Anaesthesia, 1979, Volume 34, pages 790-805 SPECIAL ARTICLE

A blueprint for day surgery

J A M E S M.B. B U R N

Historically, the surgeon to the Outpatient Department of the voluntary hospital had no access to inpatient beds, and unless he practised 'day surgery' he could not undertake surgical operations. Thus Nicholl' in 1909 was able to report a series of 9000 cases done in the outpatient department of the Glasgow Royal Hospital for Sick Children. Minor surgery has been undertaken for many years in casualty departments and outpatient departments and many surgeons have operated on day cases from their wards on routine inpatient operating lists. The real difference between these practices and day surgery now is that the latter is more highly organised, and the scope of work is more ambitious. Operating lists are devoted solely to day cases, and wards are staffed and run for these cases alone. It is a development which has taken place in the last two decades, and has been brought about because there is insufficient inpatient accommodation, which results in increased waiting lists (especially for minor surgery) and because of the progressive reduction in the hospital stay of patients and the earlier postoperative ambulation,2 which is again partially dictated by the pressure on bed occupancy, It will be apparent that other advantages and benefits flow from this method of management, but it cannot be denied that the original impetus for day surgery was an economic one. It is now rapidly becoming established as an accepted method of dealing

with all minor (and much intermediate) elective surge~y,~-'Oand it is rare in some hospitals to see these procedures done on routine inpatient operating lists. In one paediatric and neonatal surgical unit 50% of all operations are dealt with on a day basis." In due course, the scope of procedures undertaken will undoubtedly increase; much of the current surgical practice governing inpatient stay is still determined by tradition rather than necessity,6 and these practices may require radical reappraisal in the light of economic factors and scientific facts.'* There is a demand too from the public, now that many patients have experienced the convenience of day surgery, and the news media have publicised the benefits which accrue. In the United States of America the reasons for the adoption of day surgery have also been basically economic,13*l 4 but the demand has come from the patient, unable to meet the expense of prolonged hospitalisation, rather than from the surgeon. Where the State pays the bill, as in this country, the surgeon has taken the responsibility of making the most of the limited resources available to afford the best service to the greatest number. Public funds will always be inadequate to meet the needs in the field of Medicine, and this will be increasingly true in the future with the escalating costs of a progressively more sophisticated science. The role of economic projects such as day surgery will become more attrac-

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J.M.B. Burn, RD, FFARCS, Consultant Anaesthetist, Shackleton Department of Anaesthetics, Southampton General Hospital, Southampton, SO9 4XY.

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OOO3-2409/79/07OO-O790802.00

0 1979 Blackwell Scientific Publications

Blueprint for day surgery

tive in consequence and will assume a greater importance (in both the public and private sectors) in affording more minor surgical treatment at minimal cost. The purpose of this paper is to review the field of day surgical practice; it is based on publications which have appeared over the last 10 years or so, together with personal experience gained in day surgery at Southampton over the same period. The number of such cases done annually at Southampton is now around 8500.

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unit with 10 beds, and this would require one operating theatre. For every 100OOO in excess of this number an extra operating theatre and 10 beds should be available for day surgery. For the smallest unit therefore an annual throughput of 2500 day cases could be anticipated, and this would cater for most of the minor surgery in a population of 100 000.

Specificatioti

Most day surgery units in this country have not been purpose built,I6 but are conversions of Definition vacant buildings;) ’-I9 some of these conDay surgery may be broadly defined as elective versions have been highly successful and others less so, but few are suitably situated in relation minor or intermediate surgery carried out under local or general anaesthesia, on patients who to operating theatres. However, they have are admitted and discharged the same day. provided the invaluable facility of day surgery Generally speaking, it is desirable that, if at an economic cost if not under ideal conditions. general anaesthesia has been administered, the The ward area of the unit should be on ground patients should not go home until they feel level to facilitate access and departure of patifully recovered; for this reason day lists are ents. It should also be as near to the theatre preferably confined to the morning, leaving suite as is feasible; this reduces portering time, adequate time for postoperative recovery. especially as there is a rapid throughput of The practice of holding two lists (one in the these cases in theatre.’O If the unit is at a morning and a second in the afternoon) is distance from the operating theatre a reception undesirable; this becomes ‘half-day surgery’ area adjacent to theatre is necessary to keep it and is liable both to result in allowing inadequate supplied with patients. Good sign-posting from time for the recovery of the patient and to the main hospital gates is essential, and adethrow a heavy burden on the ward staff at quate car parking space is needed near the unit midday, with one batch of patients being so that the recovered patients do not have too discharged and another arriving for the afterfar to walk. If the unit is a separate entity from noon session. Of course, local conditions and the inpatient wards, it can close completely circumstances vary, and it may be feasible to at night and at the week-ends, and so save run two sessions in the day, if the patients are running costs; similarly it can be closed for having their surgery under local anaesthe~ia;~ holiday periods, if staffing shortages make this it is however important that the care of patients necessary, without disrupting the inpatient and the work of nursing staff should not suffer services which must continue uninterrupted. by an abuse of an otherwise excellent service. Reception. A lounge where documentation Similarly the facilities provided and the calibre formalities may be completed on arrival, and of staff (medical and surgical and nursing) where relatives may wait when collecting patimust be of the same high order as would be ents is almost essential. It should have access available if the operation were being undertaken to the unit office through a counter or window on an inpatient basis. Clearly emergency surgery hatch. is not appropriate for a day surgery unit. The Ofice. This is the ‘nerve centre’ of the unit where the waiting lists for day surgery are held, and from here the admission letters are Accomodation for the Day Surgery Unit despatched. Documentation and completion of identity bracelets are carried out on the patient’s Size arrival in this area and discharge letters are A District General Hospital serving a populatyped prior to the patient’s departure. In tion of 1OOOOO could make good use of a addition to normal office equipment, the gener-

