Day surgery in UK; a medical and nursing view from Norwich · 2019. 2. 5. · nursing view from...

British Association of Day Surgery www.bads.co.ukBritish Association of Day Surgery www.bads.co.uk

Day surgery in UK; a medical and nursing view from Norwich

Dr Anna Lipp, Consultant Anaesthetist, Immediate past president BADS

Helen Ball, Sister, Day Procedure Unit

Norfolk and Norwich University Hospital

British Association of Day Surgery www.bads.co.uk

Overview

• Day Surgery in Norwich

• Role of Nursing in Day Surgery

• Day surgery in UK

Day procedure Unit Norfolk and Norwich Hospital

• 1000 beds in hospital

• Population ½ million

• Day surgery unit has 39 trolley spaces

• 7 operating theatres

• 1 procedure room

• 20,000 procedures per year

Reception and waiting area

Pre operative assessment

PRE OPERATIVE ASSESSMENT

Ward area with separate male and female areas

Childrens ward and waiting

Patient changing rooms

Patients change into a gown

Leave clothes in a locked cubicle

Patients can walk to operating theatre

Trolley for operating

Trolley used throughout journey

Dedicated day surgery theatre team

Recovery

Nurse led discharge

THE UNIQUE ROLE OF THE DAY SURGERY NURSE IN ENGLAND

How the role has developed to support Service Improvement.

Helen Ball Sister Arthur South Day Procedure Unit

Norfolk & Norwich University Hospital Norwich.

The DPU Team

Why Unique ?

The nurse led Pre Assessment

process :-

Since the 1980’s nurse led pre

assessment has been undertaken in

day surgery

Nurse prescribers – mitigate risk of

cancellation.

Patient Group directives – Cascade

training amongst nursing work force

Treatments given in timely manner

Nurse role – Pushing the Boundaries

Expanding the nurse led pre assessment protocols expands day surgery opportunities to more patients with chronic conditions.

Formalised advisory flow charts

-Stroke patients

-Diabetic patients

Instructions for patients stopping WarfarinBefore Surgery

Pre-Op Assessment Nurse

Patient ID

Contact NoDoctor Name Bleep No

Plan Date Warfarin Doses Completed

5 Days Pre-Op Take usual dose of Warfarin

4 Days Pre-Op No Warfarin

Day Before Operation No Warfarin

Day of Operation No Warfarin

Day 1 Post Surgery onwards Restart your usual dose warfarin Arrange to have INR (Warfarin check) at your GP 3-5 days after starting the Warfarin

Information on pre-operative insulin doses

Nurse role – Pushing the Boundaries

Investigations and results

Anaesthetic referral

Nurse led admission process

Point of care INR testing

Point of care blood sugar testing

Point of care pregnancy testing

Point of care urinalysis

The nurse independently completes point of care testing to confirm the patient

suitability to go ahead with surgery

Use of the pain flow assessment chart for adult and paediatric patients

Day surgery Recovery Nurse

Pain Management Protocol

Assess Pain score on

movement

Pain score 0

No pain

Pain score 1

Mild pain

Pain score 2

Moderate pain

Pain score 3

Severe Pain

Assess sedation score

Score <3 give fentanyl

+/- NSAID /antiemetic

Go back to start

Score 3

Check resp rate

<8 give o2 call for help

Give oral analgesiaReassess with next

observations

Reassess with next

observations

Day surgery Recovery Nurse

Use of the early warning score for adults to indicate any on going care requirements and when the patient is ready for to transfer back to the ward

Day surgery nurse planning for discharge

PLANNING FOR DISCHARGE

DPU EXIT

Straight Leg Raise Instructions

Please remember to complete straight leg raise checks for all patients having LOWER ABDOMINAL SURGERY with any Local Anaesthetic infiltration or block to check for any weakness prior to getting out of bed. This check and time must be documented in notes.

The weakness can be caused by infiltration of local anaesthetic into the wound. Patients cannot keep their knee straight causing their leg to give way when the patient applies weight to the limb. This weakness can last 6-8 hours and patients must not stand unaided until it has recovered completely

Patient must keep leg straight when raised

Day surgery nurse planning discharge

Bladder scanning process for urological and gynaecological procedures.

DPU Discharge Checklist

No Bleeding

Every surgical wound is examined prior to the

patient being discharged

Old ooze.

Haematuria.

Vaginal blood Loss –volume? Clots?

Haematoma.

Surgical drains?

InstructionsAll patients must have their written information and

be given any specific verbal instructions concerning

their wound in the presence of their carer.

Cannula

The intravenous cannula should be removed after

the patient has mobilised post operatively.

Removal must be documented on cannula care

Passed urine

For most procedures patients are required to pass

urine.

