Chapter 6: Guidelines for the Provision of Anaesthesia Services for Day Surgery 2024
Introduction
Day surgery is the planned admission of a surgical patient for a procedure where the patient is admitted, undergoes surgery and is discharged on the same calendar day.1 If the patient remains in a hospital bed overnight on the day of their surgery they are classed as having undergone inpatient surgery. The term ‘23-hour stay’ surgery is short-stay inpatient surgery and is not included in the UK definition of day surgery. The NHS Plan (2000) stipulated that at least 75 per cent of elective surgery should be undertaken on a daycase basis.1 In 2004, the Department of Health NHS Modernisation Agency, in its 10 High Impact Changes For Service Improvement and Delivery, states that day surgery rather than inpatient surgery should be treated as the norm for elective surgery.2 In the intervening years, huge strides have been made in the development of day surgery across the country; however, there is wide variation.2 The top-performing units are achieving very high daycase rates; however, many struggling to reach the 85 per cent target recently set by GIRFT/NHSE.3 While absolute day case rates for an individual hospital may reflect differences in case mix, there is still wide variation across the country when comparing individual procedures.3
Day surgery encompasses a spectrum of surgical procedures that allow the patient to go home on the day of surgery, often after only a few hours. It represents high-quality patient care, which includes surgical techniques with reduced tissue trauma, and employs enhanced recovery, effective analgesia, minimal adverse events, provision of appropriate information and postoperative support. Improvements in the provision of anaesthesia and analgesia and the introduction of minimal-access surgical techniques allow a range of procedures to be undertaken on a daycase basis, which formerly would have required inpatient services.
Day surgery outcomes can be measured in terms of quantity (percentages of procedures undertaken on a daycase basis) and quality (for example unplanned admission rates, patient satisfaction, postoperative symptoms). For a hospital to have successful day surgery outcomes, a variety of clinical and managerial processes are required. There should be a multidisciplinary management team responsible for the strategic development and running of the day surgery unit and a dedicated clinical lead or clinical director with allocated programmed activities to allow them to lead service development. Consultant or autonomously practising anaesthetic involvement is essential in the development of policies, protocols and guidelines designed to facilitate smooth running of the day surgery unit and preoperative assessment processes.5,6,7,8,9
There should be a clear day surgery process for all patients for day surgery treated within the trust whether through dedicated facilities, which is the ideal scenario, or through the inpatient operating theatres, which should only be supported if the development of dedicated facilities is either not a viable option or there is insufficient capacity to accommodate all day surgery activity.5,9
BADS and GIRFT recommends that day case surgery is the default for all suitable elective surgical procedures Processes should be in place to ensure that all appropriate patients are considered for day surgery management.3,9,19 This includes adopting the British Association of Day Surgery Directory of Procedures and ensuring that all recommended procedures default to day surgery management where clinically appropriate.10 This is particularly relevant for the GIRFT high volume low complexity (HVLC) procedures.11 Preoperative assessment processes, which enable the majority of patients to be safely cared for within day surgery pathways, are essential.9 This includes children, the elderly and patients with complex medical conditions.9,12
Anaesthesia for day surgery should be consultant-led and all anaesthetists delivering day surgical care must be trained, experienced and skilled in the practice of anaesthesia for day surgery to provide the high-quality anaesthesia pivotal to successful outcomes.6 The day surgery unit provides an ideal training opportunity and training in anaesthesia for day surgery is essential. Anaesthesia trainees may undertake day surgery lists under appropriate senior supervision. During their day surgery training, anaesthetists need to develop techniques that permit their patients to undergo surgical procedures with minimum stress and maximum comfort and optimise their chance of early discharge.
Effective audit is essential in the provision of quality anaesthesia for day surgery.3,5,6,9,13,14
Some day surgery units or ‘treatment centres’ may be sited in a geographically separate location from the main hospital building. Self-contained units must be sufficiently equipped and have access to all the necessary perioperative support services.15 Patient selection should consider the availability of additional help in an emergency, and ease of overnight admissions if required. Patients deemed unsuitable for anaesthesia or surgery in these isolated locations may very well still be appropriate for a day surgery pathway managed through the main hospital facilities.
