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DAY SURGERY

Revised Edition 2005

2
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650, Fax: 020 7631 4352
E-mail: info@aagbi.org Website: www.aagbi.org
February 2005
MEMBERSHIP OF THE WORKING PARTY

Dr David Wilkinson Vice President


Chairman of the Working Party

Dr Hilary Aitken Council Member

Dr Roddie McNicol Council Member

Dr Ben Fitzwilliams Group of Anaesthetists in Training

Dr Ian Jackson President Elect,


British Association of Day Surgery

EX OFFICIO

Prof Michael Harmer President

Dr Peter Wallace Immediate Past President

Dr Richard Birks Honorary Treasurer

Dr Alastair Chambers Honorary Secretary

Dr David Whitaker Immediate Past Honorary Secretary

Dr Diana Dickson Honorary Membership Secretary

Dr David Bogod Editor-in-Chief

February 2005

To be reviewed by 2010
Contents Page

Summary 2
Introduction 3
Recent reports 4
Selection of patients 5
Documentation 9
Management and Staffing 10
Facilities 11
Anaesthetic management 12
Postoperative recovery and discharge 14
Regional anaesthesia 16
Postoperative instructions 17
Discharge summary 18
Audit 19
Contractual arrangements 21
Stand-alone day surgery units 22
References 23
Further reading 24
FAQs 26
Appendix 1 28
Appendix 2 31
Appendix 3 32
Appendix 4 33
Appendix 5 34
Appendix 6 35

1
Summary
Day surgery is a continually evolving specialty performed in a range
of ways across different units.

The NHS plan target of 75% of elective surgery being performed as


day cases means that this will form a high proportion of the work of
most Departments of Anaesthesia.

Pre-assessment clinics should be consultant led and nurse run. The


assessment criteria should be developed in conjunction with the
local Department of Anaesthesia.

Fitness for a procedure should relate to the patient’s health as found


at pre-assessment and not limited by arbitrary limits such as ASA
status or age.

Whatever surgery is to be undertaken as a day case, the decision


must be based on proven safety and quality.

Good quality advice leaflets, assessment forms and protocols are in


use in many centres and are available to other units.

Every day surgery unit should have representation at Trust Board


level.

Each anaesthetist should develop techniques that permit the patient


to undergo the surgical procedure with minimum stress, maximum
comfort and optimise their chance of early discharge.

Central neural blockade can be used for day stay surgery.

Effective audit is an essential component of good day stay


anaesthesia.

2
Introduction
The definition of day surgery is not clear and is interpreted differently
by Trusts around the UK; the boundaries between day surgery, 23-h
stay and 2-day stay are often blurred. The principles of care outlined
in this document apply equally to patients managed within all these
formats.

Since the previous booklet was published in 1994, major changes


have taken place in day surgery. More invasive procedures are being
performed and new anaesthetic techniques, agents and analgesics
have become available. Despite these advances it would appear that
the overall performance in day surgery has been slipping across the
UK. This may be due to complacency with previous performance and
failure to realise the potential gains for both hospital and patients of
continuing to move day surgery forward. This will need to change for
many reasons. In particular, the NHS plan[1] has set a target of 75%
of elective surgery to be performed as day cases and, in paediatrics,
the European Charter of Children’s Rights [2] states ‘Children should
be admitted to hospital only if the care they require cannot be
equally well provided at home or on a day basis’. There is also
evidence of benefit for the elderly population with studies showing a
reduction in Postoperative Cognitive Dysfunction [3]. It is important
therefore for all Departments of Anaesthesia to take a lead in this
move from in-patient surgery, as all are likely to see substantial
increases in day surgery over the next few years.

3
Recent Reports
Over the years, many reports have been published to inform those
who wish to extend or improve the manner in which they practise
day surgery. The Audit Commission, Caring for Children in the
Hospital Service and various Department of Health organisations
have all produced papers in this field and these are helpful
background reading (See Further Reading).

The NHS Value for Money report from 1991 Day Surgery: Making it
happen is still well worth reading and everyone should consult the
latest Day Surgery: Operational Guide from the Department of
Health.

The document National Good Practice on Pre-operative Assessment


for Day Surgery from the Modernisation Agency provides guidelines
for running pre-assessment clinics and suggested selection criteria
that have superseded those produced by the Royal College of
Surgeons in 1992.

NHS Estates have recently updated their building note HBN 26 that
covers facilities for surgical procedures and this, plus the Scottish
Health Planning on accommodation for day care (See Further
Reading), give good advice to those developing new facilities.

4
Selection of Patients
There are various routes for referral to day surgery: from hospital
outpatient clinics, from accident and emergency departments, from
Professionals Allied to Medicine and direct from general practice. The
exact mode of referral is unimportant as long as all adhere to agreed
protocols of patient assessment. There are no absolute criteria of
fitness for day surgery; however, it is important that the criteria are
agreed locally with the Department of Anaesthesia.
Assessment falls into two main categories:

(i) Social

(ii) Medical

Both of these are important. However, some of these factors are not
always easy to assess by the hospital doctor who has to rely on
healthcare professionals in the community to identify potential
problems.

