Quality in the Patient Pathway · Craniotomy Caesarean Section ... The Pathway to Success –Management of the Day Surgical Patient. BADS Publication 2012. British Association of

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

The patient pathway for day surgery

Dr Mary StockerPast-President British Association Day SurgeryConsultant Anaesthetist, Torbay


To be Covered

• Day Surgery Pathway

• Patient selection

• Procedures

• Measuring outcomes


What is Day Surgery?

• Planned procedure

• Intended management of day surgery

• Patient admitted/operated upon/discharged on same calendar day






Emergencies?






If they are not planned as a day case they do not count as a day case






This is NOT 23 hr stay!


Day Surgery Pathways

• GP referral for procedure

• Surgical OPA

• Patient Selection

• Booking

• Pre op assessment

• Admission

• Surgery

• Discharge

• Recovery at home




• Surgical OPA


• Booking


• Admission

• Surgery

• Discharge


All undertaken by

dedicated day

surgery team




• Surgical OPA



• Admission

• Surgery

• Discharge



GP Referral

• Do our primary care colleagues know which procedures?

• Do they know which patients are appropriate?

• Do they ensure patients are “fit to refer”?

• Do they start the day surgery message

• Do we communicate well enough?




• Surgical OPA


• Booking


• Admission

• Surgery

• Discharge



Surgical OPC

• Do our surgical colleagues know which procedures?

• Do they know which patients are appropriate?

• Do they ensure patients are “fit to list”?

• Do they start the day surgery message


Surgical OPA

• Surgeon confirms day case management intention• Default suitable procedures to day case intention

• Remember if not fit for day surgery probably not fit for elective surgery


Surgical Criteria

Which Procedures?


Audit Commission Basket of Procedures 2001

Cataract Extraction

Excision Breast Lump

Carpal Tunnel Decompression

Bat Ears

R/O Metalwork

Bunion Operations

Laparoscopy

Tonsillectomy

TURBT

Squint Correction

Orchidopexy

Anal Fissure

D&C / Hysteroscopy

Nasal Fractures

Myringotomy

Laparoscopic Cholecystectomy

Excision of Ganglion

Hernia Repair

Varicose Veins

Dupuytren’s Contracture

Haemorrhoidectomy

Circumcision

Arthroscopy

SMR

Termination of pregnancy


Surgical Criteria

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

• Can the pain of the procedure be managed by simple oral analgesia supplemented by regional anaesthetictechniques?


Surgical Criteria - 2

• Is there a low risk of significant immediate post operative complications (eg catastrophic bleeding)?

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


Surgical Criteria - 3

• Evaluate existing inpatient procedures with short(ish) LOS

• What would you need to change to enable them to be day surgery?


Long Operating Times?


Long Operating Times

Admissions Total %

Ops < 60

min191 9553 2.00%

Ops > 60

min27 1116 2.42%

p = 0.36

}χ2

Skues MA, J One Day Surgery, 2011


Miller’s Anaesthesia 7th Edition

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.’


Nearly ALL 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


What next?

Craniotomy

Caesarean Section

Joint Replacements

Carotid Endarterectomy

Endovascular Aneurysm Repairs

Emergency Procedures


How far have we come?

Specialty Procedures in 1990 Procedures in 2019

Ophthalmology Cateract Extraction Vitrectomy

Gynaecology Hysteroscopy Hysterectomy

Orthopaedics Arthroscopy Uni-chondylar Knee Replacement/THR

Urology Circumcision LaparoscopicNephrectomy

Head and Neck Tonsillectomy Thyroidectomy




• Surgical OPA


• Booking


• Admission

• Surgery

• Discharge



Which Patients?

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


Social Factors

• Responsible adult

• Maximum 1 hours drive

• Adequate housing

conditions

-inside toilet

-telephone access

-heating

-stairs


Patients who live alone

Who can provide this care?

Are all procedures equal – does everyone require a carer?


Possible Solutions

• Torbay Model: provide carers into patients homes

• Norwich Model: allow some patients home without carersafter certain procedures

• Escort vs 24 hour Care

Retief J, Morris R, Stocker M. The postoperative carer: A global view and local perspectives. Journal of One Day Surgery. March 2018.


