Free Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice by Simon Paterson-Brown MBBS MPhil MS FRCS

that delivery to understand how to introduce, create and then manage surgical developments in a timely, safe, efficient and cost-effective manner.
    Understanding how day surgery works, how traditional inpatient care can be successfully transferred to the day unit, and what is required to enable that to happen is a fundamental requirement for all those involved in the care of the surgical patient, be they surgeon or anaesthetist, nurse or manager, health purchaser or provider.
    Day surgery has been described as the planned admission of a patient to hospital for a surgical procedure which, while requiring recovery from a bed or trolley, allows the patient to return home the same day. As a consequence, procedures not requiring full operating theatre facilities and/or general anaesthesia, procedures which can be performed in outpatient or endoscopic suites, are no longer called true ‘day surgery’.
    Successful and well-managed day surgery has the potential to improve the quality of care for patients by separating their elective treatment from the bustle of emergency surgical care, both of which are traditionally managed on the same wards. Most people would rather not stay in hospital longer than necessary, and short stays reduce the risks of hospital-acquired infections. Reducing length of stay also reduces costs and can improve efficiency, reasons that make day surgery attractive to all healthcare systems worldwide.
    In the UK, the NHS plan proposed by the government in 2001 set the patient firmly at the centre of a framework for modernising the NHS. 1 The idea was to reduce waiting times, implement booking systems and introduce patient choice. However, the government was faced with capacity constraints and one solution to increase patient throughput was to reduce the length of patients' stay by focusing on increasing national day surgery rates by implementing a National Day Surgery Programme.
     
    The day surgery strategy was launched in 2002 with the broad aim of achieving 75% of all elective surgery in the UK to be performed on a day case basis by the year 2005. 2
    Day surgery now comprises over 70% of all elective surgery in the UK, over 80% in the USA and is likely to become the default method of treating most surgical patients in the next two decades. This growth has occurred over the last 30 years, most of it in the last 15. How has this come about? What are the main driving forces behind it? What are its strengths and weaknesses? This chapter covers those aspects of day surgery that are essential to good practice, and highlights some areas of current controversy.
    The development of day surgery
    The concept of day surgery is not new. In 1909, James Nicholl, a surgeon working at the Royal Hospital for Sick Children in Glasgow, reported on nearly 9000 children undergoing operations for conditions such as hernia and harelip, all of whom went home on the day of surgery. 3 He described the benefits for parent and child of returning home the same day, but stressed the importance of suitable home conditions in the success of day surgery. A decade later, in 1919, Ralph Waters, an anaesthetist in Sioux City, Iowa, reported on the ‘downtown anaesthesia clinic’ where adults underwent minor surgical procedures, returning home within a few hours. 4
    The modern era of day surgery began in the years following World War II with the realisation that prolonged bed rest was associated with high rates of postoperative complications such as deep vein thrombosis. 5 The move towards early ambulation led to earlier discharge and, for the first time, the economic benefits of day surgery were noted. 6 In 1955, Eric Farquharson of Edinburgh described a series of 458 consecutive inguinal hernia repairs performed on a day case basis at a time when the average length of postoperative stay was approximately 2 weeks. 7 The medical benefits of early ambulation were recorded and the potential impact on surgical waiting times was