Ambulatory surgery

a seminar on ambulatory surgery/ day care surgery

1. AMBULATORY SURGERY MANOJ VAIDYA

2. SYNONYMOUS TERMS- Ambulatory surgery Day-case surgery Day-care surgery Same-day surgery Come and go surgery

3. DEFINITION The original concept of day surgery was the admission and discharge of a patient for a specific procedure within the 12hr working day. Day surgery is a PATIENT PATHWAY and NOT A SURGICAL PROCEDURE Day care surgery has been defined by the Royal College of Surgeons as when the surgical day case patient is admitted for investigation or operation on a planned non-resident basis and who nonetheless requires facilities for recovery.

4. EXTENDED OR 23 HRS STAY POLICY Nowadays, many Day Units operate an ‘extended’ or ’23 hour’ stay policy, which means that patients can stay in the Unit upto 23 hours 59 minutes and still be categorized as a day case. The ‘23-hour’ stay is determined by the day unit staff and is based on the needs of individual patients, in order to ensure their safety

5. DAY CARE SURGERY & OUT PATIENT SURGERY It is important to mention that day care surgery is different from out-patient surgery in that the patients of day care surgery need some degree of post-operative specialized nursing care necessitating post-operative observation for a few hours.

6. FAST TRACK INPATIENT SURGERY Fast track surgery involves the use of a coordinated, multi disciplinary perioperative care plan to reduce complications, facilitate earlier discharge from hospital Faster recovery Faster Return to daily activities after elective surgery

7. Why Day care surgery? Rising healthcare cost Emphasis on evidence-based practice Rising patient expectations

8. HISTORY The earliest reference for day care surgery is mentioned as early as the beginning of the 20th Century by James Nicoll, a Glasgow surgeon who performed almost 9000 outpatient operations in children in 1903. Later, in 1912, Ralph Waters from Iowa, USA, described “The Down Town Anaesthesia Clinic”, where he gave anaesthesia for minor outpatient surgery.

9. Ralph’s facility, which provided care for dental and minor surgery cases, is generally regarded as the prototype for the modern freestanding ambulatory (and office-based) surgery center. Surprisingly, there was little interest in ambulatory surgical care until the late 1960s,when the first hospital-based ambulatory surgery units were developed. Formal development of ambulatory surgery occurred with establishment of the Society for Ambulatory Anesthesia & Surgery in 1984 and the subsequent development of postgraduate subspecialty training programs

10. CURRENT SCENARIO By the end of 1990, 7 million elective operations in the United States (over 30% of all elective surgical procedures) were performed on an ambulatory basis. Currently, more than 60%of all elective surgery in USA is performed in the outpatient surgical setting. In India though the exact data is unavailable, based on data from various single centre studies, the day care surgery constitute only 10-15% of elective surgical procedures. Types of various surgeries in Day Care: A study from South India Amidyala Lingaiah1, Padam Venugopal2, K Rukmini Mridula , Srinivasarao Bandaru1,5

11. OBJECTIVES OF AMBULATORY SURGERY To reduce waiting time for elective surgery To reduce inpatient admission To make surgery convenient and comfortable for the patient To reduce disruption of personal lives To reduce hospital-acquired infection To encourage early recovery and mobilization in a home environment with their family To reduce cost of surgery

12. ADVANTAGES OF AMBULATORY SURGERY PATIENTS’ ADVANTAGES Patient-centred Patient recovers in familiar environment Reduces complication Early return to daily living Reduce cost

13. HOSPITAL/ PHYSICIAN ORIENTED Increase bed availability Hospital can grow inpatient services Outpatient centre has greater efficiency & cost-effectiveness (increase throughput) Health care cost reduction (25-75%)

14. DISADVANTAGES The need for a responsible person to oversee the day care patient at home for the first 24-48 hours. The restriction of day case surgery to experienced senior staff; Extra work for the general practitioner in the postoperative period; patients often ring them for advice or treatment. The cost-effectiveness of the unit is reduced when less complex cases are dealt with on a day basis.

