Day surgery: Widening the selection criteria!

1. Day surgery:Widening the selection criteria! Dr. Rowan Thomas MBBS FANZCA MPH

2. Introduction • What are the selection criteria? • Should the criteria be changed?(A sociological perspective) • How can it be changed?(A policy perspective) • The importance of follow up and outcome review

3. Tertiary referral Hospital Day of surgery discharge not high – 25-30% Australian average 60%

6. Why Day surgery? • Economic or utilitarian drivers. • Lower morbidity • Faster mobilisation and recovery • Able to be with family • Free up resources for other health care areas

7. Is “Day surgery” care different? • Two components. Day of surgery arrival (DOSA) + Early discharge • DOSA requires: • Optimisation of co-morbidities and medications • Early assessment, communication and consent • Timely arrival and fasting • Early discharge requires: • Good pain management • Resolution of unwanted effects of anaesthesia • Good social supports • Adequate time to assess surgical complications

8. What stops people going home? • Pain (Not enough analgesia?) • Nausea (Too much opioid?) • Bleeding • Unstable co-morbidity • Incapable of self care

9. Surgical requirements • Minimally invasive techniques are widening the range of possible surgeries • Minimal risk of post-operative Haemorrhage • Minimal risk of post operative airway compromise • Pain controllable by outpatient techniques • Post-operative care that can be managed by a responsible adult or home nursing facilities • A rapid return to normal fluid and food intake ANZCA Policy PS15

10. Patient requirements • A willingness to have the procedure performed and an understanding and an ability to follow instructions • Patient’s place of residence within one hour’s travelling time from medical attention • ASA I or II. Stable ASA III or IV. Careful consideration for higher ASA grades. • Infants and children where associated paediatric facilities and experience exist. Should be older than 6 weeks (normal term) or greater than 52 weeks post-conceptual age if premature (< 37 gestation) ANZCA Policy PS15

11. Social requirements • A responsible person able to transport the patient home in a suitable vehicle. • A responsible person staying at least overnight with the patient. • Ensuring that the patient understand the requirements of post-anaesthetic care in regard to public safety. • The patient stay within one hour of medical attention until one day after surgery. • Ready access to a telephone ANZCA Policy PS15

12. Contraindications to Day Surgery • Unstable ASA III or IV. Eg. Brittle diabetes, unstable angina, symptomatic asthma. • Morbid obesity with haemodynamic or respiratory problems • Drugs: Monoamine oxidase inhibitors or acute substance abuse esp. Cocaine. • Ex-prem infants <52 weeks post-conceptual age. • Lack of responsible adult at home to transport and care for the patient.

13. Selection controversies? • Sleep apnoea • Morbid obesity • Elderly • Malignant Hyperthermia susceptibility • Anaesthetic technique – regional and neuraxial.

14. Is it the selection criteria that should be widened? • Or the application of the criteria?

15. The future: what can be changed that may affect selection criteria? • Greater use of regional techniques and local anaesthetic infusion catheters at home. • Better use of analgesic adjuncts. • 23 hour stay units • Available inpatient back up facilities • Mobile day surgery • Surgical techniques • Laparoscopic and Robotic surgery • Better management of co-morbidities

16. Talcott Parsons • Structural Functionalism • Society combines to create a homeostatic system. A change in one part creates or determines a corresponding change in another. • Also famous for describing the doctor-patient relationship and the ‘sick role’. The development of day surgery is the opposite to the traditional role he described.

17. Structural functionalism

19. Karl Marx • Every order or change in order will present a struggle between the proletariat (workers) and the bourgeoisie (capitalists). • Exploitation and alienation of the lower class will be hidden, but present in every economically motivated ideology.

21. Weber • Legitimate authority: Charismatic, Traditional and Legal-rational. • Local charismatically led systems grow into bureaucracies with Legal-rational lines of authority and responsibility • Widening selection criteria may be possible at a local level, however a greater economic impact is possible when systems are developed to establish large scale change, requiring bureaucratic models to develop.

22. Wider criteria = comprehensive support • The “care system” must be looked at as a whole • Greater support, good information and consistent expectation will lead to a wider range of day surgical options

23. Supports • Distance from hospital • Pain management routines • Nausea management routines • Preoperative optimisation and information • Nursing in the home • A number to call • A telephone • Capacity of family • Ability to admit for social reasons • 23 hour wards.

24. How can the application of the criteria be changed? • Policy development • Consultation • Iteration • Description • Change through agreement, commitment and ownership.

26. Stakeholders • Patients • Government and other funding bodies • Hospital administration • Surgeons • Anaesthetists • Nurses • Other Health providers

28. Measuring what we do • Risk is difficult to evaluate on a small sample • RCTs are not appropriate for low risk outcomes • Registries and databases are being created to collect and audit outcomes from medical interventions. • NSAS – National Survey of Ambulatory Surgery www.cdc.gov/nchs/nsas.htm

29. Registries of clinical care -some examples • Society of Thoracic Surgery: National Cardiac Surgery database • American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) • Centre for Disease Control and Prevention – National survey of Ambulatory surgery.

31. snap shot of aurora

35. Summary • Applying the criteria more widely is probably our actual challenge. • Selection criteria applied more widely through: • Technology – surgical, anaesthetic, pain management, outcome data collection • Community support • Secondary supports, i.e. inpatient services back-up • Thoughtful, local policy development • Measuring outcomes

36. Summary • Change can be difficult and it may not be right in every situation. • There are patient, surgical and social factors that need individual consideration. • Supports in the community vary from region to region. • We need to monitor, audit and evaluate outcomes to assess the work we do, because our goal of safety and comfort extends beyond the operating room, it needs to extend into the home as well.