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DAY_CARE_SURGERY[249].ppt
- 1. DAY CARE SURGERY Presentor:Mohammad Masoom Parwez Moderator: Dr. Bharati Pandya
- 2. Introduction • 50% electivesurgery in UK • 60% elective surgery in USA / Canada • 23 – 50% elective in India in selected centres • NEED • Long surgical waiting list • Reduction in available beds • High cost of in patients beds • Improvement in anaesthesia and pain control • Minimally invasive surgery
- 3. Definition • “Planned investigationsand procedures done on patients who are admitted and discharged home the same day as surgery and who require some facilities and time for recovery.” • Criteria of inclusion • Patient who spend few hours in hospital but, do not stay overnight. • Patient who spend upto 23 hrs in hospital. • Minor procedures in outpatient or accident in emergency department not included
- 4. Historical aspect • 1909 James Nicholl reported 9000 children operated as day cases • 1912 Ralph Waters founded anaesthesia clinic in same way as today’s day surgery unit • 1951 Eric Farquharson carried out hernia repair under local anaesthesia • 1960 hospital based DSU appeared in USA • 1969 Walter Heed set up 1st DSU named Phoenix surgicentre…. ….
- 5. Benefits of daysurgery • Reduced cost • Low post-operative morbidity • Reduced thrombo-embolism and hospital acquired infections • Minimal disruption to patients life • Early return to work and normal activities • Children prefer it
- 6. Contd… • More efficienthigh volume turnover of patients • Reduced waiting lists for elective surgery • In patients bed freed for major and emergency surgery • Fewer cancellation on day of surgery
- 7. Problems of daysurgery • Initial cost of setting up DSU • Good organization and management needed • Poor patient and procedure selection • Trained and efficient staff needed • Inadequate information given to patient • Morbidity from anaesthesia and surgery
- 8. Contd… • Burden ofcare passed to patient’s family • Increased community health care workload • Quality of care in day surgery should be of same high standard as that expected for inpatient surgery • Lead to emergence of DSU
- 9. Desirable features DSU •Self contained: Reception , ward , theatres and recovery area • Adjacent parking • Well planned patient flow • Maintain as high standards as inpatient wards and theatres • Bed theatre ratios as prescribed • Set protocols for selection , analgesia and discharge to be followed • Good record keeping
- 10. Contd… • Support servicesreadily available • Trained , experienced staff • Consultant led anaesthesia and surgery • Organized training with closed supervision of trainees • Clinical director in overall charge • Team work between staff groups • In tune with community services and GPs
- 11. Organization of DSU •Nurses experienced with multi-skilling specialized for children • Ancillary staff portering and domestic duties • Technicians record keeping, computer savvy accurate and complete work-skills high volume with fast turn over
- 12. Cont.… • Medical staff…. trainees are closely supervised ….. • Clinical director • A consulant surgeon or anaesthetist • Implement and audit good standards of care • Regular multidisciplinary meetings required ….
- 13. Essentials of goodday care surgery • Selection of appropriate procedure and patients • Pre-admission assessment and information • Anaesthesia and surgery with minimal morbidity and complication • Post-operative and post-discharge analgesia • Discharge criteria and postoperative instructions • Follow-up and audit
- 14. Criteria for suitableprocedures • Minimal physiological alterations • No excessive blood loss and fluid shifts • Duration of 1-2 hrs maximum • Oral analgesia after discharge • Patient reasonably ambulant after discharge • Avoid surgical drains • Urinary catheters may be used • Ensure minimal complications
- 15.
- 16. Selection criteria forpatients • Social criteria • Age • Criteria for fitness of patients for general anaesthesia
- 17. Social criteria • Responsibleadult escort patient home … • Few stairs to climb Good toilet facilities Access to telephone • Should live within 1 hr of hospital facilities • Ready access to GPs on discharge … • Concept of hospital hotels overnight supervision at low cost in hotels … • Concept of hospital at home ….
- 18. Developing countries due to long distance and difficult travelling, day surgery introduction has been slow pick up.
