GUIDELINE 3
Day Surgery Information
Children and young people in day surgery
Introduction
The needs of children and young people undergoing day surgery are very different
to those of adults, and the clinical safety margins of care are very small. They
are a vulnerable client group as they differ emotionally, psychologically, and
physiologically from adults.
As well as providing clinical care in an environment that is as safe and stress-free
as possible, care should be provided by staff who are educated in the needs of
children and young people and their carers. For many children and young people,
day surgery may be their first and only experience of a hospital environment. The
experience will often be remembered and may colour the way children react to
subsequent hospital admissions and even other life experiences into adulthood
(DH, 2003; RCN, 2011a; RCOA, 2010; RCSENG, 2013).
Care of children and young people, whenever possible, should be provided on a day
care basis. Their interests are most often best served by being in hospital for the
briefest possible time in order to provide safe and effective treatment (DH, 2003;
RCN, 2011a; RCSENG, 2013). Day care surgery is the most appropriate method
for children, providing the operation is not complex or prolonged and the child is
healthy with no significant co-existing illnesses (RCOA, 2010).
All hospitals operating on children and young people should have clear operational
policies and procedures in place specific to the needs of children. In order to
minimise anxiety and optimise care the following should be considered: preoperative assessment and preparation; pre-operative fasting guidelines; what
clothes children wear to theatre; modes of transport to theatre; nursing care; pain
management and discharge follow-up advice. (DH, 2003; RCN 2011a; NCEPOD,
2011; RCSENG, 2013).
Day surgery units should not perform surgery on children unless they have suitable
staff and facilities (Verma et al, 2011).
All nurses involved with children and young people undergoing surgery should be
familiar with the recommendations in the government and professional documents
listed in the references section.
Staff education and training
• Registered children’s nurses should be available to care for children in day
surgery. Government, statutory and professional bodies have issued guidance
and standards for clinical staff caring for children and young people. Staff
treating children must have the education, training, knowledge and skills to
provide high quality care (DH, 2003; RCN, 2011a; NCEPOD, 2011; RCN, 2013;
RCSENG 2013).
• Guidance and standards state that a minimum of two registered children’s
nurses should be on duty throughout the time in which children are cared for.
(DH, 2003; RCOA, 2010; RCN, 2013).
• A play specialist should be available to provide preparation and support to the
child or young person (DH, 2003; RCSENG, 2013).
• Immediate access to paediatric medical support should be available
(NCEPOD, 2013).
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GUIDELINE 3
Day Surgery Information
Children and young people in day surgery
• Staff providing direct care to children and young people must have a Criminal
Records Bureau check, pre-employment checks, and receive training in child
protection, in accordance with the intercollegiate document (RCPCH, 2010;
RCSENG, 2013).
• In day surgery areas, there must be staff trained to advanced-level paediatric
life support (DH, 2003).
• Day surgery units that find difficulty in recruiting registered children’s nurses
may consider rotational or across-site nursing posts. Access to a dedicated
nurse bank also ensures units can offer appropriate care to children but allows
employment on a more ad hoc basis. Nurses caring for children should receive
training to keep up-to-date with consent issues, calculation of children’s drug
dosages and resuscitation skills (RCN, 2013).
Staff skills
Due to the nature of day case surgery, there is minimal time to build up a trusting
relationship with the child or young person and their family before surgery.
• Both verbal and non-verbal communication skills must be used to ensure a
successful outcome to the day surgery process. Verbal skills are used to give
information to the parent and child or young person and must be pitched at
the right level to ensure understanding. The nurse must be able to pick up
different non-verbal signs shown by children of various ages to detect anxiety,
pain and distress.
• Information must be pitched at the correct level for both parent and child or
young person so they can make an informed choice about the procedure and
feel in control of the situation.
• All staff in contact with children and young people should be trained in the
developmental, psychological and communication aspects of care.
• All staff must be able to competently recognise and assess the level of pain
in both communicative and non-communicative children and young people.
They must be competent to administer analgesic drugs and also in non-drug
intervention (RCN, 2011a).
• Clinical staff must be able to recognise a sick child quickly and start emergency
treatment, including resuscitation.
Supporting the parents or carers
• Parents and carers should, wherever possible, be involved in all aspects of care
and appropriate facilities should be provided for them (Verma et al, 2011. DH,
2004. RCSENG, 2013).
• The nurse must ensure that the parent or carer is able to participate as much as
possible in their child’s care.
• To achieve a successful outcome for the child or young person and their family,
the parent or carer should be consulted on the expected care and encouraged to
be active participants. This often reduces the overall stress of the experience for
the child or young person and their family. They should know what is expected
of them as partners in care and receive help from staff.
