Unplanned admission rates and postdischarge complications in patients over the age of 70 following day case surgery

The elderly are a group of patients who would seem ideally suited to day surgery. However, age was initially regarded as a potential barrier to this process. We conducted a retrospective review of 1647 elderly patients (> 70 years of age) over a two-year period. Our results show a favourable outcome for these patients with low rates of unplanned admission and postoperative complications. Elderly patients seem to be at no increased risk of complications after day surgery, and show excellent satisfaction scores.     

Unplanned admissions in day surgery

The incidence of and reasons for unexpected admissions from day-surgery wards to in patient wards over a three month period in the Wessex region were assessed. The multi-centre study included ten hospitals in which 11,749 procedures were performed and 258 patients admitted, giving an admission rate of 2.25%. Pain, post operative nausea and vomiting, and delayed recovery were found to be the most significant anaesthetically related factors responsible for those admissions.     

Quality assessment in a day surgery unit

The aim of this study was to assess the quality of day surgery by examining the experiences of patients to ascertain where and how quality can be improved. Therefore interviews were carried out with 39 patients at the University Hospital in Maastricht. These interviews were compiled using a model for quality assessment of day surgery developed by the National Organisation for Quality in Hospitals in the Netherlands. Results show that patients are satisfied with the quality of day surgery. Nevertheless it appeared that improvements could be made in the fields of: information disclosure, continuity of care from the day surgery unit (DSU) to the emergency department, pain medication for some procedures and facilities for patients at home.     

Trends in colorectal day case surgery in NHS Trusts between 1998 and 2005

Objective Day case surgery is safe and offers potential benefits to both patients and healthcare providers. This study aimed to describe national changes in colorectal day case workload between 1998 and 2005. Methods Admission data relating to Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision) (OPCS‐4) coloproctology operation codes were analysed using the Hospital Episode Statistics (HES) database. Day case rates (DCRs) were calculated as the proportion of elective cases performed on an ambulatory basis. Results In total, 3 119 058 colorectal admissions were recorded on the HES database between 1998 and 2005; 1 891 474 (61%) of these were for lower gastrointestinal endoscopies. Emergency cases accounted for 527 665 (17%), elective inpatient cases for 406 368 (13%) and elective day cases for 293 551 (9%) admissions. Throughout the study period the DCRs for five commonly performed elective colorectal procedures were: 0.70 for anal lesion excisions (OPCS‐4 codes: H48.1, H48.2 and H48.3); 0.16 for haemorrhoidectomy (OPCS‐4 code: H51.1); 0.63 for anal fissure procedures (OPCS‐4 codes: H56.2 and H56.4); 0.39 for elective procedures for anal fistula (OPCS‐4 codes: H55.1, H55.2, H55.3 and H55.4); 0.37 for elective pilonidal surgery (OPCS‐4 codes: H59 and H60.2). Two emergency operations, drainage of perianal and pilonidal abscesses (OPCS‐4 codes: H58.2 and H60.3 respectively), were identified as operations potentially amenable to day surgery. Over the seven study years, an annual average of 8559 (±SD 307) admissions were coded to drainage of a perianal abscess and 4676 (±SD 478) admissions to drainage of pilonidal abscess. The average annual bed usage associated with these procedures was 18 831 (±SD 718) and 7623 (±SD 436) bed days respectively. Conclusions Colorectal day case surgery is currently under‐exploited in the NHS. By lifting some of the barriers to day case surgery significant resource savings may be possible.     

A quality assurance initiative in day case surgery: general considerations

With the increasing demand for audit in the day surgery setting, a quality assurance initiative was implemented in a busy British day surgery unit. This paper outlines how such a programme was designed and established. The indicators of quality in day surgery and the standards of practice used are discussed. The results of the data collected are discussed and the recommendations for improvement are outlined. Hopefully this paper will serve as a concrete and practical guide for the implementation of a quality assurance programme in other day surgery facilities.     

Post-operative pain in children after day case surgery

The increasing use of paediatric day case surgery requires assessment of the effectiveness of post-operative analgesia. A prospective epidemiological study of ninety-eight patients undergoing day case surgery looked at pain assessment using a self report Faces scale and a numerical rating scale for parents and nursing staff. An inpatient record was combined with a home questionnaire detailing pain assessment and analgesic use over a 48 h period. Patients undergoing circumcision with a penile ring block experienced significant degrees of post-operative pain, had high levels of use of paracetamol at home, and their first night of sleep was frequently disturbed. High levels of opioid use were found. Comparison between assessors indicated parents tended to score their child's pain higher than nursing staff in hospital. Minor paediatric surgical procedures, particularly circumcision, may be associated with considerable post-operative pain and assumptions must not be made about the effectiveness of analgesia, especially in the home.     