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ous provision of telephones and storage space for notes are required. The Ward. The size of the ward depends upon the population served by the unit. A unit designed to serve a population of 300000 should contain thirty trolley spaces, which should be separated by curtains on suspended tracks. There should be plenty of space in each trolley bay, to allow the patient adequate room to undress, and for a chair beside each trolley. The ward should be wide enough for trolleys to be manoeuvered with ease, and it should not be cluttered with furniture. High-backed chairs should be provided for patients to sit during the second stage postoperative recovery period, whilst having a cup of tea and awaiting collection by relatives. There is no need for segregation of the sexes provided curtaining or screening is adequate. A unisex ward increases the versatility of the unit. Few patients object in practice but a single side-room is an advantage more from the point of view of the very occasional patient who requires separation for medical reasons. Services required include good ‘natural’ lighting, adequate heating and ventilation for all seasons, power points for each trolley space, and a hand-wash basin for every ten trolley spaces. The medical quipmerit necessary is minimal. Sphygmomanometers (wall mounted between trolley spaces) stethoscopes and a diagnostic tray are all that is required for patient examination and for resuscitation a cardiac arrest board, an emergency box or trolley with intubation equipment and a respirator bag, a mobile electric suction apparatus and oxygen cylinders with flowmeters. Patients’ trolleys should be of the tipping type, as induction of anaesthesia and first stage recovery will take place on them. They must be fitted with brakes on the wheels, to enable patients to climb on and off in safety and cotsides which hinge down. They must be 65 cm wide and covered with Sorbo rubber mattresses 10 cm in thickness, as the patients not only have to go to and return from theatre on them, but may have to lie on them for several hours postoperatively. A drip stand and an oxygen cylinder should also be fitted in case of need. There are many advantages in using trolleys instead of beds. They occupy less space, they

save having to lift the patients out of, and back into beds, they are perfectly adequate for a few hours and they are much more economical. The Sister’s ofice is best placed centrally in the ward area, and provided with windows onto the ward so that patients can be kept under observation at all times. Normal furniture for a sister’s office is required, and in addition a small safe in which to store patients’ valuables. A clean utility room with storage units for Central Sterile Supply Department sterile dressings will be needed. Dressings often have to be changed before the patients go home and sometimes a small supply must be given to the patients to take with them. Syringes, needles and a drug cupboard will also be kept here, to enable premedication and postoperative drugs to be administered. Catheterisation or intravenous infusion are rarely required, but the appropriate disposable items should be available. A dirty utility room for the disposal of soiled dressings, linen, and for the testing of urine specimens, which the patients bring with them on admission, is required. Patients will rarely need to use bed pans or urinals since they will empty their bladders before going to the operating theatre, and should be fit to use the lavatories shortly after their return. Laoatories. One per ten trolleys should be provided and each must have a handbasin. A tea bar or kitchen is desirable to provide patients with a cup of tea and biscuits or sandwiches postoperatively. Storage. A large quantity of clean linen is used daily, including theatre gowns for patients, bed linen, trolley canvasses and dressing gowns, and this needs to be kept in a store on the ward. This may be part of a larger general store where furniture (kick stools, trolley poles, dressing trolleys etc.), disposables (sanitary pads and paper towels), and domestic cleaning items are kept. Whatever the size of the store, it is seldom large enough!

Operating theatre provision

The local circumstances will determine what arrangements can be made for the use of operating theatres. The most important requirement is that they should be fully up to the same standard of size, lighting, ventilation, equipment and staffing, as operating theatres under-

Bheprint for day surgery

taking inpatient general surgery; often intermediate type surgery is performed, and as even a minor operation may become a major one owing to unforeseen complications, the capability must exist to undertake any type of procedure. A properly equipped theatre also provides additional versatility for possible use for emergency work at night or at the weekend, thus releasing inpatient theatres for routine maintenance. The situation of the operating theatre is relevant to its function. I t has already been suggested that it should be close to the ward area. I t also needs to be close to other inpatient theatres, otherwise the remoteness of these theatres may give rise to a feeling of isolation of the theatre nursing personnel, and the possibility that standards and morale may fall. Lack of regular major surgery may tempt nursing officers to lower staffing establishments. Proximity to inpatient theatres has other advantages: for example, day theatres and inpatient theatres can work in tandem, with a consultant doing his major list in one theatre whilst his registrar is undertaking day surgery in an adjacent theatre. The consultant is then readily available for advice and help if required. Also, if the day theatre is part of, or close to, the inpatient theatre suite, it may be used in the afternoon session for routine inpatient surgery, if not required for day surgery under local anaesthesia. Anaesthetic rooms must be of the same size and equipped to the same basic standard as the inpatient anaesthetic rooms. More sophisticated equipment (blood warmers, intra-arterial pressure monitoring equipment, infusion pumps etc.) is unlikely to be required, especially if readily available from adjacent inpatient anaesthetic rooms, should an emergency arise. Recovery room. All patients leaving the operating theatre should pass through a 'first stage' recovery room, where they are held until fully conscious. This area must be situated in the immediate vicinity of the theatres to enable the anaesthetist to be instantly available in case of need. The equipment and facilities provided (including trained nurses, piped oxygen and vacuum, resuscitation equipment, cardiac monitors, ventilators, etc.) should be precisely the same as those in the inpatient recovery areas; indeed it could well serve both groups of patients.