• Nurses should ensure that the physical and psychological needs of the parents
are met if they are to give optimum support to the child throughout the day.
Parents are expected to have more responsibility for their child during day care
than inpatient care and are thought to be more anxious.
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GUIDELINE 3
Day Surgery Information
Children and young people in day surgery
Environment
• Children should be nursed in specifically designed, child friendly and safe
paediatric day care units, which reflect the emotional, developmental and
physical needs for the child or young person.
• If children and young people must be cared for on an adult day unit, there must
be a specific area for them and their parents or carers, and separate sessions
and/or facilities should be provided (DH, 2003; RCOA, 2010; NCEPOD, 2011).
• There should be appropriate facilities for play, with suitable equipment, toys,
games and a play area (DH, 2003; RCSENG, 2013; Verma et al, 2011).
• Where children are admitted to an inpatient ward for day surgery, there should
be separate policies and operational rules established.
• Young adults (16-18 years) have the right to choose between a children’s ward,
an adult ward or, if available, a ward for adolescents (DH, 2004). In reality,
choice of accommodation often depends on service provision and the procedure
being undertaken. Consideration should be given to the age and emotional
needs of the child or young person (NHS, 2007).
• The environment must be safe and secure. (DH, 2003). There should be CCTV
and swipe access in place (RCN 2011a).
Preoperative care
• Where admission to hospital is planned, children and young people should be
prepared through pre-admission play and information (DH, 2003). They should
have an appropriate clinical assessment prior to surgery. This is often most
easily performed in a pre-admission clinic (NCEPOD, 2011).
• The preparation of a child and family should begin before the child is admitted
for surgery. Both written and verbal information should be available in the
outpatient department. Direct contact with the day ward should be arranged
with the opportunity to meet the staff who will be looking after the family.
• Units should have an organised pre-admission programme that incorporates
many elements of the day surgery process. This gives the child or young person
and their parent or carer a chance to express any fears and to learn how to
prepare for admission and what to do on the day. It is an ideal opportunity
to explain the fasting rules, and to discuss postoperative pain management
and recovery care. Addressing the child and family’s physical, psychological
and social needs at pre-assessment enables the process of care to be carried
through until discharge, thereby providing an episode of care that is smooth,
timely and appropriate. Good quality verbal and written information should be
given on all relevant aspects of care (NCEPOD, 2011; RCOA, 2010).
• There are many good examples of pre-operative preparation available. The
further reading section of this leaflet offers a selection.
• While many families will have sought advice and prepared well, others will be
extremely anxious. Their fears may be transferred to the child or young person.
Nurses need to have the skill to quickly assess the family and adapt their
practice to individual needs.
• On the day of admission the child or young person and family should be
welcomed to the unit and introduced to the nurse caring for them. Ideally, if they
have attended for a pre-admission visit, the same staff should be available to
prepare the child for surgery. Play staff are invaluable in organising play and
preparation activities to help reduce anxiety and boredom.
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GUIDELINE 3
Day Surgery Information
Children and young people in day surgery
• The family and child or young person should be encouraged to take an
active part in the preoperative assessment and documentation process. The
documentation should include space to record the child’s personal likes and
dislikes (such as a nickname), any known allergies and specific anxieties.
• During the preparation process, the child or young person and their family
should be introduced to the pain assessment tool used by the unit. Enabling
children and young people to understand the process will ensure accurate
assessment can be made post-operatively and that analgesia is tailored to the
individual requirements of each child.
Policies and procedures
• Full-term infants over one month old are usually appropriate to undergo day
surgery. A higher age limit is advisable for ex-premature infants (60 weeks
post-conceptual age) (RCOA, 2010; Verma et Al, 2011).
• Elective surgery should wherever possible be scheduled on designated
children’s lists. Where not possible, designated time should be scheduled at the
start of lists. Cases should be scheduled considering the needs of children and
carers. (DH, 2003; NCEPOD, 2011; RCSENG, 2013).
• Pre-operative starvation guidelines for children and young people undergoing
day surgery currently advise:
• 2 hours for clear fluids (through which newsprint could be read)
• 4 hours for breast milk
• 6 hours for cow’s milk, formula and food (including sweets)
• chewing gum should not be allowed.
(RCN 2005).
• Fear of needles is always a concern for children and young people. The use
of a topical local anaesthetic cream such as EMLA or ametop is recommended.
Clear guidelines as to their use must be available and followed.
• Consent for the procedure should be obtained from the person with parental
responsibility and in most cases from the child or young person themselves,
in accordance with guidance from the Nursing and Midwifery Council and the
General Medical Council (see further reading section).
• Sedative pre-medication is not routinely offered to children and young people
before day surgery as the effects are unpredictable and can cause excessive
drowsiness post-operatively. Occasionally, an oral sedative may be helpful in
cases of extreme anxiety or distress.
