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Scarborough 2008 - British Association of Day Surgery

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					The Journal of
  One-Day Surgery
                 VOLUME 18 SUPPLEMENT


                     Abstracts presented at the
                 19th Annual Scientific Meeting
                       Scarborough, June 2008
PARALLEL 1: DELIVERING QUALITY CARE FOR PATIENTS




SURGERY 1: LAPAROSCOPIC CHOLECYSTECTOMY & ENT
Oral Abstracts

A1    Same day Discharge for Breast Cancer Surgery: Does it meet patient and carer needs?
      E Pennery, K Scanlon, T Baxter, J Roberts, J Marsden




PARALLEL 1: ANAESTHESIA AND PERIOPERATIVE CARE
A2    Mixed Sex in Day Surgery: Who’s opinion counts?
      J Stevenson, D Baddeley, CB Hammond, I Smith

A3    A Case Report and Review of the Perioperative Management of Autistic Children in Day Surgery
      A Arora, B Watson

A4    A Survey of Day Surgery Patients’ Perception and Satisfaction with the Consent Process
      SP Gosavi, C Davies

A5    Therapeutic Relationships and the Day Surgery Patient
      A Mottram

A6    Conscious Surgery: Influence of the environment on patient anxiety
      M Mitchell




A7    Development of a Scoring Tool for Daycase Laparoscopic Cholecystectomy
      M Weisters, Z. Soonawalla

A8    Improving Daycase Laparoscopic Cholecystectomy
      TCH White, N Dasey, D Birch, J Linsell

A9    Preoperative Discussion with a Specialist Nurse and Admission to a Short Stay Unit can Increase the Rate of
      Daycase Laparoscopic Cholecystectomy
      J Lichfield, W Hawkins, S Mukherjee, J Isaac, F Curran

A10   Middle Ear Surgery in a Day Care Setup
      M Thirukkamu, J Smith, C Davies

A11   Functional Endoscopic Sinus Surgery as a Daycase Procedure
      Y Bajaj, N Sethi, S Carr, L Knight

A12   Paediatric Tonsillectomies in the Day Surgery of a District General Hospital — A one year review
      A Mills, J Ingham, S Singham, M Stocker




A13   Are Guidelines for Preoperative Investigations being adhered to for Day Surgery?
      R Malhotra

A14   Continuous Peripheral Nerve Infusion for Ambulatory Arthroscopic VMO Advancement. What are the issues at
      home? A prospective observational study
      G Gopalakrishnan, R Edward

A15   Feasibility and Cost Effectiveness of Ultrasound Guided Supraclavicular Brachial Plexus Block as the Sole
      Anaesthetic Technique for Hand Surgery
      JB Sadashivaiah, JC John

A16   Over the Counter Medicines for Pain Relief after Paediatric Daycase Surgery
      KE Russon, JA Short

A17   Choice of Opioid for Daycase Laparoscopic Cholecystectomy: Does it matter?
      H Sycamore, JM Vernon

A18   Do Post-recovery Facilities affect Daycase Surgery Unplanned Overnight Admission Rates?
      W Manguyu, J Atolayan, E Manson, C Davies
PARALLEL 2: EDUCATION, GUIDELINES AND THE BIG PICTURE




SURGERY 2
Oral Abstracts cont.




PARALLEL 2: DAY SURGERY IN TODAY’S NHS
A19   Should Day Surgery be Performed in a Dedicated Unit? Comparison of outcomes from two different facilities
      CM Matthews, ME Stocker

A20   Training Tomorrow’s Anaesthetists as Day Surgery Champions
      A Myburgh, ME Stocker

A21   Daycase Surgery Training for Surgical Trainees: A disappearing act ?
      N Siddiqi, V Paringe, B Kumar, J Ahmad, M Hemadri, PJ Moore

A22   Implementation of a Simplified Version of NICE Guidelines Improves Clinical Compliance
      D Ail, K Shoukrey, D O’Hare

A23   Venous Thromboembolism Prophylaxis in Day Surgery
      RE Blackshaw, ML Alderson




A24   Our Experience of Setting up a Day Surgery Trauma List in an NHS Hospital
      J Payne; C Davies

A25   Audit of Trauma Case Load Suitable for a Day Surgery Trauma List and Cost Analysis
      T Colegate-Stone, C Roslee, A Tavakkolizadeh, D Simon, J Sinha

A26   A National Audit of Daycase Paediatric Foot and Ankle Surgery
      N Jagodzinski, R Begum, S Khanum, H Prem

A27   An Audited Review of Contemporary Daycase Foot Surgery
      SA Metcalfe, M Hutchby, A Maher, N Taylor

A28   Stapled haemorrhoidectomy: A Daycase Procedure of Choice for Symptomatic Haemorrhoids
      AA Riaz, A Patel, A Singh, JI Livingstone

A29   Laser Seal Haemorrhoidectomy: Effective ambulatory haemorrhoidectomy with immediate discharge and
      good outcomes.
      M Hemadri, V Paringe, N Siddiqui, PJ Moore




A30   What can Daycase Surgery Contribute to the Economy? Driving down the cost of daycase surgery using the
      single visit approach: An estimated costs calculation
      M. Hemadri, P. J. Moore

A31   Does the 18 week Wait Pressurise Patients’ Decisions about Day Surgery?
      J Machin, H Jones, J Johnson, C Shaw, CL Ingham Clark

A32   What is the Optimal Daycase List under the National Tariff?
      M Puttick, M Zilvetti, D McWhinnie

A33   Daycase Local Anaesthetic Inguinal Hernia Repair makes Economic Sense
      M Puttick, M Zilvetti, D McWhinnie

A34   Why are Patients with Primary Inguinal Hernias being Excluded from the Benefits of Day Surgery?
      JCY Leong, JR Nash

A35   Daycase Green Light Laser Prostatectomy.
      AJ Glackin, A Golash, I Smith
PLENARY PRIZE SESSION




POSTERS
Plenary Prize Session/Posters

B1    Daycase Laparoscopic Adrenalectomies: a UK experience
      S Omorphos, P Waterland, M Deakin, I Smith, A Golash

B2    A Role for Daycase Surgery in Orthopaedic Trauma Care?
      NR Howells, L Tompsett, A Moore, A Hughes, J Livingstone

B3    Ambulatory Breast Conservation Surgery with Axillary Node Sampling for Cancer: Interim results of a pilot
      randomised control trial
      M Proctor, S Marla, S Stallard, L Romics

B4    The Financial Argument for Day Surgery: Illustrated using inguinal hernia repairs
      T Dione, R McCarthy, ME Stocker

B5    Comparison of Daycase Endovenous Treatment Modalities for Varicose Veins — Analysis of postoperative
      pain and analgesia requirements
      R Kapur, S Goode, M Crockett, JM Vernon, BD Braithwaite




P1    A Survey of the Incidence of Post-Discharge Nausea and Vomiting Following Daycase Gynaecological Surgery
      TL Gregory, S Jackson

P2    A Valid Case for a Daycase Procedure or will Surgeons’ Fingernails be Bitten to the Quick?: Postoperative
      outcomes and management after closure of loop ileostomy
      W Baraza, J Wild, W Barber, K Brodie, SR Brown

P3    An Audit of Unplanned Admissions and Readmissions in a Busy Urban Day Surgery Unit
      JN Oronsaye, D Sewell, P Found, F Dunsire

P4    An Audit to Determine the Effectiveness Of Ureteroscopy as a Daycase Procedures
      ND Rao, FM Fazly, RK Calleja

P5    Analgesia after Shoulder Surgery — A need for best practice in daycase surgery?
      R Deepak, JV Edwin, C Pac-Soo

P6    Are Anaesthetic Rooms in Day Surgery Necessary?
      P Sultan

P7    Assessing the Appropriateness of Unplanned Admissions: The Torbay approach
      K Stenlake, M Stocker

P8    Attitudes to Music in the Operating Theatre — Should it be banned?
      A Mahdi, V Varadarajan, K Hashaishi

P9    Audit of Cancellations in the Day Surgery Unit of a District General Hospital
      N Purohit, A Tore, H Shien, S Green

P10   Audit of Day Surgery Attendance Rates in Plastic Surgery at Selly Oak Hospital and Associated Cost
      Implications
      Kok K, Singh S

P11   Audit of Postoperative Analgesia by Telephone Follow up and Pain Diaries
      M Laye, J Rozentals, JM Vernon

P12   Can Laparoscopic Cholecystectomies Feasibly be Performed as a Daycase Procedure in District General
      Hospitals?
      J L Morgan, O Tawfiq, M Al-Gailani
Posters
P13   Comparison of the Incidence of Unplanned Admission Rate in the First 100 and the Subsequent 98 patients
      undergoing Daycase Laparoscopic Cholecystectomy
      MI Bhatti, J Sherigarh, A Osman, M Fernando, MA Rathore, MG Brown

P14   Daycase Laparoscopic TEP Hernia Repair — Outcome and patient satisfaction
      R Verma, A Hakeem, K Kolar

P15   Direct Access Colonoscopy: A novel approach
      J Ahmed, M Rao, A Khan, NN Siddiqi, CC Mahon, KS Mainprize

P16   Direct Access Daycase Surgery for Primary Inguinal Hernia: A practical approach
      J Ahmed, M Rao, A Khan, NN Siddiqi, CC Mahon, KS Mainprize

P17   Does BADS Practice What it Preaches?
      MA Skues

P18   Does Timing of Ambulatory General Surgery affect Delay in Discharge — An institutional report
      NN Basu, M Hussain, L Miernik, B Kald

P19   Effectiveness of the Preassessment Service for Day Surgery
      I Locker, N Soundararajan, S Mathias, A Clarke

P20   Evaluation of Safety and Efficiency of Ambulatory Urogynaecology procedures performed in a 23 hour
      Daycase Surgery setting
      U Kubal, A Arunkalaivanan

P21   General Practitioners’ Attitude to Vasectomy: Its relevance to the establishment of a one stop service
      P Erotocritou; S Al-Buheissi; R Lunawat; BH Maraj

P22   How Acceptable is Daycase Laparoscopic Cholecystectomy?
      S Reshamwwalla, ER Drye, TJ Cahill, P Bowes, V Vijay, SJ Warren

P23   ‘How Are We Doing’? Patient satisfaction within King’s College Hospital Day Surgery Unit
      J Bush, J Doyle, U Fountain, T Hiles, H Peskett, R Sugarman

P24   Is it Acceptable Practice to Perform Plastic Surgical Procedures on Patients in a Satellite Day Surgery Unit?
      The patients’ perspective
      S Hassan, L Ferguson

P25   Is there a role for Morphine in Modern Day Ambulatory Surgery?–A district general hospital experience
      NN Basu, B Kald, DI Heath.

P26   Laparoscopic Cholecystectomy: Daycase vs. Overnight Stay: A retrospective audit
      M Ahuja

P27   Medicolegal Implications of Vasectomy; histology and negative semen at 4 months may be adequate to avoid
      litigation
      MS Mirza, K Pattanayak

P28   “Mini-open” Repair of Acute Tendo-achilles Ruptures — The solution?
      M El-Husseiny, C Mukundan, F Rayan, A Budgen

P29   Optimal Patient Positioning for Removal of Laryngeal Mask Airways in Children — Results of an audit cycle
      G Thomas-Kattappurathu, JA Short

P30   Oral Morphine: Is it suitable for day surgery?
      SK Mekala, K Radford, J Vernon

P31   Outcome of Laparoscopic Cholecystectomy by Harmonic Scalpel in Obese Daycase Patients
      S Ganapathi, S Hassan, R Sewell, T Parkinson, H Patel, S Patel, N Marshall

P32   Pain and Analgesia Requirements Following Endovenous Laser Ablation of Great Saphenous Vein
      SC Mckay, NR Banga, SJ Walton, JN Crinnion
P33   Preemptive Intraperitoneal Instillation of Large Volume Low Concentration Lidocaine for Postoperative
      Analgesia after Laparoscopic Cholecystectomy: An observational study
      G Gopalakrishnan, K Krishnan, M Hemadri, M Jaganathan

P34   Preoperative Fasting on Children Presenting for Plastic Surgery Trauma
      I Kannan, R Menon

P35   Reducing Waiting Times for Lymph Node Biopsies
      SAJ Pannick, H King, CL Ingham Clark

P36   Scope on Ambulatory Care for Aesthetic Breast Surgery
      RR Salman, AR Salman

P37   Senior Anaesthetic Involvement in Preassessment for Daycase Surgery
      SE Taylor, SM Lloyd

P38   Setting up a Single Visit Service. Is this the way forward?
      M Hemadri, PJ Moore

P39   Single Visit Service for Daycase and Short Stay Surgery: Encouraging preliminary results.
      M. Hemadri, V. Rao, PJ. Moore

P40   Social Aspects of Day Surgery: Time and the day surgery patient
      A Mottram

P41   Staged Informed Consent for Aesthetic Breast Surgery gives the Best Results
      AR Salman, RR Salman

P42   Streamlining the Consent Process. Can it be done?
      AEA Peet, MA Skues

P43   Surgical Site Marking in Orthopaedic Daycases
      A Vasireddy, E Dunstan, R Grewal

P44   Tackling Pain Scores after Day Surgery with Protocols for Postoperative Prescribing
      H Lakshman, JE Montgomery, ME Stocker

P45   The Changing Face of Head and Neck Surgery
      KM Ubayasiri, AJ Dickenson

P46   The effect of Intraoperative DVD on Patient Satisfaction during Daycase Regional Anaesthesia
      LA Penny, OH Whinn, V Rajaratnam, EJ da Silva

P47   The Financial Implications of Nonessential Flexible Cystoscopy
      R Nair, C Kerali, D Pearce, J Abbaraju, PL Acher, S Madaan, IK Dickinson

P48   The Impact of Multi-skilled Staff Availability on Day Surgery Operating Theatre Session Cancellations
      HA Lloyd

P49   Unplanned Admissions Following Daycase Laparoscopic TEP Hernia Repair
      R Verma, A Hakeem, K Kolar

P50   Unplanned Admissions Following Daycase Procedures — A prospective study
      A Hakeem, K Nagpal, J Muen

P51   Waiting for the Operation — A study of patients’ attitudes to waiting in a dedicated day surgery unit
      H Jones, J Machin, J Johnson, C Shaw, CL Ingham Clark

P52   Ward Facilitator — Who is that!
      D Frederiksen
Editorial comment
While we have tried to reproduce all abstracts as submitted, some Editorial discretion has been taken to
correct obvious spelling or grammatical errors. It has also been necessary to reformat tables into a
consistent style and to shorten some abstracts to conform with printing constraints. In these cases, some
Editorial amendments may have been made so as to retain the maximum amount of information possible in
the available space. The Editor hopes that none of these changes will cause any embarrassment or offence.