Who can Provide Care?Torbay Carers


Norwich Home Alone

Protocol


Both pathways have now been in place for a number of years

• excellent patient satisfaction

• no adverse outcomes


Distance from Hospital

• Rarely a problem

• Even in mid Wales/rural Devon

• Remember it is 1 hour from a hospital that can treat the condition not necessarily the operating hospital


Social Factors

The vast majority of patients are socially appropriate for day surgery or can be

enabled to be so with proactive management


Medical Factors 1980’s

1985 & 1992

Royal College of Surgeons of England

Selection CriteriaAge limit 65-70 years

ASA I & II

BMI<30

Max 60 mins operating time


Naughties

2002

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 –

BMI

Age

ASA Status


Patient Selection

1990 2019

ASA 1 and 2 No limit

Age 70 No Limit

BMI 30 No limit

IDDM No Yes


ASA

• Most stable medical conditions can reasonably be managed as a day case

• Most patients with unstable medical conditions should not be undergoing elective surgery

• Urgent or emergency surgery in these patients may require inpatient stay


AAGBI Guidelines management peri-operative diabetes 2015

• “Glycaemic control should be checked at the time of referral for surgery “

• HbA1c should be < 69 mmol.mol 1 in the previous three months.

• If HbA1c ≥ 69 mmol.mol 1, elective surgery should be delayed while control is improved then proceed with day surgery

• Diabetics are usually better at managing their own diabetes than we are!


Elderly

Usually better managed in their own environment


National Audit Office 2019The average 67 year old admitted to

hospital..

• 5% loss of muscle strength /day

• 10 days in hospital reduces

• Lung capacity by 12%

• Hip and knee muscle strength by 14%

• life expectancy by 10 years


The ElderlyAdmission Rates

5.46.1

94.6 93.9

0

10

20

30

40

50

60

70

80

90

100

Unplanned admission Successful discharge

>70

<65

%

of

pati

en

ts

Sinha et al, 2007


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 the short duration anaesthetic techniques and early

mobilisation associated with day surgery”

Day case and short stay surgery: 3

Association of Anaesthetists of Great Britain and Ireland

British Association of Day Surgery 2019


Obesity Admission Rates

0

0.5

1

1.5

2

2.5

3

3.5

4

<35 35-40 40-45 >45

BMI

% Admission Rate

Davies, Houghton and Montgomery,

Anaesthesia 2001


Obesity

• Problems occur early (induction/primary recovery)

• Everything is more difficult and takes longer

• Senior staff required

• Additional kit (airway, long instruments, special table etc)


Obesity continued

• 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 from overnight stay

• Day surgery arguably reduces risk of DVT/HAI etc


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


Patient Selection

• Is the procedure in the BADs Directory?

• Is the patient fit for surgery?

• How can we manage them as a day case?


Criteria in 2020

• Abandon universal selection criteria

• Adopt an inclusion rather than an exclusion philosophy

• Apply limitations to the procedure rather than the patient




• Surgical OPA


• Booking


• Admission

• Surgery

• Discharge



Booking

• Booking staff in the DSU

• Engage with teams

• Attend debrief

• Learn together

• Dramatic increases in utilisation


Planning the list

• “Smart” list order

–Consider recovery times / diabetics first/very young or old

–TKR/UKR/ACL/Scopes




• Surgical OPA


• Booking


• Admission

• Surgery

• Discharge



Pre operative assessment

• Plan appointment at time and place convenient and appropriate for the patient

• Ideally offer a one-stop service immediately after surgical OPC

• Face to face with nurse (occasionally telephone)

• Ideally undertaken by nurses working within the day surgery team

• Anaesthetic review of notes or patient as appropriate


Pre operative assessment

• Patient preparation for day surgery

• Discuss arrangements from admission to discharge home

• Identification of medical concerns and address early

• Medication

• BP/Hb/AF etc

• Optimisation of patient




• Surgical OPA



• Admission

• Surgery

• Discharge



Admission

• Dedicated day surgery facility best quality environment

• Limit fasting and waiting times

–Stagger admission times

–admission area close to theatre

• Enable walking to theatre where possible

–Patients and staff prefer it

–Review need for pre-op interventions that prevent walking


Fasting

European Guidelines: 2011

“tea and coffee with milk should be treated as a clear fluid and allowed up to 2 hours pre-operatively”

Perioperative fasting in adults and children: guidelines from

the European Society of Anaesthesiology

Ian Smith, Peter Kranke, Isabelle Murat, Andrew Smith, Geraldine O’Sullivan, Eldar Søreide, Claudia Spies and Bas

in’t Veld


Fasting

Association of Paediatric Anaesthetist Guidelines

Children should be allowed free access to water up to 1 hr pre-operatively


Fasting

Free access to water up to time of surgery:

• Postoperative nausea and vomiting after unrestricted clear fluids before day surgery

• McCracken, Graham C.; Montgomery, Jane

• European Journal of Anaesthesiology. 35(5):337-342, May 2018.