(i) Social Factors:

(a) The patient must be willing to undergo surgery on a day-case


basis.

(b) Following most procedures, there should be a responsible


adult, able and willing to care for the patient at home for at
least the first 24 hours postoperatively.

(c) Patients or their carers should have easy access to a


telephone.

(d) The patient’s home situation should be compatible with


postoperative care, with satisfactory standards of heating and
lighting, together with adequate kitchen, bathroom and toilet
facilities.

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(ii) Medical Factors:

(a) The patient or his/her immediate carer must understand the


planned procedure and subsequent postoperative care and be
willing to accept responsibility for providing further
supervision of the patient.

(b) The patient should be either fully fit or any chronic disease,
such as diabetes, asthma, hypertension or epilepsy, should be
controlled. (See pre-assessment).

Pre-assessment

All patients should be seen in advance of their surgery by someone


trained in pre-assessment for day surgery. Consultant led, nurse run
pre-assessment clinics provide a suitable method to attain this; it is
agreed that trained nurses are more effective than newly-trained
doctors at such work. However such clinics afford an excellent
opportunity for training of medical students and trainee doctors. Pre-
assessment is also an important time to start educating the patient
(and their carers) about their operation and postoperative care.
Most pre-assessment takes the form of completing a set of
questionnaires with a patient. (See Appendix 1). This can be done
face-to-face in a hospital clinic, on the telephone or by a GP in their
surgery. The answers given to the set questions generate appropriate
investigations according to pre-set protocols e.g. a patient of 55 years
of age who is being treated for angina will have an ECG if one has
not been performed recently. The NICE guidelines [4] for pre-
operative assessment can be used to determine what is appropriate
for each unit.

Arrangements should be put in place for all appropriate tests (e.g.


blood tests, ECG and X-ray referrals) to be carried out at the time of
the pre-assessment. There must also be a mechanism in place to
review all investigations undertaken.

In units where policies have been agreed with the local Primary Care
Team, requests for further testing or investigation may be made by

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GPs (e.g. diabetic or hypertension control or supervised weight loss),
after which the patient can be re-assessed.

Despite the ability to perform the pre-assessment in many areas


within and outside the hospital this working party believes there are
advantages if it is performed within the facility where the day surgery
will take place. Patients and their relatives then have the opportunity
to become accustomed to the environment and to meet some of the
staff that will provide their future care. This also links into the timing
of pre-assessment. Some units offer this on the same day as the
outpatient appointment when the decision is made that surgery is
required, others send for patients from the waiting list some weeks
before their operation date. Indeed, running the pre-assessment in
parallel with the surgical list on which they will be treated can allow
the relevant surgeon and anaesthetist to be available for further
consultation and the clarification of concerns. Whichever model is
chosen, it is important to ensure that patients are assessed in advance
of their admission date with sufficient time to correct any problems
without causing further delay.

Some fundamental principles of day care:

Patients should be selected according to their physiological


status not their age.

Fitness for a procedure should relate to the patient’s health as


found at pre-assessment and not limited by arbitrary limits
such as ASA status.

Obesity is not an absolute contraindication for day care in


expert hands and with appropriate resources.

What surgery can be done in a day stay setting?

Day stay anaesthesia and surgery can be performed provided there is


satisfactory control of symptoms postoperatively, and the ability to
drink and eat within a reasonable time after the completion of
surgery. Pain, nausea and vomiting must be controlled, and preferably

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the patient should be able to mobilise to some extent. It would
appear at first sight that full mobilisation is essential but this is a
relative factor e.g. if the patient is wheelchair-bound and their home
can facilitate such ‘mobilisation’ then day stay should not be
precluded. In the same way, a patient having bilateral foot surgery
may go home in a wheelchair and mobilise over the subsequent
week.

The fundamental principle is that surgery undertaken as a day case


must be based on proven patient safety and quality of care. This
requires a degree of common sense and, in some cases, the use of
23-h stay to prove feasible.

8
Documentation
Not every DSU needs to design its own assessment forms; there are
large numbers of these forms in existence in Great Britain and Ireland,
and throughout the rest of the world. Those about to start, or to update,
their practice should try to obtain as many of these forms as possible to
benefit from the experience of others. A specimen form is shown in
Appendix 1 and further examples are available from the British
Association of Day Surgery, BADS*.

Information documents should describe in plain English the day care


process. Documents should outline the pre-operative preparation,
including individual hospitals’ fasting regimens, what patients should
wear and bring to the hospital on the day, what to expect
postoperatively and how to communicate with those involved in their
care. The anaesthetic leaflets developed jointly between the Association
and the Royal College of Anaesthetists (RCA) may also be used.

It should be remembered that for reasons of education or ethnic


background not all patients or carers will be able to fully comprehend
written instructions. The Moser Report [5] has suggested that 1 in 5
adults in the UK are not functionally literate and in 2001, a report
commissioned by the Home Office [6] concluded that “a considerable
proportion of the British South Asian and Chinese communities have
little or no ability in English. This means that communicating with them
requires the use of material in Mother Tongue”. Hospitals serving
communities with large immigrant populations should take account of
this and either provide translations of their booklets or offer translating
services. All hospitals should have access to local translating services.

