Title: The Future of Day Surgery: The Ambulatory Pathway
1The Future of Day SurgeryThe Ambulatory Pathway
- Ian Smith, MD, FRCA
- Senior Lecturer in Anaesthesia
- University Hospital of North Staffordshire
- President, British Association of Day Surgery
2Benefits of Day Surgery
- Quality care
- early better recovery
- minimal disruption
- comfort of own home
- PATIENT PATHWAY
- Better care,
- Safer care
3Surgical Length of Stay Cascade
4Typical Surgical Pathway
Referral from GP Outpatient review Diagnostics Fur
ther review Decision to operate
Inpatient Waiting list Preop assessment Surgery
(if suitable)
Day case Waiting list Preop assessment Surgery
(if suitable)
5Key Pathway Areas
- Referral outpatients
- Preassessment selection criteria
- Booking
- Patient admission
- Operating lists recovery
- Discharge, documentation support
6Patient Referral
- Fit to proceed to surgery?
- Info on longterm conditions
- Understands referral may ? surgery
- Understands timescale
- Diagnostic tests
- with results
- Potential for day surgery
7Surgical Outpatients
- Surgery possible / worthwhile?
- Discuss risks benefits
- inform consent
- Day surgery possible?
- in this case
- surgical factors
8Preoperative Assessment
- Nurse performed
- clinician supervised
9Preoperative Assessment
- Nurse performed
- clinician supervised
- Various models
- centralised
- DSU
- telephone
Lewis, et al. J One-day Surg 19 32, 2009
10Preoperative Assessment
- Nurse performed
- clinician supervised
- Various models
- centralised, DSU, telephone
- Information
- procedure day of surgery
- fasting medication
- recovery pain management
11Default to Day Surgery
Suitability for day surgery
Pathway
2030
Day surgery Home if ok
Clearly suitable
4065
Inpatient care ? Home if ok
Unsure
520
Inpatient care Hospital stay
Clearly unsuitable
12Booking
- 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
13Operating Lists
- Dedicated day surgery lists
- Mix of day and short stay surgery
- efficient
- flexible
- Mix of day and inpatient surgery
- tension
- conflicting needs
14Pooled 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
15Optimising List Order
- Major cases first
- appropriate observation recovery time
- Diabetics early
- minimal disruption to routine
- Minor cases later
- LA cases can go last
- need less recovery time
16Recovery Facilities
- Fully equipped to usual standard
- trained staff
- Potential for rapid turnover
- staffing levels
- Second stage recovery
- nurse led discharge
17Patient Discharge
- Nurse led
- Supported by
- documentation
- information
18Safety Mechanisms
- Defined pathway
- Review 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
19Patient referral
Surgical outpatients
Preoperative assessment
The Streamlined Pathway
Selectioncriteria
Booking
Admission
Operating lists
Recovery facilities
Patient discharge
Documentation
Post-dischargesupport
20Future of Day Surgery
- Aging population
- Obesity time bomb
- Increasing surgical complexity
- Therefore many challenges
21Variation 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
22Incentivising Best Practice
Orthopaedic subacromial decompressionbunionsDupuytrens
Breast mastectomysentinel node
ENT tonsillectomyseptoplasty
Gynae female incontinence
Urology TUR laser prostate
General lap cholehernia repair
Best Practice Tariffs
23The Near Future?
- True day surgery
- 85
- Overnight stay
- 5
- Longer stay
- 10
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