Anaesthetists play a pivotal role in achieving successful outcomes for day surgery patients. Working as part of the multidisciplinary team, anaesthetists can and should contribute in more ways than solely providing anaesthesia.
1. Organisation and administration
1.1
Day surgery should be a consultant or autonomously practising anaesthetist/surgeon-led service with a dedicated clinical lead or clinical director who has programmed activities allocated to the role within their job plan. The role of the clinical director is to champion the cause of day surgery and to ensure that best practice is followed. This role may involve the development of local policies, guidelines and clinical governance, and should be recognised by adequate programmed activity allocation and provided with the administrative and secretarial support necessary to achieve these goals,3,5,9,13,16
1.2
The day surgery unit should have appropriate administrative support involving patient booking for lists and preoperative assessment services, communication with patients about admission times and starving instructions, and reception staff to meet and greet patients on the day of surgery and admit them electronically for their procedure.12
1.4
There should be a senior nurse manager or appropriately trained allied health professional who, together with the clinical director, can provide the day to day management of the unit.
1.5
Many larger units, especially those that are freestanding, should consider having a separate business manager to support the clinical director and senior nurse.
1.6
The clinical director should chair a management group and should liaise with all those involved in day surgery. This group will include representatives from surgery, anaesthesia, nursing, pharmacy, management, finance, community care (both nursing and medical), audit, professions allied to medicine and representatives of patient groups.
1.7
1.8
Local preoperative assessment guidelines and protocols should be established. These should be in line with current national recommendations from the British Association of Day Surgery, Getting It Right First Time, the Centre for Perioperative Care, NHS England and the Preoperative Association.4,18,19,20,21
1.9
1.10
1.11
1.12
A consultant or autonomously practising anaesthetist should be available to review an individual patient’s suitability for day surgery and to assist with preoperative optimisation, in discussion with medical specialists as appropriate. A referral service for nurses or appropriately trained allied health professionals to allow complex patients to have anaesthetic review should be developed.5,12,13
1.13
1.14
Mixed inpatient and day surgery lists may increase flexibility, but this practice should be minimised, as conflicting priorities can compromise the care of both groups.9
1.15
If it is occasionally necessary to undertake daycase surgery on inpatient operating lists, the day cases should be prioritised at the beginning of the list to allow time for postoperative recovery and discharge. Starting the list with a daycase patient may improve efficiency (no delay to starting list) in times of bed pressures.
1.16
Daycase patients should ideally be cared for in dedicated day surgery ward areas to ensure safe and timely discharge.
1.17
1.18
Locally agreed policies should be in place for the management of postoperative pain after day surgery. This should include pain scoring systems in recovery and a supply of pain relief medication on discharge, with written and verbal instructions on how to take medications and what to take when the medications have finished. Information on over-the-counter analgesics to have at home should be given at preoperative assessment.
1.19
There should be agreed protocols for the care of patients who require unplanned hospital admission following their daycase procedure.
1.20
Patients may be discharged home with residual sensory or motor effects after peripheral nerve or plexus blocks (not after neuraxial anaesthesia). Duration of the effects should be explained, and the patient should receive written instructions as to how to care for their numb limb until normal sensation.
1.21
1.22
Postoperative short-term memory loss may prevent verbal information being assimilated by the patient.26 If postoperative analgesia has been provided, clear written instructions on how and when to take medication should be provided. Other important information should also be provided in writing.5,9,25
1.23
A 24-hour telephone number should be supplied so that every patient knows whom to contact in case of postoperative complications. This should ideally be connected to an inpatient surgical area of the appropriate specialty and should not be an answerphone.
1.24
Following procedures performed under general or regional anaesthesia, a responsible adult should escort the patient home and should provide support for the first 24 hours after surgery.5 A carer at home may not be essential if there has been good recovery after brief or non-invasive procedures and where any postoperative haemorrhage is likely to be obvious and controllable with simple pressure.