Critical care after major surgery: a systematic review of risk factors for unplanned admission

Critical care admission may be necessary for surgical patients requiring organ support or invasive monitoring in the peri-operative period. Unplanned critical care admission poses a potential risk to patients and pressure on services. Existing guidelines base admission criteria on predicted risk of 30-day mortality; however, this may not provide the best predictor of which patients would benefit from this service, and how unplanned admission might be avoided. A systematic review of MEDLINE, Embase, CINAHL, Web of Science, the Cochrane database and the grey literature identified 44 studies assessing risk factors for unplanned critical care admission in adult populations undergoing non-cardiac, non-thoracic and non-neurological surgery. Comparative, quantitative analysis of the admission criteria was not feasible due to heterogeneity in study design. Age, anaemia, ASA physical status, body mass index, comorbidity burden, emergency surgery, high-risk surgery, male sex, obstructive sleep apnoea, increased blood loss and operative duration were all independent risk factors for unplanned critical care admission. Age, body mass index, comorbidity extent and emergency surgery were the most common independent risk factors identified in the USA, UK, Asia and Australia. These risk factors could be used in the development of a risk tool or decision tree for determining which patients might benefit from planned critical care admission. Future work should involve testing the sensitivity and specificity of these measures, either alone or in combination, to guide planned critical care admission, reduce patient deterioration and unplanned admissions.     

Paediatric day case surgery

Paediatric day surgery is common, and increasingly more challenging surgeries are being carried out on more complex children. The benefits to the child and parent/care-giver include less disruption to daily routines and fewer psychological and emotional effects than an overnight stay would incur. The use of day case services improves efficiency and is more cost effective for organizations. To deliver high-quality paediatric day surgery services there are several key components to address. This article discusses the role of preoperative assessment and the need to consider each case individually despite robust inclusion/exclusion criteria. Optimization of preoperative hydration, pain management and prevention of postoperative nausea and vomiting are highlighted as important factors to successful day case surgery.     

Robotic urological surgery: Prospects for Hong Kong

Robotic surgery was first begun in the early 1980s and the da Vinci robotic surgical system is currently the most commonly used system in the world. The Prince of Wales Hospital, the Chinese University of Hong Kong, was the first centre in Hong Kong to have this system installed. Since November 2005, more than 50 cases of various urological procedures have been performed, and robotic radical prostatectomy is the most commonly performed procedure in our centre. With the benefits of three‐dimensional vision, EndoWrist technology and ergonomic advantage, a result comparable to the world standard can be achieved within a short learning time. In the present article, a summary of the development of robotic surgery, as well as the early experiences of the da Vinci surgical system will be discussed.     

Transoral robotic surgery: Establishment of a programme in Hong Kong

Aim: To establish a transoral robotic surgery (TORS) programme for the surgical management of head and neck pathology including oropharyngeal lesions, and to carry out a TORS tonsillectomy. Methods: Training for otolaryngologists was planned and undertaken. Off‐site robotic training of otolaryngologists was conducted by a robotic company trainer. Visits to established international TORS programmes were made. A suitable patient was identified with the intention of undergoing a TORS tonsillectomy and evaluating the outcome. Results: A patient successfully underwent a transoral robotic surgery tonsillectomy using a surgical robot system without intraoperative or postoperative complications or sequelae. Conclusions: A transoral robotic surgery programme, including training for otorhinolaryngologists, has been established. A tonsillectomy, a feasible procedure easily carried out, was done using a surgical robot system without complications.     

Five years experience with day plastic surgery

Day surgery is increasing. This article reviews the experiences of day plastic surgery during a period of five years. The evaluation shows a low rate of postoperative complications and a high degree of patient satisfaction. According to the author's opinion a considerable part of elective plastic surgery is suitable for day surgery.     

Unplanned overnight admissions in day-case arthroscopic shoulder surgery

The majority of arthroscopic shoulder procedures can be safely performed as day-case surgery. However, despite better pain control and preoperative assessment; some patients end with unplanned overnight admission. The aim of this study was to investigate the reasons behind unplanned admissions of patients undergoing day-case arthroscopic shoulder surgery. A retrospective review of 242 consecutive cases of arthroscopic shoulder surgery performed by the senior author over a period of two years (2007-2008) was carried out. Twenty cases were planned admissions and were therefore excluded. 222 cases were included, of which 40 (18%) were unplanned overnight admissions. Documented causes for overnight stay included abnormal post-operative observations, pain and wound ooze. The age of patients who stayed overnight was significantly higher (p = 0.006). The difference in ASA grade between both groups was less marked but still statistically significant (p = 0.031). More complex procedures, such as rotator cuff repair, were more likely to result in unplanned overnight admission (p < 0.001). The experience of the anaesthetist and administration of interscalene nerve block were not significantly different between the two groups. However, patients anesthetised by less experienced anaesthetists were less likely to receive an interscalene nerve block (p = 0.016). In conclusion; higher patient age, higher ASA grade and more complex arthroscopic procedures are significant risk factors for unplanned overnight admissions in day-case arthroscopic shoulder surgery.     