15. ORGANISATIONAL STRUCTURE

16. DAY SURGERY WORK FLOW

17. PATIENT AGREES FOR SURGERY SUITABLE FOR DAY Sx ?? ALLOT OPERATION DATE ANAESTHETIC CLINIC OPTIMISE THE PATIENT IF REQUIRED & REFFERALS TO OTHER DEPARTMENTS APPROPRIATE FOR DAY CARE SURGERY DAY CARE SURGERY PROCESS EXPLAINED ALLOWED HOME AWAITING SURGERY PLAN ELECTIVE IN PATIENT OPERATION NO YES

18. A TEAM MEMBER REVIEWS DAY CARE LIST 1 TO 3 DAYS BEFORE SURGERY CALLS EACH PATIENT CAN PATIENT COME FOR OPERATION? PATIENT ARRIVES TO THE HOSPITAL ON ALLOTED DAY PATIENT REGISTERS AT DAY CARE WARD & UNDERGOES PRE OPERATION PROCESS NO PATIENT IS ASKED TO VISIT HOSPITAL FOR NEW DATE

19. SURGEON AND ANAESTHETIST REASSES THE PATIENTS FITNESS FOR SURGERY SHIFTED TO THE OPERATION THEATRE DAY CARE WARD-RECOVERY POST OP REVIEW BY ANAESTHETIST TO ASSESS FITNESS FOR DISCHARGE POST OP REVIEW BY THE SURGEON DISCHARGE WITH MDICATION DATE FOR NEXT APPOINTMENT FIT ADMIT IN WARD REGULAR WARD CARE AND DISCHARGE NOT FIT

20. TEAM MEMBER REVIEWS LIST OF POST OPERATION DISCHARGED PATIENTS CALLS EACH PATIENT TO ASSESS DAY CARE EXPERIENCE ALL THE CONVERSATION AND DATA IS DOCUMENTED

21. TYPES OF DAY CARE SURGICAL CENTRES Day Care Surgery can take place in various settings which are basically four types in use Hospital integrated unit Hospital autonomous unit Hospital satellite unit Free standing unit Each of these four has its own peculiar advantages and disadvantages

22. HOSPITAL INTEGRATED UNIT This unit provides a designated area to which patients are admitted and from which they are discharged home and in which preoperative evaluation and preparation are carried out. The hospital operating rooms and recovery rooms are used for both inpatients and Day Care Surgery patients. HOSPITAL Day care OT RECOVERY

23. HOSPITAL AUTONOMOUS UNIT This unit is totally self-sufficient. This type of unit is located within the hospital or on the grounds of the hospital, but operates totally independent of other portions of the hospital. HOSPITAL DAY CARE DAY CARE OT RECOVERY OT RECOVERY

24. HOSPITAL SATELLITE UNIT This is an autonomous facility which is sponsored and/or operated by the hospital but located away from the campus of the hospital. HOSPITAL DAY CARE

25. FREE STANDING UNIT This is an autonomous unit which is not geographically or administratively part of any other health care facility HOSPITAL DAY CARE UNIT

26. INFRASTRUCTURE LOCATION provided in an integrated set-up existing operating theatres, dedicated operating theatres/unit or a free standing dedicated ambulatory care facility.

27. FACILITIES Registration counter Waiting room Assessment room Changing rooms Procedure rooms Operating theatres Pre and post- operative wards Recovery room Pharmacy

28. STAFFING Operating surgeon A consultant Anaesthesiologist, with special interest in day care surgery, shall be responsible in developing protocols, policies, audit and clinical governance. Medical Officers Nursing Manager/Sister Theatre Scrub Nurses General Anaesthetic (GA) nurses Ancillary staff Recovery Ward Nurses

29. SELECTION CRITERIA AND SUITABLE PROCEDURES FOR AMBULATORY SURGERY Patient Criteria Social Criteria Surgical Criteria and Proposed Suitable Procedures

30. PATIENT CRITERIA a) Health Status: ASA 1 and 2 ASA 3 can be selected after consultation with the anaesthetic team provided their disease is well controlled. B) Age Limits: > 75 years and < 6 months should not be selected. c) Physical Factors: no obvious difficult airway features BMI < 35 kgm-2

31. SOCIAL CRITERIA Patients/parents must be willing to cooperate and able to understand, comply and cope with post-procedural instructions after receiving adequate information and an opportunity to discuss any anxieties. Escort: who is responsible for patient’s care and able to accompany patient home and supervised their recovery at home for a minimum of 24 hours. Transport: Suitable transport must be available to transport patient home post surgery and also to come back to the hospital in event of emergency. Peferably within 1hr distance from hospital .

32. SURGICAL CRITERIA Simple surgery < 90 minutes. minimal risk of postoperative complications e.g. haemorrhage or airway compromise. minimal postoperative pain that can be controlled by simple analgesia. No special postoperative nursing required post surgery. Patient would not have prolonged immobility after the procedure. Rapid return of normal food and fluid intake possible after the procedure

33. LEVELS OF DAY CARE SURGERY MINOR AMBULATORY SURGERY MAJOR AMBULATORY SURGERY INPATIENT SURGERY- Patient stays overnight and gets discharged within a day.

