Day surgery

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10 Day surgery

D. McWhinnie

Chapter contents

Introduction

Facilities for day surgery

The patient pathway

Day surgery procedures

23-hour surgery

Introduction

Ambulatory surgery is the generic term for surgical procedures performed on a day-case basis or with a short hospital stay. Terminology is often confusing as in North America, ‘day surgery’ often refers to a 23-hour overnight stay, while in the UK and Europe, day surgery refers to the admission and discharge of the patient on the same day as surgery.

Day surgery is a process, not a procedure and its benefits relate to a well-defined and streamlined pathway. A hospital admission of only a few hours minimizes the risk of hospital acquired infection and early mobilization reduces the risk of venous thromboembolism (VTE). Patients like day surgery and prefer to recover from their procedure in the comfort of their own home. The economic benefit of shortening the postoperative length of stay in surgery relates to the closure of inpatient beds. A move from inpatient surgery to day surgery was incorporated in the United Kingdom government’s health policy in 2000 and has resulted in the closure of many inpatient beds throughout the country.

Summary Box 10.1 Clinical effectiveness of day surgery

• The surgical outcomes of a procedure performed on a day case basis or as an inpatient should, in theory, be identical, as it is the patient pathway and not the surgery that is different

• In practice, surgical outcomes from patients undergoing day surgery rather than inpatient surgery are often better as day surgery patients are a preselected cohort of healthier patients with fewer comorbidities.

Facilities for day surgery

Day surgery facilities can be configured in a number of ways but all require a day ward, operating theatres and a recovery area. Most day units have abandoned beds in favour of trolleys and chairs and many now utilize specialized day surgery trolleys which can provide all the functions of a bed, trolley and operating table together. These trolleys accompany the day surgery patient throughout the entire patient journey, before transfer to a chair to complete second-stage recovery. Considerable time savings can be made in the theatre pathway by avoiding trolley transfers.

Free-standing units

Free-standing day units can be built within the community they serve. Patient travelling distances and times are minimized but a lack of overnight facilities constrains both patient eligibility and case mix. Only the fittest patients are accepted and surgery is of a minor or intermediate nature. Nevertheless, these units offer the most efficient use of resources, maximizing throughput of selected procedures and minimizing the cost per patient.

Any patient unable to be safely discharged when the free-standing unit closes in the evening requires ambulance transfer to the main hospital, often some distance away. Free-standing units are popular in the USA and in the last 5 years many have been built in the United Kingdom as ‘Treatment Centres’ or ‘Ambulatory Care and Diagnostic Centres’ (ACADs).

Hospital integrated units

Most hospitals now have dedicated day ward facilities. Performing day surgery through the in-patient ward offers inappropriate care to both the day patient and the in-patient. In-patients require more intensive nursing and medical care and the day patient is often neglected. The result is often an unplanned overnight admission or discharge without comprehensive discharge information requiring an unnecessary GP visit or hospital readmission. Day surgery theatres can either be separate or part of the existing theatre complex. Separate theatres can require duplication of specialized equipment but list cancellation is less likely from emergency or urgent elective cases.

Summary Box 10.2 Cost effectiveness of day surgery

• Same-day admission and discharge avoids the costs of an overnight inpatient bed

• Criteria based pre-assessment reduce unnecessary investigations

• Dedicated day or ambulatory theatre lists maximize surgical throughput

• Protocol-based discharge with comprehensive patient information reduces unplanned hospital readmissions.

The patient pathway

First patient contact

An efficient and effective ambulatory pathway (Fig. 10.1) requires the patient to arrive at the day unit on the day of surgery fully prepared for their procedure both physically and mentally. Preparation for possible day surgery starts at first patient contact with their General Practitioner. Patients will often raise the topic of day surgery themselves as their preferred management option at their initial consultation. A brief ‘health screen’ with the GP referral letter detailing the patient’s blood pressure, body mass index, medication and past medical history allows the surgeon at out-patients to consider appropriate pre-assessment required for the patient. If no diagnostic or other investigations are required, the patient can be listed for their surgical procedure and referred immediately for pre-assessment, avoiding a follow-up out-patient clinic appointment.

