PATIENT SELECTION PUSHING THE FRONTIERS

OF DAY SURGERY

Dr Theresa Hinde

Anaesthetic ST7

Council Member

British Association of Day Surgery

HOW A DAY SURGERY MINDSET CAN TRANSFORM THE OUTCOMES FOR

BOTH YOUR PATIENTS AND YOUR HOSPITAL

How a your

AIMS

• Is anyone medically inappropriate for day surgery?

• Additional considerations for urgent/emergency surgery

• Different approaches to social factors limiting suitability

• What procedures can we tackle?

BACKGROUND: PATIENT SELECTION

• More complex procedures

• Patients with significant co-morbidities

EMERGENCY AMBULATORY SURGERY

• Demand for emergency surgical activity increasing

• Need more effective ways to

• evaluate and care for patients whilst avoiding

unnecessary admissions

• maximise theatre utilisation

• improve in-patient access for sickest patients

BACKGROUND

• To maximise day surgery possibilities in your organisation are there

• Robust assessment systems?

• Options of

• Advanced surgical techniques?

• Advanced anaesthetic techniques?

• Different ways to care post discharge?

• Ways to rapidly access urgent lists for certain procedures?

ROBUST ASSESSMENT SYSTEMS

• Appropriate staff making decisions regarding suitability

• Experienced nurses using well established protocols

• Experienced clinicians available for advice and support if criteria not clearly met

• Both will help to overcome perceived barriers

• Early stages of new pathways

WHAT ARE WE TRYING TO ESTABLISH

• Are this patient’s risks increased in any way by

treatment on a day stay basis?

• Would management be different if he/she were

admitted as an inpatient?

IF THE ANSWER IS ‘NO’… . .

…..the patient is probably suitable for day surgery

Consider day surgery as default for elective surgery

MEDICAL FACTORS 1980 ’S

Royal College of Surgeons of England:

• 1985 and 1992

Selection Criteria:

• Age limit 65-70 years

• ASA I & II

• BMI<30

• Max 60 minutes operating time

NOUGHTIES

Default to Day Surgery

“Patients should only be excluded from day

surgery after full pre-operative assessment

shows a contraindication”

Day Surgery: Operational guide. DoH, London (2002)

DAY CASE CRITERIA

•But:

•Fatter Population

•Older Population

•Therefore expand…..

•ASA

•Age

•BMI

•Medical conditions

1990 2016

ASA 1 and 2 No limit

Age 70 No Limit

BMI 30 No limit

IDDM No Yes

‘ASA’ CLASSIFICATION (AMERICAN SOCIETY OF ANAESTHES IOLOGISTS)

• ASA I: Normally healthy

• ASA II: Mild systemic disease

• ASA III: Severe systemic disease

that is not incapacitating

• ASA IV: Incapacitating disease that

is a constant threat to life

• Most stable conditions can

be managed as a day case

• Most patients with unstable

conditions should not be

undergoing elective surgery

• Urgent or emergency

surgery in these patients

may require inpatient stay

ASA III PATIENTS

• ASA III patients form a disparate group

• Studies show ASA III does not predict unplanned admissions

• Ansell and Montgomery (BJA, 2004)

• Case matched study

• Admission rate is low (<3%) ASAIII = 2.9% vs non ASA II =1.9%

• Low incidence of unplanned contact with healthcare services in both

groups

• Low post operative complication rate

ASA III PATIENTS

• Conclusions:

• ASA III need not be an exclusion criterion

• Certain ASA III patients can be safely treated with good

pre operative assessment and preparation

ELDERLY BENEFITS OF DAY SURGERY

• Decreased impact on patient and family

• Usually better managed in their own environment

• Maintains daily routine and autonomy

• Decreases cognitive dysfunction and delirium

• Resumption of ‘active mobility’

PREOPERATIVE ASSESSMENT OF ELDERLY

• Follow standard protocols for evaluation and preparation

• Consider ‘frailty’ scores

• Use of these is increasing

• Social planning: involve

• Family

• Primary care physicians

• Other allied health professionals

ANAESTHETIC AND SURGICAL TECHNIQUES

• Schedule early in day

• Avoid prolonged fasting

• Employ minimally invasive surgical options

• Avoid opiates

• Local anaesthetics as far as possible

• Maintain temperature

THE ELDERLY-ADMISSION RATES

5.4

94.6

6.1

93.9

0

10

20

30

40

50

60

70

80

90

100

unplanned admission successful discharge

Admission Rates

>70 <65

Sinha et al, Hernia, 2007

% of

patients

THE ELDERLY SATISFACTION WITH DAY SURGERY

95

4.3 0.4

93.4

5.65

0.6 0

10

20

30

40

50

60

70

80

90

100

Very satisfied Satisfied Not satisfied

Satisfaction with Day Surgery

>70 <65% of

patients

OBESITY

• “most potential complications of obesity are limited to the intra

and immediate post operative environment and so obese

patients can still be managed as a day case”

• The Pathway to Success – Management of the Day Surgical Patient

• BADS Publication 2012

OBESITY

• Even morbidly obese patients can be safely managed in expert hands, with appropriate resources.