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Staffing Surgeons

Although many of the procedures are relatively simple and of short duration, they must be performed both with skill, in order that the incidence of untoward sequelae is minimal, and reasonably expeditiously so that the duration of anaesthesia (and hence recovery) is not protracted." Furthermore, there is a possibility that an unexpected finding or surgical mishap may require a more major operation to be undertaken. Again, a number of diagnostic procedures, including cystoscopies, though simple in themselves, require a considerable degree of experience and judgement to make a proper assessment or interpretation. For all these reasons it is necessary that the operator should be at least a Senior Registrar or experienced Registrar, and these lists should emphatically not be delegated to an inexperienced Registrar or Senior House Officer. Aimsthe fists

Much the same comments apply to the anaesthetic skills required. Although the anaesthetic techniques employed may not be sophisticated, there are features which make them potentially difficult, and requiring experience on the part of the anaesthetist.zz The patient arrives in the anaesthetic room almost literally 'off the and possibly with a full stomach; he must be rapidly and adequately anaesthetised for the operation, and yet be well awake, and fit to go home soon afterwards, suffering no (or minimal) sequelae from the agents used. Apart from Senior Registrars or experienced Registrars, the use of trained clinical assistants (with at least a Diploma in Anaesthetics) enables married women or general practitioners to be employed in this eminently suitable capacity. The well-defined hours, without a continuing commitment, night duty or weekend work, are ideal for such part-time anaesthetists. The virtue of tandem theatres is again evident: a consultant would be available in the next theatre should a critical situation arise or help be urgently required. The role of the General Practitioner

Though not working in the unit, the general

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practitioner’s role is important.’ Preoperatively he advises on the suitability of the patient’s home environment; postoperatively he should be prepared to look after the patient,24 and deal with any complications or treatment such as removing sutures, that may be required, though in practice he is seldom called upon to do so.

Nursing s t a j Theatre arid recocery. These areas will be staffed to the same numbers and grades as for corresponding inpatient facilities; indeed, as already suggested, the recovery area may also serve inpatient theatres, and the day operating theatre may be used for inpatients on other occasions. However, where only day patients use these areas, it is possible to use solely part-time nurses,” who can integrate their duties with their domestic commitments. The ward should be run by a Sister with a Staff Nurse as her deputy, so that there is always someone responsible on the ward to facilitate the administration of dangerous drugs etc. Below this level State Enrolled Nurses and nursing auxiliaries are satisfactory; three per ten trolleys should be sufficient. Most of the work is low dependency nursing, though the rapid turnover requires efficient organisation by the Sister in charge. As with theatre work, it is ideally suited to part-time nurses with families; where there are children of pre-school age, some enterprising local authorities and hospitals have made creches or day nursery facilities available.2 Commuriity Nurses. Like general practitioners, although they do not work in the unit, these nurses make an important contribution to the care of the day patient. They are chiefly responsible for the management of the patient at home after discharge from the unit. Whilst in most instances these nurses are part of the General Community Nursing Service, some specialised day surgery units prefer to use community nurses specifically attached to the unit, who have had appropriate training and experience in dealing with the postoperative problems peculiar to these patients.’O. 2 6 * *’ These nurses often form very close links with the hospital and, by attending weekly ward rounds they become known by medical and nursing staff, and in turn they can familiarise

themselves with the nursing and surgical techniques employed in the unit. Ancillary staff Theatre technicians. The establishment and experience of Operating Department Assistants working in a day surgery anaesthetic room or theatre should be the same as for the equivalent inpatient area. Secret aria1 Sta8

Lastly, but by no means least, are the secretarial staff, upon whom considerable responsibilities devolve. They arrange admissions and inform all parties concerned; they obtain notes and radiographs, type discharge letters for patients to take with them and furnish the unit Committee of Management with relevant statistics, to list but a few. For this post a Higher Clerical Officer grade is appropriate; there should be a junior if the unit deals with more than twenty patients per day. Good communications are the essence of success in this field, and it is the duty of the secretary to establish and maintain these lines of communication; indeed, upon her initiative and efficiency the smooth running of the unit largely depends. Selection and assessment of patients The surgical assessment

The suitability of a patient for day surgery is fundamental to the success of this practice. Patients are selected initially in the outpatient department, possibly prompted by a suggestion in the general practitioner’s referral letter. Criteria for suitability will include the type of operation proposed (minor or intermediate), wnether the patient will be ambulant afterwards, and whether the degree of postoperative pain can be controlled easily, without recourse to powerful narcotic analgesics. It is clearly important that, in so far as it is possible, the diagnosis must be accurate in order to avoid embarking on a different or more major procedure than envisaged; and the operations proposed should be usually unattended by forseeable complications. Operations likely to be followed by haemorrhage or infection are obviously unsuitable for day surgery, as are

Blueprint for day surgery Table 1. Suitable cases for day surgery Gynaecology ( I 76 I ) D and C; Laparoscopic examinations and sterilisati on^;'^ Termination of pregnancies; Cervical polypectomy; Cervical cautery: Marsupialisation of Bartholin’s cysts. Orthopaedic (755) Carpal tunnel decompression ; Removal of ganglia; Removal of exostoses: Release of trigger finger; Manipulation under anaesthesia. Paediatrics (982) Circumcision ; Herniae; Orchidopexies; Division of tongue-tie; Separation of preputial adhesions; Manual evacuation o f faeces; Endoscopies. Dental(303) Removal of wisdom teeth; Excision of odontogenic cysts; Dental clearance; Root fillings and apicectomies; Extensive dental conservation; especially in retarded children. General (2844) Excision of lipomata; Sebaceous cysts; Injection and ligation of varicose veins; Vasectomies; Anal dilatations Endoscopies; Herniae.3o ENT (15) Endoscopies; Myringotomy; Insertion of grommets; Nasal polypectomy ; Antral washouts; Submucous diathermy; Tonsillectomy and adenoidectomy.” Pain clinic work (375) Nerve blocks; Spinals and epidurals: Transcutaneous nerve stimulation.