34. COMMON DAY CARE PROCEDURES- ‘BASKET OF 25’ ORCHIDOPEXY CIRCUMCISION INGUINAL HERNIA REPAIR EXCISION OF BREAST LUMP ANAL FISSURE DILATATION & SPHICHTEROTOMY HAEMORRHOIDECTOMY LAPAROSCOPIC CHOLECYSTECTOMY VARICOSE VEIN STRIPPING AND LIGATION TRANSURETHRAL RESECTION OF BLADDER TUMOUR EXCISION OF DUPUYTRENS CONTRACTURE CARPAL TUNNEL DECOMPRESSION 12. GANGLION EXCISION 13. HYDROCELE 14. SURGERY FOR HALLUX VALGUS 15. REMOVAL OF METALWARE 16. EXTRACTION OF CATARACT 17. CORRECTION OF SQUINT 18. MYRINGOTOMY 19. TONSILLECTOMY 20. SUBMUCOUS RESECTION 21. OPERATION FOR BAT EAR 22. REDUCTION OF NASAL FRACTURE 23. D&C HYSTEROSCOPY 24. LAPAROSCOPY 25. TERMINATION OF PREGNANCY

35. Due to advances in surgical and anaesthetic techniques many more surgeries can now be managed as day care surgery THE BRITISH ASSOCIATION OF DAY SURGERY (BADS) has recommended inclusion of another 50 procedures under the Name TROLLEY of procedures . BADS now recommends Procedures like laparoscopic fundoplication, laser prostatectomy, arthroscopy of knee & shoulder, thoracic sympathectomy to be done on day case basis.

36. PREOPERATIVE ISSSUES

37. EVALUATION AND OPTIMISATION OF PRE-EXISTING ORGAN FUNCTION Classifiction of functional capacity and optimization of organ function are expected to reduce cardiovascular and other complications

38. ASSESMENT AND OPTIMIZATION OF NUTRITIONAL STATUS Poor nutritional status is an independent risk factor for complications after surgery Patients with Moderate and severe undernutrition benefit from preoperative nutritional support preferably via enteral route for at least 7 days preoperatively Patients with less severe malnutrition including those with diminished oral intake benefit from addition of few supplements o normal diet.

39. IMPROVEMENT OF PHYSICAL FITNESS Patients with poor baseline exercise tolerance and physical conditioning are at increased risk of serious perioperative complications. The strategy of augmenting physical capacity in anticipation of an upcoming stressor is termed as PREHABILITATION. Observational data suggests that simply instructing the patient to walk for 30min daily in the preoperative period may be beneficial without the need for a formal indivisualised exercise program.

40. PRE-OPERATIVE FASTING Current preoperative fasting guidelines recommend a 2 hour fasting for clear liquids and a 6 hour fast for solids.

41. PREOPERATIVE INGETION OF ORAL CARBOHYDRATE DRINK Evidence supports that it may be beneficial to provide a drink containing 100g of carbohydrate on the evening before surgery and a second drink containing a further 50g upto 2-3hrs before surgery. This measure improves preoperative feelings of thirst, hunger, anxiety and reduces post operative insulin resistance and reduces the catabolic stress response to surgery.

42. PATIENT EDUCATION For many patients impending major surgery represents a significant psychological stress. There is evidence that emotional distress delays wound healing by altering endocrine and inflammatory responses. In some centres patients are shown a short video outlining the aspects perioperative care and outcomes which may be of concern to the patient.

43. Patient should be provided information about Benefits of day care program Goals for daily nutrition intake Early postoperative ambulation Discharge criteria Care at home and warning signs to seek medical care Expected hospital stay in the event of common complications

44. PRE OPERATIVE INSTRUCTIONS FORM

45. PREMEDICATION Apart from providing sedation and reducing anxiety, premedication plays additional roles including Modulation of intraoperative haemodynamics Attenuation of postoperative side effects. ANXIOLYTICS - Fentanyl has a better profile for fast track surgery and facilitates early hospital discharge. ANTICHOLINERGICS- Glycopyrrolate is preffered (0.3mg IV). BETA BLOCKERS AND ALPHA2 AGONISTS- with their anesthetic and analgesia sparing effect, they maintain perioperative heamodynamic stability and reduce post operative pain

46. ANTACIDS AND H2 RECEPTOR BLOCKERS- H2 receptor blockers are given on the day before surgery. Administration of anti-PONV medications such as dexamethasone and ondansetron before or during induction of anaesthesia is recommended.

