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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
British Association of Day Surgery www.bads.co.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
British Association of Day Surgery www.bads.co.uk
Reception and waiting area
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Pre operative assessment
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PRE OPERATIVE ASSESSMENT
British Association of Day Surgery www.bads.co.uk
Ward area with separate male and female areas
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Childrens ward and waiting
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Patient changing rooms
Patients change into a gown
Leave clothes in a locked cubicle
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Patients can walk to operating theatre
British Association of Day Surgery www.bads.co.uk
Trolley for operating
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Trolley used throughout journey
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Dedicated day surgery theatre team
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Recovery
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Nurse led discharge
British Association of Day Surgery www.bads.co.uk
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.
British Association of Day Surgery www.bads.co.uk
The DPU Team
British Association of Day Surgery www.bads.co.uk
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
.
British Association of Day Surgery www.bads.co.uk
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
British Association of Day Surgery www.bads.co.uk
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
3 Days Pre-Op No Warfarin
2 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
British Association of Day Surgery www.bads.co.uk
Information on pre-operative insulin doses
British Association of Day Surgery www.bads.co.uk
Nurse role – Pushing the Boundaries
Investigations and results
Anaesthetic referral
British Association of Day Surgery www.bads.co.uk
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
British Association of Day Surgery www.bads.co.uk
Use of the pain flow assessment chart for adult and paediatric patients
Day surgery Recovery Nurse
British Association of Day Surgery www.bads.co.uk
Pain Management Protocol
Start
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
25mcg
+/- 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
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
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
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Day surgery nurse planning for discharge
PLANNING FOR DISCHARGE
DPU EXIT
British Association of Day Surgery www.bads.co.uk
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
British Association of Day Surgery www.bads.co.uk
Day surgery nurse planning discharge
Bladder scanning process for urological and gynaecological procedures.
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
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
plan.
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.
British Association of Day Surgery www.bads.co.uk
Day surgery nurse led discharge
Nurse led discharge –no need for Dr review
British Association of Day Surgery www.bads.co.uk
Day surgery nurse led discharge
British Association of Day Surgery www.bads.co.uk
Extending the day surgery services
Follow up phone service
Telephone pre assessment
British Association of Day Surgery www.bads.co.uk
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
British Association of Day Surgery www.bads.co.uk
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
British Association of Day Surgery www.bads.co.uk
The NHS Plan 2000
“Around three-quarters of operations will be carried
out on a day case basis with no overnight stay required”
British Association of Day Surgery www.bads.co.uk
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……..”.
British Association of Day Surgery www.bads.co.uk
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.
British Association of Day Surgery www.bads.co.uk
Royal College Surgeons Guidelines 1992
ASA 1 or 2
Age <70 but physiological age rather than chronological
BMI <30
British Association of Day Surgery www.bads.co.uk
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
British Association of Day Surgery www.bads.co.uk
Day Surgery Training in Anaesthesia
British Association of Day Surgery www.bads.co.uk
Measuring outcomes in Day Surgery
• Quality Outcomes
• Patient reports
• Unplanned admissions
• Complications
• Quantity Outcomes
• Day surgery rates
British Association of Day Surgery www.bads.co.uk
Quality Outcomes
• Cancellation rates
• Timing
• Reason
• Infection rates
• MRSA
• Clostridium difficile
• Readmission rates
• Hospital Acquired thrombosis rates up to 90 days post op
British Association of Day Surgery www.bads.co.uk
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
British Association of Day Surgery www.bads.co.uk
Model Hospital Data
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Norfolk and Norwich hospital Day case rates
British Association of Day Surgery www.bads.co.uk
General Surgery day Case Rates Norfolk and Norwich Hospital
British Association of Day Surgery www.bads.co.uk
Unplanned admissions general surgery
British Association of Day Surgery www.bads.co.uk
Day Case Rates Laparoscopic Cholecystectomy
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery
• Founded in 1989
• Annual meetings
• Developed resources for members
• Political pressure
• Tariff
• Publication day cases rates
British Association of Day Surgery www.bads.co.uk
BADS Shop
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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!
British Association of Day Surgery www.bads.co.uk