Protocols should be available for the patient to postpone and re-book


their procedure for medical or valid social reasons. Specific
information sheets, relating to the individual planned procedure,
should also be available for the patient to take home and read at
leisure. (See Appendix 2). Examples of this type of information are
available from BADS. All involved in the patient’s care should agree
about the information in such packages.
The British Association of Day Surgery can be contacted through its Administrative Officer, 35-43
Lincoln’s Inn Fields, London. WC2A 3PN. email: bads@bads.co.uk

9
Management and Staffing
Each DSU should have a Clinical Lead or Director who has a specific
interest in day case surgery and who will lead the development of
local policies, guidelines and Clinical Governance in this area. A
consultant anaesthetist with management experience is ideally suited
to such a post. This individual should have adequate time allocated
in their job-plan for this responsibility [7]. Each unit also requires
adequate staffing led by a senior nurse who provides the day-to-day
administration of the unit in liaison with the Director. The senior
nurse in charge of the day surgery unit should be expected to spend
the majority of their time within the unit. Hands-on activity by senior
staff members ensures a valid understanding of any problems that can
emerge in day-to-day practice and will enable these to be more
speedily rectified. The staffing levels will depend on the design of the
facility and the work undertaken, as well as local preferences. The
DSU must have reception staff of high quality as well as its own
nursing and ODP personnel. The staff must be specifically allocated
and trained in day surgery.

Shortage of skilled staff must not be allowed to erode the provision of


a safe service, but it is also important for units to look at how they
use their staff. Examples that are currently being developed are
extending the roles of Health Care Assistants in theatre to include
scrub duties and in the use of ODP staff for pre-assessment and
recovery duties. Each DSU should formulate its own staffing structure
which takes into consideration their local needs.

Each unit should have an operational group which should oversee the
day-to-day running of the unit. This may include representatives from
anaesthesia, surgery, hospital nursing, community nursing, general
practice, pharmacy, management, finance, audit, and ancillary care.
This group should agree an operational policy, define a timetable,
review any operational problems and organise audit strategies.

The latest recommendation from the Department of Health is that


every DSU should have representation at Trust Board level [7].

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Facilities
Care should be provided in a facility that is set aside for day surgery.
Ideally this should be purpose-built. Alternatively day surgery should
be practised in a dedicated area within the hospital. Simple, rapid
and effective exchange of information between hospital and
community personnel must be possible.

Information technology must be provided so that adequate audit of


all aspects of patient care can take place.

Many hospitals will be providing care for day patients, who require
anaesthesia, in specialised units e.g. ophthalmology, dentistry,
psychiatry, accident and emergency. It may not be appropriate to
centralise these services into one DSU but all such patients must
receive the same high standards of selection, preparation, peri-
operative care, discharge and follow-up.

Children experiencing day surgical care require all the facilities and
staffing that would be expected in any paediatric unit. Those who
practise day surgery for adults and children in the same unit must
ensure that their unit meets the guidelines outlined in Caring for
Children in the Health Services 1991. Just for the Day. National
Association for the Welfare of Children in Hospital, London (see
Further Reading).

It is crucial to remember that adult facilities are rarely appropriate for


paediatric practice. Many units may need to build and staff separate
preoperative, recovery and post-operative areas for children, or utilise
existing paediatric facilities within the hospital, to ensure optimal
care for this group of patients.

Individual units will have their own practices relating to catering


facilities for both patients and their carers. Facilities and staff must be
in place to provide appropriate food and drinks to both groups.
Management must invest adequate resources to facilitate all of these
potential challenges.

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Anaesthetic Management
Day surgery anaesthesia should be a consultant-led service. However,
as ultimately 75 % or more of all elective surgery may be taking
place in day surgery, consideration should be given to education of
trainees as recommended by the RCA. This will require organised
training schedules and the provision of suitable cover - this is
especially true of stand-alone units.

Once a patient has been selected and fully prepared for day surgery,
decisions must be made for their anaesthetic management. The
Association of Anaesthetists standards on patient monitoring and
assistance for the anaesthetist should be applied [8, 9].

Each anaesthetist should develop techniques which permit the patient


to undergo the surgical procedure with minimum stress, maximum
comfort. Analgesia is paramount and must be long-lasting but
morbidity, such as nausea and vomiting, must be minimised. For
certain procedures (e.g. laparoscopic cholecystectomy), there is
evidence that following a standard anaesthesia and analgesia plan
minimises morbidity and increases the number of patients who are
able to be discharged. Anaesthetists should adhere to such clinical
guidelines where they exist.

Policies should exist for the management of postoperative nausea and


vomiting (PONV) and discharge analgesia. There is still insufficient
evidence to recommend the use of routine prophylactic anti-emetics
in day surgery practice except in certain patient groups. These
include those with a strong history of PONV and those undergoing
certain procedures e.g. laparoscopic sterilisation, laparoscopic
cholecystectomy and tonsillectomy. Motion sickness is another strong
predictor of potential problems after anaesthesia.

However, it is important that PONV is treated seriously once it occurs


and a standard management protocol can aid the anaesthetist, the
nursing staff and the patient. (See Appendix 3).

