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Perspectives on British Day Surgery

Perspectives on British Day Surgery. Ian Smith , MD, FRCA Editor, Journal of One-day Surgery , Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent. National Health Service. Physician-only Anaesthesia. Role of Nurses. Preassessment

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Perspectives on British Day Surgery

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  1. Perspectives on British Day Surgery Ian Smith, MD, FRCA Editor, Journal of One-day Surgery, Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent

  2. National Health Service

  3. Physician-only Anaesthesia

  4. Role of Nurses • Preassessment • similar to core skills • consistent • protocol based • medical input, as needed • Theatre • Recovery • Ward management

  5. U.K. Working Practice • Surgeons have fixed operating lists • Regular pattern • Regular anaesthetist • Always together

  6. Fixed Lists—Benefits • Teamwork • Friendship • Strengths & weaknesses • Communication • Consultant delivered • Efficiency

  7. Causes of Delays Cause Incidence No consultant surgeon Patient not in hospital Transport problem Case cancelled No trainee surgeon No consent 9.4% 6.8% 6.8% 6.8% 5.4% 5.4% Overdyk, et al. — Anesth Analg 86: 896, 1998

  8. Fixed Lists—Disadvantages • Patient delays • social arrangements • psychological preparation • no clinical detriment • Workload • alternate weeks • pooled lists

  9. Anaesthetic Practice

  10. Choice of Anaesthetic • Wide variation • All drugs available • desflurane less popular • TIVA common • TCI • volatiles popular too • Regional anaesthesia unusual • ? increasing

  11. Managing the Airway

  12. The LMA • Commonly used • most cases including laparoscopy • sv • Less common • prone • tonsils & thyroid • lap chole • ProSeal

  13. Day Case Analgesia • NSAIDs • suppository • oral, pre-op • diclofenac, ibuprofen • Paracetamol • iv  popularity • Codeine preps

  14. Opioids • Sufentanil not available • Alfentanil / remifentanil for TIVA • Fentanyl very popular • good for rescue • try to avoid otherwise • Morphine still used!

  15. Local Anaesthesia • Infiltration widely used • Blocks still popular • complications • e.g., femoral nerve • Surgery under LA still uncommon

  16. Day Surgery Activity

  17. Variation Inguinal Hernia Repair % asDaySurgery 46% All Acute Hospitals Data from Audit Commission, 2002

  18. Variation Laparoscopy (gynaecology) 73% % asDaySurgery All Acute Hospitals Data from Audit Commission, 2002

  19. Variation Tonsillectomy % asDaySurgery All Acute Hospitals Data from Audit Commission, 2002

  20. Variation Laparoscopic Cholecystectomy % asDaySurgery All Acute Hospitals Data from Audit Commission, 2002

  21. Variation • Between hospitals • Between procedures • Between surgeons • Good and bad examples in most hospitals

  22. Promoting Day Surgery • British Associationof Day Surgery • Multi-disciplinary • Useful web site • www.bads.co.uk • Annual meeting • Quarterly journal

  23. Politics • 75% as day surgery • The NHS plan, 2000 • 6 months target • 18 week target • Payment by results • national tariff • Patient choice

  24. NHS Modernisation Agency(2000–2005) • Day surgery programme • clinical champions for each region • Selection criteria • Good Practice Guides • 10 High-impact Changes

  25. Modern Selection Criteria Nationalindiindi • Pragmatic • Evidence-based • Functional limitation • Suitable unless contraindications National Good Practice Guidance on Pre-operative Assessment for Day Surgery Operating Theatre & Pre-operative Assessment Programme 2002

  26. Obesity May be a Problem • Airway • Breathing • Cardiovascular • Veins • Handling • Access • Bleeding • etc, etc...

  27. Day Surgery & Obesity • Most problems peri- & early postoperative • not prevented by admission • Rapid recovery & mobilisation beneficial • Late problems start at BMI >40 • BMI 35–40 • acceptable for most procedures

  28. Other Selection Criteria • Age No upper limit • ASA 1–3 (unless other contraindications) • Diabetes If well-controlled • CVS Not if MI <6 mo, angina on minimal effort • Resp Not if SOB on minimal effort

  29. Functional Limitation

  30. Day Surgery 2006 • Laparoscopic cholecystectomy • Subacromial shoulder decompression • Lumbar microdiscectomy • “Emergency” surgery: abscess, ERPC, # clavicle • Thyroidectomy & parathyroidectomy • TURP • Laparoscopic Nissen fundoplication • Laparoscopic nephrectomy

  31. Expanding Day Surgery • Clinical benefits • Local enthusiasm • Political drive • Financial pressures • Target culture • Additional capacity

  32. Treatment Centres

  33. Treatment Centres

  34. British Contributions • Teamwork • optimum use of staff • Simplicity • anaesthesia • airway management • pain & PONV • Pragmatism

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