Professional Documents
Culture Documents
6.day Case and Short Stay Surgery 2 2011
6.day Case and Short Stay Surgery 2 2011
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GUIDELINES
Day case and short stay surgery: 2
This is a consensus document produced by expert members of a Working Party established by the Association of
Anaesthetists of Great Britain and Ireland (AAGBI) and British Association of Day Surgery (BADS). It has
been seen and approved by the Councils of the AAGBI and BADS.
surgery is allowing more procedures to be performed as outcomes in patients with multiple comorbidities,
day surgery and even higher rates should be possible. have changed the emphasis in day surgery patient
There was a major drive to promote day surgery selection. It is now accepted that the majority of
around the turn of this century, but the political focus patients are appropriate for day surgery unless there is
moved on before all of the lessons learned were fully a valid reason why an overnight stay would be to
implemented [3]. Nevertheless, the recent drive to their benefit. If inpatient surgery is being considered it
reduce length of stay and improve the quality of is important to question whether any strategies could
postoperative recovery has ensured that day surgery be employed to enable the patient to be treated as a
principles are fundamental to modern patient care. day case.
Shortened hospital stays and earlier mobilisation also Full-term infants over 1 month are usually appro-
reduce the risk of hospital-acquired infections and priate to undergo day surgery. A higher age limit is
venous thromboembolism (VTE). advisable for ex-premature infants (60 weeks post-
conceptional age). The significant risk posed by
postoperative apnoea must be considered and infants
Recent reports
with recent apnoea episodes, cardiac or respiratory
The NHS Modernisation Agency produced an oper- disease, family history of sudden infant death syndrome
ational guide detailing the facilities available in, and the and adverse social circumstances should be considered
management of, day units [4]. This was further refined for overnight admission and close monitoring. Day
in the Ten High Impact Changes document in which the surgery units should not perform surgery on children
principle of treating day surgery as the default option unless they have suitable staff and facilities.
for elective surgery was set out [3]. The NHS Institute It is recommended that a multidisciplinary approach,
for Innovation and Improvement has also produced a with agreed protocols for patient assessment including
document focusing on day case laparoscopic cholecys- inclusion and exclusion criteria for day surgery, should
tectomy [5]. Whereas this document is specific to one be agreed locally with the anaesthetic department.
procedure, many aspects of the ideal patient pathway Patient assessment for day surgery falls into three main
are equally applicable to a wide range of day surgery categories:
procedures.
Effective pre-operative assessment and preparation Social factors
with protocol-driven, nurse-led discharge are funda- (a) The patient must understand the planned procedure
mental to safe and effective day and short stay surgery. and postoperative care and consent to day surgery.
Several recent publications provide useful advice on (b) Following most procedures under general anaesthe-
the establishment and running of both services [6–10]. sia, a responsible adult should escort the patient home
The British Association of Day Surgery has pro- and provide support for the first 24 h.
duced a directory of procedures that provides targets (c) The patient’s domestic circumstances should be
for day and short stay surgery rates for over 200 appropriate for postoperative care.
different procedures [11]. These procedure-specific
targets serve as a focus for clinicians and managers in Medical factors
the planning and provision of short stay elective (a) Fitness for a procedure should relate to the patient’s
surgery and illustrate the high quality of service health as determined at pre-operative assessment and
not limited by arbitrary limits such as ASA status, age
achievable in appropriate circumstances.
or BMI [13–15].
In March 2010, the Department of Health published
(b) Patients with stable chronic disease such as diabetes,
the enhanced recovery guide that extends day surgery
asthma or epilepsy are often better managed as day
principles to inpatient surgery [12]. cases because of minimal disruption to their daily
routine.