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Some audits suggest that the routine use of intravenous fluids can
enhance the patients’ feeling of wellbeing.

Prescribing discharge analgesia should be the responsibility of the


anaesthetist and each DSU should set up an agreed system with their
Department of Anaesthesia and pharmacy. There should be a choice
of analgesic regimens to allow the anaesthetist to deal with those
who cannot tolerate certain drugs (e.g. NSAIDs) and to deal with the
range of operations performed on the unit. (See Appendix 4).

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Postoperative Recovery and Discharge
Recovery from anaesthesia can be divided into three phases:

First stage recovery - which lasts until the patient is awake,


protective reflexes have returned, pain is controlled and they can be
discharged from the recovery area
Second stage recovery - which ends when the patient is ready for
discharge from hospital
Late recovery - this phase may last several weeks, and ends when
the patient has made a full physiological and psychological recovery
from the procedure undertaken.

The anaesthetic techniques chosen should be designed to maximise


the speed and quality of recovery in the first and second stages, and
so facilitate discharge. Technique may have less influence on the late
recovery, which is affected by many additional factors, so this phase
will not be dealt with here.

First stage recovery


First stage recovery should be undertaken in a recovery area with
appropriate facilities and staffing [10]. The patient remains in this
area until awake, in control of his/her airway, orientated,
comfortable, without continuing haemorrhage or other
complications. Each unit should have clear criteria for discharge from
this area and some units may consider using a scoring system.
Aldrete [11] has suggested a system based on clinical parameters
(Appendix 5).

The use of modern drugs and techniques may allow early recovery to
be complete by the time the patient leaves the operating theatre,
allowing a significant number of patients (up to 42% in some studies)
to bypass the first stage recovery area [12]. Adopting this “fast-
tracking” system may theoretically allow cost savings by reducing the
staffing levels in the recovery area, but may increase drug costs. In
addition, for most operating lists, there will need to be some staff in
the recovery area so savings are very difficult to quantify. Whether
this concept is appropriate will depend on local factors such as case
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mix, and protocols should be established to identify when a patient
may be ‘fast tracked’. It is useful to consider that almost all patients
who undergo surgery with analgesia provided by a local anaesthetic
block will be able to be ‘fast-tracked’.

Second Stage Recovery


This stage of recovery will normally be undertaken in a ward area
adjacent to the day surgery theatre. The ward should be equipped
and staffed to deal with the common postoperative problems such as
PONV and inadequate analgesia, as well as less common
postoperative emergencies such as haemorrhage or cardiovascular
events. The anaesthetist and surgeon responsible for the operating list
should be contactable and they or a deputy should be available to
help deal with problems that arise. Protocols should exist for the
management of patients who require unscheduled admission,
especially in a stand-alone unit.

Every patient should be seen following surgery by the anaesthetist


and surgeon involved in his/her care. The nursing staff may be
delegated the responsibility for discharging the patient by using
discharge criteria agreed with the Department of Anaesthesia. If there
is any doubt about the patient’s fitness for discharge, the anaesthetist
concerned or a deputy must be contacted. Attempts have been made
to identify simple bedside psychomotor tests or scoring systems to
guide discharge status, but none has proven sufficiently useful for
routine clinical practice.

An example of a discharge criteria form is in Appendix 6.

Work has been done reviewing the evidence for some of the
traditional discharge criteria, in children and adults [13]. It has been
shown that both voiding and/or requiring patients to drink fluids
before leaving the unit are not always necessary, and may delay time
to discharge. It is important to identify and retain patients who are at
particular risk of developing later problems, such as those who have
experienced prolonged instrumentation or manipulation of the
bladder, but protocols could be adapted to allow low risk patients to
be discharged without fulfilling the traditional criteria.

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Regional anaesthesia
Peripheral nerve blocks can provide excellent conditions for day
surgery. Patients may be discharged home with residual sensory or
motor blockade, providing the limb is protected and assistance is
available for the patient at home. The expected duration of the
blockade must be explained and the patient must receive written
instructions as to their conduct until normal power and sensation
returns. The provision of oral analgesics to be taken as the local
anaesthesia begins to wear off and then subsequently on a regular
basis must not be forgotten.

Central neural blockade can also be used for day stay surgery.
Residual blockade after spinal or caudal anaesthesia may cause
postural hypotension or urinary retention despite return of adequate
motor and sensory function. These problems can be minimised by the
choice of local anaesthetic agent used (e.g. lidocaine) or more
commonly in the UK by the use of low dose local anaesthetic -
opioid mixtures.

Pflug et al. [14] suggested criteria to be met before attempting


ambulation:
Return of sensation in the perianal area (S4-5)
Plantar flexion of the foot at pre-operative levels of strength
Return of proprioception in the big toe
Patient not sedated or hypovolaemic

Concerns about post dural puncture headache (PDPH) have limited use
of spinals in day stay patients in the past, but the use of smaller gauge
and pencil-point needles has reduced the incidence to less than 1%.
More and more units in the UK are now adopting subarachnoid blocks
as a ‘preferred technique’. Information about PDPH and what to do if
this occurs should be included in the patient’s discharge instructions as
well as the provision of alternative analgesics.

