many advantages to the patient and healthcare system.
However, making day-case surgery work requires:
Appropriate patient selection
Appropriate system organisation
Tailoring of surgical and anaesthetic technique
The history of day-case surgery has been met by some resistance historically, when prolonged hospital admission and rest post surgery was seen as important. Hower, increased recognition of the benefits has led to organisational push to expand it. The NHS target is to have 75% of surgeries performed as day-case. National bodies and organisations e.g. BADS, have as such increasingly compiled lists of surgical procedures that are well suited to the day-case setup. With high volume, expert centres, some very complex surgical procedures are being able to be done on this basis too e.g. nephrectomies. Indeed, the inpatient management of surgical patients should only be seen as necessary when it has a role in improving patients care.
There are many. Advantages for the patient include
Greater patient satisfaction
Reduced disruption to life
Reduced rates of hospital associated infections/complications
Reduced rate of cancellations
Reduced cognitive decline (in elderly)
Advantages for the healthcare system include:
Greater inpatient bed capacity
Meeting waiting list targets
Lower costs arise because of the reduced care demands of patients who are not needing inpatient care, and the reduced costs of managing with the complications of staying in hospital e.g. hospital acquired infections.
As noted, to function effectively, day-case surgery has to be organised. This requires a well designed pathway from patient booking through to final discharge.
The ideal day-case surgical unit will be:
Separate from normal inpatient services
Access to inpatient service if needed
Run by dedicated, appropriately trained staff staff
Consultant led and nurse run
Patient selection and assessment
Pre theatre preparation
Patient selection This is an important part of the pathway and is discussed more below. Patients (and the surgery they are having) must be suitable to have the day-case surgery approach. This will apply to a lot of people, but careful assessment beforehand improves the safety and efficiency of the process. This includes ensuring that all relevant investigations have been done and are available on the day of surgery.
Admission Patients will be admitted on the day of surgery. As such, it is important that all information and investigations. Specific day-case pathway booklets may help streamline this information by having it physically located in a single document.
Patients will have to have been provided with the necessary information beforehand:
Location and timing
Pre theatre preparation Patients will have undergone the routine checks pre theatre. There will be space to change into theatre gowns. Where possible ‘premedication’ sedation should be avoided.
List management is an important consideration. Patients who require longer recovery periods should be done earlier in the list to allow this.
Recovery Phase 1 recovery will involve to transition back to full consciousness and the return to patient control of airway, breathing, circulation etc. Modern anaesthetic techniques means that this is usually very rapid. Phase 2 recovery refers to the longer period of recovery from anaesthesia (and surgery) prior to being fit for discharge. This includes observation to ensure that the effects of anaesthesia have fully reversed, and there are no adverse features persisting e.g. PONV, pain. This phase will usually start in the recovery area of theatres and continue on a specific day-case ward.
Discharge This will usually be nurse led and based on the patient meeting criteria that show they are now safe to leave the clinical environment. In general this is that they have had adequate observation to ensure they:
Have fully recovered from anaesthesia
Have not developed any complications (surgical or anaesthetic)
Have logistical support in place to leave e.g. supervision, transport
This involves 3 important parts:
Educating patients and carers about the surgical pathways
Provide information on the planned interventions and allow effective decision making
To identify medical risk factors and allow optimisation
This will often be done as a ‘one-stop shop’ setting in the self contained day-case complex. It will commonly be nurse led and with patients completely self-assessment documentation to allow gathering of information. This is when patients can be provided with important information about their surgical procedure and the surrounding care. Many leaflets are available via the AAGBI and RCOA.
This is a very important step to ensure that a day-case approach is feasible. It can be considered as having 3 main arms:
Surgical Factors The surgical procedure itself needs to be something that is feasible to safely conduct in a day-case setting. This will involve factors such as:
Expected complication rates (particularly of those which would require immediate medical attention e.g. haemorrhage)
Expected analgesia demands
Specific post-operative care requirements e.g. drains
The length of surgery is now less of a factor with rapid recovery from anaesthesia possible despite longer administration. It is not even essential that the surgical procedure is entirely elective in nature.
Patient Factors The medical health of the patient is another important contributor for the success of day-case surgery. These will interact with both the surgical and anaesthetic technique as well. Many medical conditions will be manageable as a day-case, but in some cases, the impact of the surgery or anaesthetic on the stability of the condition may be too much. This is a challenging area, as there is a huge range of contributing factors to this. In less straightforward patients this risk assessment will often require a skilled clinician to be involved to weigh up the relevant factors.