Selection of patients (c) Obesity per se is not a contraindication to day surgery
as even morbidly obese patients can be safely managed
Patients may be referred for day surgery from outpa- in expert hands, with appropriate resources. The
tient clinics, accident and emergency departments or incidence of complications during the operation or
primary care. in the early recovery phase increases with increasing
Recent advances in surgical and anaesthetic tech- BMI. However, these problems would still occur with
niques, as well as the publication of successful inpatient care and have usually resolved or been
Incision and drainage of abscess Evacuation of retained products Tendon repair Manipulation of
of conception fractured nose
Laparoscopic cholecystectomy Laparoscopic ectopic pregnancy Manipulation of fractures Repair of fractured
mandible ⁄ zygoma
Laparoscopic appendicectomy Plating of fractured clavicle
Temporal artery biopsy
successfully treated by the time a day case patient would Screening questionnaires (Appendix 1), in conjunc-
be discharged. In addition, obese patients benefit from tion with pre-set protocols, can offer guidance on
the short-duration anaesthetic techniques and early appropriate investigations, as routine pre-operative
mobilisation associated with day surgery [16]. investigations have no relevance in modern anaesthesia.
Although the National Institute of Health and Clinical
Excellence (NICE) guidance on pre-operative investi-
Surgical factors
gations [18] is widely used, one recent study showed no
(a) The procedure should not carry a significant risk of
difference in the outcomes of day surgery patients even
serious complications requiring immediate medical
attention (haemorrhage, cardiovascular instability). when all pre-operative investigations were omitted [19].
(b) Postoperative symptoms must be controllable by the Pre-operative preparation clinics can improve
use of a combination of oral medication and local efficiency by enabling early review of the notes of
anaesthetic techniques. complex cases, ensuring appropriate investigations are
(c) The procedure should not prohibit the patient from carried out and that patients are referred for specialist
resuming oral intake within a few hours. opinion if deemed necessary.
(d) Patients should usually be able to mobilise before
discharge although full mobilisation is not always Day surgery for urgent procedures
essential. Patients presenting with acute conditions requiring
urgent surgery can be efficiently and effectively treated
Pre-operative preparation as day cases via a semi-elective pathway [20]. After
Pre-operative preparation (formerly known as pre- initial assessment many patients can be discharged
operative assessment) has three essential components: home and return for surgery at an appropriate time,
1 To educate patients and carers about day surgery either on a day case list or as a scheduled patient on an
pathways. emergency list, whereas others can be immediately
2 To impart information regarding planned procedures transferred to the day surgery service. This reduces the
and postoperative care to help patients make informed likelihood of repeated postponement of surgery due to
decisions – important information should be provided prioritisation of other cases. A robust day surgery
in writing. process is key to the success of this service. Some of the
3 To identify medical risk factors, promote health and procedures successfully managed in this manner are
optimise the patient’s condition. shown in Table 1 [21–25]. Essential components of an
All patients must be assessed by a member of the emergency day surgery pathway are:
multidisciplinary team trained in pre-operative assess- 1 Identification of appropriate procedures.
ment for day surgery. Consultant-led and nurse-run 2 Identification of a theatre list that can reliably accom-
clinics have proved very successful. modate the procedure (e.g. a dedicated day surgery list
Pre-operative preparation is best performed within a or a flexibly run emergency theatre list).
self-contained day surgery facility, where available. 3 There should be clear pathways for day surgery in place.
This allows patients and their relatives the opportunity 4 The condition must be safe to be left untreated for a day
to familiarise themselves with the environment and to or two and manageable at home with oral analgesia
meet staff who will provide their peri-operative care (standardised analgesic pack for the patient to take
[17]. One-stop clinics, where pre-operative prepara- home).
tion is performed on the same day as decision for 5 There should be provision of clear pre-operative
surgery, offer significant advantages. patient information, ideally in writing.
to centralise these services; however, all such patients guidelines for VTE risk assessment and prophylaxis
should receive the same high standards of selection, should be followed.
preparation, peri-operative care, discharge and follow- Policies should exist for the management of post-
up as those attending dedicated day surgery facilities. operative nausea and vomiting (PONV) and discharge
Facilities should ensure the maintenance of patients’ analgesia. Prophylactic antiemetics are only recom-
privacy and dignity at all times. Side rooms are mended in patients with a strong history of PONV,
particularly useful when caring for patients requiring motion sickness and those undergoing certain proce-
an increased level of sensitivity, or for those with dures such as laparoscopic sterilisation ⁄ cholecystec-
special needs. tomy or tonsillectomy. However, it is important that
Children should be cared for in a facility that reflects PONV is treated seriously once it occurs. Routine use
their emotional and physical needs, separate from adult of intravenous fluids can enhance the patients’ feeling
patients and conforming to the standards required by of wellbeing and further reduce PONV [36].
paediatric units. Nursing staff should be skilled in
paediatric day surgical care. Parents and carers,
Regional anaesthesia
wherever possible, should be involved in all aspects
of care and appropriate facilities provided for them. Local infiltration and nerve blocks can provide excel-
lent anaesthesia and pain relief after day surgery.