• Radio 4 Inside Health interview with Mark Porter –Tuesday 26th March


Where?

Dedicated Facilities

• for entire pathway if possible

• Protected at all cost from inpatient sabotage

• Staffed by nurses with day surgery expertise


A bed or not a bed?


Medical Patients


The Solution


Should have…

No Beds

No Showers

Only simple Catering facilities

No capacity to accept an inpatient

Your Day Surgery Unit



If you want your surgeons to work there your DSU must have the best kit and the best staff

We can no longer be the poor relation



• Improved Efficiency

• Patient follows day surgery pathway throughout journey

• Fewer cancellations

• Surgical productivity maintained even when hospital is overflowing

• Better chance of successful day surgery discharge

• Higher quality outcomes


Why Dedicated facilities?National Guidance

• The ideal is a self-contained day surgery unit, with its own admission suite, wards, theatre and recovery area, together with administrative facilities. It is also the most cost effective option

• Day surgery performed using inpatient wards and inpatient operating theatres is less successful and cannot be recommended. The stay-in rate (unsuccessful discharge of patients home on the day of surgery) rises from 2.4% in a free standing unit to 14% in an inpatient ward



• Day surgery should take place within a dedicated unit or area within the main hospital site

• All members of the multidisciplinary team should be trained in day surgery practice

• Day case beds on wards do not provide the targeted service that is required to achieve good outcomes



• The ideal day surgery facility is a purpose-built, self-contained day surgery unit (DSU), with its own ward, recovery areas and dedicated operating theatre(s)

• Dedicated day surgery secondary recovery areas should be provided, which are not part of an inpatient ward area

• Day case patients should only be managed through inpatient wards in rare circumstances, as this greatly increases their chance of an unnecessary overnight stay


What do Surgeons Say?

“dedicated day wards and self-contained DSUs

separate from the main hospital building led to

significant improvements in same day discharges for patients undergoing

intended day case surgery"


Royal College of Surgeons

“Integrated day surgery unit should have its

own ward in association with the theatres serving it to

form a dedicated unit”


Why Dedicated facilities?Patient experience

• Separation from inpatient activity and “mentality” of beds, PJs and “the sick role”

• Activity continues even during maximum escalation – fewer cancellations

• Everyone else is going home so I will too

• Higher chance of successful day surgery discharge

• Higher quality outcomes


Why Dedicated Facilities?Nursing expertise

• Nurses not distracted by higher acuity patients

• Nurses with expertise in day surgery pathway

• Whole team are committed to high quality day surgery outcomes


Why Dedicated Facilities?Hospital Benefits

• Improved Efficiency


• Surgical productivity maintained even when hospital is overflowing


Why rely on your day surgery patients to drive length of stay reductions in your inpatient population?

There is more risk of inpatient population increasing length of stay of day cases

If a patient does not fulfil the discharge criteria they can be admitted to a hospital bed via the same process as any

other day surgery patient


Day Surgery Pathway

• Planned as day cases

• Dedicated pathway

• No beds/PJs


• Not affected by inpatient activity

• Managed by day surgery expert team

• Successful discharge

• Excellent outcomes

• Pathway for admission if required but unplanned admission rates will be much lower (6 vs 60%)


Inpatient pathway

• Plan as 1 day stay

• Motivate ward staff and patients to follow one day pathway

• Encourage other patients to reduce length of stay

• If a patient does particularly well send them home sooner..


Dedicated facilities?Unplanned Admission Rates

n Admissions % Admitted P value

Orthopaedic Day beds

642 108 16.8

Day Surgery Unit

634 13 2 <0.01

n Admissions % Admitted P value

Satellite Day Unit

1015 27 2.66

Day surgery Unit

6419 64 1 <0.01

Orthopaedic Day Cases in 2005

Day Cases from all specialities in 2008


Dedicated Facilities?Symptoms after discharge

Day Surgery Unit

%

Satellite Unit

%

P value

Moderate to severe pain

1.52 6.4 <0.01

Moderate or severe nausea

0.14 0.39 0.072

Patient satisfaction

99.85 99.61 0.186

Satisfaction with being a day case

99.98 99.7 <0.01

Fehrmann, Matthews and Stocker: Journal of One Day Surgery; 2009




• Surgical OPA



• Admission

• Surgery

• Discharge



Surgery and anaesthesia

• Appropriate surgical and anaesthetic technique for rapid recovery

• Remember the most expensive techniques rarely compete with the cost of an overnight stay