Further information on the use of spinal anaesthesia in day surgery


and examples of patient information leaflets can be found from the
BADS handbook ‘Spinal Anaesthesia’ [15].
16
Postoperative Instructions
All patients should receive verbal and written instructions on
discharge. They should be warned of any symptoms that they might
experience during the first 24 postoperative hours. They should be
discharged home with a supply of appropriate analgesics, a list of
possible side effects and instructions in their use. Regular dosing with
analgesics for the first 48 hours may be preferable to ‘on demand’
dosing. A list of proprietary drugs that should not be taken should be
included e.g. paracetamol if the patient has been prescribed co-
codamol.

The patient should be advised not to drink alcohol, operate


machinery or cook until the following day. The Royal College of
Surgeons guidelines in 1992 recommended that no one should drive
for 48 hours based on work with driving simulators. Recent research
suggests that, from an anaesthetic point of view, avoiding driving for
24 hours is sufficient [16].

Guidance should be given as to when sutures should be removed,


together with any specific instructions relating to the surgical
procedure. A specimen leaflet is shown in Appendix 2.

In the event of a problem, the patient must know where help or


advice can be found. A list of contact telephone numbers should be
supplied. Wherever possible these instructions should be given in the
presence of the responsible person who is to escort and care for the
patient.

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Discharge Summary
It is essential to inform the patient’s GP of the nature of the
anaesthetic and surgical procedure performed and of the patient’s
discharge. This may be by letter, facsimile or by email. However,
whichever method is chosen it must be by a secure method of
transmission and approved by the local Caldicott Guardian.

DSUs must agree with their local Primary Care Teams how back-up is
to be provided for patients in the event of problems. Most units
currently run a help-line for the first 24 hours post discharge and
telephone the patient the next day to ensure their well-being.
Telephone follow-up is highly rated by patients and can be a useful
method of auditing any immediate problems. It is important that
discussion does take place with the Primary Care Team as changes in
the provision of ‘out of hours’ Primary Care may lead to the need to
extend hospital-based support.

18
Audit
Effective audit is an essential component of good day stay
anaesthesia. The majority of patients can be discharged home after
day stay surgery but careful recording of admission rates is helpful.
Re-admission to hospital after day stay care is often cited as an
important index of a standard of care but is rarely an accurate
measure as patients may be admitted to other hospitals and thus ‘lost’
to audit.

Discharge of the patient from the DSU to the home is not the only
adequate measure of success for day surgery. Unless it can be
demonstrated that a patient is comfortable at home, with minimum
morbidity, no conclusions can be made.

There have been a variety of tools developed to determine these


results. Special questionnaires can be completed by patients and
returned to the day unit. These are notoriously inaccurate and
response rates can be very low (often below 40%). The majority of
such questionnaires are self-fulfilling or so complex that patients are
unable to complete them effectively. Conclusions drawn from such
audits are often wildly optimistic in nature. Pain, nausea, tiredness
etc. are difficult to quantify and mean different things to different
people. Phrases like severe or unacceptable pain cannot be
compared with any ‘standard measure’ and should be avoided.
Telephone questionnaires have the same drawbacks, and in addition
are time consuming and often fail to reach all patients.

Many units have a ‘telephone hot line’, usually a mobile phone,


which patients may ring to obtain further advice ‘after hours’. The
details of these calls can provide useful information.

Even when data are collected it is usually difficult to correlate them


with the detailed anaesthetic record and the personnel involved with
the care – wherever possible units should strive to link such results to
their electronic patient record.

19
Even detailed co-operation with community healthcare providers may
not allow full ‘capture’ of important data as many patients will seek
help or advice from friends or pharmacists rather than their GP or
hospital.

The answer to these dilemmas are persistence and education;


persistence in following up patients and preferably talking to them
personally and education of patients to report untoward events and
symptoms promptly and appropriately.

20
Contractual Arrangements
Day surgical care is no different to any other form of hospital activity
in terms of its contractual arrangements. Theatre and ward work is
similar wherever it is performed and should be recognised as such in
any job plan both for new and old style contracts.

Pre-operative assessment is a vital aspect of such work and should be


acknowledged as such.

Clinical Leads or Directors in Day Surgery should have an increase in


their Patient Activities (PAs) to reflect the workload of this post.

21
Stand Alone Day Surgery Units
It is expected that there were will be an increasing number of stand
alone day surgery units in the UK. Many of these will be Treatment
Centres run by the NHS (TCs) or Independent Sector (ISTCs).

The model of care from an anaesthetic point of view must remain the
same with levels of care, equipment, skilled assistance and recovery
facilities meeting national standards. It is important however, that the
operational policy includes agreement about management of certain
key issues, these include:

Management of patients who cannot be discharged home

Management of patients with problems post discharge

Medical cover for the unit until all patients are discharged

Availability of medical records

Management of medical emergencies e.g. cardiac arrest and major


haemorrhage

Transfer agreements with local Trusts and Intensive Care Facilities

Teaching, training and supervision issues

Research opportunities and support

This list is not meant to be exhaustive but gives guidance to some of


the important areas that require consideration.