• Obese patients benefit from:

• short duration anaesthetic techniques

• early mobilisation

• decreased hospital stay and associated hospital

acquired complications

Day Case and Short Stay Surgery (2)

Association of Anaesthetists of Great Britain and Ireland

British Association of Day Surgery 2011

PREOPERATIVE ASSESSMENT

• Careful assessment mandated

• Medical case note review

• Increased incidence of

• Hypertension

• Ischaemic heart disease

• Diabetes

• Reflux

• Optimise these conditions

• Particular attention when assessing for urgent surgery

• Obesity alone should not preclude day surgery

OBESITY

• Challenges:

• Problems occur early (induction/primary recovery)

• Everything may be more difficult and take longer

• Senior staff required

• Additional kit

• Plan for difficult airway, long instruments, special table etc..

OBESITY-COMPLICATIONS

• Retrospective analysis of DSU patients

• 258 patients with BMI>35

• No statistically significant difference in:

• Unplanned admission rate

• BMI >35=3.0% vs. BMI<35 = 2.7% (p=0.98)

• Post operative complications

• Unplanned usage of community and hospital based services (p=0.59)

• Conclusion:

• No evidence that BMI>35 solely an exclusion criterion for day surgery

Davies, Houghton and Montgomery, Anaesthesia 2001

OBESITY

• May not be appropriate for surgery in an isolated site, but

can still be day cases through main hospital facilities

• Once they are through primary recovery no increased risk

of complications necessitating overnight stay

OSA

• May require CPAP post-op

• Are they more likely to get this at home or in hospital?

• Beware of strong opiates

• Significant OSA in patients undergoing tonsillectomy is a

contraindication to day surgery

IDDM: AAGBI GUIDELINES(2016)

• If HbA1c greater than 69mmol.mol-1 delay elective surgery

until controlled

• Diabetics are usually better at managing their own diabetes

than we are!

• Preoperative optimisation from specialist diabetic nursing

teams is invaluable for patients with poor control

• Urgent surgery may require pragmatic approach

HYPERTENSION: AAGBI GUIDANCE (2015)

• BP >180/110:

• Refer to GP for assessment

• Aim to control to <160/100

• BP >140/90 but less than 180/110:

• Refer to GP but no reason to postpone surgery

• Urgent surgery may require pragmatic approach

CARDIAC RISK

• The likelihood of perioperative cardiac complications

cannot be entirely predicted.

• There are major, intermediate and minor predictors for

peri-operative cardiac complications.

• Refer those with major risk factors for further management

• Assessment of exercise tolerance is fundamental.

PREDICTORS OF CARDIOVASCULAR COMPLICATIONS

Minor predictors

Uncontrolled hypertension

Non sinus ECG

Stroke

Increasing age

Decreased functional capacity

Intermediate predictors

Stable angina

Previous MI

Controlled heart failure

Diabetes

Inherited/social factors

Smoking

Obesity

Alcohol excess

Raised lipids

Sudden cardiac death in family

Major predictors

Severe/unstable angina

Recent MI

Uncontrolled heart failure

Significant arrhythmia

Valvular disease

Peripheral vascular disease

MEDICAL EXCLUSIONS

• unstable ASA III, ASA IV/V

• any poorly controlled abnormality

• neonates

• ex-prem infants < 60 wks post conceptual age

• young sibling of SIDS child

• Specific to Emergency Surgery pathways:

• Sepsis or haemodynamic instability

CRITERIA IN 2017

• Abandon universal selection criteria

• Adopt an inclusion rather than an exclusion

philosophy

• Apply limitations to the procedure rather than the

patient

EMERGENCY AMBULATORY SURGERY

• Novel approaches:

• University Hospital Bath

• Emergency ambulatory surgery clinic

• Careful and timely case and patient selection may allow

urgent/emergency day case surgery

• Preoperative assessment may therefore be required for

• acutely unwell patients

• to be operated on the same or next day

PROCEDURES SUITABLE FOR EMERGENCY AMBULATORY SURGERY

• Ambulant adults with:

General Gynae Trauma ENT

Abscesses

torso and peri-anal

(not breast)

ERPC Tendon repair MUA nose

Right iliac fossa pain

Lap ectopic

pregnancy

MUA Repair fractured

mandible

Painful

non-obstructed

hernia

Fracture plating

e.g. clavicle

Wound problems

PATIENTS NOT SUITABLE FOR EMERGENCY AMBULATORY SURGERY

• Children

• Evidence of sepsis or haemodynamic instability

• Significant concurrent illness

• Condition that cannot safely be left or too painful to

manage at home

• Reduced mobility/no home input/lives alone or some

distance away

• Cognitive or communication difficulties

BENEFITS OF EMERGENCY AMBULATORY SURGERY

• Avoids unnecessary admission and associated in-patient

waits

• Saves bed days

• Freeing up capacity for emergencies

SOCIAL FACTORS

• Responsible adult

• Maximum 1 hours drive

• Adequate facilities

• inside toilet

• telephone access

• heating

• stairs

RESPONSIBLE ADULT

• How long is 24 hours?

• Who can provide this care?

• Are all anaesthetics equal?

HOW LONG DO CARERS STAY? BARKER ET AL JODS 2014

0

5

10

15

20

25

All Patients No Pain Mild Pain Moderate Pain Severe Pain

H

o

u

r

s

Mean time carer stayed (h)

Mean time to ADLs (h)

Mean time to 'safe' (h)

WHAT DID PATIENTS THINK?

Too Long Not Enough About Right

All Patients 29% 12% 59%

No Pain Predicted 33% 0% 67%

Mild Pain Predicted 57% 0% 43%

Moderate Pain Predicted 27% 18% 55%

Severe Pain Predicted 20% 15% 65%

Survey of 72 patients

POSSIBLE SOLUTIONS

• Torbay Model: provide carers into patients homes

• Kings Lynn Model: virtual ward

• Norwich Model: allow some patients home without

carers after certain procedures

• Escort vs 24 hour Care

DISTANCE FROM HOSPITAL

• Rarely a problem (even in mid Wales/rural Devon)

• 1 hour from a hospital that can treat the condition not

necessarily the operating hospital

• Procedure specific

SOCIAL FACTORS

• The vast majority of patients are socially appropriate

for day surgery or can be enabled to be so with

proactive management

SURGICAL CRITERIA

•Which Procedures?

SURGICAL CRITERIA

• Can the patient be expected to manage oral nutrition post-

operatively?

• Can the pain be managed by simple oral analgesia

supplemented by regional anaesthetic techniques?

• Is there a low risk of significant immediate post operative

complications (e.g. catastrophic bleeding)?

• Is the patient expected to mobilise with aids post-operatively?

LONG OPERATING TIMES

‘

Millers Anaesthesia 2010: The duration of surgery in the

ambulatory setting was originally limited to procedures lasting

less than 90 minutes...However, surgical procedures lasting 3 to

4 hours are now routinely performed on an ambulatory basis.’

LONG OPERATING TIMES

Admissions Total %

Ops < 60 min 191 9553 2.00%

Ops > 60 min 27 1116 2.42%

p = 0.36 No statistically significance difference in admission rates

}χ2

Skues MA, J One Day Surgery, 2011

HOW FAR HAVE WE COME?

Specialty Procedures in 1990 Procedures in 2016

Ophthalmology Cataract Extraction Vitrectomy

Gynaecology Hysteroscopy Hysterectomy

Orthopaedics Arthroscopy Uni-chondylar Knee

Urology Circumcision Laparoscopic Nephrectomy

NEARLY ALL ELECTIVE SURGERY SHOULD

BE DAY OR VERY SHORT STAY

• Lap nephrectomy

• Prostatectomy

• Lap hysterectomy

• Vaginal hysterectomy

• Thyroidectomy

• Mastectomy

• Shoulder surgery

• Anterior cruciate ligament

• Lumbar discectomy

• Abdominoplasty

• Some emergencies

SURGICAL CRITERIA

• Pushing the frontiers in your own institution:

• Elective

• Evaluate existing inpatient procedures with short(ish)

LOS

• What would you need to change to enable them to be

day surgery?

IN SUMMARY: PATIENT SELECTION

• Is the patient suitable for day surgery?

• Medical conditions-pushing the boundaries (safely)

• Social circumstances-alternatives

• Surgical considerations-advanced techniques

• Can the patient or procedure be made suitable?

• Special considerations for emergency patients

• Procedure

• Preoperative issues:

• Pain

• Sepsis

• Haemodynamic stability

• Can they safely wait?