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Fig. 10.1 The ambulatory patient pathway.

Exclusion criteria for ambulatory surgery

Day surgery remains an efficient and safe surgical process as long as only specified patients are accepted for operation. The basic criteria for acceptance for day surgery were evaluated in the 1990s and although the detail has changed, the principles remain the same i.e. body mass index (BMI) and the American Society of Anaesthesiologists’ Physical Status Classification System (ASA status). Each hospital has its own set of admission criteria dependent on the day unit facilities available and the surgical case mix to be undertaken. Stand-alone units require more strictly defined criteria than hospital integrated units to minimize unplanned overnight admissions requiring transfer to another hospital.

BMI

Body mass index is calculated by the equation: BMI = Weight (kg)/Height (m2). Obesity is defined as a BMI of greater than 30 kg/m2. The prevalence of obesity is rising and it has been estimated that 35% of the adult population, 14% of children aged 6 to 11 years and 12% of children aged 12 to 17 years are now officially categorized as obese. The practical risks of obesity in ambulatory surgery include the serious morbidities of diabetes and obstructive sleep apnoea. There is, however little evidence to support the view that obese patients suffer clinically relevant increased morbidity after day surgery leading to a higher overnight admission rate and the Department of Health suggests that most patients with a BMI of less than 40 are suitable for day surgery. However, clinical judgment must be exercised on a case-by-case basis in the context of the surgery required.

ASA status

This is used to assess the physical state of the patient prior to surgery and has been adopted worldwide (Table 10.1). Most day units accept ASA I and II patients. More advanced units and those that can deal safely with unplanned overnight admissions may accept some patients with ASA III status such as insulin-dependent diabetics.

Table 10.1 American Society of Anaesthesiologists classification of physical status

ASA I Normal healthy patients. Little or no risk for surgery.
ASA II Patients with mild systemic disease. Minimal risk during treatment. Examples include well-controlled non-insulin dependent diabetes, mild hypertension, epilepsy or asthma.
ASA III Patients with severe systemic disease that limits activity but is not incapacitating. These patients need medical input before surgery. Examples include insulin-dependent diabetes or a history of myocardial infarction, congestive heart failure or cerebrovascular accident in the preceding six months.
ASA IV Patients with severe systemic disease limiting activity and is a constant threat to life. Elective surgery is contradicted and emergency surgery requires urgent medical input. Examples include unstable diabetes, hypertension and epilepsy or a recent myocardial infarction.
ASA V Patients who are moribund and not expected to survive more than 24 hours without an operation

Pre-assessment

Pre-assessment is the evaluation of a patient’s fitness for elective surgery and is best performed by a specialized pre-assessment team of nursing staff. The team should be supported by consultant anaesthetic sessions where more complex patients are evaluated and where a final decision can be made regarding patients suitability for day surgery. The role of the pre-assessment team is to safely and accurately allocate patients for day, 23-hour or in-patient surgery as well as ensuring they have adequate social support. Pre-assessment provides an opportunity to answer patient questions and allay fears, and has been shown to reduce the rates of cancellation and non-attendance for surgery.

All elective surgical patients should initially be regarded as day cases until proved otherwise. The final decision as to the appropriate management pathway should lie with the pre-assessment team except when the surgeon for clinical reasons specifies that the patient should remain in hospital overnight. The pre-assessment process consists of a consultation, appropriate investigations if required and written information regarding admission, operation and discharge. The consultation should occur as early as possible in the pathway to enable problems to be addressed and to allow time for optimization prior to the scheduled operating date. Many hospitals require some of the optimization to be performed in primary care (e.g. blood pressure control) before accepting the patient for clinic referral. Pre-assessment performed shortly before the date of surgery may result in late postponement if unexpected medical problems are discovered. Ideally no patient should be listed for surgery until they have been deemed fit and have received sufficient information for them to give informed consent.

