british association of day surgery the future of day surgery: the ambulatory pathway ian smith, md,...
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British Association of Day Surgery www.bads.co.uk
The Future of Day Surgery:The Ambulatory Pathway
Ian Smith, MD, FRCA
Senior Lecturer in AnaesthesiaUniversity Hospital of North Staffordshire
President, British Association of Day Surgery
British Association of Day Surgery www.bads.co.uk
Benefits of Day Surgery
Quality care
– early & better recovery
– minimal disruption
– comfort of own home
PATIENT PATHWAY
Better care, Safer care
British Association of Day Surgery www.bads.co.uk
Surgical Length of Stay Cascade
Inpatient
Outpatient
Day Surg
23 hour
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Referral from GP
Outpatient review
Diagnostics
Further review
Decision to operate
Typical Surgical Pathway
Inpatient
Waiting list
Preop assessment
Surgery (if suitable)
Day case
Waiting list
Preop assessment
Surgery (if suitable)
British Association of Day Surgery www.bads.co.uk
Key Pathway Areas
1. Referral & outpatients
2. Preassessment & selection criteria
3. Booking
4. Patient admission
5. Operating lists & recovery
6. Discharge, documentation & support
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Patient Referral
Fit to proceed to surgery?Info on longterm conditionsUnderstands referral may surgeryUnderstands timescaleDiagnostic tests
– with results
Potential for day surgery
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Surgical Outpatients
Surgery possible / worthwhile?
Discuss risks & benefits– inform consent
Day surgery possible?– in this case– surgical factors
British Association of Day Surgery www.bads.co.uk
Preoperative Assessment
Nurse performed– clinician supervised
British Association of Day Surgery
Preoperative Assessment
Nurse performed– clinician supervised
Various models– centralised– DSU– telephone
Lewis, et al. —J One-day Surg 19: 32, 2009
British Association of Day Surgery www.bads.co.uk
Preoperative Assessment
Nurse performed– clinician supervised
Various models– centralised, DSU, telephone
Information– procedure & day of surgery– fasting & medication– recovery & pain management
British Association of Day Surgery www.bads.co.uk
Default to Day Surgery
Suitability for day surgery Pathway
Clearly suitable
Unsure
Clearly unsuitable
Day surgeryHome if ok
Inpatient care? Home if ok
Inpatient careHospital stay
20–30%
5–20%
40–65%
British Association of Day Surgery www.bads.co.uk
Booking
Offer choice of dates– early as possible
Mechanisms to allow booking clerks to– offer choice of dates– allow for leave– allow for teaching– allow for complexity
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Operating Lists
Dedicated day surgery lists
Mix of day and short stay surgery– efficient– flexible
Mix of day and inpatient surgery– tension– conflicting needs
British Association of Day Surgery www.bads.co.uk
Pooled Lists
Maximise day case capacity– full list– reduce waiting times
• surgeon may have to alternate weeks
Maximise day case expertise– surgery by day case enthusiasts
Greater flexibility
British Association of Day Surgery www.bads.co.uk
Optimising List Order
Major cases first– appropriate observation & recovery time
Diabetics early– minimal disruption to routine
Minor cases laterLA cases can go last
– need less recovery time
British Association of Day Surgery www.bads.co.uk
Recovery Facilities
Fully equipped to usual standard– trained staff
Potential for rapid turnover– staffing levels
Second stage recovery– nurse led discharge
British Association of Day Surgery www.bads.co.uk
Patient Discharge
Nurse led
Supported by– documentation– information
British Association of Day Surgery www.bads.co.uk
Safety Mechanisms
Defined pathwayReview by experienced nurse
– recognition of early signs of bleeding
Mechanism for recall– 24 h telephone no– surgical area (early review)– NOT GP / NHS Direct
Patient self-caring– symptoms earlier; no assumptions
Post-dischargesupport
Post-dischargesupport
Documentation
Documentation
Patient discharge
Patient discharge
Recovery facilitiesRecovery facilities
Operating lists
Operating lists
AdmissionAdmission
BookingBooking
Selectioncriteria
Selectioncriteria
Preoperative assessmentPreoperative assessment
Surgical outpatients
Surgical outpatients
Patient referralPatient referral
The Streamlined Pathway
British Association of Day Surgery www.bads.co.uk
Future of Day Surgery
Aging population
Obesity time bomb
Increasing surgical complexity
Therefore many challenges
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Variation in Practice
Day surgery rates vary considerably– between hospitals– within hospitals– within departments
Applying pathway principles– can dramatically increase day surgery
Smith, et al. —J One-day Surg 20: 80, 2010
British Association of Day Surgery www.bads.co.uk
Incentivising Best PracticeIncentivising Best Practice
Orthopaedic
subacromial decompressionbunionsDupuytren’s
Breast mastectomysentinel node
ENT tonsillectomyseptoplasty
Gynae female incontinence
Urology TUR & laser prostate
General lap cholehernia repair
BestPracticeTariffs
British Association of Day Surgery www.bads.co.uk
The Near Future?
True day surgery– ≈85%
Overnight stay– ≈5%
Longer stay– ≈10%
British Association of Day Surgery www.bads.co.uk