22
References
1. The NHS Plan. 2000. Department of Health.

2. Alderson P. European charter of children’s rights. Bulletin of


Medical Ethics, 1993; 93; 13-15.

3. Canet et al. Cognitive dysfunction after minor surgery in the


elderly. Acta Anaesthesiologica Scandinavica.
2003.47(10):1204-1210.

4. Preoperative tests – The use of routine preoperative tests for


elective surgery. National Institute of Clinical Excellence.
2003.

5. Improving literacy and numeracy: A fresh start. The report of


the working group chaired by Sir Claus Moser. 1999.

6. Communicating with non-English Speakers. A survey of


research prepared by COI Communications for the Home
Office in July 2001.

7. Day Surgery: Operational Guide. Department of Health.


2002.

8. Association of Anaesthetists of Great Britain and Ireland 2000.


Recommendations for standards of monitoring during
anaesthesia and recovery. London.

9. Association of Anaesthetists of Great Britain and Ireland 1998.


The Anaesthesia Team. London.

10. Association of Anaesthetists of Great Britain and Ireland 2002.


Immediate Postanaesthetic Recovery. London.

11. Aldrete JA, Kroulik D. A postanesthetic recovery score.


Anesthesia & Analgesia. 1970;49:924-934.

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12. Lubarsky DA. Fast Track in the Post-anesthesia Care Unit:
unlimited possibilities? Journal of Clinical Anesthesia.
1996;8:70S-72S.

13. Chung F. Are discharge criteria changing? Journal of Clinical


Anesthesia. 1993;5:64S-68S.

14. Pflug A E, Aasheim G M, Foster C. Sequence of return of


neurological function and criteria for safe ambulation
following subarachnoid black. Canadian Anaesthetist’s
Society Journal 1978; 25: 133-139.

15. Spinal Anaesthesia. British Association of Day Surgery


Handbook Series. 2004.

16. Sinclair DR, Chung F, Smiley A. General anaesthesia does not


impair simulator driving skills in volunteers in the immediate
recovery period - a pilot study. Canadian Journal of
Anesthesia 2003; 50: 238-245.

Further Reading
Association of Anaesthetists of Great Britain and Ireland 2001.
Pre-operative Assessment – The role of the Anaesthetist.

Audit Commission 1990. A shorter cut to better services. Day


Surgery in England and Wales. HMSO, London.

Audit Commission 1991. Measuring quality: the patient’s view of


Day Surgery. HMSO, London.

Audit Commission 1992. All in a day’s work: an audit of Day


Surgery in England and Wales. HMSO, London.

Cahill CJ. Basket cases and trolleys – day surgery proposals for the
millennium. The Journal of One-Day Surgery 1999;9(1): 11-12.

24
Caring for children in the Health Services 1991. Just for the Day.
National Association for the Welfare of Children in Hospital, London.

Day Surgery, Acute Hospital Portfolio, review of national findings.


Audit Commission 2001.

Day Surgery Follow-up – Progress against indicators from A Short Cut


to Better Services. Audit Commission 2001.

Fundamentals of Anaesthesia & Acute Medicine Series. Day Care


Anaesthesia.
Editor Ian Smith. BMJ Publishing. 2000.

Getting the right start: National Service Framework for Children.


Standard for Hospital Services. Department of Health. 2003.

HBN 26 Facilities for surgical procedures. Volume 1. 2004. The


Stationary Office.

Scottish Health Planning Note 52 – accommodation for day care. 2001.


National Health Service Management Executive, Value for Money
Unit 1991. Day Surgery: Making it happen, HMSO, London.

Wilkinson D J. Modern Day Surgery in Anaesthesia Review 10.


1993. Editor Leon Kaufman. Churchill Livingstone, London.

National Good Practice Guidance on Pre-Operative Assessment for


Day Surgery. Operating Theatre & Pre-operative Assessment
Programme. Modernisation Agency.

Practical Anaesthesia & Analgesia for Day Surgery. JM Millar, GE


Rudkin & M Hitchcock. 1997. BIOS. Oxford.

Ready for Discharge. British Association of Day Surgery Handbook


Series. 2002.

A Guide to Good Practice – Day Surgery in Wales, Innovations in


Care Team, Cardiff 2004.

25
FAQ
Should all my patients be able to eat and drink prior to discharge?
Although most patients should be able to eat and drink before
discharge, not all will want to. It has been shown that too aggressive
introduction of oral intake may provoke nausea and vomiting.
Provided patients are warned of the possibility of dehydration and
given advice on what to do if they cannot keep anything down, it is
not necessary that they eat and drink before discharge.

Is there an upper BMI limit for day surgery?


The incidence of complications during the operation or in the early
recovery phase increases with increasing BMI. However, these
problems would still occur with inpatient care and have usually
resolved or been successfully treated by the time a day case patient
would be discharged. In addition, obese patients benefit form the
short-duration anaesthetic techniques and early mobilisation
associated with day surgery. Consideration should also be given to
the overall fitness of the patient and the impact of the procedure
being undertaken. It is also important to have the appropriate
equipment, personnel and time available especially when
considering moving, positioning and the first stage recovery of these
patients.