Pre-assessment is offered to the patient in a number of options:

1. At source in the GP surgery. This model is used in surgical outreach clinics when the pre-assessment nurse accompanies the surgeon to the clinic. It is more cost effective however to train a practice nurse to perform the routine pre-assessments and refer more complex patients for hospital pre-assessment.

2. At the pre-assessment clinic. Formal pre-assessment consultations can be programmed in advance for 30–60 minute interviews depending on the complexity of the patient.

3. At the surgical outpatient clinic. Where a number of surgical clinics are running concurrently, it is cost effective to offer patients a ‘one-stop’ pre-assessment service. Patients requiring more complex pre-assessment can be deferred to a planned pre-assessment clinic at a later date.

4. By telephone, postal questionnaire or internet (e-mail or on-line). This model is suitable for fit patients undergoing straightforward procedures especially if they have already had a basic health screen performed at the GP surgery.

Regardless of the mode of pre-assessment, it is essential patients feel relaxed and unhurried. Adequate time is required for patient questions and clarification of detail. Patients often remember little of their consultation with the surgeon due to anxiety and pressure of time. The pre-assessment consultation offers the patient a reprise of their intended procedure and reinforcement of salient points. Relatives or the patient’s carer are encouraged to attend as they may remember important information forgotten by the patient. Written information regarding admission, discharge and the procedure itself is an essential component of the day surgery process.

The admission proforma should be standardized for all subspecialties and best practice suggests it should consist of a generic section addressing the basic health screen, current and past medication, past medical history, social factors and a supplementary section pertinent to the surgical subspecialty such as ophthalmology, orthopaedics, urology or gynaecology.

Basic health screen

This consists of the patient’s demography, BMI, blood pressure, medication and past medical history and allows ASA status to be evaluated.

Medication

A full list of current medications including dosages and indications for each drug should be obtained. Significant numbers of patients, particularly older patients, take anticoagulants or anti-platelet agents but not all patients undergoing surgery require complete cessation of this therapy beforehand. The decision is based on the consequences of stopping therapy versus the risks of bleeding during or after surgery. Many surgeons would consider performing superficial surgery such as inguinal hernia repair or excision of a large lipoma with an INR of < 1.8. In contrast, any surgery within the abdominal cavity at this INR would be contraindicated due to latent bleeding.

Warfarin

When considering cessation of warfarin, the original indication for the drug dictates the management plan.

• Atrial fibrillation (AF): Anticoagulation with warfarin reduces the annual embolic stroke rate from 4% to 2%. Stopping warfarin one week prior to surgery to normalize coagulation poses little risk of stroke.

• VTE: After DVT or PE patients are usually anticoagulated for 3–6 months. Ideally, surgery should be deferred until the course of anticoagulation has ceased. If this is not possible then conversion to heparin therapy preoperatively is advocated.

• Prosthetic heart valves: Mitral valves are intolerant of normal coagulation and conversion to heparin therapy is required, thereby excluding such patients from day surgery. Aortic valves are less susceptible to embolization due to high blood flows and closing pressures and warfarin can be safely stopped 3 days before surgery and restarted immediately after operation.

Anti-platelet agents

The most common indication for long-term therapy is arterial disease and short-term cessation of therapy carries little risk. Patients taking anti-platelet therapy for transient ischaemic attacks or for a xenograft heart valve should not have their therapy stopped and are unsuitable for day surgery. Following arterial stenting, patients usually continue therapy for one year and non-essential surgery should be suitably delayed. Aspirin or dipyridamole should be stopped 4 days before surgery and clopidogrel 7 days before surgery to ensure normal platelet function.

Past medical history

The most common problems encountered by the pre-assessment team are those of heart disease and diabetes.

Heart disease

Patients with high blood pressure can be referred back to the GP for therapy: more extensive heart disease may require a cardiology referral for optimization. The risk of myocardial ischaemia during anaesthesia is increased in the hypertensive patient and elevated blood pressure remains the most common reason for ‘on the day’ cancellations. However, the specific blood pressure where patient safety becomes compromised is unknown but admission systolic and diastolic pressures of less than 180 and 110 mmHg respectively do not increase perioperative complications and there is no need to routinely cancel patients with an elevated blood pressure below these parameters.