1.25
Transport home should be by private car or taxi; public transport is not normally acceptable following general or regional anaesthesia.
1.26
Where the patient’s general practitioner (GP) practice may need to provide postoperative care within a short time of discharge, arrangements for this should have been made with the GP in advance of the patient’s admission.
1.27
The patient’s GP should be informed of the patient’s procedure as soon as practical, and provided with a written discharge summary, which will usually be completed by the surgeon.
1.28
All patients should receive a copy of their discharge summary in case emergency treatment is needed overnight.
1.29
A number of urgent surgical operations (e.g. abscess drainage, superficial lacerations or hand trauma) can be managed on a daycase basis, with semi-elective admission to day surgery facilities on the day of operation and discharge later the same day.10,17,27 Effective preoperative assessment will add to success for these patients. In contrast, the accommodation of emergency inpatients within the ward environment of day surgery facilities, without alteration of the surgical pathway, represents a failure of bed capacity planning and causes disruption of effective day surgery.3,9
2. Patient information
The Royal College of Anaesthetists has developed a range of Trusted Information Creator Kitemark-accredited patient information resources that can be accessed from the RCoA website. The main leaflets are now translated into more than 20 languages, including Welsh.
2.1
Patients should be provided with information specific to their condition/indication for surgery in addition to information about day surgery. Clear and concise information given to patients at the right time and in the correct format is essential to facilitate good day surgery practice.5 This information should be provided before the day of surgery and may be given to patients at the surgical clinic or at their preoperative assessment. Verbal information should always be reinforced with printed material or information available from specialist sources online such as the RCoA website. Alternative means of communication with patients, including the internet, email and text messaging, should be considered.12,17
2.2
An explanation of the of the patient pathway for the day of surgery and written information should be provided. This could include infographics or video.12
2.3
Information should be arranged in such a way that is comprehensive, comprehensible, age appropriate and suitable for patients with special needs and those with other difficulties in understanding and considering the information. It may be necessary to provide information leaflets in a number of different languages to accommodate the needs of the local population.
2.4
2.5
In addition to clinical information, patients should be provided with:
- the date and time of admission to the unit
- location of the unit, travel and parking instructions, including information regarding parking costs, if relevant
- any relevant preoperative preparations required of the patient
- information on the anaesthetic to be provided, including clear instruction for preoperative fasting and hydration, and the way in which patients will manage their medication
- requirement to arrange an escort home and a postoperative carer if indicated
- postoperative discharge information, including details of follow-up appointments, management of drugs, analgesia, including stepping down of pain relief, opioids, dressings, and clear instructions on whom to contact in the event of postoperative problems.12,30
2.6
Patients should also be made aware at the preoperative assessment visit that conversion to inpatient care is always a possibility and that they should consider how this may impact on their home arrangements, including any dependent relatives.
3. Staffing requirements
3.1
Preoperative assessment clinics should have a nominated consultant or staff grade, associate specialist or specialty doctor lead involved in developing local protocols, coordination of day surgery preoperative services, selection of patients with complex issues for day surgery and audit of outcomes.12,13
3.2
Preoperative assessment staff should be specifically trained in day surgery preoperative assessment, including optimisation and preparation for day surgery.
3.3
Where possible, progress should be made towards development of dedicated day surgery teams with preoperative assessment delivered by the day surgery team to reinforce the day surgery message.
3.4
High-quality anaesthesia is pivotal to achieving successful outcomes following day surgery. The majority of anaesthesia for day surgery should be delivered by consultants or autonomously practising anaesthetists. Staff grade, associate specialist and specialty doctors and experienced trainee anaesthetists may also provide anaesthesia for day surgery. However, these doctors should be suitably experienced and skilled in techniques appropriate to the practice of day surgery and have undertaken appropriate training in the provision of anaesthesia for day surgery.12,24
3.5
Anaesthetists should have been trained in this field to the standards required by the Royal College of Anaesthetists.12
3.6
There should be adequate staffing levels provided within the department to ensure that there is minimal handover of patients between staff.31
3.7
Anaesthesia associates should work under the supervision of a consultant or autonomously practising anaesthetist at all times, as required by the RCoA.32
3.8
The secondary recovery area in the day surgery unit (day surgery ward) should be staffed to match patients’ needs. Consideration should be given to the skill mix as well as numbers of staff.