Patients may safely be discharged home with residual
Anaesthetic management
sensory or motor blockade, provided the limb is
Day surgery anaesthesia should be a consultant-led protected and appropriate support is available for the
service. However, as day surgery becomes the norm for patient at home. The expected duration of the
elective surgery, consideration should be given to blockade must be explained and the patient must
education of trainees as recommended by the RCoA. receive written instructions as to their conduct until
This requires appropriate training and provision of normal power and sensation returns. Infusions of local
senior cover, especially in stand-alone units. Staff grade anaesthesia may also have a place [37]. The use of
and associate specialist anaesthetists who have an ultrasound is increasingly gaining popularity, particu-
interest in day surgery should be encouraged to larly in upper limb surgery, and is recognised as a useful
develop this as a specialist interest and take an tool in several areas of regional anaesthesia.
important role in the management of the unit. Central neuraxial blockade (spinal or caudal) can be
Appropriate selection and patient preparation is useful in day surgery and is increasing in popularity,
crucial for day surgery. National guidelines for patient although residual blockade may cause postural hypo-
monitoring and assistance for the anaesthetist should be tension or urinary retention despite the return of
followed [34, 35]. adequate motor and sensory function. These problems
Anaesthetic techniques should ensure minimum can be minimised by choosing an appropriate local
stress and maximum comfort for the patients and anaesthetic agent or by the use of low-dose local
should take into consideration the risks and benefits of anaesthetic ⁄ opioid mixtures [38]. Suggested criteria
the individual techniques. Analgesia is paramount and before attempting ambulation after neuraxial block
must be long acting but, as morbidity such as nausea include the return of sensation in the perianal area
and vomiting must be minimised, the indiscriminate (S4-5), plantar flexion of the foot at pre-operative levels
use of opioids is discouraged (particularly morphine). of strength and return of proprioception in the big toe
Prophylactic oral analgesics with long-acting non- [39].
steroidal anti-inflammatory drugs (NSAIDs) should be Sedation is seldom needed but, if used, suggested
given to all patients if not contraindicated. For discharge criteria should be met and the patient must
certain procedures (e.g. laparoscopic cholecystectomy) receive an appropriate explanation.
there is evidence that standardised anaesthesia proto- Oral analgesics should be started before the local
cols or techniques improve outcome. Anaesthetists anaesthesia begins to wear off and also given subse-
should adhere to such clinical guidelines where they quently on a regular basis.
exist. The patient’s hydration should be checked. Con-
Although early mobilisation should be beneficial, cerns about post-dural puncture headache (PDPH)
extending the range and complexity of day surgery have limited the use of spinals in day surgery patients in
procedures may increase the risk of VTE. National the past, but the use of smaller gauge (‡ 25-G) and
pencil-point needles has reduced the incidence to written information that includes warning signs of
< 1%. Information about PDPH and what to do if this possible complications and where to seek help. Proto-
occurs should be included in the patient’s discharge cols should exist for the management of patients who
instructions as well as the provision of alternative require unscheduled admission, especially in a stand-
analgesics. Further information on the use of spinal alone unit.
anaesthesia in day surgery and examples of patient 3 Late recovery ends when the patient has made a full
information leaflets can be found on the BADS website physiological and psychological recovery from the
(http://www.bads.co.uk). procedure. This may take several weeks or months and
The current nationally agreed curriculum limits the is beyond the scope of this document.
