A day-case patient is one who is admitted for investigation or operation on a planned non-resident basis. Patients are usually discharged from the hospital or unit later on the day of the procedure. The procedure may require general, regional or local anaesthesia, sedative techniques or a combination of these.
The NHS plan predicts that 75% of all elective operations will be carried out as day cases. According to the British Association of Day Surgery (BADS), patients support day surgery because it provides timely treatment, less risk of cancellation, a lower incidence of hospital-acquired infection and an earlier return to normal activities. Procedures commonly selected for day-case care are those which take < 60 min to complete and which do not cause severe haemorrhage or produce excessive amounts of postoperative pain (Table 26.1). Increasingly complex cases are now performed as day-case procedures, including laparoscopic cholecystectomy and tonsillectomy. By extending day surgery opening hours and using staggered admission times, patients who would normally require hospital admission may be treated as day cases. The British Association of Day Surgery (BADS) publishes guidelines and protocols for the management of specific issues: for example, day surgery for patients with diabetes. BADS has also published a list of 25 procedures which should normally be undertaken as day cases. The NHS Modernisation Agency audited current day surgery rates for these procedures and set target rates for individual hospitals.
A Selection of Surgical Procedures Commonly Undertaken as Day Cases
Dilatation & curettage, laparoscopy, vaginal termination of pregnancy, colposcopy, hysteroscopy
Dupuytren’s contracture release, removal of small skin lesions, nerve decompression
Strabismus correction, cataract surgery, lacrimal duct probing, examination under anaesthesia
Adenoidectomy, tonsillectomy, myringotomy, insertion of grommets, removal of foreign body, polyp removal, submucous resection
Cystoscopy, circumcision, vasectomy, transurethral bladder resection
Arthroscopies, carpal tunnel release, ganglion removal, bunion operation, removal of metalwork
Breast lumps, herniae, varicose veins, endoscopy, laparoscopic cholecystectomy, haemorrhoidectomy, anal fissure dilatation
Circumcision, orchidopexy, squint, dental extractions
Achievement of a pain-free ambulant patient requires skilful patient selection and experienced anaesthetists and surgeons working within a day surgery unit. Large-scale reports have indicated that day surgery represents a safe, cost-effective and efficient practice. Advantages include decreased risks of nosocomial infection and deep venous thrombosis, less social disruption to patients and their families and minimal need for inpatient hospital resources. Therefore we now face the challenge of providing faster recovery, more rapid discharge and better pain relief for these patients.
The selection of patients for day-case surgery is of vital importance if maximum use is to be made of the resources in the day-case unit and also to facilitate smooth running of the unit. The selection of patients must take into account two separate aspects: firstly, the patient’s state of health, and secondly, his or her social circumstances. Patients should normally be ASA I or II, or medically stable ASA III. Recent reviews have shown that patients with a body mass index of > 35 kg m−2 do not have an increase in unplanned admission rates or postoperative complications. The Association of Anaesthetists of Great Britain and Ireland has recommended that obese patients should not be excluded from day surgery based on their BMI measurement alone. There is no evidence of significant morbidity in the immediate postoperative period when treating morbidly obese patients as day-cases. Although an increased risk of adverse events occurring intraoperatively and in the immediate recovery period in obese patients has been reported, these have not been shown to increase the incidence of unplanned admission significantly.
Evidence has shown that many elderly patients cope better at home. Careful preoperative assessment should highlight patients who will require an extended time in hospital. Elderly patients are more likely to have comorbidities and these patients should be assessed according to their physiological rather than their chronological age. Careful medical and social preoperative assessment is required to help elderly patients to benefit from shorter hospital stays with less risk of postoperative confusion. The patient should stay a minimum of a 1-h drive from the hospital on the night following surgery and they should have an adult escort available for the first 24 h. An example of guidelines used for patient selection for day-case anaesthesia is shown in Table 26.2.