• Getting undressed and wearing a theatre gown can be very distressing for
some children and young people. Many units have child-friendly gowns or allow
children to wear their own loose fitting clothing or nightwear. Nurses should
ensure a child’s dignity is maintained at all times.
• Except when the child or young person has been pre-medicated, the family should
choose the method of transport to the anaesthetic room. This could mean being
carried, walking, or riding a special car or bike rather than a theatre trolley. For
children and young people who become overly anxious in unfamiliar environments,
the use of their own push chair or wheel chair should be considered.
• A parent or carer should be encouraged to accompany the child or young person
into the anaesthetic room and stay with them until the child is asleep. The
nurse must ensure that the parent understands what to expect at the time of
induction, offer support during and after this procedure, and keep them fully
informed of progress. It must be remembered that some parents or carers will
not feel comfortable with this role. In this instance they must be supported and
reassured that this is acceptable, and the admitting nurse or play specialist
should stay with the child or young person until they are asleep.
• A child-centred approach to anaesthesia should be applied (RCOA, 2010).
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GUIDELINE 3
Day Surgery Information
Children and young people in day surgery
Post-operative care
• Parents and carers must be reunited with their child as soon as is safe and the
child is maintaining their own airway. They should be invited to sit with the child
in the recovery area and accompany the ward nurse on the journey back to the
ward. Children and young people should be returned to the ward as soon as it is
clinically appropriate to do so.
• A recovery discharge criteria must be in place (AAGBI, 2002).
• Observations should be conducted in accordance with local and national
guidance (RCN, 2011).
• Parents and carers need to be prepared for their role. They should be
encouraged and supported to help observe the child’s condition, and offer
comfort and reassurance.
• Depending on the type of surgery and local criteria, children and young people
should be offered fluids and a light diet as soon as possible on return to the
ward. Young children often settle better and are less distressed if they are
allowed to quench their thirst. Breastfed babies should be encouraged to feed
as soon as possible.
• Although analgesia is usually given during surgery or in recovery, pain
assessment should be done on return to the ward. This should be done using
the unit’s pain scale rating tool shown to the family on admission. Parents and
carers should be fully informed of all analgesia that has been given. They should
be given analgesia to take home or be advised what to buy from the chemist.
• A clear discharge criteria for home must be in place which should encompass
pain relief at home following day surgery (RCOA, 2010).
Documentation
The clinical governance agenda requires units to develop standards, protocols and
audit tools in order to monitor the quality of care. Ensuring that all patient care is
clearly and fully documented prior to the child’s discharge will aid in the process.
References
Association of Anaesthetists of Great Britain and Ireland (2002) Immediate
postanaesthetic recovery, London: AAGBI. Available at: www.aagbi.org/sites/
default/files/Immediate%20Post-anaesthesia%20recovery%202013%20
supplement.pdf (accessed 4/06/13) (Web).
Department of Health (2003) Getting the right start: the National Service Framework
for Children standard for hospital services, London: DH. Available at: www.nhs.
uk/NHSEngland/AboutNHSservices/Documents/NSF%20children%20in%20
hospitlalDH_4067251%5B1%5D.pdf (accessed 4/06/13) (Web).
Department of Health (2004) The National Service Framework for children, young
people and maternity services: executive summary, London: DH. Available at:
http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.
education.gov.uk/publications/eOrderingDownload/DH-40496PDF.pdf
(accessed 4/06/13) (Web).
Department of Health (2012) Report of the Children and Young People’s Health
Outcomes Forum, London: DH. Available at: www.gov.uk/government/uploads/
system/uploads/attachment_data/file/156062/CYP-report.pdf.pdf
(accessed 4/06/13) (Web).
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GUIDELINE 3
Day Surgery Information
Children and young people in day surgery
Department of Health (2013) Better health outcomes for children and young people,
London: DH. Available at: www.gov.uk/government/uploads/system/uploads/
attachment_data/file/141429/Pledge-web-version-2.pdf.pdf (accessed 4/06/13) (Web).
Department of Health (2013) Improving Children and Young People’s Health
Outcomes: a system wide response, London: DH. Available at: www.gov.uk/
government/uploads/system/uploads/attachment_data/file/141430/9328-TSO2900598-DH-SystemWideResponse.pdf.pdf (accessed 4/06/13) (Web).
National Confidential Enquiry into Patient Outcomes and Death (2011).
Surgery in children: are we there yet? London: NCEPOD.
NHS Institute for Innovation and Improvement (2007) Privacy and dignity – the
elimination of mixed sex accommodation: good practice guidance, Coventry: NHSIII
NHS Right Care (2013) NHS atlas of variation in healthcare for children and young
people, London: NHS Right Care. Available at: www.chimat.org.uk/variation
(accessed 4/06/13) (Web).
