Chapter 6: Guidelines for the Provision of Anaesthesia Services for Day Surgery 2021
Day surgery is the planned admission of a surgical patient for an elective or semi-elective procedure where the patient is admitted, undergoes surgery and is discharged on the same calendar day.2 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, which is more commonly used in the United States, has caused confusion among some UK practitioners. This 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 day case basis.3 In 2004, the Department of Health NHS Modernisation agency in its 10 high impact changes for service improvement and delivery stated that day surgery rather than inpatient surgery should be treated as the norm for elective surgery.4 In the intervening years, huge strides have been made in the development of day surgery across the country; however, there is wide variation.5 The top performing units are achieving very high day case rates; however, others struggle to reach the 75 per cent target as set out in the NHS plan. 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.6
Day surgery encompasses a spectrum of surgical procedures that allows the patient to go home on the day of surgery, usually after a few hours. It represents high-quality patient care using surgical techniques resulting in reduced tissue trauma, 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 day case basis, which formerly would have required inpatient services.2,7
Day surgery outcomes can be measured in terms of quantity (percentages of procedures undertaken on a day case 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 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.8,9,10,11,12
There should be a clear day surgery process for all day surgery patients 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.
Processes should be in place to ensure that all appropriate patients are considered for day surgery management.44 This includes adopting the British Association of Day Surgery (BADS) directory of procedures and ensuring that all recommended procedures default to day surgery management where clinically appropriate.7 Preoperative assessment processes, which enable the majority of patients to be safely managed within day surgery pathways, are essential. This includes children, the elderly, and patients with complex medical conditions.
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. This is in order to provide the high quality anaesthesia pivotal to successful outcomes.10 The day surgery unit provides an ideal training opportunity and training in anaesthesia for day surgery is essential. However, less experienced anaesthetists should not be the sole provider of anaesthesia.2,13 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.
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. 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. Staffing requirements
High quality anaesthesia is pivotal to achieving successful outcomes following day surgery. The majority of anaesthesia for day surgery should be delivered by consultant anaesthetists.15,16 staff grade, associate specialist and specialty doctors (SAS) grade 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 surgery1,4,17 and have undertaken appropriate training in the provision of anaesthesia for day surgery.13
There should be adequate staffing levels provided within the department to ensure that there is minimal handover of patients between staff.18
Preoperative assessment clinics should have a nominated consultant or SAS lead, and be delivered by a team specifically trained in preoperative assessment and preparation for day surgery.7
The secondary recovery area in the day surgery unit should be staffed to match patients’ needs and consideration should be given to the skill mix as well as numbers of staff.20
The secondary recovery area in the day surgery unit should be staffed with adequate numbers of registered nurses trained in nurse-led discharge.20
When children are present on the unit, there should be a registered paediatric nurse present at all times. The Royal College of Nursing standards recommend two registered paediatric nurses at all times.21
When children are present on the unit, support workers and health play specialists should play a key role within day surgery provision.21
The day surgery unit should have appropriate administrative support.
2. Equipment, services and facilities
The minimum operating facility required is a dedicated operating session in a properly equipped operating theatre.
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). This may be contained within a main hospital or in its grounds, to facilitate access to inpatient or critical care facilities, or it may be a freestanding unit remote from the main hospital site.
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 work and avoids duplicating theatre skills and equipment.
Every effort should be made to avoid mixing day cases and inpatients on the same operating list to maintain quality of care and efficiency.22
Facilities for privacy and confidentiality during preoperative discussion and examination should be provided.10 Preoperative discussions with patients in crowded waiting rooms should be avoided.
Adequate time and facilities should be provided within the DSU to enable the multidisciplinary clinical team to undertake all aspects of the admission process; including clinical assessment, further discussion about the procedure and delivery of information.
Dedicated day surgery secondary recovery areas should be provided, which are not part of an inpatient ward area. This area should ideally be separated into male and female wards.
The secondary recovery area should provide essential close and continued supervision of all patients, who should be visible to the nursing staff while maintaining privacy and dignity.
The secondary recovery area should have single -sex patient toilet facilities and ability to provide drinks and snacks.23
The secondary recovery unit should not accept inpatient activity and even at times of severe hospital escalation, every effort should be made to avoid this as it will significantly affect the day surgery activity and quality of the care provided to the day surgery patients.
Secure storage for patients’ belongings and medications should be available.
Waiting areas should be available for parents and carers who need to be available to support patients immediately after surgery.
Theatre and anaesthetic related equipment should always be equivalent to that provided for inpatient surgery. It should be regularly maintained and where possible standardised across all theatre suites within a hospital.24
The recommended Association of Anaesthetists standards of anaesthetic monitoring should be met for every patient.25
Full resuscitation equipment and drugs should be provided as outlined by the Resuscitation Council and hospital policy.26
Peripheral nerve blocks, spinal anaesthesia and intravenous regional anaesthesia often provide excellent conditions for day surgery.27,28,29 Equipment to facilitate these techniques, such as nerve stimulators and ultrasound machines, neuraxial e.g. NRfit needles and syringes should be available.