                                                                                     IAN SMITH
         Same day Discharge for Breast Cancer                        delivery. (1) Knowing what to expect in the first few days after
  A1     Surgery: Does it meet patient and                           discharge and when to act upon something was relevant
                                                                     particularly for daycase patients and their carers and perceived
         carer needs?                                                to reduce anxiety and ease unnecessary responsibility. Concern
         E Pennery, K Scanlon, T Baxter, J Roberts,                  about seroma formation was equally prevalent in day surgery
         J Marsden                                                   and inpatients. (2) Day surgery delivery of care and staff
                                                                     professionalism was valued highly and infection exposure
         King’s College Hospital NHS Foundation Trust
                                                                     perceived to be reduced. Having carers at home on the day of
INTRODUCTION: A same day discharge service for breast                discharge and for a few days afterwards was important. For
cancer surgery (mastectomy or wide local excision with axillary      same day discharge pre and postoperative community district
dissection) was commenced following patient demand at KBC            nurse input was put in place based on health professionals’
in March 2006. This qualitative focus group research aimed to        assumptions that this was a necessary additional level of
provide insight into how women and their carers perceived their      support. Patient feedback however showed this led to
surgical experience in order to further inform a service centred     confusion about who to contact with immediate problems with
on users’ needs.                                                     a preference for hospital contact. Inpatients expressed
METHODS: All women who had same day discharge between                dissatisfaction with their environment and lack of specialised
March 2006 and March 2007 and for comparison all women               nursing care. A conundrum raised by same day discharge was
between March 2005 and March 2006 who had inpatient                  despite providing an early psychological boost, how could
surgery (they would have been eligible for same day discharge        women reconcile the seriousness of breast cancer and breast
if the service had been available then) were invited by letter to    loss with same day discharge as this implied the surgery was
participate in focus group discussions. Four were conducted.         ‘minor’.
Women were requested to forward an invitation letter to their        CONCLUSIONS: Satisfaction with same day discharge was
main carer – the intention was to conduct 2 focus groups. This       unanimous and inpatient care was not reported to be superior.
was unsuccessful resulting in 2 carers being interviewed by          With adequate preparation and information giving, same day
telephone. Breast Cancer Care conducted and analysed the             discharge is as an acceptable and viable model of care. On a
focus groups due to their experience of this methodology and         practical level KBC have revised their patient information with
to avoid conflict of interest. Classical content analysis was used   an emphasis on carers’ needs and the need for postoperative
to identify predominant themes arising from the discussions.         community nurse support. Findings from this study are being
RESULTS: Women who had same day discharge would have it              used as a basis for planning further prospective research on the
again if offered. Key areas identified for service improvement       longer-term impact of day surgery on patient and carer
for all women centred on (1) information needs and (2) care          wellbeing.



         Mixed Sex in Day Surgery: Who’s                             they would like to be with patients having similar surgery
  A2     opinion counts?                                             irrespective of sex, 19% would prefer same sex irrespective of
                                                                     surgery while 70% had no preference. However, 71% were
         J Stevenson, D Baddeley, CB Hammond,                        actually nursed with patients having similar surgery and 71% of
         I Smith                                                     these found it helpful or reassuring. 35% of patients said it
         University Hospital of North Staffordshire                  would help to have another male or female in a mixed bay, 15%
                                                                     would still prefer a single sex area but half would be happy as
INTRODUCTION: A study on our former 14 bedded day surgery            the only male or female. Overall, 92% were very satisfied with
unit showed the majority of patients were not concerned about        their care and no one was dissatisfied.
sharing a bay with the opposite sex1. However, mixed sex wards                                                     Males Females Total
remain topical and controversial2. On our new, larger, 34             Single sex area                               40    60       101
bedded unit, it is thought safer to keep operating lists together     Enjoyed single sex environment                28%   70%*     53
and achieving single sex bays has proved a logistical                 No strong feelings                            68%   27%*     44
nightmare, although we do try to avoid isolated males or              Would have preferred mixed sex                2     2        4
females and manage gynaecology patients in all female bays.           Mixed sex area                                47    46       99
To allay some professional concerns with our practice, we             Enjoyed mixed sex environment                 38%   48%      42
decided to repeat our survey.                                         No strong feelings                            62%   46%      53
                                                                      Would have preferred single sex               0     3        4
                                                                     * p <0.05; not all patients recorded their gender
METHODS: Questionnaires were distributed to all patients over
a six week period, asking about the gender mix of the bay they
were in and their feelings about this. Patients were also asked      CONCLUSIONS: Our practice of using mixed sex bays is well
their preference about being with patients having similar            received and the majority of patients are unconcerned about
operations or of similar gender and whether they would find a        being in a mixed sex area when undergoing day surgery. Most
mixed sex area more acceptable with at least one other of the        patients also appreciate being with those having similar
same gender present.                                                 surgery, supporting our method of bed allocation. Unlike some
                                                                     professionals, daycase patients have few concerns about being
RESULTS: 200 questionnaires have been completed to date.
                                                                     in mixed sex areas; we counted their opinion and their opinion
Almost half the patients were in a mixed sex area (table). Most
                                                                     should count!
patients were either indifferent to, or happy with, the
environment they were in, with some differences between the          REFERENCES
sexes. As many patients in single sex areas would have               1. Hammond C, et al. Journal of One-day Surgery 2004;14(4):91–4
preferred mixed company as the opposite. 11% of patients said
                                                                     2. Daily Telegraph; 30th January 2008
         A Case Report and Review of the                             leave the unit as soon as she was awake. The perioperative
 A3      Perioperative Management of Autistic                        course was uneventful and the carers were pleased that the use
                                                                     of physical restraint had been avoided.
         Children in Day Surgery
                                                                     DISCUSSION: Day surgery is an optimal setting in which to
         A Arora, B Watson                                           manage autistic children undergoing minor and intermediate
         The Queen Elizabeth Hospital                                surgery1,2. Published work describes different sedative agents
                                                                     and routes to enable day surgery staff to help manage these
INTRODUCTION: Autism is an increasingly common condition
                                                                     patients and their carers, but none are ideal. Each delivery
with an estimated UK prevalence of 3–6 per 1000 children1.
                                                                     method has its advantages and disadvantages. Midazolam and
Autistic children often react badly to changes of routine and
                                                                     ketamine have an unpleasant taste and are best given
their perioperative management can be very difficult. Day
                                                                     disguised in a drink. The largest study found oral midazolam
surgery offers many advantages, minimising the duration of
                                                                     (0.5 mg/kg) and ketamine (7 mg/kg) to be effective sedatives2,
disruption and distress. This case report illustrates how careful
                                                                     reducing noncompliance with anaesthetic induction from 50%
planning can lead to a successful outcome.
                                                                     to 25% with no delay in discharge. Other studies confirm no
CASE REPORT: A severely autistic 11 year old, 45 kg girl, ‘E’        delay in discharge associated with various sedative
required anaesthesia for elective dental and gynaecological          premedication despite highly variable doses3. Restraint was
surgery and a renal ultrasound. E had previously exhibited           not required in this case, but its use had been discussed and
extremely challenging and aggressive behaviour in hospital and       agreed with E’s carers. Most carers expect noncompliance and
her carers were anxious about this admission. We conducted           restraint is not necessarily seen as a failure. However, with the
the anaesthetic preassessment at the patient’s home, where a         obvious short term physical risks and the unknown long term
plan was agreed with the carers. On the day, a dedicated area in     psychological effects, alternatives should be used wherever
the day surgery unit was established solely for E and her carers.    possible1. The successful perioperative management of autistic
Midazolam (0.5 mg/kg) and ketamine (4 mg/kg) were mixed in           children requires a multidisciplinary and flexible approach from
the patient’s favourite squash and her carers (who had identical     staff with knowledge of this challenging condition.
unmedicated drinks) encouraged her to take this. No staff
                                                                     REFERENCES
approached E until the sedation had taken effect. We had
coordinated the attendance of both surgeons and radiologist at       1. Courtman S, et al. Paediatric Anaesthesia 2008;18:198–207
the start of the list. The sedatives allowed easy transfer of E to   2. Van der Walt J, et al. Paediatric Anaesthesia 2001;11:401–8
theatre and induction of anaesthesia. Postoperatively the            3. Bozkurt P. Current Opinion in Anaesthesiology 2007;20:211–5
intravenous cannula was removed and E returned to her carers
while still sedated. She was left undisturbed and allowed to


         A Survey of Day Surgery Patients’                           formality. Only 41% believed that consent process was primarily
 A4      Perception and Satisfaction with the                        to serve their interests. 21% patients had an understanding that
         Consent Process                                             the consent was obtained by the staff nurses. 28% patients
                                                                     were not totally satisfied with the information given to them
         SP Gosavi, C Davies
                                                                     before the surgery and 33% did not find the consent process
         William Harvey Hospital                                     absolutely satisfactory. 17% of the patients felt need for change
INTRODUCTION: In ethical terms, the role of consent is to            in the consent process. Out of these most (53%) were unhappy
safeguard patient’s autonomy1. Consent should be an                  with the timing of obtaining consent, 23% were not comfortable
integrated part of communication process that continues              with the place while rest felt that the whole communication
throughout the preoperative, perioperative and postoperative         process of obtaining consent was inadequate.
period. Even though a structured, standardised surgical consent
form is being used in NHS, it has been observed that many            CONCLUSIONS: Many patients have limited awareness of the
patients have limited awareness about consent process,               whole purpose of consent process. There are quite a lot of
making it inadequate2. This study examines patients’                 inadequacies in the process, making it ethically inefficient. A
understanding of the function of consent and tries to find out       significant proportion of patients are not satisfied with the
any inadequacies in the process.                                     current process. So ideally surgeons should have a thorough
                                                                     discussion with the patient regarding every aspect of surgical
METHODS: It was a prospective questionnaire study.                   procedure (preassessment, actual surgical procedure,
Questionnaires were given to 75 patients on the day of surgery       complications and the postoperative period) at the outpatient
while waiting for surgery, after they signed the consent form.       clinic before actually obtaining the consent. Also consent
The questionnaires were mainly focused on patients’                  should be obtained by someone who is able to answer all the
understanding of the purpose of the consent, the method of           questions patient has concerning his operation, so the big
obtaining consent (timing, place, person taking the consent,         question is, who should be the best person for the job?
form of consent) and patients’ satisfaction with the whole
communication process. At preassessment, patients are                REFERENCES
normally given the NHS leaflet on consent3.                          1. Worthington R. Medical Ethics 2002; 28
                                                                     2. Ritchie R, et al. Journal of the Royal Society of Medicine 2008;
RESULTS: After analyzing the data, we found that patients had           101:48–9
limited understanding of the purpose of consent. Nearly half         3. About the consent form. The Department of Health leaflet on
(46%) believed the primary purpose of consent was to protect            Consent 2007
doctors and hospitals, while 13% of patients felt it was just a
         Therapeutic Relationships and the                         providing a warm supportive relationship offering a perception
 A5      Day Surgery Patient                                       of safety from threatening events. The patients’ views
                                                                   encompassed many members of the day surgery team
         A Mottram                                                 including nonprofessional as well as professional staff. The
         University of Salford                                     therapeutic relationship often began in the preoperative
                                                                   assessment clinic, where patients often seem to be “checking
INTRODUCTION: Previous studies have indicated that because         out” preassessment staff to ascertain their caring and
of the limited amount of time patients spend in Day Surgery        professional skills. On admission the therapeutic relationship
therapeutic relationships cannot be developed between staff        was established in the day surgery unit and continued in the
and patients1,2. A study was devised to ascertain all aspects of   operating theatre environment.
the patients’ experiences in day surgery. A major theme to
emerge was the importance of therapeutic interaction between       CONCLUSIONS: What may be seen to be routine objective
day surgery personnel and the patients.                            interactions between day surgery patients and day surgery
                                                                   personnel can be interpreted very subjectively by the patients
A therapeutic relationship has been described as “a dynamic        and seen to be supportive in nature. It is important that Day
relationship between a caregiver and a patient . . . the           Surgery Personnel are aware of this as it may result in a less
relationship is caring, clear, boundaried, positive and            anxious patient and less patients failing to attend on the day of
professional”3.                                                    surgery.
METHODS: 145 patients and their families were interviewed,         REFERENCES
utilising semistructured interviews, on three occasions: in the
preoperative assessment clinic; 48 hours following surgery and     1. Fox NJ. The Social Meaning of Surgery. Buckingham. Open
one month following surgery from two different day surgery            University Press, 1992
units in the north-west of England. Data collection took place     2. Mottram A. Ambulatory Surgery 2001;9:103–7
over a two year period.
                                                                   3. McKlindon D, et al. American Journal of Maternal and Child
RESULTS: Therapeutic relationships can and are developed              Health Nursing 1999;5:237–43
within the day surgery unit. Time does not appear to be a
barrier to their development. A total of 92% of the patient
sample expressed gratitude to the multi disciplinary team for




         Conscious Surgery: Influence of the                       RESULTS: The experience of being awake, possibly feeling
 A6      environment on patient anxiety                            surgeon, seeing body cut open or surgery being more painful
                                                                   were anxiety provoking aspects. Utilising factor analysis
         M Mitchell                                                ‘intraoperative apprehension’, ‘anaesthetic information
         University of Salford                                     provision and ‘health control’ were identified as central
                                                                   features. Moreover, when employing multiple regression,
INTRODUCTION: Operating theatres have historical been              apprehension associated with the intraoperative experience
designed for safe, efficient surgery on the unconscious patient    and anaesthetic information provision were significantly
and not primarily designed for the care of the ‘awake’ patient.    associated with an increase in the overall level of anxiety.
However, with the rise in day surgery, the quantity of surgery
performed under local/regional anaesthesia is increasing. Our      CONCLUSIONS: Although the surrounding clinical environment
aims were to investigate anxiety arising from the experience of    has previously been a cause of apprehension, the sensations
the clinical environment during surgery under local/regional       associated with the physical act of surgery on the conscious
anaesthesia and to uncover the specific aspects patients find      self appear also to have a considerable influence. Focusing care
anxiety provoking and possibly dissuade them from opting for       upon managing patient intraoperative experience and
such anaesthesia.                                                  providing anaesthetic information in advance may help limit
                                                                   anxiety and expel the apparent misapprehensions associated
METHODS: As part of a larger study investigating anxiety           with conscious surgery.
within modern elective day surgery, adult patients undergoing
surgery and local/ regional anaesthesia (n=214) were provided
with a questionnaire on the day of surgery for return by mail
24–48 hours following surgery.
         Development of a Scoring Tool for                          minor role. We decided to use this hypothesis to predetermine
 A7      Daycase Laparoscopic                                       list order to increase daycase rates. List case-mix and order was
                                                                    predetermined by the surgical registrar using patients’ notes.
         Cholecystectomy                                            Those patients less suitable for day surgery were listed in the
         M Weisters, Z. Soonawalla                                  morning and those highly suited to day surgery were listed in
         John Radcliffe Hospital                                    the afternoon. Any patient predicted to have a high chance of
                                                                    failing same day discharge was placed last on the list.
INTRODUCTION: Our aim was to increase the daycase rate for          Discharge was nurse led according to standard day surgery
elective laparoscopic cholecystectomy in a mixed ambulatory         discharge criteria. Pre- and post-intervention daycase rates,
and inpatient theatre complex with a day surgery ward. A            adverse events and patient satisfaction were recorded using
minority of patients deemed unsuitable for day surgery are          post-discharge phone calls. A scoring tool for ordering lists was
excluded from this unit. The project coincided with a period of     developed to aid clinical decision making and this was then
increased surgical activity so we were constrained by               validated retrospectively.
availability of theatre sessions.
                                                                    RESULTS: During the 8 week pilot study, 38 laparoscopic
METHODS: A multidisciplinary team lead by a surgical registrar      cholecystectomies were performed. Twenty eight patients were
used ‘Lean’ methodology to map the patient pathway in order         successful daycases (74%), including an octogenarian and a
to identify problems. We saw that 75% of laparoscopic               patient with diabetes. Two patients underwent open
cholecystectomy operating sessions were in the afternoon,           cholecystectomy, one of which was planned. 100% of patients
thus time of operation was the major determining factor of          deemed medically fit for discharge after 8pm chose to go home.
successful day surgery. Where patient order was actively            100% of successful daycases expressed high levels of
decided by the surgeon, young patients were usually operated        satisfaction. There were no readmissions or adverse events in
on first. Changes were implemented during a pilot study using       this group.
one all day and one afternoon theatre list on 8 consecutive
Mondays i.e. 66% of operations were performed after 1pm. The        CONCLUSIONS: Optimising theatre list order in combination
patient population of the study group was predetermined by          with extended day surgery unit hours enables every patient on
the waiting list. These changes included extending the opening      an all day operating list to be a successful daycase. We have
hours of the day surgery unit from 8pm to10pm. The team             shown that day surgery laparoscopic cholecystectomy can be
discussed the significance of factors which influence a patient’s   successful in groups not usually offered day surgery such as
suitability for day surgery. The most discriminating factors were   octogenarians, and patients with comorbidities such as
history, ultrasound findings and social support. Comorbidities      diabetes. A clinical decision making tool is a useful resource to
have an important role, as does age >70. Body Mass Index            increase daycase rates.
(excluding >40) and distance of home from hospital play a