Diabetes

Patients with diabetes can be day cases but the resource implications for pre-assessment and their admission are considerable. Strict protocols are required. Type I diabetic patients are more difficult to manage in the perioperative period than Type II patients and are more liable to unplanned overnight admission. Random blood glucose estimation is of no value in assessing suitability for day surgery and should only be performed on the day of surgery to help guide perioperative management. Stability of the disease in the months before surgery is essential in dictating the success of the admission, especially in the Type I patient. The stability of the diabetic patient can be assessed by the patient’s self-monitored blood glucose profiles in the preceding few months and by estimation of their glycosylated haemoglobin (HbA1c). This measurement is a reflection of the integrated blood glucose control over the preceding 2–3 months with extra weighting for the one month preceding the sample. The normal range for HbA1c is about 4–6% in the non-diabetic patient. An HbA1c of less then 8% suggests that the patient will be suitable for day surgery. Values above 8% indicate unsuitability for day surgery as results above this level are associated with higher fasting blood glucose, making perioperative blood glucose control more difficult to manage. An HbA1c of over 9% indicates that a review of their diabetic management should be undertaken before any elective surgery is undertaken.

All the other usual criteria for day surgery should be met and there should be no history of repeated hypoglycaemic attacks nor of recent hospital admissions due to the complications of diabetes.

Most minor and intermediate surgical procedures can be safely undertaken in adult diabetic patients with the possible exception of laparoscopic cholecystectomy due to the high risk of postoperative nausea and vomiting. Wherever possible, the patient should be managed with local anaesthesia as this may remove the need for the patient to starve preoperatively.

The three key principles in managing the diabetic patient as a day case are:

• Diabetic medication should be omitted on the morning of surgery

• The procedure should be scheduled as early as possible on the operating list

• Return the patient as soon as possible postoperatively to their usual diet and medication.

Type II patients treated with oral hypoglycaemic drugs with a fasting blood glucose < 10 mmol/l can be monitored safely but patients with higher fasting glucose should be managed either with a GKI (glucose/potassium/insulin) infusion or separate glucose drip and insulin infusion.

Type I patients will all require an infusion until they are ready for a meal after surgery and are likely to require significant anaesthetic assistance. After discharge, the patient and carer should be able to monitor and measure blood sugar at home and they should be aware of the possibilities of hyperglycaemia and delayed hypoglycaemia, especially if hypoglycaemic medication was taken significantly later on the day of surgery.

Social factors

The population of the United Kingdom has never been more mobile. Large numbers of young people are in higher education and living away from home. There are more single households than ever before and with the concept of the extended family in decline it is often difficult to identify a carer for the day case patient. Nevertheless if no other exclusion criteria are apparent, the pre-assessment nurse can explore all possibilities with the patient to ensure a responsible adult is at home the night of the procedure in case of problems. Patients’ home conditions should be appropriate for a safe and comfortable recovery with a readily accessible toilet available and access to a telephone in case of emergency. The day surgery patient should live within about 90 minutes travel to the hospital but if the patient has undergone a procedure where postoperative haemorrhage is a risk, then local protocols may dictate a shorter journey time. It is difficult for patients living in remote areas to fulfil these requirements and there may have to be an acceptance that they might have to stay overnight. However, as postoperative medical facilities are not required, they can be lodged, with their carer in local hotel accommodation overnight. Indeed, the concept of the ‘hospital hotel’ may be an option for hospitals serving rural and remote communities whereby their day surgery is performed in the hospital’s day unit but they are discharged to ‘hotel’ facilities, without medical or nursing supervision, but within the hospital campus, at a lower cost than an in-patient hospital bed.

Investigations

Many preoperative assessment clinics take blood and record 12-lead electrocardiograms for their patients but this is not evidence-based. NICE (National Institute for Clinical Evidence) conducted an extensive systematic review of routine preoperative tests and concluded that the evidence for investigations did not exist. The NICE guidelines are therefore based on the consensus opinion of healthcare professionals and relate to the grade of surgery being performed (Table 10.2), the patient’s age (Table 10.3), and the severity of any underlying disease, whether cardiovascular, respiratory or renal (Table 10.4).

