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.

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.

Fig. 10.1 The ambulatory patient pathway.

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:

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.