Dr. Rowan Thomas
MBBS FANZCA MPH

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What are the selection criteria?
Should the criteria be changed?
(A sociological perspective)
How can it be changed?
(A policy perspective)
The importance of follow up and outcome review

Tertiary referral Hospital
Day of surgery discharge not high – 25-30%
Australian average 60%

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Economic or utilitarian drivers.
Lower morbidity
Faster mobilisation and recovery
Able to be with family
Free up resources for other health care areas

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Two components. Day of surgery arrival
(DOSA) + Early discharge
DOSA requires:
◦ Optimisation of co-morbidities and medications
◦ Early assessment, communication and consent
◦ Timely arrival and fasting
Early discharge requires:
◦ Good pain management
◦ Resolution of unwanted effects of anaesthesia
◦ Good social supports
◦ Adequate time to assess surgical complications

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Pain (Not enough analgesia?)
Nausea (Too much opioid?)
Bleeding
Unstable co-morbidity
Incapable of self care

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Minimally invasive techniques are widening the range of possible surgeries
Minimal risk of post-operative Haemorrhage
Minimal risk of post operative airway compromise
Pain controllable by outpatient techniques
Post-operative care that can be managed by a responsible adult or home nursing facilities
A rapid return to normal fluid and food intake
ANZCA Policy PS15

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A willingness to have the procedure performed and an understanding and an ability to follow instructions
Patient’s place of residence within one hour’s travelling time from medical attention
ASA I or II. Stable ASA III or IV. Careful consideration for higher ASA grades.
Infants and children where associated paediatric facilities and experience exist. Should be older than 6 weeks (normal term) or greater than 52 weeks post-conceptual age if premature (< 37 gestation)
ANZCA Policy PS15

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A responsible person able to transport the patient home in a suitable vehicle.
A responsible person staying at least overnight with the patient.
Ensuring that the patient understand the requirements of post-anaesthetic care in regard to public safety.
The patient stay within one hour of medical attention until one day after surgery.
Ready access to a telephone
ANZCA Policy PS15

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Unstable ASA III or IV. Eg. Brittle diabetes, unstable angina, symptomatic asthma.
Morbid obesity with haemodynamic or respiratory problems
Drugs: Monoamine oxidase inhibitors or acute substance abuse esp. Cocaine.
Ex-prem infants <52 weeks post-conceptual age.
Lack of responsible adult at home to transport and care for the patient.

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Sleep apnoea
Morbid obesity
Elderly
Malignant Hyperthermia susceptibility
Anaesthetic technique – regional and neuraxial.

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Or the application of the criteria?

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Greater use of regional techniques and local anaesthetic infusion catheters at home.
Better use of analgesic adjuncts.
23 hour stay units
Available inpatient back up facilities
Mobile day surgery
Surgical techniques
◦ Laparoscopic and Robotic surgery
Better management of co-morbidities

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Structural Functionalism
Society combines to create a homeostatic system. A change in one part creates or determines a corresponding change in another.
Also famous for describing the doctor-patient relationship and the
‘sick role’. The development of day surgery is the opposite to the traditional role he described.

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Every order or change in order will present a struggle between the proletariat (workers) and the bourgeoisie (capitalists).
Exploitation and alienation of the lower class will be hidden, but present in every economically motivated ideology.

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Legitimate authority: Charismatic,
Traditional and Legal-rational.
Local charismatically led systems grow into bureaucracies with Legalrational lines of authority and responsibility
Widening selection criteria may be possible at a local level, however a greater economic impact is possible when systems are developed to establish large scale change, requiring bureaucratic models to develop.

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The “care system” must be looked at as a whole
Greater support, good information and consistent expectation will lead to a wider range of day surgical options

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Distance from hospital
Pain management routines
Nausea management routines
Preoperative optimisation and information
Nursing in the home
A number to call
A telephone
Capacity of family
Ability to admit for social reasons
23 hour wards.

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Policy development
Consultation
Iteration
Description
Change through agreement, commitment and ownership.

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Patients
Government and other funding bodies
Hospital administration
Surgeons
Anaesthetists
Nurses
Other Health providers

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Risk is difficult to evaluate on a small sample
RCTs are not appropriate for low risk outcomes
Registries and databases are being created to collect and audit outcomes from medical interventions.
◦ NSAS – National Survey of Ambulatory Surgery www.cdc.gov/nchs/nsas.htm

American College of Surgeons National
Surgical Quality Improvement Program
(ACS-NSQIP)
Centre for Disease Control and Prevention –
National survey of Ambulatory surgery.

snap shot of aurora

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Applying the criteria more widely is probably our actual challenge.
Selection criteria applied more widely through:
◦ Technology – surgical, anaesthetic, pain management, outcome data collection
◦ Community support
◦ Secondary supports, i.e. inpatient services back-up
◦ Thoughtful, local policy development
◦ Measuring outcomes

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Change can be difficult and it may not be right in every situation.
There are patient, surgical and social factors that need individual consideration.
Supports in the community vary from region to region.
We need to monitor, audit and evaluate outcomes to assess the work we do, because our goal of safety and comfort extends beyond the operating room, it needs to extend into the home as well.