47. INTRAOPERATIVE ISSUES

48. ATTENUATION OF SURGICAL STRESS RESPONSE The magnitude of noxious response can be reduced by perioperative interventions that modify catabolic response PHARMACOLOGICAL- neural blockade with local anaesthetics, glucocorticoids PHYSICAL (normothermia, MIS) NUTRITIONAL

49. ANAESTHETIC TECHNIQUES General anaesthesia Propofol is the IV agent of choice for induction For maintainance anaesthesia desflurane and sevoflurane are used as they fecilitate early recovery. Short or intermediate acting muscle relaxants are used. Sugamadex is a new compound which has shown to provide faster reversal of non depolarising muscle relaxants.

50. REGIONAL ANAESTHESIA REGIONAL ANAESTHESIA techniques (spinal, epidural and peripheral nerve block) have several advantages over general anaesthesia like- improved pulmonary function, decreased cardiovascular demand, lower incidence of ileus and good quality of analgesia at rest and on ambulation. For faster recovery, minidose lidocaine (10-30mg), bupivacaine (3.5-7mg) or ropivacaine (5-10mg) spinal anaesthetic techniques are combined with potent opoid analgesic like fentanyl (10-25mcg) or sufentanyl (5-10mcg).

51. TIVA techniques using propofol are popular and offer advantage of reduced post operative nausea and vomiting. Caudal block is used to reduce pain in paediatric patients for circumcision, herniorraphy , orchidopexy. Intra articular local anaesthetics are useful following arthroscopy. Femoral and sciatic nerve block for knee surgery. Nerve blocks using portable infusion pumps which the patient can continue at home.

52. INCISIONAL LOCAL ANAESTHESIA INFILTRATION of local anaesthetic is used for surgical procedures like hernia repair, anal surgery, breast procedures. Long acting local anaesthetic like bupivacaine should be injected into the wound.

53. MAINTENANCE OF NORMOTHERMIA Mild hypothermia elicits a stress response during recovery period. Maintenance of intraoperative normothermia with the use of active and passive warming devices and aggressive post operative management of shivering and residual hypothermia decreases incidence of wound infection, myocardial ischeamia and protein breakdown.

54. FLUID MANAGEMENT Strategies that avoid both hypovolemia and post operative overload are important in facilitating fast track recovery process. Intraoperative oesophageal Doppler monitoring can facilitate goal directed fluid administration by targeting specific values for the cardiac index.

55. MINIMIZATION OF INCISION AND MIS The incision should be as small as possible while allowing adequate exposure Laparoscopic techniques must be used whenever possible.

56. POSTOPERATIVE ISSUES

57. MORBIDITY AFTER DAY SURGERY MAJOR MINOR Pulmonary embolism Pain Respiratory failure PONV MI Drowsiness Haemorrhage Minor bleed Unrecognised damage to viscous Infection Headache

58. PAIN MANAGEMENT Pain remain the most common reason for delaying discharge after ambulatory surgery. The use of peripheral nerve blocks and conduction blockade for major and minor surgical procedures in combination with adjuvants provides excellent analgesia. The current strategy for post operative analgesia involves a combination of regional anaesthesia, MIS, and non opoid pharmacological interventions.

59. POST OPERATIVE NAUSEA AND VOMITING PONV continues to be a common complication of surgery with an overall incidence of 20 to 30 %. PONV delays discharge and is the leading cause of unanticipated hospital admission in ambulatory surgical patients.

60. ILEUS ILEUS causes discomfort and delays oral food intake thereby prolonging recovery and duration of hospitalisation. Other interventions like early feeding, prokinetics like metoclopramide, prophylactic nasogastric intubation, have minor effect on occurance of ileus Use of opioids should be avoided. Early mobilisation should be encouraged.

61. POSTOPERATIVE FEEDING The protocol should be tailored in accordance with the procedure being done and by the patients tolerance. For most abdominal surgeries, patients are encouraged to take liquids on the night following the operation with light solids given on the morning of post op day 1 and normal diet initiated on post op day 2.

62. MOBILISATION Emphasis on ‘ OUT OF BED DAY 0’ strategy POST OPERATIVE bed rest should be discouraged. Structured post operative mobilization is an important component of fast track surgery protocols. Patient should be given written instructions that include specific goals for each day. Adequate pain control also helps in early mobilisation.

