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

into the Department of Health's
Day surgery: operational guide
published to support the National Day Surgery Programme to achieve a 75% day case rate for elective surgery by 2005. 2 Although this tool is still used as a comparator in assessing output by Trusts and Health Authorities, 13 for development purposes it has now been superseded by the introduction of a regularly updated Directory of Procedures by the BADS. 14 The Directory, which was first introduced in 2007 and is regularly updated, lists over 200 procedures by speciality, including their OPCS and HRG codes, and provides a breakdown of how each procedure might be treated within four areas: procedure room, day surgery, 24-hour stay or under 72-hour stay. It therefore allows for the planning and development of day surgery practice within a Unit or Trust.
     
    Box 3.2    Audit Commission basket of 25 procedures 2001
    Orchidopexy
    Circumcision
    Inguinal hernia repair
    Excision of breast lump
    Anal fissure dilatation or excision
    Haemorrhoidectomy
    Laparoscopic cholecystectomy
    Varicose vein stripping or ligation
    Transurethral resection of bladder tumour
    Excision of Dupuytren's contracture
    Carpal tunnel decompression
    Excision of ganglion
    Arthroscopy
    Bunion operations
    Removal of metalware
    Extraction of cataract with or without implant
    Correction of squint
    Myringotomy
    Tonsillectomy
    Submucous resection
    Reduction of nasal fracture
    Operation for bat ears
    Dilatation and curettage/hysteroscopy
    Laparoscopy
    Termination of pregnancy
    How does it work for the patient?
    Facilities for day surgery
    The organisation of day surgery services differs from traditional inpatient surgery. Patients arrive at the hospital on the day of surgery, fully assessed, with the results of investigations already checked. Following operation, patients recover in the day unit and are discharged home, accompanied by their carer. The entire admission episode is preplanned and the routine nature of the hospital visit ensures quality care. Any error in the system results in an unnecessary overnight admission and it is therefore not surprising that the facilities for day surgery differ from inpatient surgery.
    Initially, day surgery was attempted from the inpatient ward, but this environment is a mixture of emergency admissions, unwell elective surgery patients and the ‘well’ elective day surgery patient. Quality of care for the day case patient suffered as busy ward staff naturally concentrated on the acutely ill. There was also no incentive to ensure the day patient was able to go home the same evening. In the UK, the patient's procedure was often cancelled on the day of admission as their projected bed had been occupied overnight by an emergency admission.
    Self-contained day units or dedicated day wards were therefore developed and unplanned overnight admission rates dropped dramatically from 14% on an inpatient ward to 2.4% in a dedicated day unit. 2 These units may be free-standing or integrated within the main hospital, where they benefit from the full range of available support services. The self-contained unit should have its own day surgery theatre within the day surgery suite, performing dedicated day case lists.
    Dedicated lists require appropriate staffing levels to be allocated as there is a greater intensity of work for theatre staff if several day cases are to be treated rather than a single major case. Experience has shown that the most effective units unite all managerial as well as nursing and operative functions under the same roof. Further efficiencies are made if the day unit can be accessed directly from the street or car park, and if day patients have their own dedicated car parking facilities.
    The day surgery cycle
    In traditional inpatient surgery, the patient is admitted either from the waiting list or directly from the surgical outpatient clinic if the patient is classified as urgent. In day surgery, the processes are different ( Fig. 3.1 ). In many