Figures in brackets refer to total number of day surgery cases done in Southampton 1976.

those likely to take more than 30 min of operating time, since this will have an adverse effect on the recovery from anaesthesia,** and it would also limit the number of cases which could be dealt with in a session. Willingness on the part of the patient to be treated on a day basis must be sought; this usually presents no problem as it almost certainly entails a much shorter period awaiting operation than if it were done on an inpatient basis. The types of surgical procedure suitable for Day Surgery are shown in Table 1. Generally speaking, children are eminently suitable, for apart from the obvious psychological advantages to the child, his rapid recovery from short anaesthetics and his innate resiliance allow early discharge postoperatively. Day surgery is also especially useful for minor gynaecological procedures, most of which can be undertaken on this b a s i ~ . ~ ~ - ~ ’ Assessment for anaesthesia Ideally all patients should be screened at an

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assessment ~ l i n i c in ~ ~order . ~ ~to judge their fitness for anaesthesia, but, in the absence of this facility, the anaesthetist must make his decision in the light of the pre-operative history and clinical examination, on the results of the routine blood and chest radiographic examinations which have been done before admission, and upon the list of drugs taken by the patient, as detailed on the drug enquiry form. Many of the problems encountered in some authors’ series have stemmed from inadequate pre-operative assessment and selection.22 On general principles, patients over the age of 70 years, brittle diabetics poorly controlled on insulin, and patients with severe cardiac or respiratory complications are excluded, as are patients with acute infections of the respiratory tract. Adult patients with limited mobility, who would find it difficult to climb onto and off trolleys, would also be unsuitable for day surgery. However no child is too young for day surgery, though neonates and infants should be operated upon early on the list to reduce the period of starvation and avoid dehydration and hyp~glycaemia.“~Exclusions from day surgery are not absolute; even those patients with chronic conditions can have certain surgical procedures under local analgesia; but if general anaesthesia was definitely indicated, inpatient surgery after attention to the complicating medical condition, would be recommended.

Social suitability

The suitability of home conditions is assessed by the general practitioner, and when informed by the surgeon of the intention to admit the patient for surgery on a day basis, it is the practitioner’s responsibility to advise against it if necessary. Many surgeons also make their own assessment of the domestic state in outpatients, or may ask for a Medical Social Worker’s report. Distance of the patient’s home from hospital is relevant: it is undesirable for a patient to travel more than 1 hr (or 50 km) to his home when possibly feeling nauseated or faint. There must be someone at the patient’s home to look after the patient after discharge; either a friend or relative should at least stay the night with the patient. Those patients living

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on their own who cannot make such arrangements are not considered fit for day surgery. Surgical and anaesthetic techniques Surgery

The importance of the proper selection of patients and the competence of surgical staff to the success of day surgery has already been stressed. Accidents must be avoided which could change the nature of the operation from minor to major; the latter both taking longer and requiring inpatient admission. Examples of such mishaps are the damage to bowel during the course of a laparoscopic sterilisation, or rupture of the uterus during the termination of pregnancy. Particular attention must be paid to the arrest of haemorrhage,6 even from vessels which otherwise might be expected to stop bleeding spontaneously. The possibility of reactionary haemorrhage occurring later in the day, when the patient has left hospital, must be eschewed; at the very least it could be worrying for the patient, and at the worst it could be a hazard to life. Attention to asepsis is always a feature of good operative technique, but where the patient is leaving the hospital before any signs of inflammation or pyrexia can develop, it is clearly important to be especially careful. Gentleness in handling tissues and good haemostasis will ensure there is not a ready milieu in which any contaminants can thrive. If feasible, the avoidance of skin sutures is d e ~ i r a b l e : ~sub' cuticular sutures with catgut, collogen, or D e x ~ nare~ often ~ satisfactory, and subcutaneous sutures used with Steristrips, for wounds not under tension, is an alternative method of skin closure. Both these techniques reduce wound sepsis and save the patient the necessity of having to have sutures removed. Anaesthesia

The anaesthetic technique must be good and unhurried, but reasonable facility and expeditiousness will help to reduce the time the patient is anaesthetised and enable the surgeon to make maximal use of available operating time. Instructions regarding oral abstinence may not have been as rigidly observed as if these

were inpatients, and it is prudent to have the suction apparatus available and switched on during induction. Indeed, except where preoperative assessment clinics function, the general 'work-up' may not have been comprehensive and the possibility of some pathology not having been recognised at the brief pre-operative examination must always be borne in mind. Premedication is prescribed if it is considered desirable, though narcotics tend to prolong recovery after anaesthesia. Antisialogogues are unpleasant and possibly unnecessary until induction of anaesthesia, unless intubation is proposed but, if cyclopropane or ketamine are to be used, premedication with atropine is mandatory, and some anaesthetists would strongly advocate its routine use, with or without papaveretum or droperid01,~~ depending on age and circumstances; in children trimeprazine and atropine by the oral route may be

refera able.^ The induction agent chosen will vary with individual preference, but one with a rapid action and rapid and complete recovery by clearance rather than re-distribution, is desirable; Althesin is an obvious choice. If premedication has not already been given, then it can be administered intravenously with the induction agent. In young children the same agents may be used, but cyclopropane is a useful alternative; it also has a very rapid action and recovery time, without the disadvantage of a needle. Maintenance. If the procedure does not require intubation or relaxation, maintenance of anaesthesia with nitrous oxide, oxygen and incremental doses of Althesin or fentanyl, or inhalation of halothane or enflurane will provide satisfactory operating conditions. The omission of a narcotic premedication may make maintenance of anaesthesia rather more difficult than in the fully premedicated patient. Ketamine in low dosage (2 mglkg) with nitrous oxide and oxygen gives adequate operating conditions for circumcisions and herniae for children's surgery, and it is free from either the delayed recovery or hallucinations associated with its use in adult^.^^.^^ Intubation in adults poses the problem of muscle pains in a proportion of those who are ambulant the same day, if suxamethonium is used. It is not a problem in children, who d o not