3.9
3.10
3.11
When children are present on the unit, support workers and health play specialists should play a key role within day surgery provision.32
4. Facilities, equipment and support services
Facilities
4.1
The ideal day surgery facility is a purpose built, self-contained, ring-fenced day surgery unit with its own preoperative, intraoperative and postoperative facilities. This unit may be contained within a main hospital or in its grounds to allow access to higher-level patient support services, if required, or it may be a freestanding unit remote from the main hospital site.5,9,15,36
4.2
A viable alternative is for patients to be admitted to and discharged from a dedicated day surgery ward, with surgery undertaken in the main theatre suite. This arrangement may be more flexible for complex surgery and avoids duplicating theatre skills and equipment. Day surgery patients should be prioritised as first on the main theatre list to allow recovery time for successful day surgery discharge.5,9
4.3
Daycase patients should only be channelled through inpatient wards in exceptional circumstances, as this greatly increases their chances of an unnecessary overnight stay.37
4.4
4.5
Adequate time and facilities should be provided within the day surgery unit to enable the multidisciplinary day surgery clinical team to undertake all aspects of the admission process, including clinical examination, further discussion about the procedure and delivery of information while maintaining patient dignity and privacy.12,33,34
4.6
4.7
Secure storage for patients’ belongings, clothes and medications should be available while they undergo their surgery.34
4.8
4.9
4.10
Dedicated second-stage recovery (which is usually the day surgery ward) should be provided separately from inpatient ward areas. Ideally, this area should have a single-sex set-up with respect for gender identity.38
4.11
The day surgery ward should provide essential, close and continued supervision of all patients, who should be visible to the nursing staff while maintaining privacy and dignity.
4.12
The day surgery ward should have the facility to provide drinks and snacks after surgery.34
Equipment
4.13
Equipment to allow full individualised preoperative assessment for day surgery patients should be available, including a 12-lead ECG machine, a sphygmomanometer for blood pressure, weighing scales and equipment for taking blood samples to the same standard as for inpatient preoperative assessment.12,17
4.14
4.15
4.16
4.17
The recommended Association of Anaesthetist standards of anaesthetic monitoring should be met for every patient.39
4.18
4.19
Short-acting anaesthetic drugs and appropriate equipment to facilitate their delivery should be available to day surgery units. Total intravenous anaesthesia with appropriate depth of anaesthesia monitoring is effective in reducing postoperative nausea and vomiting. Equipment for its use should be available in day surgery theatres.26,37,40
Support services
4.21
Preoperative assessment services if provided within the day surgery unit should have support from investigation laboratories or clinical testing services to support diagnosis for risk assessment and optimisation of patients. This will allow day surgery selection to be maximised for high-risk patients.12,17
4.22
Access for preoperative assessment staff to multidisciplinary teams support from other physicians, medical specialists, anaesthetists, surgeons and pain management teams should be available.12
4.23
If day surgery does not have preoperative assessment within the unit, there must be an appropriate preoperative assessment service to support effective day surgery patient selection and preparation.
4.24
Support services including radiology, pharmacy and investigative laboratories should be available.
4.25
The facility to perform a 12-lead ECG and other point of care tests, such as international normalised ratio, should be available within the day surgery unit itself.
Information technology
4.26
4.27
4.28
Results from investigations should be available via the electronic patient record or via an appropriate IT system.16
4.29
The day surgery unit must have a clear action plan of what to do in case of failure of IT system and the need to revert temporarily to paper and any equipment or documents must be readily available (e.g drug kardexes).
