Day surgery:Widening the selection

criteria!Dr. Rowan Thomas

MBBS FANZCA MPH

What are the selection criteria? Should the criteria be changed?

(A sociological perspective) How can it be changed?

(A policy perspective) The importance of follow up and outcome

review

Introduction

Tertiary referral HospitalDay of surgery discharge not high – 25-30%Australian average 60%

Economic or utilitarian drivers. Lower morbidity Faster mobilisation and recovery Able to be with family Free up resources for other health care

areas

Why Day surgery?

Two components. Day of surgery arrival (DOSA) + Early discharge

DOSA requires:◦ Optimisation of co-morbidities and medications◦ Early assessment, communication and consent◦ Timely arrival and fasting

Early discharge requires:◦ Good pain management◦ Resolution of unwanted effects of anaesthesia◦ Good social supports◦ Adequate time to assess surgical complications

Is “Day surgery” care different?

Pain (Not enough analgesia?) Nausea (Too much opioid?) Bleeding Unstable co-morbidity Incapable of self care

What stops people going home?

Minimally invasive techniques are widening the range of possible surgeries

Minimal risk of post-operative Haemorrhage Minimal risk of post operative airway

compromise Pain controllable by outpatient techniques Post-operative care that can be managed by

a responsible adult or home nursing facilities A rapid return to normal fluid and food intake

ANZCA Policy PS15

Surgical requirements

A willingness to have the procedure performed and an understanding and an ability to follow instructions

Patient’s place of residence within one hour’s travelling time from medical attention

ASA I or II. Stable ASA III or IV. Careful consideration for higher ASA grades.

Infants and children where associated paediatric facilities and experience exist. Should be older than 6 weeks (normal term) or greater than 52 weeks post-conceptual age if premature (< 37 gestation)

ANZCA Policy PS15

Patient requirements

A responsible person able to transport the patient home in a suitable vehicle.

A responsible person staying at least overnight with the patient.

Ensuring that the patient understand the requirements of post-anaesthetic care in regard to public safety.

The patient stay within one hour of medical attention until one day after surgery.

Ready access to a telephoneANZCA Policy PS15

Social requirements

Unstable ASA III or IV. Eg. Brittle diabetes, unstable angina, symptomatic asthma.

Morbid obesity with haemodynamic or respiratory problems

Drugs: Monoamine oxidase inhibitors or acute substance abuse esp. Cocaine.

Ex-prem infants <52 weeks post-conceptual age.

Lack of responsible adult at home to transport and care for the patient.

Contraindications to Day Surgery

Sleep apnoea Morbid obesity Elderly Malignant Hyperthermia susceptibility Anaesthetic technique – regional and

neuraxial.

Selection controversies?

Or the application of the criteria?

Is it the selection criteria that should be widened?

Greater use of regional techniques and local anaesthetic infusion catheters at home.

Better use of analgesic adjuncts. 23 hour stay units Available inpatient back up facilities Mobile day surgery Surgical techniques

◦ Laparoscopic and Robotic surgery Better management of co-morbidities

The future: what can be changed that may affect selection criteria?

Structural Functionalism Society combines to create a

homeostatic system. A change in one part creates or determines a corresponding change in another.

Also famous for describing the doctor-patient relationship and the ‘sick role’. The development of day surgery is the opposite to the traditional role he described.

Talcott Parsons

Structural functionalism

Every order or change in order will present a struggle between the proletariat (workers) and the bourgeoisie (capitalists).

Exploitation and alienation of the lower class will be hidden, but present in every economically motivated ideology.

Karl Marx

Legitimate authority: Charismatic, Traditional and Legal-rational.

Local charismatically led systems grow into bureaucracies with Legal-rational lines of authority and responsibility

Widening selection criteria may be possible at a local level, however a greater economic impact is possible when systems are developed to establish large scale change, requiring bureaucratic models to develop.

Weber

The “care system” must be looked at as a whole

Greater support, good information and consistent expectation will lead to a wider range of day surgical options

Wider criteria = comprehensive support

Distance from hospital Pain management routines Nausea management routines Preoperative optimisation and information Nursing in the home A number to call A telephone Capacity of family Ability to admit for social reasons 23 hour wards.

Supports

Policy development Consultation Iteration Description Change through agreement, commitment

and ownership.

How can the application of the criteria be changed?

Patients Government and other funding bodies Hospital administration Surgeons Anaesthetists Nurses Other Health providers

Stakeholders

Risk is difficult to evaluate on a small sample

RCTs are not appropriate for low risk outcomes

Registries and databases are being created to collect and audit outcomes from medical interventions. ◦ NSAS – National Survey of Ambulatory Surgery

www.cdc.gov/nchs/nsas.htm

Measuring what we do

Society of Thoracic Surgery: National Cardiac Surgery databaseAmerican College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)Centre for Disease Control and Prevention – National survey of Ambulatory surgery.

Registries of clinical care -some examples

snap shot of aurora

Applying the criteria more widely is probably our actual challenge.

Selection criteria applied more widely through:◦ Technology – surgical, anaesthetic, pain

management, outcome data collection◦ Community support◦ Secondary supports, i.e. inpatient services back-

up◦ Thoughtful, local policy development◦ Measuring outcomes

Summary

Change can be difficult and it may not be right in every situation.

There are patient, surgical and social factors that need individual consideration.

Supports in the community vary from region to region.

We need to monitor, audit and evaluate outcomes to assess the work we do, because our goal of safety and comfort extends beyond the operating room, it needs to extend into the home as well.

Summary