Blueprint for day surgery

appear to suffer. The myth that children should not be intubated as day cases, because of the danger of laryngeal oedema and respiratory obstruction, has been exploded; in the hands of reasonably competent and experienced anaesthetists the risk is practically nonexi~tent.~’ Nevertheless where intubation is unnecessary, the face mask should be used. Adult musclepains may be ameliorated by preceeding the administration of suxamethonium by a small dose of a non-depolarising agent, or avoided by intubating solely under a non-depolarising agent or under halothane. Unfortunately the latter techniques are associated with a higher incidence of sore throats, and the dose of a nondepolarising relaxant required tends to be larger than that needed for maintenance of a 20- to 30-min anaesthetic. The ability to maintain the patient at a light level of anaesthesia, anticipation of the completion of the operation, and the ability to have the patient awake on leaving the theatre, are useful attributes of day surgery anaesthesia. That the operating conditions for the surgeon must be as perfect as possible hardly needs emphasising, since this will facilitate his work and ensure a more rapid conclusion to the operation. If at the same time the technique leaves the patient free from sequelae on recovery, then it has been a very satisfactory anaesthetic. Hypotension resulting in vertigo and nausea may follow the use of high concentrations of halothane used to speed induction; the routine use of perphenazine may help to prevent nausea. Local analgesic techniques provide an alternative to general anaesthesia in adults. Local analgesia is particularly useful for orthopaedic surgery on the limbs, and may be used for cervical dilatation and curettage (by cervical genito-urinary surgery (by caudal blocks), and general surgery4 (by local infiltration or field blocks). These methods may be combined with sedation, and providing both surgeon and theatre staff are used to operating upon conscious patients, the latter do not find the experience distressing. It certainly ensures the patient is awake and in possession of all reflexes at the end of the procedure, and many of the sequelae of general anaesthesia are 48

The use of regional techniques in children is chiefly confined to the control of postoperative

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pain. It enables certain operations to be performed on day patients which would otherwise have to be done on an inpatient basis, because the severity of the postoperative pain would necessitate administration of powerful narcotic analgesics under supervision. The regional analgesic is injected under general anaesthesia preoperatively, and the operation can then be carried out under its cover, with the lightest of general anaesthesia merely to maintain unconsciousness. Kay49 popularised this technique and recommended the use of bupivacaine 0.5 in the dose of 0.5 ml per year, caudally for circumcision operations; about double this dose is required for herniae and orchidopexy operations. Administrational organisation To illustrate the whole organisation and process of providing a day surgery facility, it is convenient to follow the progress of a patient through from the initial consultation at the surgical outpatient department to the surgical Follow-up clinic postoperatively. The surgical outpatient consultation

The surgeon, having seen the patient and recommended a minor operation, may suggest that this should be done in the day surgery unit. Providing the waiting list is short the routine pre-operative investigations could be done before leaving the clinic, and the patient given a date for his admission. It may also be convenient to obtain his signature to the operation consent form, which can then be countersigned by the surgeon, certifying that he had explained the nature of the proposed procedure to the patient. The consent form can also incorporate an agreement by the patient not to have anything by mouth within 6 hr of admission and not to drive, operate machinery or drink alcohol for 24 hr after the operation. While it may not exonerate the hospital from the consequences of the patient breaking these undertakings, it will impress their importance upon him. The surgeon, in his reply to the general practitioner’s referral letter, indicates that it is proposed to undertake the operation in the day surgery unit; this tacitly invites any objection, and seeks the co-operation of the practitioner in the aftercare of the patient. The

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patient’s admission card then passes to the day surgery unit.

Pre-admission procedure

Each day the unit secretary selects patients from the waiting list for admission in 3-week’s time; the selection is made in consultation with the surgical team, or by the secretary alone following guidelines provided by the team. To maintain maximal utilisation of beds, over-booking may be justified on certain lists where patients regularly default, though this may occasionally result in inpatient accommodation having to be used if too many patients arrive. Irregular cancellations can usually be replaced by telephone calls to patients on the waiting list. Each patient selected is requested to attend for a blood test and chest radiograph before admission, unless these have already been done recently in the outpatient department. Ten days before admission the patient receives two further documents: A drug enquiry form is taken by the patient to the general practitioner, for him to record what drugs the patient is currently taking; this form incorporates a notice that the patient is being admitted on a specified date for day surgery, so the practitioner is aware of his patient’s admission. Instructions to patients request the patient to bring a specimen of urine when he is admitted and helshe should be accompanied by a spouse to sign a consent form if sterilisation is proposed. He is asked to take nothing orally after midnight prior to admission and to arrange to have transport to collect him after the operation. He must also have a friend or relative awaiting his return and he should refrain from making any social or other engagements for the evening after his return, but should go to bed as he may feel unwell if he remains ambulant. If the patient feels unwell before admission, he should inform the unit ofice, so that the admission can be cancelled and a replacement date booked. Transport to the hospital is rarely provided; indeed, immobility would exclude a patient as being suitable for day surgery. Notification of the patient’s proposed admission should also be passed to the Community Nursing Service,

so that they can be forewarned of the demands likely to be made in the ensuing week.

Admission procedure

The patient is brought to the hospital by a friend or relative (preferably a spouse, or parent in the case of a child) by 0830 hr. Punctuality is important; late arrivers will obtain little benefit from their prernedication, and they may delay the start of the list. Children are encouraged to bring their favourite cuddly toys with them. After registration, the patient has an identity bracelet affixed and completes any necessary documentation. The escort may then depart, but parents of children are expected to stay until their offspring go to theatre. The patients enter ‘the ward area, where they change into theatre gowns and lie upon their trolleys. Their clothes are put into plastic bags, which are sealed and kept on a tray under the trolley; valuables are handed to Sister who locks them in a safe in her office. The anaesthetists examine all patients preoperatively, if this has not been done in an assessment clinic. Any patient found unfit is discharged without further investigation and arrangements are made for his admission as an inpatient, or readmission in a few weeks as a day patient, after resolution of the disability. The surgeon usually visits each patient also, to check the lesion for which surgery is p o posed, and possibly to mark its site. The patient will be invited to empty his bladder, remove any dentures or jewellery, and return to his trolley to await premedication, shaving (if applicable) and despatch to the theatre.