5. Areas of special requirement
Children
5.1
The lower age limit for day surgery depends on the facilities and experience of the staff and the medical condition of the infant and proposed surgery. Infants aged less than 60 weeks postconceptual age are not normally considered unless medically fit and the unit has the appropriate expertise. Risks should be discussed with parents and carers on an individual basis.32,33,42
5.2
5.3
Infants with a history of chronic lung disease or apnoea should be managed in a centre equipped with facilities for postoperative ventilation.
5.4
Infants, children and young people should, where possible, be cared for in a dedicated paediatric unit or should have specific time allocated in a mixed adult/paediatric unit, where they are separated from adult patients.32,45 Environment should be safe and well suited to age and stage of development of the child or young person.34
5.5
5.6
There should be access to a paediatrician. Where the day surgery unit does not have inpatient paediatric services, robust arrangements should be in place for access to a paediatrician and transfer to a paediatric unit if necessary.32
5.7
5.8
Children requiring day-stay anaesthesia for non-surgical procedures such as imaging, endoscopy, laser treatment to skin lesions, radiotherapy, and oncology investigations and treatments should have the same standards of care as those having surgical procedures.
5.9
Special considerations for younger children undergoing day case tonsillectomy/ adenoidectomy surgery should be made depending of expertise at the centre and current national guidelines. Skilled preoperative assessment services, including thorough assessment of children with obstructive sleep apnoea (OSA) and experienced anaesthetists and surgeon are required to deliver this safely. Surgery and perioperative care, including care on the post-anaesthetic care unit and on the ward, should be delivered by a team with ongoing experience with young children and who maintain regular training.40
5.10
5.11
Emergence delirium is more common in young children having short procedures; it is distressing for parents and staff, and impairs the quality of recovery. Anaesthetic techniques should be modified to minimise the risk of emergence delirium in susceptible children to facilitate smooth recovery and discharge.5,50,51
Prisoners
5.12
Pathways and policies for treating prisoners as day cases should be agreed with the local prison services.52 This should include a risk assessment and information required to determine whether adjustments are needed to maintain the privacy and dignity of the patient and the safety of staff and other patients. The preoperative assessment team must highlight these requirements to the day surgery team.
5.13
The hospital should ensure that prisoners have adequate access to postoperative analgesia. Some prisons do not have the facility to provide analgesia if the medical officer is not on duty. In these cases, arrangements are required to enable the prisoner to access the required postoperative medication within the prisoner’s cell or for additional arrangements to be made to enable patients to receive overnight postoperative analgesia.
5.14
The hospital should consider making an agreement on the safe provision of privacy and dignity for prisoners with the local prison governor regarding the use of restraints.50
5.15
The staff should ensure that patients have sufficient information and autonomy to give informed consent, including access to translation where appropriate.
Emergency day surgery
5.17
5.18
5.19
It is essential to determine whether the patient is safe to be sent home with oral treatment and analgesia for up to 24 hours while awaiting urgent surgery on a daycase basis.27
Frail and older patients
5.20
Day surgery can be an advantageous choice for the frail or older patient allowing better recovery in their own familiar environment at home and avoiding a hospital stay with risk of exposure to infections.54
5.21
5.22
Perioperative plans should be made with carers or relatives involving access to day surgery pathways to increase the chance of success.12
5.23
5.24
Planned early mobilisation and multimodal, opiate light analgesic regimens should be used to reduce postoperative delirium in high-risk frail or elderly patients.51
5.25
Equipment available to measure depth of anaesthesia may help to facilitate recovery with fewer postoperative complications.52
Breastfeeding patients
5.26
Where possible, day surgery is preferable to avoid disrupting normal routines. Guidelines from the Association of Anaesthetists Guidelines on breastfeeding and sedation in breastfeeding women should be followed.56
5.27