         Improving Daycase Laparoscopic                             no statistical difference in their age (p=0.4), ASA grade
 A8      Cholecystectomy                                            (p=0.27), or sex (p=0.49). However patients who were
                                                                    admitted had undergone significantly longer surgery (p<0.01),
         TCH White, N Dasey, D Birch, J Linsell                     and were more likely to have been operated on after midday
         University Hospital Lewisham                               (p<0.01).
INTRODUCTION: It is widely reported that daycase surgery for        CONCLUSIONS: The implementation of the clinical pathway
Laparoscopic Cholecystectomy (LC) is safe and feasible1,2.          has significantly increased daycase rates and reduced the
However the national average daycase LC rate is 6.4%, while         overall length of stay. This has not been associated with an
the highest performing organisations achieve a daycase rate         increase in morbidity. The need for overnight admission is not
between 40% and 50%. A prospective study was carried out to         always predictable preoperatively as there is no difference in
assess the success of the implementation of a new clinical          sex, age or ASA grade between the inpatient and daycase
pathway for daycase LC.                                             cohorts. Admission was predicted by increased length of
                                                                    operation and late starts. In conclusion, elective daycase LC is
METHODS: All LCs performed at our hospital between January          safe and effective and confers considerable cost benefit.
and June 2006 and January and June 2007 were included in the        Daycase should be the default for all elective LCs and these
study. Length of stay, morbidity and mortality were compared        should be performed on the morning list.
between the two groups, and patient characteristics of the
inpatient and daycase cohorts were also analysed.                   REFERENCES
RESULTS: In 2006 the daycase rate was 9.7%. In 2007 this had        1. Johansson M, et al. British Journal of Surgery 2006;93:40–5
increased to 53.7% and the overall length of stay had reduced       2. Leeder PC, et al. British Journal of Surgery 2004;91:312–6
(p<0.01). There had been no change in the rate of
complications, the rate of readmissions or in the rate of
conversion to open surgery.
When comparing Daycases with Inpatients in 2007, we found
         Preoperative Discussion with a Specialist                    complications or readmissions following discharge in either
 A9      Nurse and Admission to a Short Stay Unit                     group. The patients who stayed overnight were found to be
                                                                      more likely to have presented with biliary complications (21%
         can Increase the Rate of Daycase
                                                                      vs 0%), have a thick walled gallbladder on USS (26% vs 0%)
         Laparoscopic Cholecystectomy                                 and have had their operation start later than 2pm (26% vs 3%).
         J Lichfield, W Hawkins, S Mukherjee, J Isaac,                They were also seen to have a higher mean /median weight
         F Curran                                                     (94.03/89 vs 84.9/83.7 kg), a slightly longer mean operating
         Royal Wolverhampton Hospitals NHS Trust                      time (50.4 vs 47.4 minutes) and were more likely to have had
                                                                      bile spillage during the operation (37% vs 13%). They were less
INTRODUCTION: Assuming that they have no significant
                                                                      likely to have been seen by our specialist nurse or have a
comorbidities and have someone to look after them at home,
                                                                      documented discussion about daycase surgery by the surgeon
patients undergoing laparoscopic cholecystectomy (LC) in our
                                                                      than those who were discharged the same day (37% vs 55%).
Upper GI unit are admitted with an intention to treat as a
                                                                      Of those who were discharged on the day of surgery 48% went
daycase. We endeavour for them to be put early on the
                                                                      to our specialist ward and 52% were admitted to the Short Stay
operating list and for them all to be reviewed by our specialist
                                                                      Unit. Of those who stayed overnight, 58% went to the specialist
nurse pre- and postoperatively, with a follow up telephone call
                                                                      ward, 1 (5%) went to the colorectal ward and 37% to the Short
the next day. We aimed to see if there were any trends in the
                                                                      Stay Unit.
group who were not being discharged on the day of surgery.
                                                                      CONCLUSIONS: So far this year we are achieving a respectable
METHODS: A prospective audit of all patients admitted under
                                                                      60% same day discharge rate for LC. Perhaps predictably, in
our care with an intention to treat as daycase LC.
                                                                      this cohort of patients we have found that operating late, obese
RESULTS: 54 consecutive patients have so far been recruited           patients, spillage of bile during the operation and preoperative
into this ongoing study since January 2008. 3 of these were           biliary complications can lead to an increased hospital stay.
converted to open surgery, all due to dense adhesions around          However, admission to the Short Stay Unit and having a
the gallbladder. 31 (57.4%) were successfully discharged the          preoperative discussion about daycase LC seem to increase the
same day with the remaining 19 (35.2%) being discharged the           chances of a successful same day discharge and these are
following morning. Further analysis compared these two                areas where we should be focusing our efforts.
groups. Both groups were similar for age, ASA, anaesthetic &
operative technique, grade of operating surgeon and time on
the waiting list. One patient in each group had developed
jaundice on the waiting list. There have been no major




         Middle Ear Surgery in a Day Care                             antiemetic prophylaxis was left to the individual anaesthetist. 16
A10      Setup                                                        patients were discharged on the same day and 8 patients were
                                                                      discharged the next day. The main reason for overnight stay was
         M Thirukkamu, J Smith, C Davies                              vomiting.
         William Harvey Hospital, Ashford
                                                                      Occasionally, the operating session over ran, which had a domino
INTRODUCTION: Historically middle ear surgery was performed           effect on the afternoon activity. This problem has been addressed
in a main theatre setting requiring in patient stays. Middle ear      by have a “fire break” session when we have middle ear surgery
surgery is safe in a day care unit setup1, 2. We undertook a          on the list.
retrospective study to find out the viability of middle ear surgery   CONCLUSIONS: The overnight stay rate in our study was 33%.
in a day care unit. The duration of surgery, from induction of        Our experience showed that with the correct planning of
anaesthetic to leaving first stage recovery can be up to two and a    operation lists and utilising of resources, middle ear surgery
half hours.                                                           could be performed safely on a daycase basis, despite an
METHODS: The study was conducted in our purpose built day             overnight stay of 33%. If the 23hour classification was used, all
surgery centre. It included all middle ear surgeries from             patients went home within 23 hours. Follow up of these patients
September 2004 to March 2008.We looked at unplanned over              indicated a high level of satisfaction with their care.
night stays and the factors that precipitated the need for patients   REFERENCES
to be admitted as inpatients.
                                                                      1. Qureshi A, et al. Journal of Laryngology and Otology 2006;
RESULTS: The type of surgeries included myringoplasties,                 120(1):5–9
tympanoplasties, modified radical mastoidectomies. 24 cases
were identified during this period, of which 11 were male and 13      2. Subramaniam S, et al. Medical Journal of Malaysia
were female patients. The age of the patients varied from 7 years        2006;61(4):474–6
to 80 years. Of these, there were 21 ASA I, 2 ASA II and 1 ASA III
patients. All patients had general anaesthetic; the choice of
         Functional Endoscopic Sinus Surgery                         these patients 39 (37.1%) had chronic sinusitis and the rest 66
 A11     as a Daycase Procedure                                      (62.8%) patients had nasal polyposis and sinusitis. Sixty one
                                                                     patients (58.1%) were operated on the morning list while the
         Y Bajaj, N Sethi, S Carr, L Knight                          rest 44 (41.9%) patients were operated in the afternoon. Of
         York District Hospital                                      these patients 24 (22.8%) patients had previous nasal
                                                                     surgeries. The majority of patients 91/105(86.7%) went home
INTRODUCTION: Functional Endoscopic Sinus Surgery (FESS)
                                                                     the same day with all remaining patients being discharged the
is the mainstay of surgical treatment of chronic sinusitis.
                                                                     next day. The only complication in this study was bleeding in
Daycase surgery has the advantage over inpatient surgery by
                                                                     7 patients (6.7%). At the follow up appointment 90/105
being cost-effective and resource conserving. The objectives of
                                                                     (85.7%) patients were satisfied with the postoperative results.
this study were to look at our results of daycase Functional
Endoscopic Sinus Surgery (FESS).                                     CONCLUSIONS: Daycase Endoscopic Sinus Surgery can be
                                                                     done safely as a daycase procedure. The most important
METHODS: This study was a retrospective case notes review of
                                                                     factors for successful outcomes are correct patient selection in
daycase FESS operations performed at Leeds General Infirmary
                                                                     terms of general health and social circumstances and a
between February 2004 and February 2007. The details of the
                                                                     dedicated daycase team.
patient’s demographics, the operative details and the
postoperative recovery details and follow up was recorded.
RESULTS: A total of 105 daycase FESS operations were
included in this study with an age range of 16 to 93 and a sex
distribution of 44(41.9%) females and 61(58.1%) males. Of




         Paediatric Tonsillectomies in the Day                       difference in readmission rates (p=0.65, χ2 test) with 3 day
A12      Surgery of a District General Hospital                      surgery (14%) and 11 (11%) inpatient pathway patients being
         — A one year review                                         readmitted 3–6 days post surgery due to secondary
                                                                     haemorrhage.
         A Mills, J Ingham, S Singham, M Stocker
                                                                     CONCLUSIONS: The key to the successful implementation of
         South Devon Healthcare Trust                                this procedure was the close cooperation of a dedicated team
INTRODUCTION: Paediatric tonsillectomies were introduced             enabling both efficient and safe surgery. Paediatric nurses and
into the day surgery unit in April 2007 at Torbay. This followed a   play specialists were essential, particularly to provide activities
feasibility study of these patients treated through the inpatient    for children during the postoperative period. This audit showed
pathway1. We report our outcomes from the first year of this         minimal complication rates. The single admission was the first
service.                                                             case through day surgery and so inexperience in postoperative
                                                                     management may have played a part in the decision. The
METHODS: The procedures were carried out by a single
                                                                     coblation technique is ideal for day surgery due to good
surgeon, anaesthetist and theatre nurse. They were supported
                                                                     haemostasis, however relative inexperience of this technique
by paediatric trained nursing staff and a play specialist.
                                                                     by the other ENT surgeons has limited the numbers of cases
3 tonsillectomies were booked monthly on a morning list.
                                                                     treated in the day surgery unit. Pressure to meet the 18 week
Exclusion criteria included home distance of greater than 30
                                                                     target resulted in some patients being treated via the inpatient
minutes and age less than 3. Patients were anaesthetised
                                                                     system. It is hoped that with more surgeons trained in coblation
according to the modified Epsom protocol2 using disposable
                                                                     techniques and improved referral pathways our daycase
reinforced LMAs. The surgeon used the coblation technique.
                                                                     percentages will increase further. The future of this service may
Observations were performed for 6 hrs postoperatively
                                                                     include adult tonsillectomies. Although complications such as
followed by a nurse led discharge. Patients were followed up
                                                                     scarring and fibrosis are more common this should not
the next day by telephone.
                                                                     preclude a day stay approach.
RESULTS: 21 (17%) of 123 paediatric tonsillectomies were
                                                                     REFERENCES
performed through the day surgery unit. 8 patients (8%) lived
outside the geographic criteria for day surgery. Of the 102          1. Ingham J, et al. Journal of One-day Surgery 2007;
patients treated through the inpatient system 9 were                    17(Supplement):P23
discharged on the same day. Mean theatre time was 59 minutes         2. Ewah BN, et al. Anaesthesia 2006;61:116–22.
(sd ± 13.37) and the mean length of postoperative stay was 6
hours 41 minutes (sd ± 34.3). There was one unplanned
admission (4.8%). 18 out of 20 (90%) patients were contacted
the next day, there were no complaints of nausea, vomiting,
drowsiness or breathing difficulties. 13 patients (65%) reported
no pain, 2 (10%) had mild pain, 3 (15%) moderate pain, and no
patients reported severe pain. In all the cases the parent
satisfaction level was very high. There was no significant
         Are Guidelines for Preoperative                              on any medication. Only 16 patients (22.9%) underwent no
A13      Investigations being adhered to for                          preoperative investigations. Half of patients underwent blood
                                                                      tests, 24.3% (17 patients) had an electrocardiogram (ECG)
         Day Surgery?                                                 performed, 2.9% (2 patients) had a chest X ray (CXR) and 1.4%
         R Malhotra                                                   (1 patient) underwent spirometry. Only 63 (67.7%) of the 93
         University Hospital Aintree                                  blood tests performed were indicated according to the
                                                                      guidelines. Amongst the blood tests that were not indicated,
INTRODUCTION: The DOH aims to have three quarters of all              only 5 (16.7%) abnormal results were observed. Of the 17 ECGs
operations performed on a daycase basis within the next               performed, 7 (41.2%) were not indicated. Neither patient who
decade. As the number of daycase patients increase, it must           had a CXR performed had an appropriate indication. According
remain cost-effective and resource conserving. Routine                to the guidelines, any patient needing spirometry as part of
preoperative investigations are inefficient and expensive.            their preoperative assessment should not be considered for
Guidelines for preoperative investigation have been produced1         daycase surgery.
to ensure that unnecessary testing is not performed. This audit
aims to assess whether these guidelines are being adhered to          CONCLUSIONS: This audit shows that 35.4% of the
in day surgery.                                                       preoperative investigations for daycase patients were not
                                                                      indicated according to guidelines and only 1 (2.5%) resulted in
METHODS: A retrospective audit of 70 randomly chosen                  a change in management. Inappropriate investigations increase
patients who underwent daycase gynaecological surgery                 the financial burden on the NHS, put patient safety at risk and
during the period of January to March 2008 was performed.             are a burden on the time of health care professionals. This audit
Case notes were reviewed for demographic data, past medical           shows that a significant number of preoperative investigations
history and medications; the preoperative assessment forms            are being performed on patients that are not indicated and do
and investigations ordered were assessed. The indication for          not affect their management. Improved awareness and
each investigation was assessed against national guidelines.          compliance with guidelines informing of the appropriate
RESULTS: Of the 70 patients included, average age was 46,             indications for preoperative investigations in daycase surgery is
76% were ASA grade 1 and 24% were ASA grade 2.                        needed.
Hysteroscopies and laparoscopies were the most common                 REFERENCE
procedures. Hypertension, cardiac and thyroid diseases were
the most common comorbidities. There was no documented                1. NHS Preoperative Assessment Steering Board. April 2003
past medical history in 64.3% of patients and 71.4% were not