Anaesthesia in day case laparoscopic female sterilization: a comparison of two anaesthetic methods

BACKGROUND: Laparoscopic sterilization (LS) in women is a procedure frequently carried out in a day case setting. The purpose of the study was to measure postoperative pain, nausea and vomiting (PONV), the incidence of unplanned overnight admissions and patient satisfaction with two different anaesthetic methods. METHODS: From August 1997 to January 1999 the LS patients were anaesthetized with propofol + fentanyl/alfentanil, N2O and atracurium, and from January 1999 to end of 2001 they were given TIVA with propofol + remifentanil. Postoperative pain was managed with standardized high doses of paracetamol and NSAID in both groups. Data were collected from hospital records and from questionnaires given to all the patients. RESULTS: Six hundred and eighty-one women were sterilized. There were no significant differences in postoperative pain between the two groups, with 8.2 and 12.1 per cent, respectively, experiencing severe pain. Significantly fewer patients experienced moderate or severe postoperative nausea after the introduction of remifentanil anaesthesia (3.3 vs. 11.7%, P = 0.001). Eleven patients (1.8%) were admitted overnight, with no difference between the two groups. 94.5% and 96.3% of the patients were either satisfied or very satisfied with their treatment (P = 0.50). CONCLUSION: Both anaesthetic methods provide equally good postoperative pain relief, few unplanned admissions and a high degree of patient satisfaction when combined with postoperative paracetamol and NSAID. Patients anaesthetized with remifentanil and propofol have less postoperative nausea.     

The surgical therapy for the lower limb varices in day surgery

1775 varicose patients (1318 female, 457 male) with mean age 47.7 years have been operated in One Day Surgery in III Department of General Surgery and in the Phlebology Centre of the University of Siena between June 1 1985 and May 30 1996. 1274 (71.7%) patients underwent internal saphenectomy of which 947 (53.3%) through short stripping, 327 (18.4%) through long stripping, 106 (5.9%) external saphenectomy, 90 (5.1%) revision of the saphenous-femoral junction, 258 (14.5%) phlebectomies; 16 (0.9%) external valvuloplasty sec. Mancin, 31 (1.7%) other operations. All patients were discharged on the same day of operation. The obtained instrumental and clinical results show an improvement of haemodynamics, with 21% varicose residue for incontinence perforating veins on long stripping internal saphenectomy. In their experience in the surgical treatment of varicose veins, the authors affirm that the policy of One Day Surgery is not greatly affected by the surgical technique adopted but more so by the anaestesiological technique used and the clinical condition of the patients.     

Relaxation of the criteria for day surgery laparoscopic cholecystectomy

BACKGROUND: For day case laparoscopic cholecystectomy programmes, studies suggest that overnight admission may be predicted by the following factors: gall bladder wall thickness, patient age over 55 years and previous sphincterotomy. This study investigated the effect of relaxing selection for a day surgery laparoscopic cholecystectomy programme, by removing these factors from the exclusion criteria. METHODS: Between September 2002 and April 2003, patients for elective laparoscopic cholecystectomy were considered for day surgery subject to standard criteria. For the initial part of the programme, patients were additionally excluded according to the risk factors mentioned above. RESULTS: Thirty-three patients underwent intended day case procedures. The first 16 were selected according to the more rigorous criteria. The latter 17 were significantly older, with a significantly higher incidence of gall bladder wall thickening. There were seven admissions, three in the former part of the study and four in the latter. CONCLUSION: The exclusion criteria described are not necessary for a good same-day discharge rate.     

Outcome of ASA III patients undergoing day case surgery

Background. Day case surgery is becoming more acceptable, evenfor patients with complex medical conditions. Current recommendationssuggest that patients who are graded as American Society ofAnaesthesiologists physical status (ASA) III may be suitablefor this approach. There is only a small amount of publisheddata available to support this. We present a retrospective reviewof ASA III patients who had undergone day surgical proceduresin our unit. Methods. We carried out a retrospective case controlled reviewof 896 ASA III patients who had undergone day case proceduresbetween January 1998 and June 2002 using the existing computerizedpatient information system. The system records admission rates,unplanned contact with healthcare services and post-operativecomplications in the first 24 h after discharge. Results. We demonstrated no significant differences in unplannedadmission rates, unplanned contact with health care services,or post-operative complications in the first 24 h after dischargebetween ASA III and ASA I or II patients. Conclusion. With good pre-assessment and adequate preparationASA III patients can be treated safely in the day surgery setting. Br J Anaesth 2004; 92: 71–4     

对日间手术病房患者实施人文关怀的效果探讨

目的 探讨人文关怀措施对日间手术患者焦虑及术后康复的影响,为医护人员实施专业的人文关怀护理服务提供参考。 方法 将接受日间手术的110例腹股沟疝患者随机分为对照组与干预组各55例。对照组给予常规护理,干预组在常规护理的基础上实施人文关怀护理干预。比较两组术前焦虑评分、术后饮食与下床活动时间及护理满意度。 结果 干预组术前焦虑评分显著低于对照组,术后进食时间、下床活动时间显著早于对照组,护理满意度显著高于对照组（均P＜0.01）。 结论 为日间手术病房患者实施人文关怀服务可减轻其心理压力,加速术后康复,提高护理满意度。