Patients should be supported to breastfeed as normal following surgery with appropriate facilities, including allowing the infant to feed in the perioperative period. There is no requirement to discard breast milk immediately after surgery.53
5.28
Multimodal analgesia should be used, including regional anaesthesia. Opioid analgesia can be used if required, but the patient should be given advice regarding observing the infant for signs of excessive drowsiness. Additional advice for prescribing for breastfeeding patients can be found in the guideline from Association of Anaesthetists Guidelines on breastfeeding and sedation in breastfeeding women.45
Morbidly obese patients
5.29
5.30
Anaesthetic review at preassessment is recommended for those patients whose body mass index (BMI) is greater than 40 kg/m2 with associated comorbidities. Optimisation is important but should allow safe day surgery. Patients who are super morbidly obese (BMI > 50 kg/m2) need particular care in preoperative assessment and optimisation and may need additional equipment or staffing to be arranged for safe management.12,54
5.31
Patients should be assessed for their risk of sleep apnoea using validated tools such as STOP BANG.5 Such tests should be embedded in the preoperative assessment process and should be followed by referral for treatment with continuous positive airway pressure (CPAP). Obstructive sleep apnoea is a multisystem disorder. Thorough preoperative investigation to exclude associated cardiac disorders (Including right-heart strain or pulmonary hypertension), metabolic dysfunction or neuropsychiatric disorders, is important.55 Anaesthetic review can determine suitability to proceed to day surgery.12,17,59
5.32
While even patients who are morbidly obese (BMI > 40 kg/m2) can be cared for through a day surgery pathway, it may be inappropriate to operate on them in an isolated environment. In this case, their surgery could be undertaken through a day surgery pathway using the main hospital operating theatres if this environment has the specialist equipment required for obese patients. The patient should, where possible, be transferred to the day surgery unit for subsequent secondary recovery and discharge.54
Patients with severe anxiety or Learning disability
5.33
Pathways for patients with additional needs, such as severe anxiety or learning difficulties, should be developed so individualised care can be delivered to minimise anxiety and stress to the patient.
5.34
Pathways should be multidisciplinary, starting at preoperative assessment and involving a learning difficulty nurse specialist, if appropriate, the patient’s usual care team, the day surgery team anaesthetist for the list and a surgeon, as appropriate.12
5.35
Patients GP or psychiatrist may need to be involved if sedation prior to coming to hospital is required.
5.36
It is recommended that the day surgery team has a lead nurse to oversee this pathway.
5.37
5.38
Consideration is needed regarding admission times and where the patient is on the list.
5.39
A postoperative analgesia plan should be discussed and agreed as part of the planning process.
Isolated sites
5.40
Preoperative assessment should identify those patients suitable for day surgery in an isolated site.17
5.41
Where day surgery is performed in isolated units, practice should comply with the RCoA guidelines on anaesthetic services in remote sites.62
5.42
There should be agreed pathways for patients who require admission to hospital following their day surgery procedure.5
6. Training and education
6.1
6.2
Standards and training for clinical staff working within the primary recovery area should be as defined within RCoA guidelines for the provision of anaesthesia services for the perioperative care of elective and urgent care patients.12
6.3
Training should be multidisciplinary, with the use of simulation encouraged.16
6.4
Appropriate and comprehensive training for anaesthetists in this subspecialty should be given according to current standards as defined by the RCoA.63
6.5
Training for all clinical staff involved in the day surgery pathway should emphasise the following aspects:
- patient selection and optimisation for day surgery
- provision of effective postoperative pain relief64
- strategies for dealing with postoperative nausea and vomiting
- the necessity of a multidisciplinary team approach in day surgery care
- the requirement for ‘street fitness’ on discharge
- the postoperative care of patients in the community.
7. Financial considerations
There is a huge focus on the elective recovery programme and reduction in the backlog of patients waiting for elective surgery. Over 75% of this surgery involves day surgery procedures.11,65 Creation of surgical Hub centres to facilitate this is being developed. Resources should be delivered to allow perioperative processes to be optimised to maximise day surgery numbers.