• Senior staff

• Best kit

• Any specific discharge criteria specified

• Documentation completed in theatre


Recovery

• Protocols for pain and PONV with standard management

• Pre printed analgesia and anti-emetic prescriptions

• Criteria led discharge to second stage




• Surgical OPA



• Admission

• Surgery

• Discharge



Patient Discharge

• Plan from initial referral and at pre op assessment

• TTOs, pre-prepared

• Nurse led discharge

–Appropriate for any length of stay

–Specify criteria




• Surgical OPA



• Admission

• Surgery

• Discharge



Patient support after surgery

• Need for transport home and carer afterwards must be explained

• Not all patients will need carer for 24 hr

• Depends on surgery and risk of complications

• Patients circumstances

• Availability of support if needed

• 24 hour access to skilled advice


Measuring Outcomes

• Day case rates

• Unplanned admissions

• Postoperative symptoms

• Patient satisfaction

hospital IT systems/model

hospital etc

Post-op phone calls


Suggested Metrics

• Identify key aspects of day surgery pathway

• Are they in place

• Identify high volume procedure

• Arthroscopy/Lap Chole/tonsillectomy/hernia

• Identify challenging procedure

• THR/hysterectomy/mastectomy/thyroidectomy

• Identify emergency procedure

• ORIF Mandible/”Hot” Lap Chole/Ankle ORIF/Ectopic Pregnancy/Torsion


Benchmark

• Is ideal day surgery pathway in place

• Day Surgery rates for high volume procedure

• Day Surgery Rates for Challenging Procedure

• Day Surgery Rates for Emergency Procedure

• Unplanned admission rates


Analyse “failures”

• Identify all patients having the high volume procedure who did not achieve day surgery

• What would need to change in the pathway to address this?


Develop new pathways

• What changes are needed in your pathway for your challenging procedure to enable it to move to day surgery?

• Who are the key players?

• How can you implement this?


Knee Arthroscopy


Knee Arthroscopy


ACL Reconstruction


Unicompartmental Knee Replacement


Total Hip Replacements


Total Knee Replacements


Summary of Patient Pathway

• Plan pathway at every stage to ensure intended day surgery management

• Ensure all appropriate patients are managed as day cases

• Social care rarely an issue

• Medical conditions rarely an issue

• Procedures – embrace the BADS directory

• Use dedicated day surgery facilities whenever possible

• Evaluate process to ensure high quality

• Measure day case rates by procedure against national targets

• Monitor day case rates against peers


Day Surgery Joint ReplacementsThe Torbay Story

• 2010: Uni-Chondylar Knee Replacements

• 2019: Total Hip Replacements

• 2019: Total Knee Replacements (early results)


Reducing the length of stay

TKR / THR stays have reduced over past 10 years

– Rapid Recovery pathway

– Typically 3-4/7

UKR was commonly managed as TKR


Accelerating time to discharge

Multidisciplinary approach to reducing LOS

– Rapid Rehab pathway for TKR/THR already well established

– Physios / Nursing staff / OTs all “on board” with concept & mindset

– Patient Re-Education: Set expectations

– Established benefits for patients

• More rapid recovery of function

• Less hospital acquired infection & complications

• Bed & cost savings


UKR: accelerating time to discharge

Introduced one night stay for UKR in 2009 at Torbay

Used Norfolk and Norwich model (Malcolm Glasgow)

– General Anaesthetic +/- short acting spinal

• Early mobilisation

– Large volume of local anaesthetic



Local Infiltration of Anaesthetic (LIA) technique

40 ml 0.25% Chirocaine (levobupivacaine)

– Black spinal needle (22 G)

– Penetrate the back of the joint capsule, ACL/PCL, fat pad, remaining capsule

– All divided tissue infiltrated

– Infiltrate periosteum (pain receptors ++, Ref D Dalury)



LIA and General Anaesthetic allowed early mobilisation

– Reduced inpatient stays to one overnight stay

Step Change: Subsartorial saphenous nerve blocks

– Introduced for TKRs at Torbay 2010

– Effective analgesia, but not complete

– Does not block motor function


Subsartorial saphenous nerve block


Fem

Artery

Needle

Sartorius

Saphenous

nerve


Daycase uni package

Listed for morning case, 1st on list

General Anaesthetic, Saphenous n block, +/- spinal

Dexamethasone IV

IV Teicoplanin and Gentamicin, one dose

1g Tranexamic acid at induction

Routine uni procedure (Oxford and ZUK) under TQ, 250mmHg

Local anaesthetic infiltration

Meticulous closure, absorbable skin suture, tissue glue

Opsite dressing, wool & crepe


Post-op

Return to standalone daycase unit

Wear normal clothes, no PJs!

