The Future of Day Surgery: The Ambulatory Pathway

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The Future of Day SurgeryThe Ambulatory Pathway

• Ian Smith, MD, FRCA
• Senior Lecturer in Anaesthesia
• University Hospital of North Staffordshire
• President, British Association of Day Surgery

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Benefits of Day Surgery

• Quality care
• early better recovery
• minimal disruption
• comfort of own home
• PATIENT PATHWAY
• Better care,
• Safer care

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Surgical Length of Stay Cascade
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Typical Surgical Pathway
Referral from GP Outpatient review Diagnostics Fur
ther review Decision to operate
Inpatient Waiting list Preop assessment Surgery
(if suitable)
Day case Waiting list Preop assessment Surgery
(if suitable)
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Key Pathway Areas

1. Referral outpatients
2. Preassessment selection criteria
3. Booking
4. Patient admission
5. Operating lists recovery
6. Discharge, documentation support

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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

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Surgical Outpatients

• Surgery possible / worthwhile?
• Discuss risks benefits
• inform consent
• Day surgery possible?
• in this case
• surgical factors

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Preoperative Assessment

• Nurse performed
• clinician supervised

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Preoperative Assessment

• Nurse performed
• clinician supervised
• Various models
• centralised
• DSU
• telephone

Lewis, et al. J One-day Surg 19 32, 2009
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Preoperative Assessment

• Nurse performed
• clinician supervised
• Various models
• centralised, DSU, telephone
• Information
• procedure day of surgery
• fasting medication
• recovery pain management

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Default to Day Surgery
Suitability for day surgery
Pathway
2030
Day surgery Home if ok
Clearly suitable
4065
Inpatient care ? Home if ok
Unsure
520
Inpatient care Hospital stay
Clearly unsuitable
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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

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Operating Lists

• Dedicated day surgery lists
• Mix of day and short stay surgery
• efficient
• flexible
• Mix of day and inpatient surgery
• tension
• conflicting needs

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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

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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

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Recovery Facilities

• Fully equipped to usual standard
• trained staff
• Potential for rapid turnover
• staffing levels
• Second stage recovery
• nurse led discharge

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Patient Discharge

• Nurse led
• Supported by
• documentation
• information

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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

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Patient referral
Surgical outpatients
Preoperative assessment
The Streamlined Pathway
Selectioncriteria
Booking
Admission
Operating lists
Recovery facilities
Patient discharge
Documentation
Post-dischargesupport
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Future of Day Surgery

• Aging population
• Obesity time bomb
• Increasing surgical complexity
• Therefore many challenges

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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
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Incentivising Best Practice
Orthopaedic subacromial decompressionbunionsDupuytrens
Breast mastectomysentinel node
ENT tonsillectomyseptoplasty
Gynae female incontinence
Urology TUR laser prostate
General lap cholehernia repair
Best Practice Tariffs
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The Near Future?

• True day surgery
• 85
• Overnight stay
• 5
• Longer stay
• 10

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