7.1
Funding for pathway redesign and facilities has been provided by central government and local commissioners. Cost analysis should consider all finances, including capital and maintenance costs, staffing and training costs for both the theatre and the ward, as well as costs related to the procedure itself.21
7.2
When selecting options for anaesthetic techniques within the day surgery unit, consideration should be given not only to the cost of delivering that anaesthetic but to the wider patient outcome costs. High-quality anaesthetic techniques and consumables, including drugs, maybe economically viable even if apparently more expensive.24
7.3
7.4
Investment in senior staff experienced in the practice of day surgery is required to ensure high-quality efficient processes.24
8. Audit and quality improvement
8.1
The Royal College of Anaesthetists has published guidance for audits and quality improvement projects in day surgery.6 Each day surgery unit should have a system in place for the routine audit of important basic clinical and organisational parameters such as:
- clinical: unplanned inpatient/overnight admissions following surgery, postoperative symptoms (e.g. pain, nausea and vomiting)
- organisational: non-attendance rates, patients cancelled on the day of operation.
8.2
Outcome measures in day surgery that should also be monitored are:9,21
- clinical: perioperative clinical adverse events, postoperative morbidity (sore throat, headache, drowsiness, venous thromboembolisms, unplanned return to theatre on same day of surgery, unplanned return or readmission to day surgery unit or hospital)
- comparator: outcomes for more complex operations should be compared to ensure that day surgery clinical and patient outcomes match those with longer hospital stays
- organisational: the proportion of elective surgery performed as day surgery, theatre use (late starts, early finishes)14
- qualitative: patient satisfaction, friends and family data, patient-reported outcome measures.
8.3
Current practice in day surgery includes more complex procedures and more elderly patients. Audit of complications related to wound-healing process and impaired mobility based on risk scores can help to improve the safe delivery of a day surgery service.
8.4
Audits should rely only on procedure specific data and not on overall percentages. Auditors can compare activity by procedure and unit.14
8.5
Audit and quality improvement should be coordinated and led by designated staff members. Audit and quality improvement should feed into the hospital’s governance process.14
8.6
Audit and quality improvement should be integrated into wider areas of anaesthetic and surgical practice.21
8.7
Audit in clinical practice and patient care in day surgery should involve all staff. A system should exist for the regular feedback of audit information to staff, to reinforce good practice and help to effect change and, hence, drive quality improvement. This feedback may take the form of regular meetings or updates, or a local newsletter.21
8.8
For commissioning purposes, suggested indicators of quality of a day surgery unit include:9 ,21
- day surgery existing as a separate and ‘ring-fenced’ administrative care pathway
- a senior manager directly responsible for day surgery
- preoperative assessment undertaken by staff familiar with the day surgery pathway
- provision of timely written information
- appropriate staffing levels
- nurse-led discharge
- provision for appropriate postoperative support including follow-up and outreach after home discharge
- involvement and feedback from patients, the public and community practitioners.
This list is not exhaustive and other factors such as theatre use, levels of unplanned overnight admissions after day surgery, management of pain relief and postoperative nausea/vomiting, and complication and readmission rates are also important quality indicators that should be audited regularly.
9. Implementation Support
The ACSA scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations so that departments can refer to them while working through their gap analyses.
Departments of anaesthesia can subscribe to the ACSA process on payment of an appropriate fee. Once subscribed, they are provided with a ‘College guide’ (a member of the RCoA working group that oversees the process) or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the standards document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.
The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards or have implemented the standards in innovative ways.
One of the outcomes of the ACSA process is to test the standards (and by doing so to test the GPAS recommendations) to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.
Areas for future development
Research into best practice day surgery should be encouraged.
The following areas are suggested for future research and development:
- procedures not currently undertaken as day surgery, including urgent/emergency surgery that could move into the day surgery arena
- whether a specific ring-fenced day surgery preoperative assessment service leads to fewer avoidable cancellations on the day of surgery
- whether patients are established on effective CPAP for severe obstructive sleep apnoea safe to undergo more complex day surgery operations
- how much the use of opioids can be reduced in day surgery.
Glossary
Clinical lead – staff grade, associate specialist and specialty doctors undertaking lead roles should be autonomously practising doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role and they should participate in quality improvement and continuing professional development activities. Individuals should be fully supported by their clinical director and be provided with adequate time and resources to allow them to effectively undertake the lead role.
Immediately – unless otherwise defined, ‘immediately’ means within five minutes.