Short acting anaesthetic drugs and appropriate equipment to facilitate their delivery should be available in day surgery units.
The use of operating trolleys for the entire patient pathway rather than theatre tables and hospital beds should be considered to maximise efficiency and reduce manual handling risk.
Support services including radiology, pharmacy and investigative laboratories should be available.
The facility to perform a 12-lead electrocardiogram and other point of care tests, such as international normalised ratio, should be available within the DSU itself.
Information technology systems in the DSU should be designed to record all elements of the day surgery pathway and allow for paperless records.
All information systems used in inpatient theatres should be available in day surgery theatres.
Information systems should allow for regular reporting and locally customised reporting to support quality improvement work.
3. Areas of special requirement
Day surgery is particularly appropriate for children.
The lower age limit for day surgery depends on the facilities and experience of the staff and the medical condition of the infant. Ex-preterm neonates should not be considered for day surgery unless medically fit and beyond 60 weeks post conceptual age.30
Infants with a history of chronic lung disease or apnoeas should be managed in a centre equipped with facilities for postoperative ventilation.
Nursing staff caring for children should be skilled in paediatric and day surgical care and trained in child protection.
There should be access to a paediatrician. Where the DSU 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.30
Pathways for the treatment of prisoners as day cases should be agreed with the local prison services.
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. Special arrangements may be required to allow certain medications to be available within the prisoner’s cell or for additional arrangements to be made to enable patients to receive overnight postoperative analgesia.
The hospital should consider making an agreement on the safe provision of privacy and dignity for prisoners with the local prison governor with regard to the use of restraints.
Emergency day surgery
Consideration should be given to the provision of theatre time dedicated to emergency day surgery.
Suitable cases for treatment as day cases should be identified by the surgical team.7
Preoperative assessment should when possible be provided to the same standard as that used for elective day surgery.
Morbidly obese patients
Super morbidly obese patients (BMI >50) should be assessed on an individual basis to ascertain whether additional equipment or staffing are required for their safe management.
Whilst even morbidly obese (BMI >40) patients can be managed through a day surgery pathway, it may be inappropriate to operate upon 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.
4. Training and education
Standards and training for clinical staff working within the primary recovery area should be as defined within Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients.
Training should be multidisciplinary, with the use of simulation encouraged.41
Appropriate and comprehensive training in this subspecialty should be given according to current standards as defined by the RCoA.19
Training needs to emphasise the following aspects:
- patient selection and optimisation for day surgery
- provision of effective postoperative pain relief42
- strategies for the prevention of postoperative nausea and vomiting (PONV)
- the necessity of a multidisciplinary team approach in day surgery care
- the requirement for ‘street fitness’ on discharge
- the postoperative management of patients in the community.
5. Organisation and administration
Each DSU should have a clinical director or specialty lead. This will often, but not always, be an anaesthetist with some management experience. The role of the clinical director is to champion the cause of day surgery and 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 appropriate administrative support. 7,9
There should be a senior nurse manager who, with the clinical director, can provide the day to day management of the unit.
Many larger units, especially those that are freestanding, may find it helpful to have a separate business manager to support the clinical director and senior nurse.
The clinical director should chair a management group and liaise with all those involved in day care. This 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.
Each unit should have a multidisciplinary operational group that oversees the day to day running of the unit, agrees policies and timetables, reviews operational problems and organises audit strategies.55
Protocols should be available to maximise the opportunity for patients with significant co-morbidities (e.g. diabetes, morbid obesity, sleep apnoea) to be safely managed via a day case pathway.
Consultant anaesthetic advice should be available to comment on an individual patient’s suitability for day surgery and to assist with preoperative optimisation.
Clinical investigations rarely inform the suitability for day surgery or influence subsequent management or outcome.3,44 Those that are appropriate should be ordered at preassessment, according to a locally agreed protocol. A mechanism for review and interpretation of the results of tests ordered before the day of surgery should be developed.
The patient should be provided with written information outlining the day surgery pathway, planned procedure and anaesthetic, and expectation of postoperative recovery.
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.22
If it is occasionally necessary to undertake day case surgery on inpatient operating lists, the day cases should be prioritised at the beginning of the list to allow time for postoperative recovery and timely discharge.
There should be agreed protocols for the management of patients who require unplanned hospital admission following their day case procedure.
If day surgery is being undertaken in an isolated site, protocols should define finding an inpatient bed and mechanism of transport for a patient requiring an overnight stay.
Locally agreed written discharge criteria should be established.
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.