Royal College of Anaesthetists (2010) Guidance on the provision of paediatric
anaesthesia services, London: RCOA. Available at: www.rcoa.ac.uk/documentstore/guidance-the-provision-of-paediatric-anaesthesia-services-2013
(accessed 4/06/13) (Web).
Royal College of Nursing (2013) Defining staffing levels for children’s and young
people’s services, London: RCN. (IN PRESS)
Royal College of Nursing (2011a) Health care service standards in caring for
neonates, children and young people, London: RCN. Available at: www.rcn.org.
uk/__data/assets/pdf_file/0010/378091/003823.pdf (accessed 4/06/13) (Web).
Royal College of Nursing (2005) Perioperative fasting in adults and children, London:
RCN. Available at: www.rcn.org.uk/development/practice/clinicalguidelines/
perioperative_fasting (accessed 4/06/13) (Web).
Royal College of Nursing (2011b) Standards for assessing, measuring and
monitoring vital signs in infants, children and young people: RCN guidance for
children’s nurses and nurses working with children and young people, London: RCN.
Available at: www.rcn.org.uk/__data/assets/pdf_file/0004/114484/003196.pdf
(accessed 4/06/13) (Web).
Royal College of Paediatrics and Child Health and other contributing organisations
(2010) Safeguarding children and young people: roles and competences for health
care staff: intercollegiate document, London: RCPCH. Available at: http://fflm.ac.uk/
upload/documents/1290784237.pdf (accessed 4/06/13) (Web).
Royal College of Surgeons of England (2013) Standards for children’s surgery,
London: RCSENG. Available at: www.rcseng.ac.uk/publications/docs/standards-inchildrens-surgery (accessed 4/06/13) (Web).
Verma R, Alladi R, Jackson I, et al (2011) Day case and short stay surgery:
2, Anaesthesia, 66(5),May, pp.417-434.
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GUIDELINE 3
Day Surgery Information
Children and young people in day surgery
Further reading
Association of Paediatric Anaesthetists of Great Britain and Ireland
(no date) Children and young people (section of website). Available at:
www.apagbi.org.uk/children-and-young-people (accessed 4/06/13) (Web).
Campbell, A (2011) Pre-operative fasting guidelines for children having day surgery,
Nursing Children & Young People, 23(4), May, pp.14-19.
Cosh, (2012) Formal networks needed to improve surgical care. Nursing Children &
Young People, 24(1), February, pp. 6-7.
Department of Health (1994) The Allitt inquiry. London: HMSO.
Department of Health (2002) Day surgery: operational guide: waiting,booking
and choice, London: DH. Available at: webarchive.nationalarchives.
gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4005487 (accessed 4/06/13) (Web).
Department of Health (1996) NHS the patient’s charter: services for children and
young people, London: DH
Department of Health (1991) Welfare of children and young people in hospital.
(Endorsed by the Welsh Office and DHSS Northern Ireland). London: HMSO.
General Medical Council (2008) Consent: patients and doctors making decisions
together, London: GMC. Available at: www.gmc-uk.org/static/documents/content/
Consent_-_English_0911.pdf (accessed 4/06/13) (Web).
Higson J and Finlay T (2010) Pre-assessment for children scheduled for day surgery,
Nursing Management , 17 (8), December, pp.32-38.
Hogg, C (1994) Setting standards for children undergoing surgery, London:
Action for Sick Children.
Nursing and Midwifery Council (2013) Consent, London: NMC. Available at:
www.nmc-uk.org/Nurses-and-midwives/Regulation-in-practice/Regulation-inPractice-Topics/consent/ (accessed 4/06/13) (Web).
O’Shea M, Cummins A and Kelleher A (2011) The perceived effectiveness of a
pre-admission visit for children (and their parents) undergoing day surgery
procedures, Journal of Perioperative Practice, 21 (7), July, pp. 244-248.
O’Shea M, Cummins A and Kelleher A (2010) Setting up pre-admission visits for
children undergoing day surgery: a practice development initiative, Journal of
Perioperative Practice, 20(6), June, pp. 203-206.
St-Onge (2012) Reducing paediatric anxiety pre-operatively: strategies for nurses,
ORNAC Journal, 30(4), December, pp.14-19.
This publication is due for
review in August 2015.
To provide feedback on its
contents or on your experience
of using the publication,
please email publications.
feedback@rcn.org.uk
Tourigny, Clendinneng, Chartrand, and Gaboury, (2011) Evaluation of a virtual tour
for children undergoing same-day surgery and their parents, Paediatric Nursing,
37(4), July, pp. 177-183.
Publication code: 004 464 (Updated June 2013)
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