Enter day-case mentality – everyone else is going home

Mobilise with physio ASAP

Check x-ray

No routine bloods

Dressings debulked prior to discharge


Discharge Criteria

Transfer from supine to standing

Walk > 100 feet without assistance

Ascend / descend stairs


Discharge package

Analgesia requirements anticipated

– Co-codamol 30/500 TT QDS

– Ibuprofen 400mg TDS,

– PRN Tramadol 50mg (max 200mg/day)

– (Pregabalin, Buprenorphine patch)

– Movicol

Thromboprophylaxis:

– s/c Fragmin on day, then home on Dabigatran or Aspirin

– TED stockings as per NICE


Discharge Package

Patient education & reassurance

Availability of 24 hr helpline

Open SOS appt for following day

Phone call from DSU on post op day

– pain scores, nausea / vomiting / dizziness

– satisfaction questionnaire

Outreach team home visit


Pilot study

“appropriate” patients offered daycase uni

– ASA 1-2

Planned Daycase Planned Inpatient

Number 72 58

Mean Age 62.3 yrs 10 .1 66.4 yrs 9.6

Male 33 (46%) 31 (53%)

Female 39 (54%) 27(47%)

Mean ASA 1.9 2.0


Results

62 of 72 planned daycases successfully discharged on day of surgery

Further 3 patients planned as admissions but discharged on day


Results

Pain Scores Nausea Vomiting Dizziness Drowsiness Satisfaction

None: 24 (34%)

Mild: 27 (39%)

Moderate:14 (20%)

Severe: 5 (7%)

None: 68 (97%)

Nauseated: 2 (3%)

None: 65 (93%)

1 episode: 4 (6%)

3 episodes: 1

None: 67 (96%)

Mild: 3 (4%)

Moderate: 0

Severe: 0

None: 69

Mild: 1

Moderate: 0

Severe: 0

Very dissatisfied: 0

Dissatisfied: 0

Neutral: 0

Satisfied: 29 (41%)

Very satisfied: 41 (59%)


Results

Admissions (failed discharge):

Wound ooze (1)

Pain control (2)

Poor mobility or confidence (7 patients, four of whom had undergone surgery later in the day)

No readmissions

Currently 90% are managed as daycases


Take home messages:

Expectations set outcomes

Patients (possibly) need to be first on list

Patients are pleased to be managed as day cases


Day Case Hip Replacement

Mary you must be joking..


Hull were first 2016..

Chris Walker, 71,

was booked into

Castle Hill Hospital

in Hull at 7.30am

last Monday – and

discharged ten

hours later.


Then Northumberland 2016…



If they can do it….

MDT involvement

– Physio

– Outreach Nurse

– Anaesthetists

– Day Surgery Staff

– Surgeon


So we did!

Pathway Developed

Patients selected

Fingers crossed






1st Torbay Day Case THR


Hip replacement Patient Feedback

“Much better experience than my 1st THR a year ago. I can’t understand why I spent 4 days

in hospital that time!”

“Popped into see him today and he had just walked back from the end of the road! Still

doing very well and says his recovery has been

easier this time round at home.”

“I would tell other people considering

this that there’s nothing to be

scared of: it’s been great!”


Results so far..

• Single Surgeon initially (now 3)

• 15 months

• 26 patients scheduled

• 25 patients successfully discharged plus 2 TKR

• Excellent patient satisfaction


Where Next?

• Roll out THR to other surgeons

• Implement Day Case Total Knee Replacements

• Recent introduction of shoulder replacements

• Realistic Target 20% THR/TKR as day case

– 140 cases/year

– 560 bed days


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Documents

Quality in the Patient Pathway · Craniotomy Caesarean Section ... The Pathway to Success –Management of the Day Surgical Patient. BADS Publication 2012. British Association of