There are probably no absolute limits, but late complications are


more likely when the BMI exceeds 40 Kg/m2. Those taking an
interest in this area can still look after these patients successfully.

What advice should I give about driving?


The residual effects of general anaesthesia could make driving unsafe
and patients having a general anaesthetic should be advised not to
drive for about 24 hours. Similar advice is often given to patients
receiving sedation. More importantly, patients should not drive until
the pain or immobility from their operation allows them to safely
control their car and perform an emergency stop. This may take
several weeks, for example, following an open inguinal hernia repair.

26
How do I introduce new procedures into the day unit?
This depends on many factors – the procedure, the surgeon,
anaesthetic colleagues, nursing staff and even local geography to
name but a few. A simple guide is to evaluate each procedure on an
in-patient or as a 23-hour stay in the first instance. Limit the number
of anaesthetists and surgeons involved at this stage to ensure that you
can optimise (and evaluate) your anaesthetic and analgesic regimens.
This will allow you and your surgical colleague to make step changes
to your management of the patients until you are confident that they
can be discharged safely and with adequate analgesia. Once you
have moved the procedure to the day surgery setting successfully you
can look to expand the number of surgeons and anaesthetists
involved as appropriate. Ensure that all the lessons learned during the
evaluation phase are clearly passed on to colleagues. For more
demanding procedures this will mean setting up guidelines for the
surgeons and anaesthetists.

What is the lower age limit for day surgery?


There are a wide range of lower ages quoted by different units, and
there is no single age at which it becomes safe to send young infants
home following day surgery. Day surgery units should not perform
surgery on children unless they have suitable staff and facilities. Some
units will allow full term infants with ages over one month to
undergo day surgery. A higher age limit is usually set for ex-
premature infants. It is vital that infants for day surgery at these low
ages are carefully selected. The significant risk posed by postoperative
apnoeas must be considered. Infants with recent apnoeas, cardiac or
respiratory disease, low weight or who will receive opiates may
require overnight admission and close monitoring.

Practitioners with further concerns or questions relating to specific


anaesthetic details should look at the Association, BADS or SAMBA
websites at
www.aagbi.org.uk
www.bads.co.uk (look at the discussion forum)
www.sambahq.org

27
Appendix 1
An example of a preoperative screening assessment for patients who
are being considered for day case surgery as used by the University
Hospital of North Staffordshire.

Will you:- PLEASE TICK THE CORRECT BOX


be able to be driven home by private car?.. YES NO DATE COMPLETED
have someone to take you home?.. YES NO / /
have a telephone at home?.. YES NO
have easy access to a lavatory?.. YES NO
have someone at home to look after
you for 24 hours?.. YES NO

Have you ever suffered from any of the following?:-


heart attack... YES NO —• If so, when?
angina (chest pain on exercise,
at rest or at night)... YES NO
breathlessness (shortness of breath)... YES NO —• If yes, answer the
following:
asthma... YES NO a. do you feel breathless:
bronchitis... YES NO at rest YES NO
high blood pressure... YES NO on lying flat YES NO
heart murmur... YES NO on exertion YES NO
rheumatic fever... YES NO on climbing stairs YES NO
convulsions or fits... YES NO
kidney or urinary trouble... YES NO b. how far can you walk before
breathlessness stops you
yards
anaemia or other blood problem... YES NO
excessive bleeding or bruising... YES NO
hepatitis... YES NO
severe indigestion or heartburn... YES NO
diabetes... YES NO —• If yes, is it:
arthritis... YES NO diet controlled
muscle disease (e.g., muscular dystrophy) tablet controlled
or weakness... YES NO insulin controlled
deep vein thrombosis or blood clot in lungs (PE)... YES NO
swollen ankles... YES NO
Do you have a pacemaker?... YES NO
Do you have sickle cell disease or trait?... YES NO

28
What is your Height? ........................... Blood pressure .............................................
........................... (To be completed by nurse)
What is your Weight? ........................... Heart rate.......................................................
........................... (To be completed by nurse)
Have you ever had a serious illness (if yes please name
......................................................................................
ALLERGY or reaction to medicines, elastoplast, latex,
........................................................
If a woman, are you pregnant or taking the “pill” or HRT?......................................................

(PLEASE NOTE THAT YOU MAY NEED TO BE OFF THE PILL FOR AT LEAST FOUR WEEKS
BEFORE SOME OPERATIONS)

Do you have any of the following (please circle)......


Dentures Crowned teeth Contact lenses
Hearing aid Pacemaker
Do you:
take any regular medicines YES NO ...If yes please list
(tablets, patches, injections, inhalers)?... 1.......................................
2.......................................
3.......................................
smoke (cigarettes/pipe)?.. YES NO 4.......................................
5.......................................
drink more than 11⁄2 pints of beer YES NO
or 3 shorts a day?...
use any drugs recreationally?... YES NO ...If yes please list
.......................................

TYPE OF ANAESTHETIC USED


What operations have you had before if any? (please list)
1.................................................. GA / SPINAL / LOCAL
2.................................................. GA / SPINAL / LOCAL
3.................................................. GA / SPINAL / LOCAL
4.................................................. GA / SPINAL / LOCAL
5.................................................. GA / SPINAL / LOCAL

Did you have any anaesthetic or surgical complications? (please list)


1..........................................................................
2..........................................................................
3..........................................................................