Table 10.2 Grade of surgery related to NICE preoperative investigations

Grade 1 Diagnostic laparoscopy or endoscopy, breast biopsy
Grade 2 Inguinal hernia, varicose veins, knee arthroscopy, tonsillectomy
Grade 3 Thyroidectomy, abdominal hysterectomy, TURP
Grade 4 Colonic resection, joint replacement, artery reconstruction

Table 10.3 Investigations depending on patient’s age and grade of surgery.

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Table 10.4 Investigations depending on patient’s disease type and severity.

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A pregnancy test should be conducted if the patient says she may be pregnant although many units now perform pregnancy tests routinely.

A sickle cell test is required for:

• patients of African or Afro-Caribbean descent

• patients with a family history of homozygous sickle cell disease or heterozygous trait

• patients from the Eastern Mediterranean, Middle East and Asia.

Hospitals should develop their own protocols for pre-assessment based on the NICE guidelines. The more variation in the process, the more likely an unintentional adverse outcome can occur.

Summary Box 10.3 Pre-assessment

• All elective surgical patients should be pre-assessed

• All patients undergoing a procedure suitable for day surgery should initially be defaulted to day surgery, and only if not clinically fit should they be allocated to an overnight stay

• The pre-assessment team should be empowered to allocate the appropriate length of stay to each individual patient

• Pre-assessment should be performed early in the patient pathway to avoid late cancellation for surgery. This can occur if the patient is found to be unfit for day surgery, with insufficient time to optimize their health.

The surgical waiting list

Before leaving the pre-assessment clinic, the patient should have an idea of when their operation is likely to be scheduled. Dates when the patient is unavailable due to holidays or work commitments should be noted. Contact telephone numbers are recorded and the patient should be asked if they would consider a short notice cancellation date for their operation. As waiting times for different surgeons for day surgery can be variable, many hospitals have adopted a policy of ‘pooling’ the more common day procedures such as hernia, laparoscopic cholecystectomy and varicose vein surgery. This ensures surgical waiting times for day surgery are equitable between surgeons.

Admission for surgery

An efficient and effective ambulatory pathway requires the patient to arrive at the day unit on the day of surgery fully prepared for their procedure both physically and mentally (Fig. 10.2). Admission administration is minimal. Patients can sign their consent form to confirm they wish to proceed with their operation at any appropriate point before their procedure. If the patient signs the form in advance, a health professional involved in their care on the day should also sign it to confirm the patient still wishes to proceed. The diagnosis and planned surgery should be confirmed as still appropriate and the operation site marked. Although consent remains valid indefinitely unless withdrawn by the patient, many hospitals time-limit consent forms to 3 months after dating on safety grounds.

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Fig. 10.2 Successful day surgery depends on careful explanation to the patient in advance of the surgical appointment.

Scheduling for theatre

Day surgery patients should have their operation as early as possible on the operating list to ensure safe and comfortable discharge before the end of the day. With dedicated day lists, patients requiring the longest recovery time either because of the length of operation or the nature of the surgery, should be prioritized. Afternoon day lists may require scheduling of local anaesthetic cases towards the end of the list to ensure all patients can be successfully discharged. Adding day cases to major surgery lists has advantages and disadvantages. Where there is more than one anaesthetist allocated to a list, it is possible to start with a minor or intermediate day case while the major case is being prepared for anaesthesia in the anaesthetic room. Delays can inevitably occur and many surgeons prefer to commence the list with a major procedure so that if complications do occur they are often manifest in the afternoon rather than late in the evening. Mixed ambulatory lists, where available, offer the optimal use of the operating theatre with the true day cases early in the day and those patients scheduled for a 23-hour stay receiving their surgery later.

