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Insights on British Day Surgery: Enhancing Efficiency and Patient Care

Explore the British day surgery landscape, from preassessment to anaesthetic practices, and learn about the benefits and challenges of fixed operating lists. Discover the factors influencing anaesthetic practice choices and the importance of managing the airway and providing optimal analgesia. Gain an understanding of the variation in day surgery activity and the strategies for promoting and expanding day surgery in the UK.

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Insights on British Day Surgery: Enhancing Efficiency and Patient Care

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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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