scope of PA (A)s. On completion of training they are
not qualified to undertake regional anaesthesia or Postoperative instructions and discharge
regional blocks [40]. All patients should receive verbal and written instruc-
tions on discharge and be warned of any symptoms that
might be experienced. Wherever possible, these instruc-
Postoperative recovery and discharge tions should be given in the presence of the responsible
Recovery from anaesthesia and surgery can be divided person who is to escort and care for the patient at home.
into three phases: Advice should be given not to drink alcohol, operate
1 First stage recovery lasts until the patient is awake, machinery or drive for 24 h after a general anaesthetic
protective reflexes have returned and pain is controlled. [45]. More importantly, patients should not drive until
This should be undertaken in a recovery area with the pain or immobility from their operation allows
appropriate facilities and staffing [41]. Use of modern them to control their car safely and perform an
drugs and techniques may allow early recovery to be emergency stop. Procedure-specific recommendations
complete by the time the patient leaves the operating regarding driving should be available.
theatre, allowing some patients to bypass the first stage All patients should be discharged with a supply of
recovery area [42]. Most patients who undergo surgery appropriate analgesics and instructions in their use.
with a local anaesthetic block can be fast-tracked in this Analgesia protocols (Appendix 4) relating to day
manner. surgery case mix should be agreed with the pharmacy.
2 Second stage recovery ends when the patient is ready for Free pre-packaged take-home medications should be
discharge from hospital. This should ideally be in an area provided as they are convenient and prevent delays and
adjacent to the day surgery theatre. It should be unnecessary visits to the hospital pharmacy.
equipped and staffed to deal with common postoper-
ative problems (PONV, pain) as well as emergencies Discharge summary
(haemorrhage, cardiovascular events). The anaesthetist It is essential to inform the patient’s general practitioner
and surgeon (or a deputy) must be contactable to help promptly of the type of anaesthetic given, the surgical
deal with problems. Nurse-led discharge using agreed procedure performed and postoperative instructions
protocols is appropriate (Appendix 3). Some of the
given. Patients should be given a copy of this discharge
traditional discharge criteria such as tolerating fluids and
summary to have available should they require medical
passing urine are no longer enforced. Mandatory oral
assistance overnight.
intake is not necessary and may provoke nausea and
Day surgery units must agree with their local primary
vomiting and delay discharge. Voiding is also not always
required, although it is important to identify and retain care teams how support is to be provided for patients in
patients who are at particular risk of developing later the event of postoperative problems. Best practice is a
problems, such as those who have experienced pro- helpline for the first 24 h after discharge and to
longed instrumentation or manipulation of the bladder telephone the patient the next day. Telephone follow-
[43]. Protocols may be adapted to allow low-risk up is highly rated by patients, provides support for any
patients to be discharged without fulfilling traditional immediate complications, and is useful for auditing
criteria. Mild postoperative confusion in the elderly postoperative symptoms and patient satisfaction.
after surgery is common. This is usually insignificant
and should not influence discharge provided social Audit
circumstances permit; in fact, the avoidance of hospi-
talisation after minor surgery is preferred [15, 44]. Effective audit is an essential component of assessing,
Patients and their carers should be provided with monitoring and maintaining the efficiency and quality of
patient care in day surgery units. Systems should be in specialty for advanced level training [50]. However,
place to ensure the routine collection of data regarding formal day surgery training programmes for anaesthetic
patient throughput and outcomes. There have been a (and surgical) trainees are rare.
variety of tools developed to determine patient out- The competencies required by the RCoA cover the
comes. Questionnaires, which rely on the patients’ entire day surgery process, not simply the anaesthetic
completing documentation and returning them to the component. It is essential to design a well-structured
day unit, are notoriously inaccurate and response rates module that provides training in anaesthesia for all
are often very low. The most successful units collect data aspects of day surgery and exposure to the organisa-
electronically at all stages of the day surgery process. tional challenges of running a day surgery unit. To
The RCoA’s compendium of audit recipes devotes a facilitate this, it is recommended that advanced training
section to possible audits relevant to day surgery [46]. It should take place in a dedicated day surgery unit [50],
must be stressed that the most reliable way of yet few such units exist. It is important to remember
improving service is continuous audit and review of that high quality day surgery requires the experience of
outcomes rather than one-off snapshots. Information senior anaesthetists (and surgeons) and that although
regarding trends in the patients’ outcomes should be the day surgery unit is an ideal environment for
widely distributed amongst the members of the team. training junior medical staff, relying on them to deliver
Audit of day surgery services relate primarily to the service results in poorer quality patient outcomes
quality of care and efficiency. Examples of day surgery and reduced efficiency [51, 52].