63. USE OF DRAINS AND CATHETERS DRAINS and catheters impede independent mobilisation. Reviews of randomised trials do not support the use of routine prophylactic drainage for thyroid surgery, cholecystectomy, colorectal anastomosis.

64. DISCHARGE CRITERIA Oral intake is tolerated Pain is well controlled Voiding without difficulty In deciding when patients have recovered enough to allow their safe transfer to an ambulatory surgical unit (ASU), or Phase II recovery, the PADSS and Aldrete scoring system has been used

65. POST ANAESTHESIA DISCHARGE SCORING A TOTAL PADSS SCORE >/= 9 IS CONSIDERED FIT FOR DISCHARGE

66. POST DISCHARGE FOLLOW UP PATIENT SHOULD BE ABLE TO Contact the team member of the day care surg team should any problem like fever, wound redness, discharge arise. A follow up telephone call should be made 24 to 36 hrs after the patient goes home. Patient should visit the clinic between post operative day 7 and 10 and then seen again at 1 month after the operation Patients are given specific written instructions about the recovery course.

67. BARRIERS Failure to recognize daycare surgery as priority - clinician’s preference - patient’s attitude Lack of financial incentives Lack of specialized facilities Poor management and organization of outpatient surgery unit

68. PROBLEMS FACED IN DEVELOPING COUNTRIES lack of awareness in the patient population, poor communication and transport, poor facilities for proper training of doctors in day surgery specialty and sidelining the surgical specialties. Health Ministries in favour of other programmes particularly those related to HIV/AIDS, Malaria and Tuberculosis as well as maternal and child health.

69. Benefits of ambulatory surgery Lack of dependence on the availability of hospital beds Greater flexibility in scheduling operations Low morbidity and mortality Lower incidence of infection Lower incidence of respiratory complications Higher volume of patients (greater efficiency) Shorter surgical waiting lists Lower overall procedural costs Less preoperative testing and postoperative medication

70. AUDIT Effective audit is an essential component of assessing, monitoring and maintaining the efficiency and quality of patient care in day surgery units. Routine collection of data regarding patient throughput and outcomes

71. EXTENDED RECOVERY CENTRES AND LIMITED CARE ACCOMMODATION (MEDI MOTELS, HOSPITAL HOTELS) Ideally, all ambulatory patients should go home the day of surgery, with responsible escort to home. The concept of extended (Overnight) recovery after ambulatory surgery and Limited Care Accommodation ( Medi Motels ) or hospital hotel is being promoted in some countries for day care surgery patients who do not fulfil the criteria for discharge home. A hospital hotel is defined as a place close to the hospital, where the patient is supposed to have the same facilities and staffing as in an ordinary hotel, but where there are somewhat better facilities for handling unanticipated medical problems.

72. DAY CARE SURGERY IN SPECIAL ENVIRONMENTS Awake craniotomy for tumour resection has been performed as a day case in the UK. In the interventional X-ray suite, uterine artery embolisation is a day case procedure, whereas endovascular aneurysm stents and several other procedures are appropriate for a short stay approach. All the accepted standards for delivery of anaesthesia, assistance for the anaesthetist, minimal monitoring and the availability of appropriate recovery (post-anaesthesia care unit (PACU)) facilities should be achieved

73. INTRODUCING NEW PROCEDUE TO DAY CARE The successful introduction of new procedures to day surgery depends on many factors, including the procedure itself and surgical, nursing and anaesthetic colleagues. It is important to evaluate the procedure while still performing it as an overnight stay and identify any steps in the process that require modification to enable it to be performed as a day case, e.g. timing of postoperative X-rays, modification of intravenous antibiotic regimens, physiotherapy input and analgesia protocols

74. INTRODUCING NEW PROCEDUE TO DAY CARE A multidisciplinary visit to another unit that may be already performing the procedure on a day case basis may be helpful. Initially limiting the procedure to a few colleagues (surgeons and anaesthetists) allows an opportunity to evaluate and optimise techniques and to implement step changes so that the patient can be discharged safely

75. DAY CARE SURGERY IN INDIA Dr. M. M. Begani is the founder president of the indian association of day case surgery He is pioneer in promoting day care surgery and day care surgery centres in india . Nova medical centres- a chain of day care units.

76. REFERENCES ACS Text book of surgery 7 th edition Bailey & Love’s text book of surgery 26 th edition SABISTON Text book of surgery 20 th edition Schwartz principles of surgery Smith and Atkinheads text book of anaesthesia 6 th edition.