                                     FBC          U&E          LFT        TFT         Clotting     ECG         CXR          Spirometry
Performed                             35           30           10         8           10           17          2            1
Indicated                             29           22           1          8           3            10          0            0
Not indicated (%)                     6 (17%)      8 (27%)      9 (90%)    0           7 (70%)      7 (41)%     100%         100%
Abnormal (%)                          15 (43%)     3 (10%)      3 (30%)    0           0            2 (12%)     1 (50%)      100%
Change management                     0            2            0          0           0            0           0            1




         Continuous Peripheral Nerve Infusion                         5 mls/hour as a continuous infusion delivered by elastomeric
A14      for Ambulatory Arthroscopic VMO                              pump. Perioperative care was standardised Rescue opioids
                                                                      given as appropriate. Oral analgesics were given to take home.
         Advancement. What are the issues at                          Discharge criteria were followed according to institute protocol.
         home? A prospective observational                            We looked at the admission rate, postop pain score (0–10),
         study                                                        sleep, analgesic requirement, patient satisfaction (0–10),
         G Gopalakrishnan, R Edward                                   catheter compliance and problems.
         Hull Royal Infirmary                                         RESULTS: The results were promising. The readmission rate
                                                                      was six percent. The mean pain scores at rest was 3.1 and
INTRODUCTION: Vastus medialis obliquus (VMO) muscle is the            during movement 4.2. Less than 10% had sleep awakening of
major dynamic stabiliser of the patella. Arthroscopic repair of       four. Overall satisfaction score was 8.1 out of 10. One patient
VMO with lateral release is done for anterior patellar                had catheter kinking. There were no problems of any local
stabilisation which is common in sports injuries. This surgery is     anaesthetic toxicity.
associated with severe pain, many times requiring inpatient
admission. With advancement of analgesic technique and                CONCLUSIONS: In this prospective observational study we
continuous home infusions it is now being done as daycase. We         found it is feasible to send patients home with continuous
did a prospective observational study to find out the feasibility     peripheral nerve block and multimodal analgesic technique and
of sending patients home with local anaesthetic nerve infusion.       follow them up after arthroscopic VMO advancement and
                                                                      lateral release procedure. The dose and volume of continuous
METHODS: This prospective study was after institute approval.         infusion of ropivacaine, the overall cost effectiveness and the
Thirty patients who fulfilled our day surgery fitness criteria        optimum analgesic requirement and issues in the community
were included. All of them had general anaesthesia with               have to be determined.
continuous femoral nerve block (CFNB) with 2% lignocaine with
epinephrine 10–20 ml. For maintenance 0.1% ropivacaine,
         Feasibility and Cost Effectiveness of                     RESULTS: The mean block time and anaesthetic time were 9.47
 A15     Ultrasound Guided Supraclavicular                         min (3–21) and 16.93 min (8–33) respectively. One patient had
                                                                   block failure and was converted to GA. None of the remaining
         Brachial Plexus Block as the Sole                         patients required additional analgesia. 95% (20/21) of patients
         Anaesthetic Technique for Hand                            graded their anaesthetic management as excellent and would
         Surgery                                                   prefer the same, if needed in future. 95% of patients met
         JB Sadashivaiah, JC John                                  discharge criteria in the recovery and all patients were
                                                                   discharged on the same day. In comparison, patients who had
         Robert Jones and Agnes Hunt Orthopaedic and
                                                                   similar surgery under GA had an admission rate of 20.18%
         District Hospital
                                                                   (44/218). We calculated a saving of £406 for each daycase
INTRODUCTION: Hand surgery is performed as a daycase               patient, who had the surgery awake and was successfully
procedure in our hospital under general anaesthesia. We            discharged. Considering the fact that we perform nearly 400
prospectively evaluated the feasibility of using ultrasound        daycase hand surgery each year, this could amount to a
guided peripheral nerve blocks1–3 as the sole anaesthetic          significant saving that can be utilised for training and to
technique for hand surgery.                                        improve patient care.
METHODS: Twenty one adult patients scheduled for elective          CONCLUSIONS: Ultrasound guided peripheral nerve blocks are
hand surgery received ultrasound guided supraclavicular            a cost effective way of providing good surgical and
brachial plexus block, supplemented with ulnar, radial and         postoperative analgesia for daycase hand surgery with a high
median nerve blocks as needed. The time taken for                  success rate and excellent patient satisfaction. With proper
performance of the blocks (block time) and time taken to           training, they can be successfully performed within the time
achieve surgical anaesthesia (anaesthetic time – defined as        constraints of the regular operating lists.
loss of cold sensation in the tourniquet area and in the           REFERENCES
operative area) was noted. Any intraoperative and immediate
postoperative anaesthetic and analgesic supplementation was        1. Williams SR, et al. Anesthesia and Analgesia 2003;
documented. Patients who failed the discharge criteria and            97:1518–23
were retained as inpatients were recorded. Inpatient admission     2. Chan V, et al. Anesthesia and Analgesia 2003; 97:1514–7
rate of patients who underwent similar surgery under GA during
                                                                   3. Marohfer P, et al. British Journal of Anaesthesia 2005;
the same period was noted.
                                                                      94:7–17



         Over the Counter Medicines for Pain                       children were approached preoperatively, given an explanation
A16      Relief after Paediatric Daycase                           of the audit and asked to complete a data form at home to
                                                                   record the severity of pain experienced and analgesics given
         Surgery                                                   during the first 48hours postoperatively. A SAE was provided.
         KE Russon, JA Short                                       RESULTS: Hospital data were returned on 96 children and 48
         Rotherham General Hospital and Sheffield                  parent forms were returned. 2 of the 100 children were
         Children’s Hospital                                       admitted. 94/96 (98%) of children were discharged with
                                                                   analgesia available at home. Although 100% (48) parents
INTRODUCTION: A significant number of patients have pain at        remembered receiving verbal information, only 25% (12) said
home following daycase surgery1. Many patients prefer to use       they had received written information. 5/48 (10%) of parents
analgesic preparations with which they are familiar, and it is     reported that their child experienced severe pain at home
the routine practice of our day care ward that patients are        during the first 48hours following surgery. Only 21/48 (44%) of
encouraged to use their own supplies of paracetamol and            parents reported that their child had no or mild pain in the first
ibuprofen at home, rather than providing prescribed take home      48 hours. It was noted that 11/ 25 (44%) children whose
analgesia packs. We wished to audit whether pain was being         parents reported them to have moderate or severe pain had
adequately managed following daycase surgery in our hospital.      not received regular analgesia and 16 of these 25 children
If children were experiencing pain at home we were interested      (64%) received an inadequate dose of analgesia, based on the
to find the reason for this; lack of appropriate analgesia or      weight of the child.
inadequate education on how to manage the pain.
                                                                   CONCLUSIONS: The quality of pain relief experienced by our
METHODS: This was a prospective audit of 100 patients. We          daycase patients is clearly falling short of the standard set. To
used audit standards of the Royal College of Anaesthetists2,       explain this, we suggest patients are being underdosed by
modified for use with our paediatric patients:                     using age rather than weight, analgesia is not being given on a
• 100% discharged with analgesics available at home                regular basis and few parents receive written information on
                                                                   pain control. We are now developing a parent information
• 100% discharged with verbal and written instructions about       leaflet incorporating individualised doses of simple analgesics
   pain control                                                    for each child, calculated by weight, and clear instructions to
• <5% patients reporting “severe” pain in the first 48 hours       administer analgesics regularly at least for the first 48 hours
  after discharge                                                  after surgery.
• >85% patients reporting no or mild pain after discharge (with    REFERENCES
  medication)                                                      1. Kokinsky E, et al. Paediatric Anaesthesia 1999;9:243–51
For each patient, data were collected about the type of surgery,   2. Royal College of Anaesthetists. Raising the Standard: A
anaesthetic and analgesia given in hospital. Parents and              compendium of audit recipes 2006
         Choice of Opioid for Daycase                              There was no difference in pain scores between patients who
A17      Laparoscopic Cholecystectomy: Does                        received morphine as compared with fentanyl (χ2 = 4.12, df = 3,
                                                                   p = 0.25), nor in their recovery times (unpaired T test, P=0.25,
         it matter?                                                95% CI 18.9–71.1). 82 % of patients received a nonsteroidal
         H Sycamore, JM Vernon                                     antiinflammatory drug (NSAID). Of those that did not, 7/17
         Nottingham University Hospitals NHS Trust,                (41%) reported a pain score of 3. This compares with 8/54
                                                                   (15%) that received NSAID reporting a pain score of 3. Every
         City Campus
                                                                   patient received pre or intraoperative paracetamol and local
INTRODUCTION: In the opinion of our experienced recovery           anaesthetic infiltration to port access sites. 89% of patients
nurses, following laparoscopic cholecystectomy, patients given     received intraop fluids. 92% of patients received at least 1
intraoperative morphine appeared to have less postoperative        prophylactic antiemetic and 18% of patients received 2. 30% of
pain in comparison to those given fentanyl. We investigated        patients reported nausea in recovery and 4% patients vomited.
whether there was any difference in pain scores for patients       6/71 (8.5%) patients were admitted; 4 for pain, 1 for
given different opioids. BADS suggests the unplanned               postoperative nausea and vomiting (PONV), 1 following
admission rate following daycase laparoscopic                      laparotomy.
cholecystectomy should be less than 10%1. A multimodal             CONCLUSIONS: In this small study no difference was found
approach to analgesia is recommended, and that all patients        between the efficacy of morphine and fentanyl as analgesia for
receive prophylactic antiemesis and intraoperative fluids. We      daycase laparoscopic cholecystectomy. The addition of a NSAID
also carried out an audit to assess whether our current practice   appears to confer significant analgesic benefit and should be
meets these standards.                                             standard practice unless absolutely contraindicated. PONV
METHODS: The notes of 71 patients who had undergone                remains a significant problem in daycase laparoscopic
daycase laparoscopic cholecystectomy were examined                 cholecystectomy patients who have received single agent
retrospectively. These comprised 13 men and 58 women (ASA          prophylaxis. We recommend that 2 prophylactic antiemetics are
I–II, age range 18–73). The same consultant surgeon performed      given, one of which is dexamethasone, because of its potential
each procedure.                                                    additional analgesic benefits2.
RESULTS: All patients were given an intraoperative opiate:         REFERENCES
73% received morphine, 24% received fentanyl and 3%                1. British Association of Day Surgery. Daycase Laparoscopic
received tramadol. Alfentanil and remifentanil were not               Cholecystectomy. 2004
considered due to their short duration of action. Pain was
repeatedly assessed in Recovery by a verbal rating score where     2. Bisgaard T. Anaesthesiology 2006;104:835–46
0= no pain, 1= mild pain, 2= moderate pain and 3= severe
pain. The highest pain score recorded was used for analysis.
Both patients who received tramadol had a pain score of 3.



         Do Post-recovery Facilities affect                        17–65 and 20 aged 67 or more. 96 patients were ASA 1–2 and
A18      Daycase Surgery Unplanned                                 10 ASA 3. 44 patients were from ENT, 37 general surgery,
                                                                   17 gynaecology and 8 orthopaedics. Surgery time was under
         Overnight Admission Rates?                                1 hour in 85 patients and ended before 1500 hours in 73. Most
         W Manguyu, J Atolayan, E Manson, C Davies                 patients received general anaesthesia (94), with multimodal
         William Harvey Hospital                                   analgesia, antiemetics and iv fluids. Immediate recovery was
                                                                   uneventful in 98 patients. 71 patients were admitted to
INTRODUCTION: Daycase surgery at our hospital is performed         specialty specific inpatient wards with 24 overnight
in a dedicated day surgery centre, Channel Day Surgery Centre      admissions. 35 patients were admitted to the CDSC
(CDSC), and the hospital inpatient theatres. The ASA grade and     postrecovery ward with no overnight admissions.
complexity of procedure are similar for patients in both           10 (22.7%)overnight admissions were in ENT, 9 (24.3%)
facilities. Following surgery in inpatient theatres, patients      surgery, 4 (50%) orthopaedics and 1 (5.9%) gynaecology.
proceed to a postrecovery facility either in the inpatient wards   Reasons for overnight admission were 7 (29.2%) surgical,
or the CDSC postrecovery ward. Unplanned overnight                 6 (25%) anaesthetic, 3 (12.5%) medical, 5 (20.8%) late finish,
admission rates are perceived to be different between both         3 (12.5%) unclear and 0 social.
facilities. We performed an audit to compare the overnight         CONCLUSIONS: The unplanned overnight admission rate was
admission rate for daycase surgery performed in inpatient          higher than the audit standard and CDSC rate supporting
theatres to the consensus standard of 2%1,2 and the CDSC rate      observations that post-recovery facilities affect this. Two
of 1.1% and identify contributing factors.                         models of post-recovery care support day surgery discharge in
METHODS: This prospective questionnaire based audit was            inpatient wards. One is the presence of a dedicated ‘daycase’
performed from 30th January to 13th February 2008. Daycase         bay on the ward. The gynaecology ward has adopted this model
surgery patients operated on in inpatient theatres were            and had the lowest specialty specific admission rate. Another
followed up using the questionnaire and information obtained       option is the presence of a dedicated ‘day surgery’ team on the
on patients’ demographics, surgery, anaesthetic, recovery and      ward to support the discharge of suitable patients.
postrecovery period.                                               REFERENCES
RESULTS: The audit population comprised 106 patients with 24       1. Healthcare Commission. Acute Hospital Portfolio Review:
overnight admissions and an unplanned overnight admission             Day Surgery, 2005
rate of 22.6%. CDSC had a throughput of 326 patients with an
unplanned overnight admission rate of 1.1%. 50 patients were       2. Association of Anaesthetists of Great Britain & Ireland. Day
male and 56 female. 16 patients were aged 0–16 years, 70 aged         Surgery, 2005
         Should Day Surgery be Performed in a                       Both primary and secondary outcome measures were
 A19     Dedicated Unit? Comparison of                              significantly better in the DSU. However for the SU there was a
                                                                    great improvement in admission rates compared with previous
         outcomes from two different facilities                     levels of 17% when inpatient wards were used. Most
         CM Matthews, ME Stocker                                    admissions from SU were due to process problems; such as
                                                                    having had inpatient preassessment or last minute changes
         South Devon Healthcare NHS Foundation Trust                from inpatient to daycase, whereas those from the DSU were
INTRODUCTION: Our trust has a very successful day surgery           due to clinical need. The balance of procedures carried out in
unit (DSU) but demand now exceeds capacity and some                 both units were very similar and do not account for these
daycases have been treated through inpatient wards with             differences.
haphazard clinical processes resulting in high admission rates.     CONCLUSIONS: There was a huge improvement in day surgery
We have now opened a “satellite day surgery ward” (SU) in the       outcomes from the SU, compared to our previous
main hospital, run using the successful clinical processes          arrangements. This is attributable to implementation of
established in DSU. Other hospitals in our region have              established processes from our DSU, ensuring nursing staff
abandoned dedicated DSUs in favour of treating daycases             have responsibilities to daycase patients only and bringing the
through main theatres and we wished to compare outcomes of          SU under the management of the DSU. Despite the streamlined
the two processes in a single trust.                                process, the outcomes still do not equate to those of our DSU
METHODS: The SU was opened on a segregated bay of a main            and admission rates remain above recommended standards1.
hospital ward in January 2008. The processes were                   Our secondary outcomes are all within the national guideline
standardised according to our local best practice. Outcomes for     limits2. Other DGHs in our region have abandoned dedicated
both DSU and SU were collected over a 3 month period on our         DSUs in favour of daycases through main theatres. We have
Daynamics computer system. Our primary outcome measure              shown that even if day surgery unit processes are used, neither
was unplanned admissions; secondary measures were pain              admissions rates nor other outcomes are as good as those
and nausea scores and patient satisfaction from telephone           through a dedicated DSU. We feel this is powerful evidence for
calls at 24 hours.                                                  such a unit.
RESULTS:                                                            REFERENCES
                             SU       DSU     p value               1. Stocker ME. Raising the Standards: A compendium of audit
 Total patient numbers       285      1842                             recipes 2006;5.6: 116–7
 Admission rates             3.10%    1.53%   0.049                 2. Jackson I, et al. Raising the Standards: A compendium of
 Minimal or no pain          86.20%   97.60% <0.001
                                                                       audit recipes 2006;5.3: 110–1
 Minimal or no nausea        98.90%   100%    0.002
 Good patient satisfaction   98.50%   99.7%   0.03
 Satisfaction as daycase     99.50%   100%    0.03




