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Current Anaesthesia & Critical Care (2007) 18, 176180

www.elsevier.com/locate/cacc

FOCUS ON: DAY CASE

Day surgery overview: Where are we now, how did we get here and where are we going?
Ian Jackson
Department of Anaesthesia, York Hospitals NHS Foundation Trust, Wigginton Road, York YO30 8HE, UK

KEYWORDS
History of day surgery; Benchmarking; Political incentives for day surgery; Training

Summary Day surgery began in the 1900s and has since become a benecial form of care which is practised, to varying extents, in most countries. Without ignoring the numerous clinical benets of day surgery, this overview will focus on the current position of day surgery in the United Kingdom and will examine the various political initiatives which are making this form of surgical care ever more desirable. These rapidly evolving changes also have implications for future training in anaesthesia. As day surgery becomes the default option for elective care, the majority of anaesthetists will need to ensure their anaesthetic techniques minimise the complications that can interfere with successful same day discharge, while highly trained specialists, capable of achieving good results with the more complex cases, will also be required. & 2007 Elsevier Ltd. All rights reserved.

Introduction
Day surgery is an increasingly common form of care with numerous clinical and nancial benets. Patients appreciate a streamlined booking system with minimal risk of cancellation on the day of surgery and enjoy a good-quality recovery with specialised nursing care, excellent analgesia and minimal complications. The healthcare system also benets from efcient healthcare without the expense of overnight hospital accommodation.

Denition
In the United Kingdom (UK), day surgery is dened as the admission of selected patients to hospital for a planned surgical procedure with them being allowed to return home the same day.1 However, when comparing day surgery rates for a particular operation, it is important to realise that different denitions are used around the world and some countries (e.g., North America) include patients with a stay of less than 24 h. Another important fact that many clinicians do not understand is that the UK Department of Health (DH) will only count a patient as a day case if they were placed on the waiting list for management as a day case by their surgeon; this is called their management intent.

E-mail address: ian@sunnysideup.org.uk

0953-7112/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.cacc.2007.07.008

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Day surgery overview Those listed for surgery as an inpatient but who are then successfully managed as a day case unfortunately do not count as day cases for hospital performance gures. This may not be entirely unreasonable, however, since a patient sent home at the last minute may not have enjoyed the preoperative preparation and quality of care which are important to the safety and success of day surgery. 177 performance in a basket of 25 procedures (Table 1) to compare Trusts. It is important to realise that, although this is a useful audit tool for comparison, these procedures only represent about 30% of potential day surgery activity. In the report it was calculated that another 74,000 patients per year could be moved from inpatient treatment and be managed as a day case if all units performed as well as the best. The basket of 25 procedures is now used by the NHS Institute for Innovation and Improvement as part of their Better Care, Better Value Indicators.8 These allow each organisation to compare their performance against a local peer group and suggests savings that could be made if performance was improved. Currently, there are very good nancial reasons for Trusts to move to day surgery, to shorten lengths of stay for inpatients and to promote same day admission for surgical cases across the UK. These nancial issues appear most acute across England and this is leading many Primary Care Trusts (PCTs) to question the value and effectiveness of many traditional day surgery procedures. Varicose vein surgery, myringotomy,

Historical context
Day surgery is not new and indeed in 1909 Nicoll2 reported his work on nearly 9000 children who underwent day surgery for such conditions as harelip, hernia, talipes and mastoid disease at the Royal Hospital for Sick Children in Glasgow. Nicoll recognised the need for suitable home conditions and co-operation with General Practitioners, indeed he was a gifted enthusiast who was years ahead of his time. It was the 1950s before surgical colleagues started to question the wisdom of enforced bed rest following surgery and consider the dangers this exposed the patient to.3 It is interesting to note that at this time our surgical colleagues were starting to discuss the possibility of treating more patients through the same number of beds (due to reduction in lengths of stay) and the potential for day surgery to reduce waiting lists.3,4 The gradual move to day surgery in the UK was largely driven by a few enthusiasts throughout the 1970s and 1980s until a report entitled Guidelines for day case surgery was produced in 1985 (revised in 1992) by the Royal College of Surgeons of England.5 This report stated that day surgery is now considered the best option for 50% of all patients undergoing elective procedures and was published at a time when the national average was under 15%. The British Association of Day Surgery (BADS) was formed 4 years later in 1989 to promote the provision of day surgery, but with an emphasis on safety, quality and excellence. There have been two major DH led initiatives promoting day surgery, the rst in the early 1990s and the second in 2004. However, despite the importance of day surgery being recognised as one of 10 streams of work that would revolutionise the Health Service,6 performance across the UK remains poor.7