The Operation

The list should start about 1 hr after the patients’ admission. On arrival in the theatre suite the identity of the patient is checked, and the ward blankets and pillows are changed but the patient’s clothes in their plastic bag remain on the bottom of the trolley. Anaesthesia is induced, and the patient passes to the operating theatre. It is important for the efficient and smooth running of the theatre, that only day cases are done on the list, and

Blueprint for day surgery

inpatients are not brought to the day theatre as otherwise there is scope for muddle. The nursing and anaesthetic staff, many of them part-time, while able to cope with day cases, may find some types of inpatient work too demanding. The combined situation is also open to abuse, in that inpatient cases may cause the list to over-run. Conversely if a proper day surgery unit exists, day cases should not be taken to inpatient theatres, sicce this equally is a recipe for muddles and mistakes and it is a waste of valuable inpatient operating time. A rapport between day theatre staff and day ward staff is useful, and this becomes impossible if day cases are distributed throughout inpatient theatres. The operation having been performed, the surgeon dictates the operation note into a pocket tape-recorder, the cassette of which accompanies the patient and his notes out of theatre, into the first stage recovery ward.s2 Here routine observations and care are carried out in precisely the same way as for inpatients. As in the ward area there is no segregation of sexes; curtains are provided, but are only used for certain procedures (e.g. urethral catheterisation). When the patient is fully conscious and alert, all protective reflexes have returned, and parameters have stabilised, he is returned to the ward area for the second stage of his recovery. All patients will have departed from the operating suite by 1230 hr allowing even the last patient about 3 to 4 hr total recovery time before going home. Postoperatiite care and discharge

On return to the ward, the patient remains on the trolley, sleeping or resting. Postoperative drugs (analgesics or antiemetics) are given as indicated : papaveretum may be necessary, but the nature of this surgery means that often pentazocine or paracetamol are quite adequate. Observation of the wound (dressing) is maintained, lest bleeding from the skin persists; dressings are changed as necessary. Parents are encouraged to sit by their children, so they are seen when the child awakens. The anaesthetist and surgeon visit the ward at the end of the operating list to ensure the patient’s condition is satisfactory, and he is recovering well. Although the ultimate responsibility for the patient’s fitness to be discharged rests with these two,

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it is in practice often delegated to the Sister, who is able to contact either, should she feel concerned. When fully recovered, the patient dresses; a nurse should be present at this time, in case postural hypotension and faintness occur, resulting in the patient falling and injuring himself. The curtains around the trolley are then drawn back. The trolleys may be pushed together, thereby increasing the ward area in which the patients sit in easy chairs and enjoy the light refreshments (tea and sandwiches) which are provided. Meanwhile the clerical staff will have telephoned the patient’s general practitioner’s surgery to inform them that the patient has had his operation, and will be returning home as planned. The surgeon’s operation note will have been typed on to thecase notes, and a copy in the form of a discharge letter (HMRI) will be posted to the patient’s general practitioner that evening. Transport home is normally provided by a friend or relative, but an ambulance can be provided on a doctor’s authority if it is considered essential (e.g. if the patient feels nauseated); but patients may not travel on public transport and, of course, they may not drive themselves. The community nurse liaison officer, having visited the unit in the afternoon, will have a list of the patients operated upon, and any details of subsequent treatment that will be required, such as removal of drains or sutures. She will pass this information on to the appropriate community nurse. The patient is handed a leaflet on discharge from the unit. This reminds him of the ‘do’s and dont’s’ on arriving home (viz. go to bed, avoid alcohol until the following day, d o not drive a car or handle machinery,s3 call your own doctor if worried about your condition and you feel unable to visit him, and ensure that you are at home the following day when the community nurse calls. These instructions are also given verbally to ensure they are clearly understood, and to reinforce their importance. A small supply of mild analgesic tablets to last 24 hr is provided, together with any necessary dressings for the wounds. An appointment for follow-up in the outpatients department is handed to the patient; any valuables returned, and when friends or relatives arrive, the patient is allowed to depart.

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lnpat ien t admission

Should the Sister not be satisfied with the fitness of a patient for discharge, she contacts the surgeon or anaesthetist and, if it is considered necessary, the patient is admitted to an inpatient bed. There can be no question of nonavailability of beds, or of having to transfer the patient to another hospital ‘on take’. It must be clearly understood that for day surgery to be feasible, a bed must always be found for the unexpected admission.8 The incidence of admissions (4% in our unit) depends upon various factors. It is negligible for anaesthetic reasons when local anaesthesia is used, but for patients having general anaesthesia there is a definite incidence; this is chiefly due to persistent nausea and vomiting, vertigo or faintness due to postural hypotension. It varies with the experience of the anaesthetist and the duration and nature of the surgery. Similarly the surgical reasons for admission are usually due to haemorrhage or surgical mishap which also depend partly on the skill of the surgeon and the nature of the procedure. Occasionally unexpected findings at operation require more major surgical procedures, following which admission is necessary.

The return home and,follow up

Patients are advised to remain in bed at home for the rest of the day. They should have only light meals to reduce the risk of vomiting, and avoid alcohol which may be potentiated by the residual effects of general anaesthesia. The community nurse calls the following day, or within 48 hr at the latest, to check that there are no sequelae persisting from the anaesthetic and to change the wound dressings if necessary. She may advise regarding analgesics for wound or trunk pain, sore throats or residual headaches. Postoperative complications are recorded in a routine report on each patient; this takes the form of a simple follow-up chart, which is returned to the day surgery unit, so that the surgeons and anaesthetists can be aware of the incidence of these, and if possible take steps to 5 4 In our unit the incidence reduce them.22s48* of these minor sequelae is under 10%; the figure of 77% quoted in a paper recently is quite unacceptable.