          Training Tomorrow’s Anaesthetists as                      module as described by the College [1]. Modules are 3 months
A20       Day Surgery Champions                                     long, during this time trainees have at least 20 teaching
                                                                    sessions. Where possible service lists are also be undertaken
          A Myburgh, ME Stocker                                     within the day surgery unit. Trainees are expected to take
          South Devon Healthcare NHS Foundation Trust               responsibility for their own education and to ensure that their
                                                                    training allocations cover all the sessions required to achieve
INTRODUCTION: The NHS Plan predicts 75% of elective                 the necessary competencies and learning opportunities during
operations will be carried out as daycases. To achieve this, day    their time in our unit. Training in anaesthesia for day surgery is
surgery needs to be driven by experienced and enthusiastic          a core part of the module; however other aspects such as
clinicians, however formal day surgery training programmes for      preassessment, patient preparation, recovery and discharge
anaesthetic and surgical trainees are rare. The Royal College of    criteria, audit and follow up also comprise a large part of the
Anaesthetists stipulate that trainees complete intermediate         training. They learn the importance of a good day surgery
and advanced training modules in day surgery within a               process to successful patient outcomes and attend weekly
dedicated day surgery unit. Training in day surgery is              meetings of the unit’s management team. Resources available
recognised as receiving low priority in some centres1 and           to trainees include protocols and evidence of local and national
highlighted as a module where the training provided should be       best practice.
regularly audited against College recommended standards. The
Day Surgery Unit in Torbay is one of a few units within the         RESULTS: To date 3 trainees have completed this module. All
southwest equipped to provide this core module of anaesthetic       have achieved all the competencies required, and have
training. Furthermore, as one of the nationally leading units for   provided excellent feedback regarding the module structure.
day surgery, we offer a wealth of clinical, teaching and            CONCLUSIONS: We believe that formal day surgery training
managerial experience. In 2006 we established a Special Study       modules are rare and that without them the processes which
Unit for medical students aiming to help students begin their       underpin successful day surgery outcomes are failing to be
journey towards day surgery practitioners of the future2. It is     understood. We recommend our approach to day surgery
with the success of this module behind us that we have built        training to other units and soon hope to develop a similar
upon our experience to develop a training module for                module for our surgical colleagues.
anaesthetic trainees.                                               REFERENCES
METHODS: The module is specifically designed to target              1. Rowe L, Raising the Standards: A compendium of audit
training towards the competencies stipulated in the training           recipes 2006;14.6:313
documents produced by the Royal College of Anaesthetists. It
also aims to meet the audit criteria required for a training        2. Appelboam R, et al. Journal of One-day surgery 2008;18:19–21
         Daycase Surgery Training for Surgical                       year 1 and 36 trainees (45%) at speciality trainee year 2.
A21      Trainees: A disappearing act ?                              Trainees were from a variety of surgical specialities: general
                                                                     surgery (n=34), orthopaedics (n=27), urology (n=8), ear nose
         N Siddiqi, V Paringe, B Kumar, J Ahmad,                     & throat (n=7), vascular surgery (n=3), thoracic surgery (n=2).
         M Hemadri, PJ Moore                                         None of the trainees stated that daycase surgery is part of their
         Scunthorpe General Hospital                                 formal surgical training timetable. However, 83% of trainees
                                                                     (n=66) stated that they made an effort to attend a daycase
INTRODUCTION: Daycase surgery is an evolving discipline              surgery list per week. Of these trainees 95% (n=63) felt that
within all branches of surgery. Surgical training is undergoing      they did not receive an adequate level of supervision during
rapid changes with the advent of modernising medical careers         daycase surgery lists. The level of satisfaction amongst trainees
and the Intercollegiate Surgical Curriculum Project (ISCP).          towards daycase surgery training was poor with 67 trainees
Furthermore trainees must fulfil a requirement for certain           (84%) expressing dissatisfaction. All 80 trainees (100%) felt
number of index procedures to be learnt in the face of reduced       that daycase surgery should be part of formal surgical training
exposure due to European Working Time Directive. The purpose         through the ISCP.
of this study is to determine the exposure of junior surgical
trainees to daycase surgery throughout the UK.                       CONCLUSIONS: This study shows a significant level of
                                                                     dissatisfaction amongst surgical trainees towards the level of
METHODS: A questionnaire survey was conducted amongst                exposure and quality of daycase surgical training. Furthermore
surgical trainees from twelve NHS trusts in the UK, consisting of    all participants felt that daycase surgery training should be
8 questions on the level of their involvement in daycase surgery     protected and formalised as part of the ISCP.
and an area of free text allow trainees to voice concerns or
issues.
RESULTS: Surveys were completed by 80 surgical trainees: 33
(41%) trainees from district general hospitals and 47 (59%)
trainees from teaching hospitals. 13 trainees (16%) were at
foundation year 2 level, 31 trainees (39%) at speciality trainee



         Implementation of a Simplified                              RESULTS: The clinician’s compliance in the control group was
A22      Version of NICE Guidelines Improves                         38.1 %( 78/126) which improved to 62.6% (94/150) in the study
                                                                     group. (p<0.001, Chi-square test). The number of patients who
         Clinical Compliance                                         were over investigated decreased from 49.2% in the control
         D Ail, K Shoukrey, D O’Hare                                 group to 26.6% in the study group. (p<0.05, Chi- square
         QEH Kings Lynn                                              test).The number of patients who were under investigated
                                                                     reduced from 12.6% to 12 % but this was not statistically
INTRODUCTION: Preoperative investigations are often based            significant.
on local guidelines or personal choice of individual clinicians.
In June 2003, the National Institute of Clinical Excellence (NICE)                                Controls          Study group
issued a guideline on the use of routine preoperative tests in       Total patients                 126                 150
patients undergoing elective surgery1. These guidelines are          Compliance with NICE       48 (38.1%)           94 (62.7%)
exhaustive but not user friendly. We decided to investigate if a
                                                                     Noncompliant with NICE     78 (61.9%)           56 (36.3%)
simplified version of the guidelines would improve clinician’s
                                                                     No over-investigated       62 (49.2%)           40 (26.6%)
compliance when ordering preoperative tests.
                                                                     No under-investigated       16 (12.6%)          16 (10.6%)
METHODS: The recommendations given by NICE were
simplified into 4 simple charts (Intervention) and these were
made available in the preassessment clinics. Data collected          CONCLUSIONS: The simplified version of the NICE guidelines
during a 2 week period before the intervention (Control              tables improved clinician’s compliance in the practise of
Group)was compared with a similar 2 week period after                ordering preoperative tests for elective surgery. It also reduced
intervention(Study Group).Data collected included the patient’s      the rate of over investigations although the rate of under
age, ASA status (including major comorbidities as appropriate)       investigations was not reduced.
and the nature of surgery in inpatients and day surgery patients     REFERENCES
presenting for elective surgery. The clinician’s compliance when     1. NCCAC. Preoperative Tests, The Use of Routine Preoperative
ordering these investigations as per the NICE guidelines was            Tests for Elective Surgery — Evidence, Methods and
evaluated.                                                              Guidance. London: NICE, 2003
         Venous Thromboembolism                                      Patients with one risk factor receive graduated compression
A23      Prophylaxis in Day Surgery                                  stockings; those with more than one risk factor received the
                                                                     stockings and low molecular weight heparin one hour before
         RE Blackshaw, ML Alderson                                   surgery. 71/80 (89%) patients were assessed on their need for
         South Devon NHS Foundation Healthcare Trust                 VTE prophylaxis according to our guidelines. 30/80 (45%) of
                                                                     patients were eligible for graduated compression stockings.
INTRODUCTION: NICE produced guidelines on reducing the               Two patients required LMWH. This would represent an annual
risk of venous thromboembolism (VTE) for surgical inpatients in      cost for compression stockings in our unit £6411.60. Since the
April 2007 1. There are currently no similar national guidelines     pilot, a patient group directive allowing nurse prescribing and
in day surgery 2. As increasingly complex procedures are             administration of LMWH has been approved. Training to enable
performed on a day stay basis, having robust guidelines for the      nurses to assess and counsel patients at risk of VTE is
prevention of VTE is imperative in safeguarding high standards       underway and a patient leaflet with information on venous
of care. This article describes the initiation, introduction and     thromboembolism produced.
management of VTE guidelines in our day surgery unit.
                                                                     CONCLUSIONS: There are no national guidelines for VTE
METHODS: Development of the guidelines occurred in three             prophylaxis in day surgery. Increasingly complex procedures
phases: evaluating the NICE guidelines and performing a              are performed as daycases. We recognised the need to formally
literature search to assess current best evidence for VTE            assess and give appropriate prophylaxis in this patient group.
prophylaxis in day surgery; liaising with clinicians involved to     After gaining expert opinion from clinicians and using current
obtain a consensus of expert opinion; producing and piloting         best evidence from a literature search, we developed and
guidelines in our day surgery unit. In the pilot, all patients       piloted guidelines in the day surgery unit. Day surgery nursing
having day surgery over a one week period were assessed and          staff assess all patients for risk factors, giving both verbal and
given VTE prophylaxis according to the guidelines. Some              written information on VTE at preadmission. Appropriate VTE
adjustments were made to the guidelines following this.              prophylaxis is given when the patients are admitted for day
RESULTS: Risk factors were identified as follows: Patient            surgery. We recommend this format to other day surgery units.
factors: Age >60 years; Obesity (BMI >30); History of DVT/PE;        REFERENCES
Combined Oral contraceptive pill / HRT; Inflammatory bowel
disease; Active malignancy; Thrombophilia; Post partum (<6           1. National Institute for Health and Clinical Excellence. Venous
weeks);Prolonged immobility/recent travel. Surgical Factors:            thromboembolism. April 2007
Major Laparoscopic procedure; Varicose veins; Prolonged              2. Smith I. Journal of One day Surgery: 2007;17:2–3
surgery (>60 minutes); Foot or ankle surgery; Knee
arthroscopy; Shoulder surgery




         Our Experience of Setting up a Day                          soft tissue, removal of foreign body, arthroscopy and
A24      Surgery Trauma List in an NHS                               menisectomy, or repair lateral tendons, tendon repair,
                                                                     aspiration of joint, excision of ganglion. Patients had either GA,
         Hospital                                                    regional anaesthetic only or with sedation. 3–4 patients are
         J Payne; C Davies                                           operated on each session. Our unplanned overnight stay is 4%.
                                                                     The main reason for staying overnight was inadequate pain
         William Harvey Hospital Ashford
                                                                     relief within first hour postop. Patients were consequently
INTRODUCTION: Prioritisation of major trauma patients often          given morphine which reduced their ability to ambulate
results in delay of a day or two before patients with minor          effectively. Patients who needed to see a physiotherapist
trauma get to theatre. The word trauma means “Physical               attended the nearest department to their homes. During the
Injury”. “Daycase” refers to a patient admitted and discharged       first few weeks the list ran efficiently, until one member of the
same day 1,2. Consequently, the expression “Daycase Trauma           DSTIG went on annual leave and the person acting up was not
List” aptly describes our Tuesday pm orthopaedic list. For over      as enthusiastic. So the pathways were rigorously redesigned
a year trauma patients have had surgery on a daycase bases in        and the project reported weekly to the Trust’s Theatre
Channel Day Surgery Centre. This presentation describes our          Productivity Broad.
experience.                                                          Other problems encountered and solutions were: 1) Equipment
METHODS: A Day Surgery Trauma Implementation Group                   resources: Liaison with the operating surgeon is vital to ensure
(DSTIG) was formed; members were theatre sister, orthopaedic         that all equipment is available for the pm list.
matron, surgeon, anaesthetist and a manager. A patient care          2) Communication between the teams: this was resolved by
pathway was developed, which commenced with presentation             having a Tuesday am preop meeting. 3) Communication with
of the patient at any of the following: A&E, GP referral, fracture   patients carers: Leaflets and a designated Link nurse.
clinic and orthopaedic outpatients. All patients eventually          4) Obtaining a bed for unplanned overnight stay: persistence
joined the day surgery patients care pathway for the rest of         CONCLUSIONS: The Day Surgery Trauma list has saved several
their treatment. It was vital to develop a communication             bed days. It has enhanced multidisciplinary working with A&E,
pathway to ensure that patients arrived on day of surgery            fracture clinics, GPS, orthopaedic surgery and the day surgery
adequately prepared. All the various healthcare groups               centre. It is safe and an effective use of resources. Patients like
communicated timely and effectively. Patients are contacted          it.
the day prior to surgery to confirm attendance and reiterate any
fasting details.                                                     REFERENCES
RESULTS: The types of orthopaedic procedures suitable were:          1. Cooke T, et al. Achieving day surgery targets. London:
removal of metalwork, open reduction of fracture and internal            Advance Medical Publications, 2004
fixation, manipulation under anaesthetic of joint, debridement       2. Darzi A, Day Surgery Operational Guide 2002
          Audit of Trauma Case Load Suitable for                         RESULTS: A total of 41 day surgery trauma cases were
A25       a Day Surgery Trauma List and Cost                             performed in the 4 month study (57% were male and 43% were
                                                                         female, mean age of 37 years and age range 8–95 years). Upper
          Analysis                                                       limb procedures accounted for 59% (24/41) of those
          T Colegate-Stone, C Roslee, A                                  performed. An average of 3 cases were completed per list
          Tavakkolizadeh, D Simon, J Sinha                               (range of 1–5 cases). There were 5 recorded complications
          King’s College Hospital                                        (1 patient did not attend and 4 were cancelled due to overrun).
                                                                         The average day surgery tariff charge was £1354 whilst for
INTRODUCTION: Day surgery trauma lists are becoming an                   inpatient surgery it was £1069. However the average procedural
increasingly popular and widespread approach to address the              cost for daycase trauma surgery was £149 compared to £611 as
inpatient trauma demand on NHS services. Daycase surgery                 an inpatient.
has widely accepted economic and patient related advantages.
                                                                         CONCLUSIONS: A wide variety of fracture fixation and soft
We have recently implemented such a list on a weekly basis at
                                                                         tissue procedures were successfully completed as day surgery
our day surgery unit. The aim of this study was to perform a
                                                                         trauma. On financial review, the cost benefits of day surgery
prospective audit of the cases undertaken on the day surgery
                                                                         trauma include the lower average cost per procedure (£462)
trauma list over a 4 month period and analyse the potential
                                                                         compared to that of inpatient trauma alongside the higher
related cost benefits of this approach.
                                                                         average tariff it generates (£285). Therefore the average cost
METHODS: We performed a prospective audit of the trauma                  benefit per day surgery procedure in our unit is £747. Day
workload done in the day surgery setting. Further analysis was           surgery trauma also potentially frees up more inpatient beds
performed with respect to: the spectrum of procedures                    for true elective procedures with the subsequent tariffs that
performed on day surgery trauma lists; complications noted               these procedures may generate. Further it aids patient access
and the costs for these procedures as daycase trauma surgery             to definitive health care events and potentially improves the
compared to the cost for inpatient trauma surgery. The specific          experience of health care for the patient.
tariff charges for the procedures and the actual procedural
costs, both as daycase and inpatient events, were calculated
from the respective tariffs codes for them.