Table 1 Basket of 25 procedures used by the Healthcare Commission17 for benchmarking purposes. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Orchidopexy Circumcision Inguinal hernia Excision of breast lump Anal ssure dilation/excision Haemorrhoidectomy Laparoscopic cholecystectomy Varicose vein stripping/ligation Transurethral resection of bladder tumour Excision of dupuytrens contracture Carpal tunnel decompression Excision of ganglion Arthroscopy Bunion operations Removal of metalware Extraction of cataract Correction of squint Myringotomy with or without grommets Tonsillectomy Submucus resection Reduction of nasal fracture Correction of bat ears Dilation and curettage/hysteroscopy Diagnostic laparoscopy Termination of pregnancy

Current situation
Day surgery activity shows tremendous variation across the UK.7 The Health Care Commission uses

This was never intended to be a comprehensive list and numerous other procedures are also suitable for day surgery.

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178 tonsillectomy and extraction of wisdom teeth are just some of the procedures under review and these may become increasingly rare procedures. It is unfortunate that these changes are being driven by local nancial problems when there is recognition that many procedures do require review but would be better discussed and managed on a national basis. Payment by Results which involves the payment of a national tariff for each procedure has also introduced incentives for Trusts to move to day surgery. The payment received is the same irrespective of whether the patient is managed as an inpatient or a day case. This is leading some Trusts to maximise their use of day and short stay surgery so inpatient beds can close, thereby reducing their running costs. Currently, there is no incentive for PCTs to specically commission day surgery, as there is no saving from their budgets; however, this may change in the future. While England is attempting multiple reforms based on competition to drive change, Scotland is using co-operation across large health communities to plan services t for the future that take into account the availability of medical and nursing manpower. This vision for the future was delivered by the Kerr Report9 which has been accepted by the Scottish Parliament. BADS is supporting the Scottish Executives implementation of change through their Planned Care Improvement Programme. One of the ve keystones of this initiative is that day surgery should be treated as the norm. Wales have had a national day surgery programme that organised a multidisciplinary Good Practice Group which published a Guide to Good Practice in Day Surgery.10 Since then, the Welsh Audit Ofce and National Leadership and Innovation Agency for Healthcare have led a review of day surgery across Wales and have presented their nding to the Welsh Assembly.11 While nancial pressures may be challenging the use of certain procedures, medical advances will have a far greater effect on day surgery practice. Several surgical procedures are already being replaced by less invasive, non-surgical alternatives (Table 2). It is felt that several surgical specialties will increasingly become ofce based with the majority of their work taking place in outpatients and day surgery. Gynaecology, urology and ENT are leading the way with these developments and some units are reaching the stage where they have no inpatient beds. In recognition of this, BADS has extended its remit and now promotes quality care in both day case and the short stay surgery setting. In 2006, BADS published the rst edition of the I. Jackson
Table 2 Examples of medical advances that are changing day surgery practice. Surgical procedure affected Knee arthroscopy Laparoscopy and dye Hysterectomy or thermoablation Surgical termination of pregnancy New medical technique MRI Ultrasound monitored contrast injection Mirena coil Medical termination of pregnancy

Table 3 Denition of column headings in the British Association of Day Surgery Directory of Procedures.12 Procedure room Day surgery 23 h stay Under 72 h stay Operation that may be performed in a suitable clean environment outside of theatres Traditional day surgery, discharged without overnight stay Patient admitted and discharged within 24 h Patient admitted and discharged within 72 h

BADS Directory of Procedures12 which looks at over 160 operations across nine surgical specialties. Each operation is divided into four possible treatment options (Table 3), ranging from management in a treatment room to requiring a 72 h stay in hospital. Leaders in each eld were approached for what they felt would be achievable when appropriately trained staff, equipment and facilities were available for some of the common procedures in their specialties. The resulting Directory gives an indication of the direction each specialty will be moving in over the next few years, although it should be noted that surgical, anaesthetic and nursing skills will need to be developed in many areas to allow this to happen.

Training for the future

As day surgery is going to form an ever-increasing part of most hospitals elective workload, it will also play an important part in most anaesthetists working lives. Unfortunately, in the past many have seen it as a second-class area to work in, perhaps

