Day surgery
unique to day surgery to ensure safe discharge home, they can instruct patients in what to expect and reinforce the day surgery message in a positive manner. Their knowledge of which procedures should be daycase by default can help guide not only patients towards successful daycase surgery, but also clinicians and administrative teams. Pre-operative assessment is also a step in
the pathway where it could be easy to exclude patients that are more complex from day surgery. It can be inherently difficult to reduce a comprehensive assessment to a black or white yes/no answer for day surgery for patients with comorbidities. The skill of the pre-operative assessment team is to be able to piece together the holistic picture and identify those for whom day surgery may be possible from a surgical, medical and social perspective. It is important to have pre-operative assessment staff that can make an excellent judgement about whether patients are optimised or will manage at home post discharge. They should be aware that particular anaesthetic techniques, such as spinal anaesthetics, mean that even complex patients can still be done as day surgery procedures. They should also understand that referral of complex patients to an Anaesthetist who is experienced in day surgery for review, will help in offering day surgery wherever possible. If this individualised review is not available, perceived complexity can be a barrier for patients to get onto a day surgery pathway. It is vital to manage these complex patients well and communicate decision making processes, so that the clinical team on the day of surgery know potential problems and have agreed their suitability, and there are not cancellations on the day. In deciding whether a procedure could be carried out as a daycase, it is often useful to consider what would be done differently were the patient to remain an inpatient? What are the barriers to discharge? Are these surgical, medical or social? Can they be overcome e.g through changing surgical or anaesthetic techniques, specific follow up care pathways, or adapted policies on supervision at home post-
operatively? For example, there are some units that have successfully introduced a policy where certain cases are allowed home without the traditional carer in the home overnight, which can make day surgery more practical for those living alone than previously.
The day of surgery Ward staff admitting the patients on the day of surgery influence success in a similar way. If they are not able to rapidly gain the trust of a patient and describe the sequence of events that the patient will experience, then there will be less trust post-operatively when they are being encouraged to mobilise soon after surgery, when they may still have some pain. Thus, staff who have confidence and knowledge about the day surgery pathway can get more patients home successfully. Day surgery ward staff have an extended
role in nurse-led discharge. They must be fully trained, supported and confident to carry out this role well. It is a large responsibility, and many difficult situations may arise such as patients not wanting to go home, becoming aggressive or relatives refusing to co-operate. Their skills are very important in managing these situations to achieve successful discharge. Delivering effective day surgery anaesthetics is a skill that not everyone will be involved in regularly. Unless there is a realisation that particular techniques should be utilised to maximise the chance of early recovery and
The whole team should be part of pathway development to achieve success including management staff, clinicians, nurses, theatre staff, allied health care professionals, pharmacists and administrative teams. Day surgery champions can help this happen, provide education, and demonstrate success to colleagues.
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day surgery success, more patients will have an unplanned overnight stay, which is a failure of the day surgery process. To overcome these barriers it is best to have a Consultant Anaesthetist with experience in day surgery to lead within the daycase unit. They can assist in ensuring lists are carried out by senior trained anaesthetists, while organising training for others to gain the necessary anaesthetic skills to get the patients home the same day. Getting those having longer, more complex or painful procedures home can be challenging. The use of regional anaesthetic techniques, such as nerve or plexus blocks, can make the difference between good analgesia allowing discharge and poor analgesia requiring overnight stay. The lead Anaesthetist should be involved in producing any appropriate perioperative guidelines for effective analgesia and avoidance of post-operative nausea and vomiting (PONV). These may include regional anaesthetic techniques where helpful. In the same way, consultant surgeons should
co-ordinate and organise their day surgery lists, so that training of future surgeons is a priority. Surgical techniques and use of local anaesthesia infiltration where suitable can be paramount for allowing day surgery to be successful. In some operations, such as thyroid surgery, meticulous attention to control of bleeding can be central to allowing reduction in serious complications that can prevent day surgery being feasible. ‘High-turnover list’ time management is a particular skill to be learnt that will help day surgery efficiency and viability. The efficient filling of lists in day surgery is pivotal for success. Surgeons with enthusiasm and good surgical techniques for day surgery patients help achieve the turnover of patients seen in high performing units. Training theatre staff to be familiar with and skilled across different specialties and procedures can ensure greater theatre utilisation and efficiency in a daycase unit. A strong training programme, led by the Day
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