          A National Audit of Daycase Paediatric                         RESULTS: Postal questionnaires were sent to 135 practicing
A26       Foot and Ankle Surgery                                         consultants with 87 (64%) replies over 3 months. The survey
                                                                         revealed that certain procedures were being performed as a
          N Jagodzinski, R Begum, S Khanum, H Prem                       daycase in fewer than 35% of centres in the UK. These included
          Birmingham Children’s Hospital                                 excision of tarsal coalitions, tendon transfers, metatarsal
                                                                         osteotomies and posterior and posteriomedial releases for
INTRODUCTION: Nearly all foot and ankle surgery performed                clubfoot. These same procedures are performed routinely as
at Birmingham Children’s Hospital is done as a daycase.                  daycases at Birmingham Children’s Hospital.
Although it is widely practiced in adults, it is still not the case in
children. Our aims were to compare our practice with other               We identified 24 “major operations” on 19 patients that were
hospitals in the UK and to identify any shortcomings in our              performed as a daycase in 21 months at Birmingham Children’s
service provision. Our hypothesis is that most foot and ankle            Hospital. We focussed on a single surgeon series with a once
surgery is safe and appropriate to be performed in children as a         weekly afternoon operating list. We contacted the parents of
daycase, even on an afternoon list.                                      these patients by telephone and we completed a satisfaction
                                                                         survey for each. We demonstrate that there were no problems
METHODS: A postal questionnaire was sent to all consultant               that should have warranted an inpatient stay.
members of the British Society of Children’s Orthopaedic
Surgery to identify which operations were being performed as             CONCLUSIONS: Most paediatric foot and ankle surgery can be
inpatients (“Major surgery”) and daycases (“Minor surgery”).             performed satisfactorily as a daycase which has obvious cost
We then identified all patients who had “major surgery” as a             implications for the NHS. Although this is an accepted practice
daycase at Birmingham Children’s Hospital over a 21 month                among adults, the majority of paediatric orthopaedic units are
period. We then conducted a retrospective telephone                      yet to accept this protocol.
satisfaction survey of these patients and reviewed their case
notes to assess our service provision.
         An Audited Review of Contemporary                         RESULTS: FHSQ foot pain scores improved for 774 (89.5%)
 A27     Daycase Foot Surgery                                      patients; Foot function improved for 653 (75.5%) patients;
                                                                   Shoe scores improved for 531 (61.39%) patients; foot health
         SA Metcalfe, M Hutchby, A Maher, N Taylor                 improved for 632 (73.06%)patients; general health improved
         Solihull CT                                               for 349 (40.35%) patients; Physical activity improved for 523
                                                                   (60.46%) patients; Social capacity improved for 406 (46.94%)
INTRODUCTION: Daycase elective foot surgery with the               patients; Vigour improved or 409 (47.28%)patients. FHSQ
assistance of local anaesthesia offers an alternative to           minimal important difference scores were achieved for foot
traditional inpatient treatment with the added benefits of         pain in 658 patients (76.1%); foot function in 575 patients
reduced bed occupancy reduced costs & improved efficiency.         (66.5%); and general foot health in 612 (70.75%) patients.
Daycase foot surgery is typically associated with low
complication rates and high levels of patient satisfaction. This   CONCLUSIONS: This review concludes the daycase foot
review presents the results of 865 consecutive daycase foot        surgery is a safe & effective treatment option with very low
surgery procedures.                                                complication rates & high levels of patient satisfaction.

METHODS: All cases were fully audited using the Foot Health        REFERENCES
Status Questionnaire (FHSQ)1, which is an independently            1. Bennett, PJ, et al. The Australasian Journal of Podiatric
validated audit tool. Additionally the FHSQ scores in three            Medicine 1998;32:55–9
domains were evaluated for Minimally Important Differences2.
                                                                   2. Landorf KL, et al. The Foot, 2007
FHSQ data is collected preoperatively and postoperatively at 12
and 24 weeks. Data was also collected for perioperative &
postoperative sequalae, unplanned admissions, postoperative
infections & revision surgery.




         Stapled haemorrhoidectomy: A                              minutes with an average of 24 minutes. There were no major
A28      Daycase Procedure of Choice for                           complications although the majority of patients warranted
                                                                   oversewing of bleeding points around the staple line after the
         Symptomatic Haemorrhoids                                  stapling procedure. 11% (n=7) of patients were discharged the
         AA Riaz, A Patel, A Singh, JI Livingstone                 same day and 88% (n=58) had overnight stay. At routine
                                                                   follow-up at 1 month, nine patients (14%) had had minor
         Watford General Hospital                                  degrees of faecal urgency, frequency and soiling rectal
INTRODUCTION: Since Longo first described it in 1998, Stapled      bleeding, all of which subsequently resolved. A third of the
Haemorrhoidectomy (SH) has been emerging as the procedure          patients did not require analgesia after discharge and further
of choice for symptomatic haemorrhoids1. Several studies have      44% (n=29) needed just diclofenac. Nearly 50% had complete
shown it to be a safe, effective and relative complication free    resolution of symptoms and returned to work within a week.
procedure2. In 2001 the Audit Commission included                  The satisfaction data showed that 90% of patients were
Haemorrhoidectomy as one of its 25 procedures suitable for         completely satisfied with the procedure at initial follow-up,
Day Surgery. Since then, studies have suggested that SH may        which increased to 98% after 6 months–4 years follow-up.
also be safely performed as a daycase procedure. Patients          CONCLUSIONS: Our present study shows that SH is a safe and
following SH had reduced, postoperative pain, hospital stay,       very well tolerated procedure with low postoperative analgesic
analgesic requirements and earlier return to work3. The aim of     requirements, high patient satisfaction and early return to
this study was to determine the suitability of SH as a daycase     work. The majority of patients could avoid an overnight stay
procedure at a District General Hospital.                          which would make this procedure suitable for day surgery. With
METHODS: From June 2001 to May 2005, 66 patients who               careful patient selection, daycase stapled haemorroidectomy is
underwent SH were included in this study. It was routine           certainly feasible and we have now adopted this as our
practice that SH was performed by one dedicated surgical           technique of choice for haemorrhoidal disease.
team. Patients were discharged when comfortable. Parameters        REFERENCES
recorded included postoperative complications, analgesic           1. Longo A. 6th World Congress of Endoscopic Surgery.
requirements, cost effectiveness, duration of hospital stay and       Mundozzi Editore: Naples, 1998;777–84
patient satisfaction. Follow-up was performed at 4 weeks with
a further telephone follow-up up to 4 years after. Analysis was    2. Shalaby R, et al. British Journal of Surgery 2001;88:1049–53
performed using the Mann-U test. Multivariate analysis of the      3. Beattie GC, et al. Colorectal Disease 2006;8:56–61
means was performed using the Krushal-Wallis Test.
RESULTS: Of the 66 patients that underwent SH 43 (65%) were
male and 23 (35%) were female. The mean age was 49.8 years
(range 16–78 years). The operating time ranged between 15–40
         Laser Seal Haemorrhoidectomy:                              stay over 24 hours due to postoperative bleeding resolved
A29      Effective ambulatory                                       without intervention. Readmission rate was 6.6% (n=4) with
                                                                    2 patients admitted for anal oedema and 2 patients admitted
         haemorrhoidectomy with immediate                           for oedema and pain; all discharged after observation and
         discharge and good outcomes.                               reassurance. Common complications encountered where
         M Hemadri, V Paringe, N Siddiqui, PJ Moore                 chronic anal fissures 6.6% (4/60) of which 3.3 (2/60) healed
                                                                    with management by 0.4% glyceryl trinitrate topical cream for
         Goole and District Hospital                                6 weeks. 3.3% (2/60) encountered proctalgia due to non
INTRODUCTION: Laser Seal haemorrhoidectomy (Diomed 810              healing fissures currently under treatment.
nm at 20 watts) is turning out to be reliable procedure             CONCLUSIONS: Our experience demonstrates that Laser Seal
impacting immediate postoperative and medium term outcome           technique provides a good outcome and in skilled hands would
measured on various parameters. As opposed to previously            give good results with minimal ano rectal anatomical and
described laser dissection and vaporisation we advocate the         physiological alteration while enhancing patient experience of
Laser Seal technique under local anaesthesia with documented        haemorrhoidectomy. We are almost able to guarantee that all
good outcome.                                                       our haemorrhoidectomies can be performed as daycases which
METHODS: Retrospective data analysis of duration spanning a         is a major shift from the published results. We are almost able
2 year period of laser seal haemorrhoidectomy performed at a        to guarantee that all our haemorrhoidectomies can be
single centre.                                                      performed under local anaesthetic and conscious sedation
                                                                    which is again a major shift from the published results. Cost
RESULTS: Retrospective analysis yielded sixty patients (n= 60)
                                                                    benefit analysis of the procedure would reflect the economical
with a male: female ratio of 31:29 with age range of 32–81
                                                                    impact of the procedure.
years. 98.3% where performed under local anaesthesia and
sedation while 1.6% (1/60) needed general anaesthesia. The
rates of hospital discharge were 95% less than 2 hours with
1.6% (n=1) needing hospital stay over 2 hours but less than 24
hours due to the use of general anaesthesia and 1.6% having to




         What can Daycase Surgery Contribute                        have assumed 4 visits by the patient to the hospital as typical
A30      to the Economy? Driving down the cost                      of the conventional model. We have not allowed for the
                                                                    following: a) Indicated follow ups; b) Patient requested follow
         of daycase surgery using the single                        ups; c) Readmission (our readmission rate does not vary greatly
         visit approach: An estimated costs                         from published figures).
         calculation                                                RESULTS: Secondary care saves £544.40 per patient compared
         M. Hemadri, P. J. Moore                                    to the conventional model. This is afforded as a result of no
                                                                    separate out patient consultation (£113), no separate
         Goole and District Hospital
                                                                    preassessment (£15), administration costs (£341.40)
INTRODUCTION: We are using our Single Visit model for               (calculated as groin hernia tariff £1138 minus 30%). The
suitable daycase and short stay general surgical patients. Using    primary care trust saves £75 per patient as a result of the no
publicly available data we calculate estimated savings afforded     routine follow up policy. The savings to patients in our area on
by using this model for the primary care trusts, secondary care     the basis of fuel costs alone are £13.26 (average one way
trusts and patients. In the conventional model, patients go         mileage of 17 miles and return of 34 miles at the rate of £0.13
through OPD, Preassessment, Admission and Follow up. In the         per mile on Single Visit compared to an average 4 the
Single Visit Model, they pay a single visit to secondary care for   conventional model). The savings to the English NHS patient
all the processes needed for daycase surgery.                       would be £8.19 (average 21 miles). We project our foundation
                                                                    trust could save £938000 by the use of the Single Visit model
METHODS: We have used the following publicly available data:
                                                                    (at 2000 patients). Our area PCTs could save £150000. The NHS
a) DOH HRG based tariffs; b) ESRC’s distance travelled in
                                                                    in England could save a minimum of £871,040,000 (at
England for NHS treatment document; c) DOH data on number
                                                                    1.6million Single Visit users). English NHS users savings on
of daycases in the NHS; d) HMRC guidance on fuel cost
                                                                    travel costs £17,472,000.
reimbursement calculation. We have used a figure of 30%
which our foundation trust currently uses to top slice when         CONCLUSIONS: The capacity sparing effect, savings to the
calculating savings derived from administrative costs. We have      patient in terms of lost wages, relatives visiting, additional
made the following assumptions: a) Savings on administrative        family arrangements, overall carbon foot print are not included
cost has been calculated on the basis of groin hernia repair        in this presentation. We believe that our Single Visit model
tariff as we see that as a notional average typical of day          could lead to very large financial savings for the NHS, patients
surgery; b) Approximately 50% of all daycase patients will be       and the economy in general. Thus the daycase surgeons could
suitable for the one stop model; c) Our trust has the same          contribute very significantly to the economy.
daycase proportions as the national population; d) Private
petrol small car transportation is assumed as typical; e) We
         Does the 18 week Wait Pressurise                            following an outpatient consultation with a surgeon (90%) or
A31      Patients’ Decisions about Day Surgery?                      directly booked from GP referral (10%; mainly hernias, lumps
                                                                     and bumps). Both groups waited a mean of 7 weeks from
         J Machin, H Jones, J Johnson, C Shaw,                       decision to treat to date of surgery (STT). 94% of patients had a
         CL Ingham Clark                                             referral to treatment time (RTT) of under 18 weeks. 87%
         The Whittington Hospital NHS Trust                          patients accepted the first date offered for surgery, usually
                                                                     saying that their health was important and took priority. The
INTRODUCTION: The 18 week referral to treatment target was           reasons for others not accepting the first date are given in the
a product of the 2004 NHS Improvement Plan that aims to              Table.
ensure that all patients receive quality care with no
unnecessary delays. There has been considerable pressure on            Reason for deferring surgery                  number
hospital trusts to achieve the target. Some have achieved it, but      Work                                            13
it is unknown whether this may have created a rushed and               Family commitments                              10
pressurised atmosphere, affecting patient satisfaction. The aim        Booked holidays                                  4
of this study was to canvass day surgery patients’ opinions on         Time to think                                    2
their waiting times from referral to treatment.                        Time to talk to GP                               2
                                                                       Other                                            1
METHODS: Patients attending a single DSU over a 4 week                 Total                                           26
period in early 2008 were later contacted by telephone and
interviewed by a person independent of their clinical care,          Only 11% of patients said that they felt pressured into accepting
using a standardised questionnaire. Patients were asked how          the first date offered for surgery. Some questioned whether
long they had waited between referral and treatment (RTT), and       they were getting NHS or private care, given the speed of
between agreeing with a doctor that they wanted surgery and          booking.
treatment (STT). They were asked if they had accepted the first      CONCLUSIONS: The vast majority of patients are happy with
date offered or had chosen a later date, and if so, why. They        being offered an early date for surgery, consistent with the aim
were also asked whether they had felt under pressure to accept       of the 18 week target. Better communication with the public
the first date offered.                                              may help understanding that NHS treatment will now usually
RESULTS: Of 399 adult patients treated in the DSU between            be offered in a very short timescale from referral.
11/2/08 and 8/3/08 205 (57%) were successfully contacted
and completed the questionnaire. Their ages ranged from
16–95 (mean 51). Patients were either booked for day surgery