Children very rarely suffer nausea or vomiting after returning home, and the occurrence of behavioural disorders (enuresis and temper tantrums) or chest infections is equally rarely seen. Subsequent visits by the nurse may be made to remove sutures, or the patient can attend the general practitioner’s surgery for this to be done. If more major complications arise (e.g. wound or serious chest infections) the nurse should advise the patient to consult his own doctor, or she can seek his advice. Return to work. Providing the patient feels fit, and he has been seen by the community nurse, he may return to work on the day after his operation. If he has to remain off work for more than 3 days, he will need to collect a National Insurance Certificate from the general practitioner, and this will provide an opportunity for the practitioner to assess his patient’s progress. Should the general practitioner consider the patient needs readmission to hospital, a bed must always be made available in the ward of the surgeon under whose care the patient had been in the day surgery unit, whether that ‘firm ’happens to be ‘on take’ or not that day. The patient should never contact the unit directly after discharge; it will be closed in the evenings anyway, nor should the patient ever come to the hospital directly, except for an emergency such as severe haemorrhage, when an ambulance should be called. The Committee of Management and the Operational Policy of the Unit A small committee of management, represent-

ing those immediately concerned with day surgery, should supervise the running of the unit and deal with any problems that arise. It may be essentially the same as the steering committee which set up the unit, with representatives from the surgeons, anaesthetists, nursing staff and unit secretary providing the hospital views, while the community is represented by a general practitioner and a senior nursing officer of the community nursing service. Other members may be co-opted if particular problems make this desirable. The committee need only meet quarterly, to deal with any problems or complaints that have arisen, with requests for additional sessions or new equipment, and to discuss any general policy decisions.

Blueprint for day surgery The committee receives and discusses the unit statistics (numbers operated upon, patients on the waiting list, incidence of admissions) and reviews the general efficiency of the unit. It should also be concerned with the standards of patient care, and with monitoring the follow-up of patients after discharge. It is also responsible for closing the unit if staffing difficulties arise over holiday periods or at other times making it unsafe or uneconomical to run on depleted numbers and for communicating these decisions to all the users and services concerned. The operational policy A further function of the committee of management is to draw up an operational policy. This should clearly state the conditions and constraints placed upon the users of the unit, and the manner in which the unit will be run. Each surgical firm and responsible party working in, or with, the unit receives a copy of the policy, and whilst it studiously avoids any infringement of clinical management of patients, it must define precisely the responsibilities and duties of all concerned. Providing these are adhered to, no problems are likely to arise which cannot be readily resolved.

Discussion Economic considerations The most powerful argument for day surgery is that it provides surgical treatment for minor conditions in the most economical way possible; by dealing solely with such cases the day surgery unit becomes extremely efficient and capable of treating large numbers at minimal cost. 5 6 - 5 8 ‘Hotel’ expenses. Apart from a ‘snack’, no meals have to be provided, washing facilities are minimal and no baths are taken, beds and bed-linen are not required, thus reducing laundry demands and at night and weekends lighting, heating and water requirements are avoided as the unit is closed. Stafing. Considerable economy in staffing can be effected because the ratio of nurses to patients in the ward area is low, and hence only a few nurses are employed to deal with the large number of patients being treated; highly trained ward nurses are not required, gpart from

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the Sister and her deputy (Staff Nurse), as SEN’S and auxiliary rmses are perfectly adequate for this work and, as the unit is closed at night and at the weekends, there is no requirement for staff at these times. An additional important factor is that there is seldom difficulty in obtaining staff for day surgery units, as they can be recruited from part-time married women, whose skills may otherwise be unused because their domestic commitments preclude their employment elsewhere in the hospital. The hours worked in a day surgery unit, the lack of weekend work, the closing of the unit over holiday periods such as at Christmas and in August, mean that such staff can combine this job successfully with their family life. This is equally true for married anaesthetic clinical assistants. At the same time from the administrator’s point of view the unit has great versatility of function. If there is an acute staff shortage, the unit can be closed and staff deployed temporarily elsewhere; this is in contrast to inpatient units which are unable to close because of their emergency commitment. On the other hand in the event of a sudden demand which might follow a major disaster or epidemic, the ward area could be temporarily taken over for the reception of patients and only minor inconvenience caused to those who have to have their elective surgery postponed. The freeing of inpatient facilities. Syphoning off minor cases means that more beds are available in the inpatient wards to deal with more major surgery. In terms of costeffectiveness it is important that every inpatient surgical bed is filled by patients requiring the full facilities of the hospital as major surgical patients. It also incidentally makes the ward easier to run, since paradoxically major surgical cases, who are likely to remain in hospital for a number of days or weeks, place less of a burden on ward staff, than the daily influx of many minor surgical cases, each requiring documentation, examination, preparation for theatre, postoperative management and discharge. Short of a massive infusion of money for more theatres, staff, wards etc., day surgery would seem to hold out the only hope of reducing the interminable waiting lists, which have existed in the National Health Service (NHS) since its inception, for, if the majority

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of minor cases could be removed from inpatient waiting lists, it would dramatically shorten them to more reasonable proportions. Benefits to the patient

