An Anaesthetist’s perspective on Same Day Surgery

Dr. Rowan Thomas St. Vincent’s Health

Same day concepts

     Sameday – not listed in English dictionary. Day surgery – admission, surgery and discharge on the one day. (US <23hr 59min) Ambulatory surgery – Day surgery, not 23hr Day of surgery admission (DOSA) – can include day surgery and multiple day stay surgery. (Sometimes called Same day admission.) 23 hour stay and ‘medi-hotel’ – developments extending the capacity of day surgical units.

Anaesthetic issues

 Pre-operative assessment and management  Management of post-operative pain, nausea and vomiting  Neurologic, respiratory and cardiovascular recovery from anaesthesia.

Day anaesthesia (& surgery)

 Multidisciplinary team approach  Appropriate patient selection and education – medical and social aspects  Routine surgery, without blood loss  Routine pain management  Adequate recovery and home support  Are anaesthetic techniques modified?

 Greater use of local anaesthesia

Flexible care

 Often surgery varies and patients can have significant co-morbidities  An individual approach requires judicious preoperative assessment and tailored hospital or home support.

 Pre-operative assessment is the key to safe post-operative planning. Discharge on the day of surgery, depends on careful patient selection.

Preadmission at St. Vincent’s

 1998. 10% DOSA. One third of patients seen in preadmission. Random selection  Day surgery rates not recorded  High cancellation rate due to failure to attend  Screening tests ordered routinely  No anaesthetic involvement  PIER (Preoperative Investigation, Education and Research) centre established

Preadmission at St. Vincent’s

 Triage questionnaire to improve selection of patients for preoperative consultation.

 Resident staff run the clinics with anaesthetic consultation. Unusual design, but involves the residents.

 Most patients complete a questionnaire when placed on the waiting list. (Reviewed six monthly)  Patients attend clinic about two weeks prior to surgery.

Triage for preadmission

 Two page questionnaire. Designed to be completed by the patient and assessed according to protocol.

 Dual purpose. Clinical information available in the history. Well or stable younger ASA II patients not needing investigation, having surgery without blood loss can avoid preadmission.

 One third now ‘fast-tracked’.

Triage for preadmission

 Very effective method for eliminating costly & unnecessary ‘screening’ investigations  Only 300 (5%) elective patients per year involve anaesthetic consultation  Anaesthetists not taken from theatre where their skills are probably of greater use.

DOSA & Day surgery

 August snapshot (419 elective admissions)  89% Overall DOSA. (Lowest - vascular 62%)   121 (29%) Discharged on the day of surgery. Plastic surgery accounts for nearly half.

Some ‘cross-over’ between intended and actual stay.

 Many units perform complex surgery not suitable for day surgery.

 Lap. cholecystectomy has been tried unsuccessfully as a day surgery procedure.

Cancellations

 Of 50 cancellations in August, 10% (5) due to inadequate preoperative investigation or information.  Compare with 20% - lack of time, 10% - no bed, 10% - emergency case, 10% unexpectedly unwell, 20% - cancelled by patient.

 Cancellation need not always be regarded as a failure. It can be a learning opportunity, but is also an important barrier for trapping errors.

DOSA at St. Vincent’s

 Most elective patients now come through DOSA. Originally designed for 10% - 20% of elective surgery. Discharge is a separate event and is based on surgical and patient factors.

   Patients are seen by anaesthetist in DOSA or in the anaesthetic induction room.

Staggered arrival in the morning – needs only one nurse.

Afternoon staff call the next day’s patients to check that they are ready.

Benefits of DOSA

 Patients generally prefer to be at home prior to surgery.

 Preadmission clinics become integral to the system. Timely investigation. Preoperative education & discussion. Involvement of resident staff in the management of elective surgical preparation  Eliminates the night-time preoperative round.

 Hospital bed available for emergency or post operative care.

Disadvantages

 Dilutes the responsibility for preoperative care.

 Despite good education, patients regularly arrive un-fasted or not having taken usual medication  Many patients have not had the benefit of a prior discussion with an anaesthetist.

 Rushed preoperative morning visit by anaesthetist. Not all clinical decisions can be predicted by other clinicians. Complex cases - need time to consider anaesthetic options.

Disadvantages

 Rushed arrival and transfer to theatre for the first patient. Heightened patient anxiety.  ‘Consent’ is a bureaucratic charade.  Interpreters not easily available at 0700.

 Late starts to surgical lists or long breaks between cases.

 Patients are now very aware of the waiting time prior to surgery.

Is day surgery safe?

 VCCAMM 1997 – 1999  32 deaths wholly or partly related to anaesthesia. 12 involved inadequate preoperative assessment or management.

 6 Elective. 4 Semi-urgent. 2 Emergency  “Of concern were the deaths of two day-stay patients undergoing minor procedures”

Future challenges

  Better systems for the provision of information about the surgery and anaesthetic.

Better systems for ‘two-way’ communication between the clinician in the preadmission clinic and the anaesthetist and surgeon doing the procedure.

 Ideally the anaesthetist and surgeon performing the procedure could use the opportunity provided by preadmission to consult with the patient.

Conclusion

 Safety, provided by thorough preoperative assessment and flexible pathways for post-operative care must always have a high priority.

 Information management and informatics systems will contribute to better communication.