         What is the Optimal Daycase List                            patients can generate =£6510–£7730. For this the surgical and
A32      under the National Tariff?                                  anaesthetic costs are minimal. Conversely 2–3 laparoscopic
                                                                     cholecystectomies can only generate £3674–£5511. Patients
         M Puttick, M Zilvetti, D McWhinnie                          having this operation are more likely to need a bed for an
         Milton Keynes General Hospital                              overnight stay and these figures do not take into account the
                                                                     increased operating costs due to the equipment and
INTRODUCTION: The introduction of Payment by Results (PBR)           disposables used.
and the national tariff means that there is a fixed fee for
procedures. Often these fees bear little or no resemblance to        CONCLUSIONS: Giving some thought to the make up of a list
the actual cost of the operation. Trusts and surgeons are under      can optimise income stream for the trust. A direct access lumps
increasing pressure to utilise operating time efficiently and this   and bumps list is economically viable under the national tariff.
includes economic constraints as well as meeting waiting list        While performing laparoscopic cholecystectomy as a daycase is
targets.                                                             good for patients, economically it is not the best use of a
                                                                     dedicated daycase list. Other more simple procedures such as
METHODS: We present economic modelling of a hypothetical,            inguinal hernia repair and lumps and bumps excision can use
half day, daycase operating list and examine how altering the        the list more effectively, particularly if a direct access system is
make up of that list can optimise income to the trust.               used without a prior visit to outpatients.
RESULTS: A list or 4–5 hernias can generate an income of
£5135–£7690. A direct access lumps and bumps list of 8–10
         Daycase Local Anaesthetic Inguinal                                                  23h GA           DC GA        DC LA
A33      Hernia Repair makes Economic Sense                          Op clinic                £100            £100        Direct £0
                                                                     Preassessment            £100            £100        Online £10
         M Puttick, M Zilvetti, D McWhinnie                          Anaesthetic             GA £25          GA £25         LA £10
         Milton Keynes Hospital NHS Foundation Trust                 Anaesthetist        Cons & ODP £100 Cons & ODP £100   No £0
                                                                     Mesh                      £50             £50           £50
INTRODUCTION: The introduction of Payment by Results (PBR)           Bed                    Inpt £236       DSU £100      DSU £100
                                                                     Consumables              £50             £50            £50
and the national tariff means that there is a fixed fee for          Theatre time         45 min £288     45 min £288    50 min £320
procedures. Often these fees bear little or no resemblance to        Total                    £949            £813          £540
the actual cost of the operation. We present economic                Income                   £1080           £1080         £1243
                                                                     Margin                    £131           £267           £703
modelling of a hernia repair to demonstrate cost effectiveness
in surgery.                                                          CONCLUSIONS: The costs of performing a daycase local
METHODS: We aimed to develop an economic model for                   anaesthetic hernia repair as part of a direct access programme
elective hernia repair, incorporating all the costs and discuss      are significantly lower than those of traditional pathways.
how costs may be minimised while maintaining quality and             These costs are well below the income from the national tariff.
meeting targets. This was incorporated into a direct access          Daycase LA hernia repair is cost-effective and profitable.
hernia programme and the economic breakdown presented.
The component parts addressed were clinic fee,
preassessment, type of bed, theatre time, consumables &
diathermy, mesh, sutures and anaesthetic
RESULTS: This Table illustrates the component costs of the
patient pathway through a hernia repair under GA or local
anaesthesia, inpatient or daycase stay




         Why are Patients with Primary                               overnight as a result. A further 11 patients (20.3%) were
A34      Inguinal Hernias being Excluded from                        excluded from day surgery for no discernible reason. The
                                                                     remaining patients were accommodated on inpatient lists
         the Benefits of Day Surgery?                                because no day surgery lists were available, 8(14.9%) or
         JCY Leong, JR Nash                                          because of cardiovascular comorbidity, 7(13%), respiratory
                                                                     comorbidity, 4(7.4%), lack of home help, 2(3.8%), surgical
         Derby Hospitals NHS Foundation Trust
                                                                     comorbidity, 1(1.9%) or size of hernia, 1(1.9%). The reasons for
INTRODUCTION: Current recommended practice is for the                6 patients (11.1%) were undetermined due to missing case
majority of primary inguinal hernia repairs to be done as day        notes.
surgery; 95% according to current guidelines in the BADS
                                                                     CONCLUSIONS: In Derby, the treatment of primary unilateral
directory of procedures1. Obstacles to day surgery have been
                                                                     inguinal hernia as day surgery is only half the 95% achievable
identified as including pre-existing medical conditions, surgical
                                                                     by the best. The commonest reason for failure is not the
factors, social factors and clerical errors2. In Derby, the
                                                                     patient’s health. The reasons are related to facilities and
proportion of inguinal hernia repairs performed as day surgery
                                                                     administration. There were health reasons given for preventing
has stood at 50% for some years. The aim of this audit was to
                                                                     day surgery but with greater experience and confidence of the
explore the reasons for such a low daycase rate.
                                                                     surgeons, some of these patients could avoid hospital
METHODS: A retrospective audit was undertaken of all elective        admission. Day surgery rates will only be optimised in surgical
unilateral primary inguinal hernia repairs being performed           units which invest in all aspects of day surgery – facilities and
across the trust during the two month period of September and        administration as well as dedicated anaesthetists and
October 2007. The notes of those patients operated on                surgeons.
inpatient lists were retrieved and reviewed in order to ascertain
                                                                     REFERENCES
the indications for exclusion from day surgery. If the indications
were unclear, a brief questionnaire along with the patient’s         1. British Association of Day Surgery. BADS Directory of
notes was sent to the consultant surgeon responsible for the            Procedures 2007
patient’s care.                                                      2. Clark S, et al. British Journal of Surgery 1996;83:1383–4
RESULTS: A total of 104 primary inguinal hernia repairs were
performed of which 54(51.9%) were done on inpatient lists with
a median length of stay of 1 night, while 50(48.1%) were
performed as daycases. Of the 54 procedures performed on
inpatient lists, 14(25.9%) had been originally intended for day
surgery but were done on inpatient lists, the majority staying
         Daycase Green Light Laser                                 CONCLUSIONS: Whilst GLL prostatectomy might be viewed as
A35      Prostatectomy                                             a less technically demanding procedure than conventional
                                                                   transurethral prostatectomy the learning curve is certainly
         AJ Glackin, A Golash, I Smith                             greater than the 5 cases described by the instrument
         University Hospital of North Staffordshire                manufacturers. Bleeding, obscuring the operative field, can be
                                                                   difficult to control and is a problem in some patients. The use of
INTRODUCTION: We present our initial experience with green         a low dose spinal technique is appropriate in our population of
light laser prostatectomy in fifteen patients treated as           comorbid patients. The patients presented above go home
daycases.                                                          catheter free. It might be possible to send other patients home
METHODS: Fifteen male patients were admitted for GLL               to have their catheter removed in the community the day
prostatectomy. They received either a low dose spinal or           following surgery thereby further utilising our bed allocation.
general anaesthetic. The operative procedure was completed
and the patients returned to the ward with a catheter in situ. A
trial of voiding was undertaken on the same day and the
patients discharged home with routine prostatectomy
instructions.
RESULTS: All procedures were completed without
intraoperative complications. There were no transfusions.
Catheter removal was undertaken as planned. No patient
required readmission for complications following discharge.
         Daycase Laparoscopic                                        and three right adrenalectomies. The mean op time was 120
 B1      Adrenalectomies: a UK experience                            min mean blood loss was <50 ml. Average patient age was 48.3
                                                                     years (35–62) and average adrenal tumour size was 32 mm. The
         S Omorphos, P Waterland, M Deakin,                          diagnosis was Conn’s disease in 4 cases and
         I Smith, A Golash                                           hyperaldosteronism in 3. Average postoperative hospital stay
                                                                     was 340 minutes. There were no intraoperative complications
         University Hospital of North Staffordshire
                                                                     or conversion to open procedure. Postoperative analgesia
INTRODUCTION: Since the initial description of laparoscopic          comprised 1600 mg ibuprofen SR and regular co-codamol. No
adrenalectomy in 1992 by Gagner et al, this minimally invasive       patient was rehospitalised for any reason. All patients
surgical technique has gained wide popularity and worldwide          expressed satisfaction having their operation as a daycase.
acceptance1,2. Numerous reports emphasise the advantages of          Histology demonstrated 3 cases of adrenal hyperplasia and 4
laparoscopic approach over open techniques including lower           cases of Conn’s adenoma.
complication rates, less blood loss, less pain from long             CONCLUSIONS: To our knowledge, we report the first UK series
incisions, less analgesic requirements, earlier return to activity   of outpatient laparoscopic adrenalectomies. As our experience
and diet and shorter hospital stay1,2. Very few reports have         has increased, operation time has decreased. Laparoscopic
outlined their experience with ambulatory laparoscopic               adrenalectomy via the transperitoneal approach has been
adrenalectomies3. In our centre we have performed seven              proven safe and effective in our hands. Furthermore we have
laparoscopic ambulatory adrenalectomies from March 2006 to           shown that selective cases can be safely performed as
March 2008. We report our experience and the outcomes of this        daycases. We therefore conclude that ambulatory laparoscopic
procedure, which is now considered the standard surgery for          adrenalectomy is feasible and safe, and leads to high patient
adrenal tumours at our institution.                                  satisfaction. It results in reduced postoperative morbidity, zero
METHODS: Seven patients underwent ambulatory                         mortality and reduced hospital stay. It must be emphasised
laparoscopic adrenalectomy. Each patient fulfilled certain           that ambulatory adrenalectomy should be limited to highly
preoperative and postoperative inclusion criteria, including         selected patients and performed by minimally invasive
informed consent, body mass index 40 or less, adrenal tumour         surgeons who have considerable experience with laparoscopic
less than 50 mm., uncomplicated laparoscopic surgery                 adrenal surgery.
completed by 12 pm, perioperative haemodynamic stability and         REFERENCES
pain control by oral analgesics. All patients had a working
diagnosis of Conn’s syndrome excluding patients with                 1. Gagner M, et al. Surgery 1993;114:1120–4
Cushing’s disease and phaechromocytoma.                              2. Lezoche E, et al. Surgical Endoscopy 2000;14:920–5.
RESULTS: All seven patients successfully underwent                   3. Gill I, et al. The Journal of Urology 2000;163:717–720
ambulatory laparoscopic adrenalectomy. There were four left



         A Role for Daycase Surgery in                               total number of additional days spent in hospital by daycase
 B2      Orthopaedic Trauma Care?                                    eligible patients was 69. 34 days were due to preoperative
                                                                     delay and 35 were due to postoperative delay. The mean
         NR Howells, L Tompsett, A Moore,                            number of preoperative days in hospital was 1.33(range 0–3)
         A Hughes, J Livingstone                                     and postoperative days 1.85 (range 0–8). There was a wide case
                                                                     mix of procedures performed that were deemed as appropriate
         Bristol Royal Infirmary                                     for daycase surgery. 76% were upper limb or soft tissue
INTRODUCTION: Utilisation of daycase surgery units for               procedures. Of the procedures performed 82% were suitable to
orthopaedic trauma is an uncommon concept 1. Limited reports         be performed by trainees. The causes for preoperative delay
of its use in specific orthopaedic trauma cases have been            established two main issues. Limited dedicated operating
encouraging2,3. There is currently no formal provision for           theatre capacity for daycase eligible procedures resulting in
daycase surgery for orthopaedic trauma patients at our trust.        their de-prioritisation and limitations on dedicated bed
The aim of this study was to identify the proportion of trauma       availability. The cause for postoperative delay was more
patients that would be suitable for daycase surgery and the          variable but on the whole was for reasons which with
proportion of these that currently undergo procedures as a           appropriate protocols could have been avoided.
daycase, with a view to establishing a more formalised daycase       CONCLUSIONS: This study has identified that a significant
trauma service.                                                      proportion of orthopaedic trauma workload would be
METHODS: We undertook prospective data collection on all             appropriate to be carried out as a daycase. Without an
orthopaedic referrals in our institution over a 1 month period in    appropriate daycase surgery setup, current delays are causing
January 2008. Information was recorded for date and time of          69 unnecessary bed days per month in our institution. Causes
referral, admission, operation and discharge. Nature of injury,      for current delays are related to lack of synchrony between
type of procedure performed, grades of surgeon involved and          timing of admission and surgery and lack of appropriate
length, nature and reason for any pre or postoperative delay         discharge protocols. We are in the process of developing a
was also recorded. All patients requiring surgery were assessed      business plan for implementation of a dedicated daycase
on their suitability for daycase surgery as defined by               trauma service at our institution and suggest that this may be
predetermined patient-related and surgery-related criteria.          an appropriate use of daycase facilities in other trusts.
RESULTS: Of all the patients referred during the study period        REFERENCES
there were 129 patients requiring surgery. Of the operated           1. Audit Commission. Day Surgery – Review of National
patients 80 (62%) had a procedure suitable to be performed as           Findings: December 2001
a daycase as defined by surgical factors. Of these, 57 (44%)
patients met criteria for day surgery as defined by patient          2. Chandratreya AP, et al. Injury 2006;37:502–6
factors. Of the patients eligible for daycase surgery (n=57),        3. Schonauer F, et al. Ambulatory Surgery 2001;9(2):99–102
only 27% had their procedures performed as a daycase. The
         Ambulatory Breast Conservation                             RESULTS: Seventeen patients have been recruited and
 B3      Surgery with Axillary Node Sampling                        followed up so far. The inpatient arm holds 9(52.9%) patients
                                                                    and the outpatient arm 8 (47.1%). Patient pain were similar
         for Cancer: Interim results of a pilot                     over the first 48 hours postoperatively (mean at 24 h: IP
         randomised control trial                                   3.64/10, DC 4.3/10) (mean at 48 h: IP 3/10, DC 4/10). Nausea
                                                                    scores were similarly matched (mean at 24 h: IP 0.81/10, DC
         M Proctor, S Marla, S Stallard, L Romics                   2.14/10) (mean at 48 h: IP 1.43/10, DC 0.63/10). Psychological
         Victoria Infirmary                                         recovery over the first thirty days postoperatively has been
                                                                    shown to be comparable between both groups. No difference in
INTRODUCTION: Ambulatory surgery is a safe option for a
                                                                    infection rates between the two groups has been identified.
variety of surgical procedures and has been shown to be
possible for those suitable for breast conservation surgery with    CONCLUSIONS: Daycase surgery for breast cancer is safe with
associated economic advantages1,2. There is little data directly    comparable physical and psychological recovery to that of an in
comparing the physical and psychological recovery between           patient procedure.
patients attending for ambulatory or in patient care.               REFERENCES
METHODS: Patients suitable for daycase surgery presenting           1. Marchal F, et al. European Journal of Surgical Oncology
with a breast cancer amenable to breast conservation surgery           2003;31:495–9
were enrolled. Patients were randomised to undergo wide local
excision and axillary sentinel node biopsy as an in patient (IP)    2. Ranieri E, et al. One-day surgery in a series of 150 breast
or daycase (DC) procedure. Patient diaries, serial Functional          cancer patients: efficacy and cost-benefit analysis. Chirurgia
Assessment of Cancer Therapy (FACT) questionnaires, and                Italiana 2004;56(3):415–8
Surgical Site Infection monitoring forms were used to assess
physical and psychological recovery in both groups.