Economic advantages were mentioned first because historically this was the stimulus which led to the development of day surgery, but hospital facilities are first and foremost for patient care, and there are many advantages for the patient in day surgery, which justify its introduction, apart from economic considerations. Psychological advantages. It is obviously undesirable to separate children from their parents and home for a longer period than is absolutely necessary. The incidence of behavioural disturbances that follow a child’s stay in hospital is not insignificant or unimportant. If parents are allowed in the day ward until the child goes to the operating theatre, and can be there when the child returns, the separation is absolutely minimal and the emotional stress to both child and parents is much red ~ ~ e d . The ~ ’ need ~ ~ for ~ *visiting ~ ~ is also abolished and this may save the parents money and time otherwise spent in travelling long distances. Hospitalisation of adults as inpatients makes them feel ‘different’ also, and the longer this is necessary, the more ‘major’ or ‘serious’ the illness appears to the patient; on the other hand a procedure which allows the patient to return home the same day, is considered to be trivial and hardly merits the stigma of ‘being ill’. Segregation of day cases from inpatient wards also means less disturbance to inpatients recovering from major procedures, and minor day cases are spared the sometimes harrowing experience of being next to patients who have had major surgery performed. Convenience. The normal practice of admitting the patient on the day before his operation and discharging him the day after it, means that 3 days are taken up, even for the most minor operation. The same operation done in the day surgery unit would involve one, or at the most, 2 days being taken off work. For the patient having a minor operation, most of the time spent in hospital is as a hotel guest, requiring neither skilled medical nor nursing care, and this period could as well be spent at home enjoying the comfort, food and company, without any

adverse effect upon convalescence. This is particularly true for some women, who may not find it easy to arrange for the care of their children whilst in hospital; even if they have to remain in bed at home after Day Surgery, they can organise the family in a way which would be impossible from a hospital bed. Some women indeed have found it so inconvenient to enter hospital for treatment as inpatients that they have deferred doing so, especially when the complaint is troublesome rather than serious like varicose veins. Day surgery permits them to receive treatment without interfering with their family obligations. Avoidance of long waiting lists. Apart from reducing the inpatient waiting lists by removing the minor cases, day surgery also permits a considerable increase in the turnover of minor cases. In one paediatric and neonatal surgical unit, where the waiting list time was nearly 2 years for minor procedures, the introduction of a day surgical unit reduced this to under 4 weeks. For the adult patient with a minor but nevertheless incapacitating or painful lesion of a benign nature, the prospect has hitherto been one of a prolonged wait for perhaps many years; day surgery brings the possibility of surgery within weeks or months6* Reduction of cross infection. Most wound infections acquired in hospital are derived from the environment. These contaminants are particularly hazardous not only because they are caused by alien strains of bacteria to which the patient has no immunity (in contrast to those in his home environment to which he is likely to have a high degree of immunity) but also because they are much more likely to be resistant to antibiotics. The incidence of wound infection in day surgery patients is generally very low, and, if infection does occur, it responds rapidly to antibiotics. Apart from wound infections, a number of inpatient children acquire intercurrent infections in hospital, and these often necessitate considerable prolongation of their stay in h o ~ p i t a l . ~ ’ . ~ ~ The eflect on surgical complications. Despite alarmist fears of possible complications, which could theoretically arise in patients operated upon in day surgical units, the incidence has, in practice, not been found to be any higher than after inpatient management.6s In fact, the incidence of thromboembolism has been found lower in day surgery patients postoperatively-

Bhrepriritfor day surgery presumably because of the absence of preand postoperative confinement t o bed. Ecotiornic bericfjts to the putierrt aria' tke commuriity. The patient, like the hospital, benefits economically from day surgery. By accelerating the treatment of minor incapacitating conditions, the patient is enabled to return to work quicker, and contribute to his own and the community's economy. Even if the patient has remained at work whilst awaiting treatment, the efficiency of this work is often enhanced by correction of the surgical defect. Possible disadvantages of day srrsgesy I t has sometimes been said that the nursing o n inpatient wards is heavier when only major and intermediate surgery are carried out and there is no leavening effect of minor surgery, since the former requires more demanding care. The latter statement may be true, though for the convalescent period even major cases tend t o look after themselves, while as has already been mentioned, the rapid turnover of minor cases on a general surgical ward often poses a considerable work-load problem, which many nurses also find unsatisfying, owing to the brevity of contact. The work-load of community nurses is undoubtedly increased, in caring for day surgery patients, but these nurses appear to enjoy this contact with acute surgical practice. Although day surgery may reduce the minor surgical waiting lists, it may have the effect of increasing the major surgical lists because, by increasing the number of diagnostic procedures such as cervical dilatation and curettage and cystoscopies, it leads to a number of conditions being found which require major surgery. Thus, although day surgery units remove minor cases from inpatient beds and make room for more major cases, they also generate a greater need for these beds. In teaching hospitals, the lack of contact between students and acute minor surgical cases may mean the loss of valuableexperience,66 and a special effort needs to be made to ensure that students attend the day surgical unit to avoid this. Having indicated the economic advantages of day surgery, it would be less than honest not to concede that the establishment of a unit is never economical to the budget of a hospital

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in a hospital service like the N H S which is free at the point of use. This is because, when a unit opens, no inpatient beds are closed; therefore the 'beds' in the unit are additional. Although the cost per patient may fall, the overall costs of running the hospital rise. It is paradoxically a fact that without such units, the waiting lists would grow longer, but the hospital would not have to find additional funds. It follows that day surgery units never save hospitals money; they merely provide a more economical way of treating a larger number of patients surgically. In hospital systems where payment is made at the point of use day surgery units can be a source of considerable revenue because of their low overhead costs. Cotichisiori Providing the selection of the patients is good, the staff and facilities adequate for the demand, and there is cooperation in the community, there are very few disadvantages to day surgery. The risk of disastrous postoperative complications is potential rather than real for these are rarely, if ever, seen in practice. It must be accepted that although the more common minor complications such as dizziness and nausea can be reduced with improved techniques, they will nevertheless usually be more frequent than if the patient were in hospital. This is probably the main price the patient has to pay for the ability to remain in the bosom of his family but it is not a high one when set against the many advantages. Summary The design, staffing mode of operation and economics of day surgery units have been discussed with particular reference to the British National Health Service. Key words

ANAESTHESIA; S U R G E R Y ; outpatient; day stay ORGANISATION.

Acknowledgments The author is most grateful to Mrs K.J. Betts for the considerable secretarial work involved

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