The Future of Day Surgery:
The Ambulatory Pathway
Ian Smith, MD, FRCA
Senior Lecturer in Anaesthesia
University Hospital of North Staffordshire
President, British Association of Day Surgery
British Association of Day Surgery
www.bads.co.uk
Benefits of Day Surgery
Quality care
– early & better recovery
– minimal disruption
– comfort of own home
PATIENT PATHWAY
Better care,
Safer care
British Association of Day Surgery
www.bads.co.uk
Surgical Length of Stay Cascade
Inpatient
23 hour
British Association of Day Surgery
Day Surg
Outpatient
www.bads.co.uk
Typical Surgical Pathway
Referral from GP
Outpatient review
Diagnostics
Further review
Decision to operate
Inpatient
Day case
Waiting list
Waiting list
Preop assessment
Preop assessment
Surgery (if suitable)
Surgery (if suitable)
British Association of Day Surgery
www.bads.co.uk
Key Pathway Areas
1. Referral & outpatients
2. Preassessment & selection criteria
3. Booking
4. Patient admission
5. Operating lists & recovery
6. Discharge, documentation & support
British Association of Day Surgery
www.bads.co.uk
Patient Referral
Fit to proceed to surgery?
Info on longterm conditions
Understands referral may  surgery
Understands timescale
Diagnostic tests
– with results
Potential for day surgery
British Association of Day Surgery
www.bads.co.uk
Surgical Outpatients
Surgery possible / worthwhile?
Discuss risks & benefits
– inform consent
Day surgery possible?
– in this case
– surgical factors
British Association of Day Surgery
www.bads.co.uk
Preoperative Assessment
Nurse performed
– clinician supervised
British Association of Day Surgery
www.bads.co.uk
Preoperative Assessment
Nurse performed
– clinician supervised
Various models
– centralised
– DSU
– telephone
British Association of Day Surgery
Lewis, et al. —
J One-day Surg 19: 32, 2009
Preoperative Assessment
Nurse performed
– clinician supervised
Various models
– centralised, DSU, telephone
Information
– procedure & day of surgery
– fasting & medication
– recovery & pain management
British Association of Day Surgery
www.bads.co.uk
Default to Day Surgery
Suitability for day surgery
Pathway
20–30%
Clearly suitable
Day surgery
Home if ok
40–65%
Unsure
Inpatient care
? Home if ok
5–20%
Clearly unsuitable
British Association of Day Surgery
Inpatient care
Hospital stay
www.bads.co.uk
Booking
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
British Association of Day Surgery
www.bads.co.uk
Operating Lists
Dedicated day surgery lists
Mix of day and short stay surgery
– efficient
– flexible
Mix of day and inpatient surgery
– tension
– conflicting needs
British Association of Day Surgery
www.bads.co.uk
Pooled 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
British Association of Day Surgery
www.bads.co.uk
Optimising 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
British Association of Day Surgery
www.bads.co.uk
Recovery Facilities
Fully equipped to usual standard
– trained staff
Potential for rapid turnover
– staffing levels
Second stage recovery
– nurse led discharge
British Association of Day Surgery
www.bads.co.uk
Patient Discharge
Nurse led
Supported by
– documentation
– information
British Association of Day Surgery
www.bads.co.uk
Safety 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
British Association of Day Surgery
www.bads.co.uk
Patient referral
Surgical
outpatients
Preoperative
assessment
Selection
criteria
Booking
Admission
Operating lists
Recovery
facilities
Patient
discharge
Documentation
Post-discharge
support
The Streamlined Pathway
Future of Day Surgery
Aging population
Obesity time bomb
Increasing surgical complexity
Therefore many challenges
British Association of Day Surgery
www.bads.co.uk
Variation in Practice
Day surgery rates vary considerably
– between hospitals
– within hospitals
– within departments
Applying pathway principles
– can dramatically increase day surgery
British Association of Day Surgery
Smith, et al. —
J One-day Surg 20: 80, 2010
Incentivising Best Practice
Orthopaedic
subacromial decompression
bunions
Dupuytren’s
Breast
mastectomy
sentinel node
ENT
tonsillectomy
septoplasty
Gynae
female incontinence
Urology
TUR & laser prostate
General
lap chole
hernia repair
British Association of Day Surgery
Best
Practice
Tariffs
www.bads.co.uk
The Near Future?
True day surgery
– ≈85%
Overnight stay
– ≈5%
Longer stay
– ≈10%
British Association of Day Surgery
www.bads.co.uk
British Association of Day Surgery
www.bads.co.uk