Factors which may impact include:
Age - no hard upper or lower limit, but may impact on decision making e.g. neonates not very suitable
ASA status - ASA 4 patients may not be suitable, though this is a crude assessment method
Obesity - morbidly obese patients (BMI >40) are generally at higher risk of complications and so less suitable. However, there are many benefits from a day-case approach e.g. mobilisation.
It is important to remember that many chronic diseases e.g. diabetes, epilepsy, can actually be managed better by the patient in their own environment because of their expertise in their condition.
The patient also has to be a willing and active contributor to the process. Whilst many patients have a strong preference for early discharge, this is not universal, and would impact on the effectiveness of a day-case approach.
Social Factors Some of these will impact on the safety for discharge rather than other aspects of the pathway. Patient’s who are discharged will need help with certain activities after discharge e.g. transport, and socially isolated patients may not manage with a day-case approach because of this. They will need to be with someone (an able bodied adult) for 24 hours following surgery who can help with problems and call for help in the event of any complications. A telephone must be available for this. The distance that the patient lives from medical care may be a factor in some surgical scenarios i.e. when it may prevent timely access to medical help in the event of a complication.
This is a key step in the effectiveness of day-case surgery. There should be clear identification of patients who are safe to leave, and recognition that there are some cases where admission is required. The patient must be:
Recovered from anaesthesia
Alert and orientation
Eating & drinking (although not always required)
Standing & walking
Has passed urine (not always required)
No major disruption to patient’s chronic medical conditions
No evidence of post-op complications
Wound dressings checked
Logistical considerations in place
Appropriate adult (and transport)
Written discharge advice
The provision of anaesthesia has to fit into the goals of day-case surgery. Whilst many of the improvements in anaesthetic technique have allowed the expansion of day-case surgery, there still needs to be careful thought put into the anaesthetic plan. As such, guidance suggests that the management should be heavily consultant led.
Much of the management will be the same. The primary goals will be:
Rapid recovery from anaesthesia
Specific areas of consideration may include.
Airway management The use of an LMA may reduce the anaesthetic requirement (for intubation) and the need of muscle relaxation. The rate of sore throat is probably lower than with intubation. The use of suxamethonium should probably be avoided because of the high incidence of muscle pains.
Maintenance Most current volatile agents have a similarly rapid recovery profile in anything but long anaesthetic cases. In longer cases, desflurane or sevoflurane is likely preferable to isoflurane. TIVA may be useful as it produces a lower incidence of PONV.
Analgesia Opioid use should be minimised as possible due to the side effects of sedation and PONV. A multimodal analgesia plan should be implemented to facilitate this. Premedication with paracetamol +/- NSAID could be an option. Indeed because of the strong benefits of NSAIDs in this regard they should be strongly considered unless there is the presence of a contraindication. If necessary, short acting opioids should be the preference over long acting ones, e.g. morphine.
Antiemetics PONV could be a reason for admission following surgery. PONV management should be undertaken as for other patients, with risk assessment, minimisation of risk factors, appropriate prophylaxis and rescue therapy.
Hydration Adequate hydration can improve several of the outcomes that are desirable for day-case surgery, such as reduced dizziness, PONV, and drowsiness. Consideration should be given to 20ml/kg fluid. Appropriate use of fasting guidelines (reducing intake of free fluid) can also help.
Regional anaesthesia In some cases this can be a useful adjunct to analgesia therapy. However, in some cases it offers little benefit over local infiltration with local anaesthetic agent. Consideration should be given to its use when it has clear advantages over this:
Avoidance of general anaesthesia
Patients can still be discharge home with persisting motor or sensory blockade if it is safe and appropriate advice has been given.
Spinal anaesthesia is still suitable for day-case anaesthesia. Traditional dose spinal blocks may cause problems with prolonged motor or sympathetic ANS blockade that would impede recovery and discharge. A low-dose spinal block has been described for such a scenario:
1ml 0.5% heavy bupivacaine
10 mcg fentanyl
Made up to 3ml total with 0.9% NaCl
This has several advantages:
Short block (usually 1 hour) with only slightly slower onset
Ambulation possible in 2-3 hours
Minimal sympathetic ANS block.
Links & References
Burtenshaw, A. Long, K-L. Day-case surgery and anaesthesia 1: Advantages and organisation. e-LFH. 2012
Burtenshaw, A. Day-case surgery and anaesthesia 2: Patient selection and discharge criteria. e-LFH. 2012
Smith, I. Rajamanickam, R. Day case surgery and anaesthesia 3. e-LFH. 2012
Day case and short stay surgery. AAGBI and BADS. 2011.
Quemby, D. Stocker, M. Day surgery development and practice: key factors for a successful pathway. CEACCP. 2014. 6(1): 256-261