An Anaesthetist’s perspective on Same Day Surgery

1. An Anaesthetist’s perspective on Same Day Surgery Dr. Rowan Thomas St. Vincent’s Health

2. Same day concepts • Sameday – not listed in English dictionary. • Day surgery – admission, surgery and discharge on the one day. (US <23hr 59min) • Ambulatory surgery – Day surgery, not 23hr • Day of surgery admission (DOSA) – can include day surgery and multiple day stay surgery. (Sometimes called Same day admission.) • 23 hour stay and ‘medi-hotel’ – developments extending the capacity of day surgical units.

3. Anaesthetic issues • Pre-operative assessment and management • Management of post-operative pain, nausea and vomiting • Neurologic, respiratory and cardiovascular recovery from anaesthesia.

4. Day anaesthesia (& surgery) • Multidisciplinary team approach • Appropriate patient selection and education – medical and social aspects • Routine surgery, without blood loss • Routine pain management • Adequate recovery and home support • Are anaesthetic techniques modified? • Greater use of local anaesthesia

5. Flexible care • Often surgery varies and patients can have significant co-morbidities • An individual approach requires judicious preoperative assessment and tailored hospital or home support. • Pre-operative assessment is the key to safe post-operative planning. Discharge on the day of surgery, depends on careful patient selection.

6. Preadmission at St. Vincent’s • 1998. 10% DOSA. One third of patients seen in preadmission. Random selection • Day surgery rates not recorded • High cancellation rate due to failure to attend • Screening tests ordered routinely • No anaesthetic involvement • PIER (Preoperative Investigation, Education and Research) centre established

7. Preadmission at St. Vincent’s • Triage questionnaire to improve selection of patients for preoperative consultation. • Resident staff run the clinics with anaesthetic consultation. Unusual design, but involves the residents. • Most patients complete a questionnaire when placed on the waiting list. (Reviewed six monthly) • Patients attend clinic about two weeks prior to surgery.

8. Triage for preadmission • Two page questionnaire. Designed to be completed by the patient and assessed according to protocol. • Dual purpose. Clinical information available in the history. Well or stable younger ASA II patients not needing investigation, having surgery without blood loss can avoid preadmission. • One third now ‘fast-tracked’.

9. Triage for preadmission • Very effective method for eliminating costly & unnecessary ‘screening’ investigations • Only 300 (5%) elective patients per year involve anaesthetic consultation • Anaesthetists not taken from theatre where their skills are probably of greater use.

10. DOSA & Day surgery • August snapshot (419 elective admissions) • 89% Overall DOSA. (Lowest - vascular 62%) • 121 (29%) Discharged on the day of surgery. Plastic surgery accounts for nearly half. • Some ‘cross-over’ between intended and actual stay. • Many units perform complex surgery not suitable for day surgery. • Lap. cholecystectomy has been tried unsuccessfully as a day surgery procedure.

11. Cancellations • Of 50 cancellations in August, 10% (5) due to inadequate preoperative investigation or information. • Compare with 20% - lack of time, 10% - no bed, 10% - emergency case, 10% - unexpectedly unwell, 20% - cancelled by patient. • Cancellation need not always be regarded as a failure. It can be a learning opportunity, but is also an important barrier for trapping errors.

12. DOSA at St. Vincent’s • Most elective patients now come through DOSA. Originally designed for 10% - 20% of elective surgery. Discharge is a separate event and is based on surgical and patient factors. • Patients are seen by anaesthetist in DOSA or in the anaesthetic induction room. • Staggered arrival in the morning – needs only one nurse. • Afternoon staff call the next day’s patients to check that they are ready.

13. Benefits of DOSA • Patients generally prefer to be at home prior to surgery. • Preadmission clinics become integral to the system. Timely investigation. Preoperative education & discussion. Involvement of resident staff in the management of elective surgical preparation • Eliminates the night-time preoperative round. • Hospital bed available for emergency or post-operative care.

14. Disadvantages • Dilutes the responsibility for preoperative care. • Despite good education, patients regularly arrive un-fasted or not having taken usual medication • Many patients have not had the benefit of a prior discussion with an anaesthetist. • Rushed preoperative morning visit by anaesthetist. Not all clinical decisions can be predicted by other clinicians. Complex cases - need time to consider anaesthetic options.

15. Disadvantages • Rushed arrival and transfer to theatre for the first patient. Heightened patient anxiety. • ‘Consent’ is a bureaucratic charade. • Interpreters not easily available at 0700. • Late starts to surgical lists or long breaks between cases. • Patients are now very aware of the waiting time prior to surgery.

16. Is day surgery safe? • VCCAMM 1997 – 1999 • 32 deaths wholly or partly related to anaesthesia. 12 involved inadequate preoperative assessment or management. • 6 Elective. 4 Semi-urgent. 2 Emergency • “Of concern were the deaths of two day-stay patients undergoing minor procedures”

17. Future challenges • Better systems for the provision of information about the surgery and anaesthetic. • Better systems for ‘two-way’ communication between the clinician in the preadmission clinic and the anaesthetist and surgeon doing the procedure. • Ideally the anaesthetist and surgeon performing the procedure could use the opportunity provided by preadmission to consult with the patient.

18. Conclusion • Safety, provided by thorough preoperative assessment and flexible pathways for post-operative care must always have a high priority. • Information management and informatics systems will contribute to better communication.