Patients may be discharged home with residual sensory or motor effects after nerve blocks or regional anaesthesia.27 The duration of the effects should be explained and the patient should receive written instructions as to their conduct until normal sensation returns.
Postoperative short term memory loss may prevent verbal information being assimilated by the patient.45 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.9,46
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 to an acute surgical area and should not be an answer phone.
Following procedures performed under general or regional anaesthesia, a responsible adult should escort the patient home and provide support for the first 24 hours after surgery.9 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.47,48
Transport home should be by private car or taxi; public transport is not normally appropriate.
Where the patient’s general practitioner (GP) 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.
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.
All patients should receive a copy of their discharge summary in case emergency treatment is needed overnight.
For commissioning purposes, suggested indicators of quality of a DSU include: 10
- 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, however, is not exhaustive and other factors such as theatre utilisation, 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.
A number of urgent surgical operations (for example, abscess drainage, superficial lacerations or hand trauma) can be managed on a day case basis,49 with semi-elective admission to day surgery facilities on the day of operation and discharge later the same day.50 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 ambulatory care.47
6. Financial considerations
The recent drive to reduce length of stay and improve quality of postoperative recovery (Enhanced Recovery) is based on day surgery principles.51 Probably the biggest driving force for the expansion of day surgery is the potential financial gain from its use.52 There are financial incentives to achieve shortened hospital stays (Best Practice Tariff) and early mobilisation to reduce the risk of hospital acquired infections and venous thromboembolism.
Funding for pathway redesign and facilities has been provided by central government and local commissioners. Cost analysis should take into account 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.
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.53
Business planning by hospitals and surgical departments should ensure that the best resources in terms of equipment and staffing are available within the day surgery unit to provide high quality, efficient, cost effective day surgery services.
Investment in senior staff experienced in the practice of day surgery is required to ensure high quality, efficient processes.54
A one time investment may be needed to build a dedicated day surgery unit, setting up admission and discharge lounges, preoperative assessment clinics and allied support staff such as physiotherapy and pharmacy.
7. Research, audit and quality improvement
- clinical: perioperative clinical adverse events, minor postoperative morbidity pain, nausea and vomiting, sore throat, headache, drowsiness, unplanned return to theatre on same day of surgery, unplanned overnight admission, unplanned return or readmission to day surgery unit or hospital.
- organisational: proportion of elective surgery performed as day surgery, cancellation of booked appointments, failure to arrive on day of surgery, cancellation on the day of surgery.
- social: patient satisfaction, functional health status/quality of life.
- economic: efficiency rate of theatre utilisation.
Each DSU should have a system in place for the routine audit of important basic parameters such as unexpected admissions following surgery, non-attendance (DNA) rates, patients cancelled on the day of operation, postoperative symptoms e.g. pain and PONV and patient satisfaction.55 The Royal College of Anaesthetists has also issued guidance for audits in day surgery.56
Audits should rely only on procedure specific data and not on overall percentages. Auditors can compare activity by procedure and unit.
Audit and quality improvement should be coordinated and led by designated staff members.
Audit and quality improvement should be integrated into wider areas of anaesthetic and surgical practice.
Audit and quality improvement should be integrated into wider areas of anaesthetic and surgical practice.
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.
Research into best practice day surgery should be encouraged.
8. Implementation support
The Anaesthesia Clinical Services Accreditation (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.
9. Patient information
Patients will 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.9 Much of this information may be given to patients at preoperative assessment. Verbal information should always be reinforced with printed material. Alternative means of communication with patients, including the internet, email and text messaging, should be considered.
Diagrammatic representation of the patient journey through day surgery may help explain the process.
Information should be arranged in such a way that it is comprehensive and comprehensible, and should be available in a format suitable for the visually impaired and those with other difficulties 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.24
At a minimum, information provided to patients should include:
- the date and time of admission to the unit
- location of the unit, travel and parking instructions including information regarding parking costs
- details of the surgery to be undertaken, and any relevant preoperative preparations required of the patient
- information on the anaesthetic to be provided, including clear instruction for preoperative fasting, and the way in which patients will manage their medication
- requirement to arrange an escort home and a postoperative carer
- postoperative discharge information, including details of follow up appointments, management of drugs, pain relief including stepping down opiates and dressings, and clear instructions on whom to contact in the event of postoperative problems.59
Patients must 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.
Areas for future development
The following areas are suggested for future research and development:
- preoperative investigations for day surgery: do they add any clinical value?
- expansion of day surgical emergency procedures.
- do all patients undergoing day surgery under general anaesthesia require a carer for 24 hours postoperatively?
- procedures not currently undertaken as day surgery, which could with developments of surgical an anaesthetic techniques move into the day surgery arena?
Immediately – unless otherwise defined, ‘immediately’ means within five minutes.
Clinical lead - SAS doctors undertaking lead roles should be autonomously practicing 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 CPD 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.