processes amenable to audit that have some measurable A list of topics that might be included in a day
outcomes are shown in Table 2. surgery module is shown in Appendix 5.
Audit of patients’ satisfaction should be carried out The training delivery should be audited; some
routinely. A robust database is helpful; however, suggestions for this are given in the RCoA audit
the best databases fail to effect change unless the compendium [46].
information is clearly displayed and freely disseminated The day surgery unit is an excellent environment for
to the day surgery users. Monthly graphs and figures surgical and nursing training and many of the aspects
detailing all outcomes and trends should be dissemi- covered above are equally applicable to surgical and
nated to everyone, particularly to key individuals nursing colleagues.
empowered to influence change.
Day surgery in special environments
Teaching and training
A number of complex and highly specialist procedures
The RCoA has placed Day Surgery as a core module in are beginning to enter the day surgery arena. Awake
all three components of anaesthetic training: Basic (year craniotomy for tumour resection has been performed
1 ⁄ 2) [47], Intermediate (year 3 ⁄ 4) [48] and Higher as a day case in the UK [53]. In the interventional
(year 5 ⁄ 6 ⁄ 7) [49]. It also recommends day surgery as a X-ray suite, uterine artery embolisation is a day case
procedure, whereas endovascular aneurysm stents and be aware of this in managing any risk. Any association
several other procedures are appropriate for a short stay with a nearby acute unit should be reviewed regularly.
approach. Optimal care for these procedures should be Remoteness is a factor to be considered in the
developed by those with expertise in day and short stay delivery of a safe and efficient service. A minimum of
surgery, working in collaboration with specialists in the two anaesthetists on site should be considered at any
management of the specific procedure. Many of these one time. Prolonged travel time may be an issue for
procedures are undertaken in challenging environ- visiting staff. On-call commitments must be taken into
ments, such as X-ray departments. All the accepted account so as to avoid accidents and fatigue either in
standards for delivery of anaesthesia, assistance for theatre or when travelling.
the anaesthetist, minimal monitoring and the availabi- The operational policy must agree clear manage-
lity of appropriate recovery (post-anaesthesia care unit ment of certain key issues. These include:
(PACU)) facilities should be achieved. • Management of patients who cannot be discharged
home.
• Management of patients with problems after discharge.
Introducing new procedures to day surgery
• Appropriate cover for the service and patients until
The successful introduction of new procedures to day they are discharged.
surgery depends on many factors, including the proce- • Appropriate patient screening and selection with
dure itself and surgical, nursing and anaesthetic col- availability of medical records.
leagues. It is important to evaluate the procedure while • Management of medical emergencies, e.g. cardiac arrest
still performing it as an overnight stay and identify any and major haemorrhage, and the availability of mate-
steps in the process that require modification to enable rials and skilled personnel to deal with complications
it to be performed as a day case, e.g. timing of when the anaesthetist is in theatre.
postoperative X-rays, modification of intravenous • Transfer agreements with local hospitals and intensive
care facilities
antibiotic regimens, physiotherapy input and analgesia
• Robust, tested communications between the stand-
protocols [54]. A multidisciplinary visit to another unit
alone unit, the nearest acute hospital and the ambu-
where the procedure is performed successfully as a day
lance services.
case can be very helpful. Initially limiting the procedure • Teaching, training and supervision and opportunities
to a few colleagues (surgeons and anaesthetists) allows for research.
an opportunity to evaluate and optimise techniques and This list is not meant to be exhaustive but gives
to implement step changes so that the patient can be guidance to some of the important areas that require
discharged safely and with good analgesia. Support from consideration.
