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![2011 – 16 cases to 2015 – 489
cases
Uterus size – bulky to 28 weeks
Dominant fibroid – 2 to 26.4 cm
Number – 2 to 17
Day care surgery – 456, admissions
33 [7.2%] with only 5[1.1%]
conversions.](https://image.slidesharecdn.com/daycaresurgery2-190718192548/85/Day-care-surgery-9-320.jpg)
![▪ Day care surgery – 365,admissions – 22
[6%]
▪ Uterus size – 40g to 3.27kg
▪ Readmissions, transfers, conversions – None
▪ Blood transfusion – none
▪ Bladder injury – one [0.27%]](https://image.slidesharecdn.com/daycaresurgery2-190718192548/85/Day-care-surgery-10-320.jpg)
Uploaded byYamal Patel
Day care surgery
The document presents a comprehensive overview of the evolution and implementation of day care surgery (DCS) in a healthcare setting, highlighting its benefits such as reduced hospital stay, cost savings, and enhanced patient satisfaction. It outlines the criteria for patient selection, surgical procedures performed, and challenges faced in the adoption of DCS, including issues with patient awareness and insurance cooperation. The text also emphasizes the importance of patient education, multimodal pain management, and post-operative care protocols in ensuring successful outcomes for same-day surgeries.
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Day care surgery
- 1.
- 2. • Honorary lecturer,Agakhan university hosp. • Past Director, ICMAS • Vice Chair, KESES • Executive Board member, ISGE • Associate MRCOG • Member, AAGL
- 3. Introduction History TerminologyDevp. Of DCS Procedures Patent selection Discharge criteria conclusions
- 4. HISTORY James Nicoll, Glasgow,Scotland– 9000 outpatient procedures on children 1903 first hospital based ambulatory unit developed 1960 IAAS formed by 12 national associations • Currently > 25 country members 1995
- 5. SETUPS Hospital integrated Hospital separated (but accessible to the hospital) Satelite ambulatory unit (under same administration) Free standing unit ( totally independent) Office based
- 6. OUR SETUP Free standing unit– dedicated to MIS Study period – 2011 to 2015
- 7. 1121 (85%) 41(3%) 137 (10%) 21 (2%) LAPAROSCOPIC SURGERIES -1379 DAY CARE SURGERY ADMISSION - CONVERSION ADMISSION - 1 DAY MAJOR HOSPITAL TRANSFER
- 8. 489 (36%) 387 (28%) 212(15%) 196 (14%) 95 (7%) SURGERIES - 1379 MYOMECTOMY TLH ADHESIOLYSIS/TUBOP LASTY OVARIAN CYSTECTOMY OTHERS
- 9. 2011 – 16cases to 2015 – 489 cases Uterus size – bulky to 28 weeks Dominant fibroid – 2 to 26.4 cm Number – 2 to 17 Day care surgery – 456, admissions 33 [7.2%] with only 5[1.1%] conversions.
- 10. ▪ Day caresurgery – 365,admissions – 22 [6%] ▪ Uterus size – 40g to 3.27kg ▪ Readmissions, transfers, conversions – None ▪ Blood transfusion – none ▪ Bladder injury – one [0.27%]
- 11. Some still believein open TAH/myomectomy Great variation hospital stay - 2-5 night stay Nbm 2-3 days, drains etc Surgeons want to play safe Patients not aware of available options Insurance companies ignorant and uncooperative.
- 12. ▪ Initial reluctancefrom hospitals ▪ (stand alone day surgery unit) ▪ Dedicated team ▪ Short stay to actual day care surgery ▪ Stay < 6-8 hr post-op
- 13. ▪ Which procedures? ▪Widening due to improvements in : ▪ Surgical techniques ▪ Anaesthetic techniques ▪ Pain control
- 14. ▪ Widening ▪ Suctionevac. ▪ Cerclage ▪ Bartholins ▪ Cystectomy ▪ Now TLH, Myomectomy, endometriosis, tuboplasty, diagnostic, hysteroscopies, adhesiolysis , etc “ Almost ALL“
- 15. CRITERIA OF DAY CARESURGERY? ▪ Which patients? ▪ Surgical criteria: ▪ No increased risk of haemorrhage ▪ Able to allow oral intake in few hr ▪ One that allows early mobilization ▪ Abd/ thoracic cavity opened only by MIS ▪ No requirement of prolonged specialist post-op care ▪ Post-op pain amenable to oral medication ▪ Anaesthesia side effects that delay discharge must be minimal ▪ Expected duration of surgery
- 16. ▪ Medical: ▪ Fitness– physiological age,ASA,BMI etc ▪ Good control chronic disease – DM, HTN ▪ Social: ▪ Patient counselled well ▪ Consent for DCS ▪ Responsible adult to escort home ▪ Support for first 24hr at home ▪ Not far away from hospital
- 17. IAAS TERMINOLOGY –INTERNATIONAL ASSOC. FOR AMBULATORY SURGERY Day surgery/ambulator y surgery/day only /same day surgery: Admit on day of surgery carefully selected and prepared patients for planned, non-emergency surgery and discharge same day within hours of the surgery. Extended recovery: 23 hr, overnight stay, single night Short stay: 24-72 hr in hospital prior to discharge Inpatient: Patient admitted in a hospital for a stay 24 hr or more
- 18. ▪ A procedurecarried out in a medical practitioners professional premises in an appropriately designed and equipped service room.