Anaesthesia and analgesia

Day surgery may be performed under general, local or regional anaesthesia. General anaesthesia remains the most popular mode of anaesthesia in this country but local and regional techniques are gaining popularity with both patients and professionals alike due to the absence of postoperative cerebral upset. While there is no ‘ideal’ day case general anaesthetic, the aim is to provide rapid and safe recovery with minimal pain or postoperative nausea or vomiting. Modern anaesthetic agents such as desflurane or sevoflurane are ideally suited to day surgery as is total intravenous anaesthesia (TIVA) with Propofol. The use of the laryngeal mask rather than endotracheal intubation has changed anaesthetic practice in day surgery since its introduction in 1988, allowing a more rapid turnaround of patients.

Prior to the procedure, non-steroidal anti-inflammatory drugs should be given where there are no contraindications. It is not necessary to provide the drug intravenously or by the PR route as oral administration one hour before surgery produces better and longer-lasting pain relief. Paracetamol may also be given preoperatively to reduce the need for more potent opioids and their unwanted side effects. It is more effective when given intravenously with analgesic effects similar to those of NSAIDs.

Local anaesthesia has always been useful in day surgery for the removal of ‘lumps and bumps’ but increasingly, it provides an excellent and safe technique for the repair of inguinal herniae and other abdominal wall herniae, especially in patients with major comorbidities. Furthermore, patients can usefully be scheduled late on the day list late ensuring maximal utilization of theatres.

Recovery

The recovery of patients after day surgery starts at the end of anaesthesia and finishes with the return to normal activities. Recovery consists of three phases.

• First stage – until the patient is awake after anaesthesia

• Second stage – until the patient is discharged from hospital

• Late – until the patient has returned to normal activities.

The two most common problems encountered in first and second stage recovery are postoperative pain and nausea (PONV).

The management of pain in recovery is best managed using a pain score protocol. For moderate pain, oral analgesia can be given as soon as the patient is awake and able to swallow safely.

Suitable drugs include paracetamol, paracetamol/codeine compounds and NSAIDs if not already administered pre- or perioperatively. Severe pain is best treated with a rapid onset, short-acting opiate such as intravenous fentanyl.

The management of PONV can be divided into general measures given to all patients and specific medication given to those at higher risk (Table 10.5). General measures include the use of short-acting anaesthetics, pre-emptive non-opioid analgesia and a reduction in the fluid deficit by minimizing the preoperative fast and giving IV fluids peroperatively. Patients at risk for PONV may require the routine administration of a 5HT3 antagonist such as ondansetron or granisetron; if at very high risk, dexamethasone 4–8 mg may be given in addition.

Table 10.5 Risk factors for PONV

Key risk factors Additional surgical risk factors
Female gender Oral or ENT surgery
Non-smoker Squint surgery
Previous history of PONV Laparoscopic surgery
Suffers motion sickness  
Perioperative use of opioids  

Discharge criteria

The decision as to when a patient is fit for discharge from the day unit should be taken by trained nursing staff using agreed discharge criteria protocols (Table 10.6). A postoperative visit by the surgeon and anaesthetist is encouraged at the end of the operating list, but awaiting a member of the busy surgical team to discharge the patient usually results in delay.

Table 10.6 Discharge criteria for day surgery

• Vital signs stable and comparable to those recorded on admission

• Orientation to time, place and person

• Pain controlled and oral analgesics supplied

• Understands the use of medications issued and written information supplied

• Ability to dress and walk (if appropriate)

• Minimal nausea or vomiting

• Minimal wound bleeding

• Has a responsible adult to take them home

• Has a carer at home for the next 24 hours

The criterion of being able to take oral fluids before discharge has now been abandoned as encouragement to drink postoperatively increases the incidence of PONV. Oral intake remains necessary in selected patients such as diabetics. Voiding before discharge in patients with a low risk of urinary retention is also considered unnecessary.

When the discharge criteria are met, the patient and their carer should be offered both generic and procedure-specific written discharge information to encompass:

• medication

• wound care dressing renewal and suture removal (if required)

• bathing or showering

• return to normal activities including work, sexual activities and exercise

• signs and symptoms which may indicate a problem

• contact emergency telephone number and follow-up arrangements

• travel after day surgery.