community nursing can be helpful, especially in these
early stages. Once the procedure has been successfully
moved to the day surgery setting it can be expanded to Short stay surgery and enhanced recovery
include other surgeons and anaesthetists as appropriate. New approaches to the assessment and management of
Clear clinical protocols help to ensure that all the lessons patients undergoing more complex surgery are being
learned during the evaluation phase are clearly passed on used to improve the quality of recovery, reduce the
to colleagues. incidence of postoperative complications and reduce
lengths of stay. Many of these techniques are based on
Isolated day surgery units
the wider application of well-established day surgery
principles and are aimed at improving the quality of
Many day surgery facilities in the UK and Ireland are recovery so that the patient is well enough to go home
isolated and the number of these is increasing. sooner. These strategies are variously called enhanced
Currently, there is no set absolute minimum distance recovery, fast-track [55], accelerated or rapid recovery.
between any stand-alone unit and the nearest acute or For any surgical operation there is a large variation in
associated hospital, although large distances are uncom- average lengths of stay in hospitals across the UK and
mon. The commissioning of any new isolated stand- Ireland. Increasing numbers of hospitals are focusing on
alone unit requires analysis of its suitability for the the short stay pathway and plan to manage the majority
provision of intended services. These facilities may or of their elective patients with stays of fewer than 72 h.
may not be purpose-built and the Clinical Lead must To achieve the maximum benefit from this, hospitals
are developing 24-h stay facilities (some as part of their Postoperative factors
existing day units) and are embracing these principles. Effective analgesia that minimises the risk of PONV
and allows early mobilisation plays a vital role in
Principles of enhanced recovery enhanced recovery. Systemic opioids should be
Enhanced recovery is the outcome of applying a range of avoided where possible and regular oral (or intrave-
multimodal strategies that are designed to prepare and nous) analgesia with simple analgesics (paracetamol and
optimise patients before, during and after surgery, NSAIDs) should be used. For more invasive proce-
ensuring prompt recovery and discharge [12]. Most of dures, epidural analgesia should be maintained in the
these principles are already well established in day postoperative period. Hydration should be maintained
surgery, which can be considered the ultimate example with intravenous fluids but discontinued as soon as the
of enhanced recovery. Anaesthetic departments should patient returns to oral fluids, and PONV should be
play a major role in this as they can contribute extensively treated aggressively using a multimodal approach to
to all phases of the patients’ management. Many of these therapy.
interventions are derived from day surgery. The patient should be mobilised within 24 h. They
should be aware and encouraged to meet milestones for
Pre-operative factors mobilisation, drinking and eating. This requires active
Pre-operative preparation of the patient plays a crucial involvement from both the medical and nursing teams
role and identifies additional risk factors and ensures in the immediate postoperative period. The provision
that their medical condition is optimised. Cardiopul- of a specified dining room, with access to high calorie
monary exercise testing provides further information to drinks and where meals can be taken, encourages the
enable anaesthetists to discuss these risks with their patient to mobilise.
patients and ensure that high-risk patients are coun- There should be a target discharge date set for which
selled appropriately. An appropriate level of intensive the staff, patients and relatives should aim, and as in day
or high dependency care can also be put in place if surgery the discharge should be a nurse-led process and
necessary. Patients and their carers should receive a not dependent on consultant review.
careful explanation about the procedure and what will
happen to them at every stage of the peri-operative
The patient’s perspective
pathway. This includes resumption of food, drink,
mobilisation and information about discharge and A Mayo Clinic study in 2006 showed that patients
when this is likely to take place. As with day surgery, want their doctors to be confident, empathetic,
the provision of written information is vital. humane, personal, forthright, respectful and thorough
Patients should usually be admitted on the day of [56]. Interestingly, there was no mention of compe-
surgery with minimal starvation times (i.e. 3 h for tence, implying that patients inherently believe their
fluids) and consideration given to the use of oral doctors to be competent. A survey carried out by
carbohydrate loading. Analgesia with paracetamol and MORI on behalf of the RCoA in May 2000 found
NSAIDs should be started pre-operatively if not that 35% of the general public did not believe that
contraindicated, and hypothermia avoided. anaesthetists were medically qualified doctors [57].