Guidelines for Patient Selection for Day-Case Surgery Under General Anaesthesia
ASA 1 or 2 and medically stable ASA 3
Age: > 52 weeks post-conceptual age
Weight: body mass index = weight/height2 (kg m−2)
≤ 35: acceptable
> 35: discuss with anaesthetic department
Generally healthy, i.e. can climb two flights of stairs
MI/TIA/CVA within 6 months
Hypertension: persistent diastolic pressure > 110 mmHg
Poor exercise tolerance
Symptomatic valve disease
Acute respiratory tract infection
Asthma requiring regular β2-agonists or steroids
Alcoholism /narcotic addiction
Severe arthritis of jaw or neck
Cervical spondylosis/ankylosing spondylitis
Myopathies/muscular dystrophies/ myasthenia gravis
Advanced multiple sclerosis
Epilepsy > 3 fits per year
Monoamine oxidase inhibitors
The selection of patients for day-case surgery is made at the time of outpatient consultation and routine measurement of pulse rate and blood pressure, urine analysis and other relevant investigations (e.g. ECG, full blood count and sickle cell testing) are performed; performance of these routine tests minimizes the number of problems when patients are admitted on the day of surgery. A standardized patient health/anaesthesia questionnaire and preliminary nurse assessment with appropriate referral for anaesthetic consultation minimize difficulties encountered on the day of surgery. Pre-assessment clinics provide an opportunity to educate patients and have been shown to reduce both cancellations by patients and unnecessary preoperative investigations. Children should be treated as day cases if possible and children scheduled for day-case procedures should be healthy and usually ASA I or II. Premature babies who have not reached 52 weeks post-conceptual age should not be considered for day-case surgery because of the risk of postoperative apnoea, and special consideration should be given to babies who have been receiving ventilatory support. The parent must be able to cope with the pre-procedure instructions and with the care of the child following treatment. The parent must agree to day treatment and be available to stay throughout the day although there may be exceptions for older children who attend regularly. Home facilities and travelling conditions should be taken into account. Following a general anaesthetic, the use of public transport is inappropriate.
Following selection of a patient for day-case surgery, the nature of the operation and the routine of management are explained fully to the patient and the consent form may be signed. Many units issue the patient with explanatory leaflets, CDs/DVDs or even podcasts explaining the procedure. A date for surgery can then be arranged and registration completed, as for an in-patient admission. It is wise to book any pathological or radiological investigations which are required well in advance of the day of admission.
The patient should be given written instructions detailing the date and time of attendance at the day unit, with written instructions relating to preoperative starvation and the patient’s regular medication, e.g. antihypertensives, should be taken as usual but oral hypoglycaemics must be omitted on the morning of surgery. These instructions should be written clearly in plain English (or another appropriate language). The patient is usually advised not to eat anything from midnight for a morning operating list.
Recent clinical studies suggest that overnight fasting may not be required in adults or children. Pulmonary aspiration occurs usually in emergency abdominal and obstetric procedures where there may be complicating factors such as recent food and fluid intake, trauma or administration of opioid analgesics. These factors do not normally apply to healthy elective day-case patients. The universal order of nil by mouth from midnight should apply only to solids. Clear fluids should be allowed until 3 h before the scheduled time of surgery. The effect of giving patients 150 mL of clear fluid 2 h before general anaesthesia for termination of pregnancy has been studied; the results showed that clear fluids do not increase the incidence of regurgitation or vomiting during anaesthesia and the postoperative period and that preoperative thirst was decreased in the clear fluid group. It is advisable to ask patients who smoke to refrain from smoking for 4–6 weeks before the operation. Patients should be asked to bring with them all tablets and medicines which they take regularly.
ORGANIZATION OF THE DAY-CASE UNIT
In order to help improve the number of day-case operations, BADS has produced a directory of 160 procedures. Attached to each of these procedures are four possible management options.
Procedure room; an operation which can be performed in a suitable clean environment outside the operating theatre.
Day surgery; traditional day surgery.