- 19. Age • Upper agelimit 70 years • Physiological age is more important than actual age • Lower age limit facilities available • Experienced staff • Procedures undertaken
- 20. Criteria for selectionof anaesthesia • Patient • Fit and ambulant • Not grossly obese ( BMI <30 ) • Able to climb one flight of stairs • Do not book patients with cardiovascular disease • Poorly controlled hypertension (BP > 170/100) • Angina , CCF or PVD • MI ,CVA or TIA in last 6 mnths • Symptomatic valvular disease • Cadio-myopathy
- 21. Contd … • Respiratorydisease • Severe asthma or COPD • Others • IDDM or poorly controlled NIDDM • Renal, hepatic disease • Alcoholic , narcotic addiction • Multiple sclerosis , myasthenia gravis • Severe psychiatry disease
- 22. Contd … • Donot book patient taking • Anticoagulants • Monoamine oxidase inhibitors • Digoxin • Systemic steroids • Anti-arrhythmics • Oral contraceptives • GTN
- 23. Assessment before admission •Surgeons are not good in assessing patients …. • Anesthesiologists impractical ….time , cost , manpower-wise • Alternative Filtering process • Special nurses using planned questionnaire for assessment • Investigations done according to answers • Anaesthesiologists review the case
- 24. Pre-admission information… • Onfront page • Time and date of operation with contact nos. • Need for an escort or taxi to go home • Females to notify DSU if pregnant or in menses • Instructions not to drive for 48 hrs • Fasting instructions • Do not omit medication unless specified • Instructions for clothing , valuables
- 25. Contd… • Other informationon day surgery • Map , parking and how to find DSU • Brief description of what will happen, PEMs • Duration for stay and time for escort to come • Post-anaesthetic restrictions on driving etc. • Who to contact on discharge
- 26. Contd… • Procedure specificinformation • Procedure of operation • Preoperative preparation • Expected postoperative morbidity • Rest duration • Wound management , stitch removal and follow up
- 27. Benefits of pre-admissionclinic • Problems sorted out before admission • Unnecessary investigations reduced • Cancellation on day of surgery reduced • Patients better prepared and informed • Non-attendance reduced • Peri operative complications reduced • Unplanned overnight admission reduced
- 30. Morbidity after daysurgery • Major • Myocardial infarction • Pulmonary embolus • Respiratory failure • Cerebrovascular accidents • Major postoperative haemorrhage • Unrecognised damage to viscus …..
- 31. Contd… • Minor • Pain •Nausea and vomiting • Dizziness and drowsiness • Minor bleeding • Infection • Sore throat and headache ….
- 32. Anaesthesia • Anaesthetic morbidity major reason for unplanned readmission • Two types • Local /regional anaesthesia • General anaesthesia
- 33. Local anaesthesia • Ideal •Excellent for elderly • Economical • BUT • More time consuming • Requires gentle hand • Not preferred by patients
- 34. Contd… • Types • Spinal •Caudal • Epidural • Disadvantage • Time required to give and start action are more • Delay in mobilization • High incidence urinary retention
- 35. Contd … • Drugused • Long acting bupivacaine • If increased speed of onset lignocaine added • Prilocaine , chloroprocaine Beir block….
- 36. General anaesthesia • Goodfor children • Propofol drug of choice for IV induction • Drug of choice for maintenance • Good anaesthetic condition • Rapid Problem-free recovery • Incidence of post op nausea and vomiting is less
- 37. Contd… • Inhalation induction •Sevoflurane drug of choice for induction • Has replaced halothane • Maintenence volatile agent • Isoflurane • Enflurane • Nitrous oxide in oxygen
- 38. Contd … • Shortacting opoid • Alfentanyl or fentanyl • Reduces dose • Provide analgesia early post op • Remifentanyl ultrashort acting opoid .
- 39. Analgesia • Good paincontrol is essential to prevent • Delay in discharge • Unplanned overnight admission • GP consultation after discharge • Distress and dis-satisfaction • Limitation to early mobilisation • Prolongation of return to normal function • Morphine • Less used as sedative PONV
- 40. Contd… • Multimodal analgesia •NSAIDS • Local anaesthetics • Short acting opioid • Oral analgesics 3-5 days post discharge
- 41. Discharge guidelines • Orientedto time, place, person • Tolerate oral fluids • Can void • Dress • Walk without assistance • Patient must not have • Nausea and vomiting • Excessive pain • Bleeding or • Fever
- 42. Follow-up audit andquality control • Good day care surgery means reduction in: • Nonattendance • Cancellation • Complication before and after discharge • Overnight admission • Readmission • Are audited and improvement made • Telephone call next day reassures patient immediate feedback of analgesia and problems
- 43. Future • It isnot the Fastest surgery on the Fittest patient • But has included older less fit patients with more major procedures • And with advancement in medical science has good prospects
- 44.