29
Is there anything else the surgeon/anaesthetist should know?
...................................................................................................................................................

Have you any questions about the procedure?


...................................................................................................................................................

Has any member of your family had problems with anaesthetics?


...................................................................................................................................................

If so, what, when, who?


...................................................................................................................................................

Should you have any difficulty in answering any of the above questions please consult your
family Doctor.
Thank you for completing this questionnaire.

TO BE COMPLETED BY SURGEON
REMARKS: PRIORITY: ROUTINE / SOON / URGENT
PROPOSED OPERATION: DAY CASE / INPATIENT
CHECK LIST: CONSENT LA / GA
PREMED TTOS
INVESTIGATIONS COMPLETED
FBC U/E CXR PFT ECG OTHERS

DATE FOR OPERATION: ...../...../....... WARD...................

30
Appendix 2
Example patient information sheet

Policy from Day Surgery Unit, Yorkhill Hospital, Glasgow

31
Appendix 3
Management of the patient with postoperative nausea/vomiting.

Group 1 Patients with mild/moderate nausea


Patients will be given a single dose of antiemetic.
Cyclizine 50 mg slowly iv – If have already had cyclizine then
Dexamethasone 8 mg slowly iv

Group 2 patients with severe nausea or are vomiting


Give patient 1 litre of Hartmann’s over 1 hour (unless
contraindicated)
Administer cyclizine 50mg slowly iv (exclude this if has already
received a dose in recovery)
Administer dexamethasone 8mg slowly iv

Review patient at 1 hour, if still experiencing nausea and vomiting


then administer Granisetron 1mg IV

Following this, patient should be reassured that all measures have


been taken and asked whether they wish to go home or remain in
hospital overnight. It should be explained that this is a self limiting
side effect and that no further active treatment will be possible.

Policy from Day Surgery and Treatment Unit, York Hospitals NHS
Trust

32
Appendix 4
Oral Analgesia Prescription for Adult Patients
Day Surgery and Treatment Unit

Patient label Consultant

Please prescribe oral analgesia for patients on this form. 4 choices are
provided for analgesia depending on expected severity of discomfort
following the operation. Non standard analgesia regimes may still be
prescribed on the patients discharge letter on the few occasions this should
be necessary. Each patient will receive 1 standard day unit pack of the
drugs prescribed.

Minor
Drug Dosage Signature
Co-codamol 8/500 2 tablets 4 - 6 hourly

Intermediate
Drug Dosage Signature
Diclofenac (Voltarol) 50mgs 8 hourly

Codydramol 1 - 2 tablets 4 - 6 hourly

Major
Drug Dosage Signature
Diclofenac (Voltarol) 50 mgs 8 hourly

Co-codamol 30/500 1 - 2 capsules 4 - 6 hourly

Prescription where there is contraindication to non steroidal

Intermediate or Major
Drug Dosage Signature
Co-codamol 30/500 1 - 2 capsules 4 - 6 hourly

Dispensed by................................... Checked by...................................

Policy from Day Surgery and Treatment Unit, York Hospitals NHS Trust
33
Appendix 5
Modified Aldrete Score
Activity – can move voluntarily on command
4 extremities 2
2 extremities 1
0 extremities 0

Respiration
Able to deep breathe and cough freely 2
Dyspnoea, shallow, or limited breathing 1
Apnoea 0

Circulation – BP compared with preanaesthetic level


+/- <20mm Hg 2
+/- 20-50 mm Hg 1
+/- > 50 mm Hg 0

Consciousness
Fully awake 2
Rousable to speech 1
Not responding 0

O2 saturation
Maintains O2 saturation >92% on room air 2
Needs O2 supplement to maintain SpO2 > 90% 1
O2 saturation <90% even with O2 supplement 0

Patients with an Aldrete score of 9 or 10 may to be discharged from


first stage recovery area.

34
Appendix 6.
An example of discharge criteria following day case surgery as used by
Kings Lynn and Wisbech Hospitals.

DISCHARGE ASSESSMENT CRITERIA DISCHARGE ARRANGEMENTS


YES NO YES NO
Alert and orientated TTO drugs given and
instructions
Observations are within Out patient appointment
patients normal limits given
Taking and tolerating Dressing to be removed at
fluids/foods home in…………….days
Able to stand and walk Dressing to be removed by
unaided practice nurse in…… .days
Is pain/nausea controlled Sutures to be removed by
practice nurse in……days
Appointment made?
Wound checked District Nurse referral
Venflon removed Sick certificate given
ECG stickers removed Instructions given and
agreed
Passed urine, clear / Responsible adult escort
(if applicable)

Comments: Transport
Help line number given
out of hours & unit number
Seen by physio
Block/spinal leaflets given

Discharge Nurse……………………… Time of discharge……………………


Discharge address ( if different from home address)
...................................................................................................................................
...................................................................................................................................
Telephone number ......................................................................................................

Patient happy with care they received and happy to be discharged


...................................................................................................................................

35
Notes

36
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Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org

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