Procedures and patients with low risk of urine

retention maybe discharged without passing urine

but should be given the advice leaflet with

instructions of what to do if they experience

difficulties voiding after discharge. These details

should be documented in the care plan.

Some procedures may also require a bladder scan

before discharge e.g. TVT. Please see detailed

guidance on bladder scanner machine.

For any patient that has not passed urine who has

diagnosis of Chronic Kidney Disease seek

additional advice from the Renal Nurse Specialist.

Alert and Orientated

Patients must be alert and orientated prior to

discharge.

For the majority of patients some sedative effects

remain from the anaesthetic and analgesia.

Carer must be available for 24 hours post

procedure.

Information about the post-operative recovery

must be available to both patient and carer.

Stable vital signs

Select appropriate frequency to record blood

pressure, pulse, respirations in the post-

operative period.

Adhere to departmental pain assessment

protocol

Blood pressure and pulse is not grossly different

from the pre-operative baseline observations.

Unstable vital signs/ Complications

Look for Chest pain, pallor, fainting and

irritability.

Ensure quick identification and concerns of

unstable vital signs of blood pressure, pulse and

respirations are raised with Senior staff and

Anaesthetist effective treatment is provided

accordingly.

Any concerns relating to vital signs should be

reported to the senior staff and anaesthetist –

concerns and outcomes to be documented.

Eating and drinking

Prior to discharge all patients should be offered

oral fluids unless specifically identified not

necessary.

Once oral fluids tolerated offer light snack.

Patients to be able to tolerate fluids and diet prior

to discharge.

Nausea controlled

Patients are not be discharged if feeling

nauseated or vomiting.

Anti-emetics to be administered accordingly.

Patients may need admitting if nausea and

vomiting persists.

Day surgery nurse led discharge

Nurse led discharge –no need for Dr review

Day surgery nurse led discharge

Extending the day surgery services

Follow up phone service

Telephone pre assessment

The Future

Support students in day surgery environment – this is the workforce of the future.

In house competency packs

Review of nursing establishment – introducing diverse approaches to training with nursing associates and in house development packs

Day surgery in UK

• Available in most hospitals in 1990s

• Government encouragement to develop day surgery units

• Royal Colleges produced Guidelines for Day Surgery

• Training programmes include day surgery

• Outcomes measured for quality and quantity day suregry

• Data published nationally on day surgery rates

The NHS Plan 2000

“Around three-quarters of operations will be carried

out on a day case basis with no overnight stay required”

National Programmes

“The day surgery strategy was launched in January 2002 with the aim of driving forward day surgery in the NHS. There is a need to increase capacity in the NHS to meet current demands and day surgery has an important role to play in achieving this. Expanding day surgery provides an exciting opportunity to improve patient care in modern clinical settings……..”.

Financial incentives

• Enhanced tariff for specific day surgery procedures

• Must be planned as intended day case

• Patient must not be in a hospital bed at midnight

• 23 hour stay is not day surgery

• £300 extra per surgical case

• Range of specialties e.g Laparoscopic Cholecystectomy, laser prostates, tonsils, bunions.

Royal College Surgeons Guidelines 1992

ASA 1 or 2

Age <70 but physiological age rather than chronological

BMI <30

Royal College Anaesthesia guidelines 2018

• All patients to be considered suitable for day surgery unless specific issues identified at assessment

• ASA grade, age, BMI should not be used to exclude patients from day surgery

• Use of local and regional anaesthesia makes day surgery safe for many cases

Day Surgery Training in Anaesthesia

Measuring outcomes in Day Surgery

• Quality Outcomes

• Patient reports

• Unplanned admissions

• Complications

• Quantity Outcomes

• Day surgery rates

Quality Outcomes

• Cancellation rates

• Timing

• Reason

• Infection rates

• MRSA

• Clostridium difficile

• Readmission rates

• Hospital Acquired thrombosis rates up to 90 days post op

Patient Experience

• Every patient asked to report experience

• Results published for all areas of hospital and every hospital in NHS

• Criticism if feedback is poor

Model Hospital Data

Norfolk and Norwich hospital Day case rates

General Surgery day Case Rates Norfolk and Norwich Hospital

Unplanned admissions general surgery

Day Case Rates Laparoscopic Cholecystectomy

British Association of Day Surgery

• Founded in 1989

• Annual meetings

• Developed resources for members

• Political pressure

• Tariff

• Publication day cases rates

BADS Shop

BADS Handbooks

British Association of Day Surgery www.bads.co.ukBritish Association of Day Surgery www.bads.co.uk

BADS 2019

Central London

27-28th JuneWe are excited to be holding our

30TH ANNIVERSARY CONFERENCE

at the beautiful

Royal Society of Medicine

LONDON, W1

SAVE THE DATE!

Day surgery in UK; a medical and nursing view from Norwich · 2019. 2. 5. · nursing view from...

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