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Day surgery overview even as too easy and lacking in the cachet of looking after more major inpatient cases. However, day surgery offers its own challenges and perhaps, rather like obstetric anaesthesia, offers more rapid feedback on success or failure, especially with regard to the quality of care provided. Training in day surgery appears in the new guidelines from the Royal College of Anaesthetists for Intermediate (ST Years 3 and 4) and Higher and Advanced Level (ST Years 57) trainees.13,14 Day surgery forms one of seven General Units of Training in which it is expected that all trainees will receive appropriate intermediate level training and in which formal Workplace Assessments will take place. This is subsequently developed for ST Years 57, with day surgery being one of the options included in Higher training. Within this it is also recognised that day surgery may offer experience and training in the organisation and management of a service. It is unfortunate that, despite recognition of the importance of day surgery in these documents (and their predecessors), little progress in formal teaching has taken place around the UK. As larger number of elective patients are managed through day units, with more challenging cases and procedures, this will have to change. These challenging cases have resulted in many units developing protocol-led anaesthetics to ensure favourable outcomes for their patients.15,16 It is important that trainees are exposed to these, understand the basis of their development and the implications they hold for future practice. For their part, trainees should express an interest in day surgery to those who control rota placements. The planned workplace assessments in day surgery for the Intermediate Level trainees should ensure a good grounding that the Higher Training can build on. The trainee should also remember the possibilities of research or audit within day surgery. There is a rich vein of possible projects, large patient numbers and it is an area that is largely untapped in the UK. There is also the possibility of publication via the Journal of One-Day Surgery or even presentations at the BADS Annual Scientic Meeting.a 179 changes that will have a lasting effect on anaesthesia. An increasing number of the patients we manage will be day cases or will stay in hospital for under 24 h. Although the management of anaesthesia and postoperative morbidity should form a part of all anaesthetic care, it becomes increasingly critical for these patients. The current wide variability in practice and performance amongst anaesthetists will be easy to monitor and I believe this will lead to the development of protocol-driven anaesthesia. Hospitals will continue to reduce the number of inpatient beds they have available and centralisation of critical services will mean that many of us will be working in centres that only provide day and short stay surgery. Rather than being seen as negative, these changes could have a positive impact on the quality of both our patients and our own lives. It is up to us to rise to the challenge.

References
1. Department of Health. Day surgery: operational guide. Waiting, booking and choice. 2002. Available from: /http://www.dh. gov.uk/PolicyAndGuidance/OrganisationPolicy/SecondaryCare/ DaySurgery/fs/enS. 2. Nicoll JH. The surgery of infancy. Br Med J 1909;2:7534. 3. Palumbo LT, Paul RE, Emery FB. Results of primary inguinal hernioplasty. AMA Arch Surg 1952;64(3):38494. 4. Farquharson EL. Early ambulation; with special reference to herniorrhaphy as an outpatient procedure. Lancet 1955; 269(6889):5179. 5. Royal College of Surgeons of England. Commission on the provision of surgical services. Guidelines for day case surgery. London: HMSO; 1992. 6. Department of Health NHS Modernisation Agency, 2004. 10 high impact changes for service improvement and delivery. Available from: /http://www.wise.nhs.uk/cmsWISE/HIC/ HIC+Intro.htmS, 2004. 7. Acute hospital portfolio review, day surgery. Available from: /www.healthcarecommission.org.uk/serviceprovider information/reviewsandinspections/acutehospitalportfolio/ guidance.cfm/cit_id/416S, 2005. 8. Better care, better value indicators. Available from: /www.productivity.nhs.ukS. 9. Building a health service t for the future. Available from: /www.scotland.gov.uk/Publications/2005/05/23141307/ 13135S, 2005. 10. Day surgery in Wales: a guide to good practice. Available from: /http://www.wales.nhs.uk/sites3/docmetadata.cfm? orgid=484&id=40941S, 2004. 11. Making better use of NHS day surgery in Wales. Available from: /www.wao.gov.uk/assets/englishdocuments/WAO_ Day_Surgery_Eng_web.pdfS, 2006. 12. British Association of Day Surgery. BADS directory of procedures. London: 2006. 13. Royal College of Anaesthetists. CCT in anaesthesia III: competency based specialist registrar years 1 and 2 training and assessment. A manual for trainees and trainers (January

The future and how this will affect anaesthesia

It should be obvious that across the UK, day surgery and short stay surgery are about to undergo major
a

For further information, see www.bads.co.uk

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2007). 2007. Available from: /www.rcoa.ac.uk/index.asp? PageID=57#CCTS, 2007. 14. Royal College of Anaesthetists. CCT in anaesthesia IV: competency based specialist registrar years 3, 4 and 5 training and assessment. A manual for trainees and trainers (January 2007). Available from: /www.rcoa.ac.uk/index. asp?PageID=57#CCTS, 2007.

I. Jackson
15. Ewah BN, Robb PJ, Raw M. Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy. Anaesthesia 2006;61(2):11622. 16. Association of Anaesthetists of Great Britain and Ireland. Day surgery. Rev. ed. London: 2005. 17. Audit Commission. Day surgery: review of national ndings. London: Audit Commission Publications; 2001.