Day surgery
Tackling the barriers to day surgery
Day surgery should be a priority as it is cost efficient for hospitals, reduces admissions, and leaves a greater number of inpatient beds free for more major surgery patients. Consultant Anaesthetists, Dr. Rachel Tibble and Dr. Lindsay Hudman, discuss the barriers to day surgery and outline some of the key strategies to overcome them.
Day surgery is defined as surgery where admission, operation and discharge occur the same calendar day and is not, in the UK, referring to 23-hour discharge seen in other countries, although these are frequently discussed together. Historically, day surgery has been viewed as only being suitable for relatively minor procedures in otherwise fit and healthy patients, but that viewpoint is changing with excellent examples of successful day surgery pathways for more complex procedures becoming widespread. The British Association of Day Surgery
(BADS) has published a directory of procedures for which successful pathways have been demonstrated and suggests national targets for the percentage of all such procedures that hospitals should seek to achieve as day surgery. New procedures are added to the list as flag-ship units achieve success. Awareness is also growing that patients with more complex medical comorbidities can be supported through day surgery with appropriate planning.
In particular, the use of regional anaesthesia and awake surgery is key to facilitating day surgery for some patients. The common theme within most successful units is the existence of structured and multi- disciplinary day surgery pathways and teams or ‘day surgery champions’ that impact the entire patient journey from listing through to after discharge.
Outpatient clinic At the point of surgical decision in the outpatient clinic, the surgeon can influence the success of day surgery pathways immensely. If the surgeon decides all patients for those operations listed in the BADS Directory of Procedures will be day surgery until proven otherwise, then the patient will be informed from the start and have appropriate expectations of what day surgery involves. Their confidence in the pathway will be embedded and start to grow. This is much more likely to lead to successful day-of-surgery discharge and planning for post-operative home
support by the patient. If the surgeon does not act as an advocate for day surgery and the patient is told by a member of the team that they will, or are likely, to stay overnight, then efforts later in the pathway by the members of the MDT encouraging same day discharge, if appropriate, can be more difficult. The patient may never discover the advantages and benefits day surgery could have for them. Increasing discussion and collaborative working between the surgical, anaesthetic and pre-operative assessment teams regarding optimisation of comorbidities and perioperative pathways may enhance awareness of what may be considered possible, as the access to day surgery widens. The surgeon being aware that even patients
that are older, frail, or with many co-morbidities or a high BMI should no longer be automatically excluded can have a really positive effect on listing for day surgery. Referral to an anaesthetic review clinic, which is recommended, for optimisation and discussion of appropriate anaesthesia for day surgery is very helpful in creating a smooth journey for the patient. Recently, in some areas, pre-operative assessment review clinics involving Geriatricians (POPS clinics) are being set up for frail, older patients to optimise co-morbidities and undertake a medicines review thereby ensuring they are in the best condition for surgery. This makes it more likely day surgery can be offered and recovery will be faster. Support and awareness of these clinics will help facilitate day surgery.
Pre-op assessment In pre-operative assessment clinics, the attitudes and knowledge of pre-operative staff can facilitate or hinder the success of the day surgery pathway. If the pre-operative staff are knowledgeable about the day surgery pathway, and the nuances of pre-op assessment that are
July 2024 I
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