- 19. ▪ Hours toolate ▪ Social issues ▪ Issue of transport ▪ Family not willing ▪ Excess PONV or pain ▪ Poor recovery in ward ▪ Complicated surgery
- 20. Studies worldwide –DCS deliver the same high quality care as that of hospital admitted patients or may actually be safer 60% or more surgery in US performed as daycare Expected to go to 75% over next decade
- 21. FOR SUCCESS OFDCS PATIENT SELECTION PATIENT INFO AND EDUCATION PRE-OP ASSESSMENT AND TESTS PAC PATIENT ACCEPTABILITY PROTOCOL DEVELOPMENT AUDIT
- 22. Pain PONV Patient education andperception Discharge planning Follow-up care at home Is readmission a taboo?
- 23.
- 24. ▪ Explain whatDCS means – involve patients in decision making ▪ Date, time and place to arrive ▪ Informed consent ▪ Prior anaesthetic check – ASA I/II, allay anxiety ▪ No smoking at least 12hr ▪ NBM from midnight ▪ Changes to current medication scheduling or dosing ▪ No J-ASA or blood thinner for a week prior
- 25. Bring all medsregularly taken to hospital Stop COCPs at least 48hr prior Shower evening before or on day of surgery Report wounds, cuts or rashes on site of surgery Remove nail polish Leave jewellery at home Inform about URTI and allergies No alcohol day before No shaving of abdomen
- 26. Pre-emptive management of pain andnausea Balanced anaesthesia Induction with propofol, muscle relax with atracurium, orogastric tube, IPPV, maintenance with O2, N2O and isoflurane Supplemented with TIVA ( remifentanyl) in myomectomy to maintain a hypotensive anaesthesia.
- 27. ▪ Multimodal analgesia: ▪Identify high risk patients early - anxious ▪ iv fentanyl, iv diclofenac 75 as infusion, iv PCM as infusion, ▪ LA infiltration, LA instillation into peritoneal cavity ▪ TAP block ▪ Opioid sparing ▪ Preventive analgesia
- 28. ▪ MECHANISMS OF ACTIONOF PAIN MEDICATION
- 29. ▪ Multimodal antiemesis: ▪ iv dexa 8mg at induction, iv ondansetron 4-8 mg ▪ Avoid opioids if possible ▪ Can use droperidol or metoclopramide
- 31. IMMEDIATE POST-OP Early ambulation Oral fluidsin 2-3 hr Close monitoring in recovery ward Maintain pain score chart Nurse mediated discharge in 5-6hr
- 32. DISCHARGE PLANNING “protocol driven nurse-led discharge”
- 33. Stable vitals No newsigns and symptoms post-op Manageable PONV Mild tolerable pain Passed urine Smooth surgery without complications Walk comfortable without assistance Responsible adult escort and support for 24hr
- 34. Diet: light mealat night, normal breakfast next day Activity Medication – antibiotic,analgesia,anti- emetic, anti acidity,anti-constipation Wound care Danger signs Emergency contact number Telephonic enquiry by nurse at night or visit at home PRN
- 35. DAY 3 POST OP 1WEEK LATER
- 36. DCS ADVANTAGES ▪Patient and family ▪More personalized ▪ Recover in familiar home environment ▪ Avoid complications of long hospital stay – nosocomial infections, DVT etc ▪ Resume personal life earlier ▪ Higher satisfaction
- 37. ADVANTAGES ▪ Hospital ▪ Cost25%-75% lesser ▪ Less nursing and medical supervision ▪ Ease scheduling patients and surgeons ▪ More numbers can be treated ▪ Decompression of busy hospital beds
- 38. ▪ Healthcare system ▪Cost containment ▪ Can be made more accessible
- 39. ▪ Will changedesign of health care facilities and composition of health care workforce ▪ Hospitals of ‘future’ – more OT and fewer beds ▪ Lesser strain on ward staffing ▪ More home based nursing care.
- 40. ▪ Prof. RafiqueParkar ▪ Dr Wanyoike Gichuhi ▪ ICMAS
- 41.