Patients may return to driving a minimum of 48 hours after general anaesthesia due to impaired reaction times. The procedure undertaken and its surgical site will also determine resumption of driving which can only occur when the patient can safely perform an emergency stop. It is unclear after what time period patients can safely fly after surgery and it will vary with the complexity and extent of the procedure. Air travel where trapped gas or air may still remain within a body cavity as in laparoscopic or middle ear procedures requires extra caution as retained gas expands in flight due to the lower atmospheric pressure. The immobility associated with continuous travel of more than 3 hours within 4 weeks of surgery raises the risk of venous thromboembolism.

Summary Box 10.4 Principles of day surgery care

• Patient information

• Patient counselling

• Exclusion criteria

• Pre-assessment

• Optimization of health

• Day of surgery admission

• Theatre scheduling

• Minimally invasive surgery

• Pre-emptive analgesia

• Regular analgesia

• Avoid opiate analgesia if possible

• Minimize postoperative nausea and vomiting

• Fluid therapy

• Early mobilization

• Discharge criteria

• Discharge information

• Nurse-led discharge.

Day surgery procedures

The rapid expansion of minimal access techniques in surgery over the last 20 years has offered many possibilities for converting a surgical procedure from an in-patient to a day case. Anaesthesia and analgesia have markedly improved and procedures up to 2 hours long can even be performed on a day case basis provided they are scheduled early in the day. For many years the Audit Commission ‘Basket of 25’ surgical procedures provided a template for day surgery (Table 10.7). However, as most of these procedures are minor or intermediate in nature (accounting for only about 25% of all day surgery) and several others are now obsolete, the ‘Basket’ is now of limited value. There is also a realization that reducing the length of stay of the short stay surgical pathway for each patient by one day provides a similar reduction in overnight bed days as converting a patient from a 23-hour stay to a day case. The British Association of Day Surgery (BADS) directory of procedures offers information on over 200 day and short stay surgical procedures indicating the percentage of a particular procedure which could be performed as a day case, as an overnight 23-hour stay or a short stay admission up to 72 hours given ideal theatre and organizational conditions. A selection of these aspirational percentages for common day and short stay surgical procedures is shown in Table 10.8.

Table 10.7 Audit Commission ‘basket of 25 procedures’

1. Orchidopexy

2. Circumcision

3. Inguinal hernia repair

4. Excision breast lump

5. Anal fissure dilatation or excision

6. Haemorrhoidectomy

7. Laparoscopic cholecystectomy

8. Varicose vein stripping or ligation

9. Transurethral resection of bladder tumour

10. Excision of Dupuytren’s contracture

11. Carpal tunnel decompression

12. Excision of ganglion

13. Arthroscopy

14. Bunion operations

15. Removal of metal ware

16. Extraction of cataract

17. Correction of squint

18. Myringotomy

19. Tonsillectomy

20. Sub mucous resection

21. Reduction of nasal fracture

22. Operation for bat ears

23. D & C / hysteroscopy

24. Laparoscopy

25. Termination of pregnancy

Table 10.8 BADS directory of procedures – aspirational percentages for selected surgical operations.

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Many surgeons and anaesthetists are concerned about patient safety after discharge and often cite risk of postoperative haemorrhage at home as a reason for keeping the patient in hospital overnight. Primary (reactionary) haemorrhage occurs within the first 4–6 hours after surgery and although uncommon can be addressed within the working day. Secondary haemorrhage occurs 2–4 days after surgery and even if the patient had an in-patient procedure, they would still have returned home by the time this event occurred.

23-Hour surgery

In 23-hour surgery, the patient is admitted early in the morning for a morning list or late morning for an afternoon list and remains in hospital overnight. The following morning transfer to a discharge lounge for breakfast occurs before admission of the next day’s patients. Twenty-three hour surgery provides a resource for patients with significant comorbidities but requiring a day case procedure, or for patients undergoing more major surgery where the length of stay has been significantly reduced by enhanced recovery techniques such as in laparoscopic colorectal procedures. The 23-hour unit is a useful intermediate management option for evaluating procedures new to day surgery in a safe environment before scheduling them through the day unit.

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