Hence, there is a credibility gap that anaesthetists need
Intra-operative factors to address. It is important to ensure that patients are
Minimally invasive surgery should be combined with made aware that anaesthetists are highly qualified
use of regional anaesthesia where possible. Thoracic professional doctors. The patient information leaflets
epidurals or other regional anaesthetic techniques produced by the AAGBI and the RCoA can be useful
should normally be used for abdominal surgery in in this regard.
patients likely to require more than oral analgesia It is important to realise that to most patients,
postoperatively. Long acting opioids, nasogastric tubes anaesthesia means general anaesthesia with loss of
and surgical drains should be avoided. Intra-operative consciousness during the procedure, and the patient
fluid therapy should be goal directed to avoid sees this as ceding total control to someone else.
sodium ⁄ fluid overload and attention should be paid to Nobody is really completely comfortable with this.
maintaining normothermia. Anaesthetic techniques are The psychology of surrendering control can result in
otherwise similar to day surgery with the expectation patient attitudes that may not be explicitly commu-
that patients will mobilise and eat ⁄ drink later in the day. nicated to the anaesthetist. This can cause a lot of
stress and anxiety. Patients are therefore worried 2 NHS Institute for Innovation and Improvement. Better
about: Care, Better Value Indicators. http://www.productivity.
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Waiting, Booking and Choice, 2002. http://www.dh.gov.
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Other concerns that are relatively common to Pre-operative Assessment and Patient Preparation – The Role
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with loss of control: 7 British Association of Day Surgery. Ten Dilemmas in
• Embarrassment about perceived loss of control of Preoperative Assessment for Day Surgery. London: BADS,
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bodily functions e.g. wetting the bed, or saying
8 British Association of Day Surgery. Organisational Issues
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in Pre Operative Assessment for Day Surgery. London:
• Nausea and vomiting.
BADS, 2010.
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55 Wilmore DW, Kehlet H. Recent advances: management Hospital. Caring for children in the Health Services. Just for
of patients in fast track surgery. British Medical Journal the Day. London: The Stationery Office, 1991.
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56 Li JT. The quality of caring. Mayo Clinic Proceedings 2006;
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57 Corrado M, Carluccio A. Perceptions of anaesthetists – a
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the Royal College of Anaesthetists for National Anaes-
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13 Scottish Health Planning Note 52: Accommodation
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1 Association for Perioperative Practice. Staffing for Health Facilities Scotland, 2001.
Patients in the Perioperative setting. Harrogate: AfPP, 14 Smith I, ed. Day Care Anaesthesia. Fundamentals of
2008. Anaesthesia & Acute Medicine Series. London: BMJ
2 Department of Health. Getting the right start. National Books, 2000.
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3 Department of Health and Children. Children First: ment of Ireland, 2009. http://www.audgen.gov.
National Guidelines for the Protection and Welfare of ie/documents/annualreports/2008/Appropriation_
Children. London: DoH, 1999. Account_2008Rev1.pdf (accessed 11 ⁄ 01 ⁄ 2011).
4 Health Service Executive. HSE National Service Plan
2010. Dublin: HSE, 2010.
Appendix 1
Sample screening questionnaire for use in day surgery. University Hospital of North Staffordshire, with
permission.
Appendix 2
Sample patient information sheet for use in day surgery. Royal Surrey County Hospital NHS Foundation Trust,
with permission.
Appendix 3
Discharge checklist for day surgery. Reproduced from: British Association of Day Surgery. Nurse Led Discharge.
London: BADS, 2009, with permission.
Minimal pain
Minimal bleeding
Cannula removed
Follow up appointment
Referrals made
Dressings supplied
Sick certificate
Appendix 4a
Acute pain protocol for adult surgery.
Pain intensity Discharge medication Doctor’s signature (sign one box only)
A None None
Appendix 4b
Pain categories for common procedures in the day surgery unit, to be used in conjunction with the above.
A B C D
EUA ⁄ MUA, examination ⁄ manipulation under anaesthesia; ACL, anterior cruciate ligament