         The Financial Argument for Day                             inguinal hernia repairs acquire a surgical site infection,
 B4      Surgery: Illustrated using inguinal                        compared with 0.78% of inpatients2.This equates to 104
                                                                    additional infections nationally within the hernia population,
         hernia repairs                                             each infection increases costs by a factor of 4.8. Recovery from
         T Dione, R McCarthy, ME Stocker                            surgery has an average cost to the economy of £76.57 per
         South Devon Healthcare NHS Foundation Trust                person per day3. Day surgery protocols guiding early return to
                                                                    work could save £1,685 per person. 3.1 million people work
INTRODUCTION: Day surgery has been identified as key to             from home and day surgery would allow them to continue to do
improving standards and efficiency as demonstrated by being         so.
“Change Number 1” of the “10 High Impact Changes for Service
Improvement and Delivery”. We have evaluated the financial          CONCLUSIONS: Day surgery has many financial benefits over
benefits of day surgery using inguinal hernia repairs as an         inpatient surgery. It increases the margins of profit from
example, as this is one of the most commonly performed              surgery, through reduced outgoings and better use of
elective procedures in the UK, at a rate of 80,000 annually.        resources. The benefits increase the greater the scale of its
                                                                    implementation, by enabling the closure of beds thereby
METHODS: Data regarding the costs of inguinal hernia repairs        removing the associated overhead costs of bed maintenance
and hospital admissions were obtained from audit and research       and staffing. Infections, which are most likely to be contracted
performed at Torbay Hospital. Information regarding infection       during convalescence, are avoided. The cost to the economy of
rates, recovery times and costs to the economy was gathered         recuperation is reduced, as people can continue to work from
from literature searches.                                           home. Day surgery can also be used to revolutionise attitudes
RESULTS: In our trust the theatre cost of an inguinal hernia is     to the length of convalescence and reduce the cost to the
reduced by 37.5% (£960 vs £600) if performed in the day             economy by reducing the time that people take off work
surgery unit. This is due to reduced theatre costs (£15/minute      following surgery
in inpatient theatres vs £12/minute in day surgery) and             REFERENCES
improved efficiency and patient flow in the day surgery unit
resulting in an additional case being performed per session.        1. Cooke T, et al. Achieving day surgery targets. London:
Additional non-pay ward costs of £20 are also incurred for             Advance Medical Publications, 2004
inpatient treatment . . . If the BADS target of performing 85% of   2. Mlangeni D, et al. American Journal of Infection Control
inguinal hernia repairs were reached (currently 68%) we would          2005;33(1):11–14
treat 96 fewer inpatients per year saving £36,480pa. Were this
                                                                    3. www.bytestart.co.uk/content/news/1_12/sickies-cost-uk-
mirrored across the Department of Health’s “Basket of 25”1, the
                                                                       economy.shtml
reduction in the number of inpatient admissions would be great
enough to warrant bed bay closures, which holds much greater
capacity for saving. National Studies show 0.65% of daycase
         Comparison of Daycase Endovenous                         RESULTS: Four cohorts comprising 92 patients (125 legs) were
 B5      Treatment Modalities for Varicose                        assessed; open surgery (n=29), EVLA (n=18), RFA (n=58), and
                                                                  FOAM (n=6). Median age was 54 and male: female ratio 1:2,
         Veins — Analysis of postoperative                        median CEAP classification was C3. There was no difference in
         pain and analgesia requirements                          patient demographics between groups. Pain was reduced by
         R Kapur, S Goode, M Crockett, JM Vernon,                 endovenous treatment compared to surgery (p=0.006).
         BD Braithwaite                                           Univariate analysis showed reduced pain with RFA and FOAM.
                                                                  Bruising was reduced by endovenous treatment (p=0.005).
         Queen’s Medical Centre, Nottingham                       Analgesia requirements were less with RFA compared to EVLA
INTRODUCTION: Endovenous treatment for varicose veins is          (p=0.01).
increasingly common. Benefits include reduced postoperative       CONCLUSIONS: Endovenous treatment resulted in significantly
pain and analgesia requirement. Most trials compare only one      less postoperative pain than traditional open surgery. Of these,
treatment type with open surgery. This analysis compares the      patients treated with RFA had less pain and analgesia
outcomes of all major endovenous treatment modalities with        requirements.
traditional surgery: laser ablation (EVLA), three types of
radiofrequency ablation (RFA) and foam sclerotherapy (FOAM).
METHODS: Patients undergoing varicose vein treatment as a
daycase between 2002 and 2007 were prospectively assessed.
All patients were under the care of one consultant surgeon. All
underwent preoperative duplex assessment, and postoperative
management protocol was the same for every patient.
Endpoints were the same for all cohorts; postoperative pain,
analgesia requirement, bruising and activity were assessed by
visual analogue scale (VAS). Statistical analysis was performed
on all data using SPSS (V.15).
         A Survey of the Incidence of Post-                        the 13 who took morphine had PDNV, three linked it to PDNV
 P1      Discharge Nausea and Vomiting                             and one was readmitted because of PDNV. Two of the 11 who
                                                                   did not take morphine had PDNV (χ2 ns). All patients who
         Following Daycase Gynaecological                          developed PDNV had received one antiemetic before discharge
         Surgery                                                   and seven, two. There was no relationship between the
         TL Gregory, S Jackson                                     incidence of PDNV and calculated risk score.
         Poole General Hospital                                    CONCLUSIONS: An important number of our patients
                                                                   undergoing daycase gynaecological surgery suffer PDNV. This
INTRODUCTION: Nausea and vomiting are among the
                                                                   may last longer after laparoscopy and post-discharge oral
commonest and most distressing postoperative symptoms. Up
                                                                   morphine. We have changed our policy on the basis of this
to 30% of day surgery patients may develop post-discharge
                                                                   study and discharge these patients with oral ondansetron. The
nausea and vomiting (PDNV)1. Post-discharge opioid analgesia
                                                                   frequency and duration of PDNV will be re-examined later this
might contribute to the risk. We routinely discharged day
                                                                   year.
surgery patients after laparoscopy with oral morphine but
without antiemetics. By contrast we discharged patients after      REFERENCES
hysteroscopy without opioids. We compared the incidence of         1. Gupta A, et al. Anesthesiology 2003;99:488–95
PDNV in both groups.
                                                                   2. Apfel CC, et al. Anesthesiology 1999;91:693–700
METHODS: Data were collected from 50 consecutive patients
by retrospective chart review and standardised telephone
interview one week postoperatively. We calculated a risk score
for each patient (0–4) using the simplified Apfel scoring
system2.
RESULTS: Seven of the 24 (29%) laparoscopy patients and six
of the 26 (23%) hysteroscopy patients experienced PDNV
(χ2 ns). (There were nine unplanned admissions; two for control
of PONV (not included)). The duration of PDNV was greater in
the laparoscopy patients (0–3 vs 0–1 days (χ2 p < 0.05). Five of




         A Valid Case for a Daycase Procedure                      (67.5%) had had bowel function within 3 days. Six patients
 P2      or will Surgeons’ Fingernails be Bitten                   went home before bowel function and none were readmitted.
                                                                   Twenty patients (25%) developed complications which included
         to the Quick?: Postoperative outcomes                     wound infection (8%), small bowel obstruction/ileus (6%),
         and management after closure of loop                      enterocutaneous fistula (1%), anastomotic leak (1%), rectal
         ileostomy                                                 bleeding (4%), urinary retention (4%), urinary tract infection
         W Baraza, J Wild, W Barber, K Brodie,                     (3%), chest infection (1%) and late abdominal wall abscess
         SR Brown                                                  (1%). 16% of patients remained in hospital for more than 5 days
                                                                   despite having no postoperative complications.
         Sheffield Teaching Hospitals NHS Trust
                                                                   CONCLUSIONS: It has previously been shown that closure of
INTRODUCTION: The closure of a defunctioning loop ileostomy        loop ileostomy can be performed as a daycase procedure. This
is a commonly performed operation. Recent studies have             study represents a snapshot of current postoperative surgical
shown that it can be performed in the daycase setting reducing     practice and outcomes. It also confirms that the majority of
the length and cost of hospital stays after the procedure. By      patients undergoing closure of loop ileostomy can be
analysing our patients who have undergone reversal, we aimed       discharged earlier than they are at present. The provision of
to determine the potential factors behind the length of hospital   support networks in the community and the implementation of
stay.                                                              modified UK daycase surgery protocols may aid the push
METHODS: A database of all patients undergoing closure of          towards making this operation routinely a daycase procedure
loop ileostomy at one specialist colorectal unit was examined.     without compromising patient safety.
The times taken to discharge, morbidity and readmission rates
were recorded. Patients undergoing haemodialysis, those with
spinal injuries and those who underwent closure of ileostomy
as part of a multiple procedure were excluded.
RESULTS: 80 patients underwent reversal of ileostomy
between January 2001 and January 2006 and were suitable for
analysis. Median age was 63 years (range 22–81). The median
length of stay was 4 days (range 2–32) and the average length
of stay for patients with no complications was 4.4 days. Many
appeared able to be discharged earlier. Seventy two patients
(90%) were able to tolerate a solid diet within 48 hours and 54
         An Audit of Unplanned Admissions                           1.5 days (range 1–12). 17% of admissions were preventable with
 P3      and Readmissions in a Busy Urban                           a further 17% possibly so. The readmission rate at 48 hours
                                                                    was 0.7%, 3% at 14 days and 3.9% at 28 days. The indication
         Day Surgery Unit                                           for readmission was surgical 98%, anaesthetic 1% and medical
         JN Oronsaye, D Sewell, P Found, F Dunsire                  1%. 70% of readmissions at 28 days were emergency
                                                                    department visits, 25% inpatient admissions and 5% day
         Kings College Hospital, London
                                                                    surgery unit attendances. Urology, ophthalmology,
INTRODUCTION: Unplanned admission and readmission rates             orthopaedics, general and gynaecology had the highest
are widely used quality indicators of patient care in day surgery   readmission rates with a mean length of stay of 1 day (range
practise. The Royal College of Anaesthetists (RCA) suggests a       0.04–5). 56% of readmissions were possibly preventable.
target unplanned admission rate of <2%1. Target readmission         CONCLUSIONS: Our unplanned admission rate of 1.98% is just
rates vary. Our unit has a high turnover of major surgical cases    below the target rate set by the RCA and compares favourably
in complex medical patients. We undertook a prospective audit       to other studies2. It could be further reduced by improving the
to ensure unplanned admissions and readmission rates are            preoperative assessment process and by optimising
within acceptable limits.                                           management of surgical and anaesthetic complications. Our
METHODS: All daycase patients between September and                 readmission rate at 28 days was unexpectedly high compared
November 2007 were included except private patients. We             to national guidelines and other studies3. However only a
captured unplanned admissions and readmissions via the ward         quarter of these patients required inpatient admission and
admission register. We also manually crosschecked finalised         many could have been managed in the Primary Care setting.
operating lists with the patient’s medical records for evidence     Surgical indications for readmission included bleeding,
of readmission 28 days after their operation date. Data             infection, urinary retention and pain. Initial further analysis
retrieved from the medical notes included patient age, sex and      suggests improved patient selection, discharge information
surgical specialty; department to which presentation occurred;      and analgesia may reduced readmission rates in the future.
indication and management during admission; duration of             REFERENCES
hospital stay and for readmissions the interval between
surgery and readmission. We also assessed whether                   1. Royal College of Anaesthetists, Raising the Standard:
admissions or readmissions were preventable.                           A Compendium of Audit Recipes. 2006:12–4
RESULTS: A total of 2062 patients were treated over two             2. Awad IT, et al. European Journal of Anaesthesiology. 2004;
months. The unplanned admissions rate was 1.98%.                       21:379–83
Indications were surgical 51%, anaesthetic 27%, medical 15%         3. Watson B, et al. Journal of One-day Surgery
and social 7%. Breast, urology, vascular and general surgery           2004;14(4):103–4
had the highest admission rates with a mean length of stay of



         An Audit to Determine the                                  main reasons were pain and pyrexia, pain alone, pain and
 P4      Effectiveness Of Ureteroscopy as a                         vomiting, urinary retention and undocumented in 2 cases. Six
                                                                    patients had stents in situ, while six individuals had had
         Daycase Procedures                                         previous stenting procedures. It was found that 3 of the cases
         ND Rao, FM Fazly, RK Calleja                               in the former group compared to one in the latter were
                                                                    readmitted, thus a total of 4 (50%) of patients were readmitted.
         Norfolk & Norwich University Hospital                      The average hospital stay for readmissions was 4.5 days, only
INTRODUCTION: Ureteroscopy is a useful tool for the                 one patient stayed for 15 days. The male (26) to female (13)
diagnosis and treatment of ureteric disease. Its main role is in    ratio was 2:1, with an average age of 54.15 years.
the treatment of urolithiasis, including calculi retrieval and      CONCLUSIONS: Ureteroscopy can be performed successfully
disintegration, as well as stent insertion post procedure.          as a day procedure, 80% of patients being discharged without
Current literature suggests this can be performed as a daycase      complication. The main indication for the procedure was
procedure in low risk patients1, with only a few patients           urinary tract calculi of the lower 1/3 of the ureter. It was noted
requiring admission thus saving on hospital resources such as       that only 15 cases presented with stones with documented loin
beds and nursing care. The presence of ureteric stents was          pain, the numbers may have been higher as urinary tract calculi
thought to be a contributing factor for readmission3 and the        are associated with a certain amount of pain and during an
use of prophylactic antibiotics and analgesia can reduce            elective procedure, the patient could have been in a pain free
readmission rates2. The aims of this study was to ascertain the     state. The readmission rate was 20%, the main cause was pain
effectiveness of ureteroscopies as daycase procedures by            (62.5%). The average hospital stay was 4.5 days. (Four cases
observing the number and causes of readmissions, as well as         (50%) of readmissions had stenting procedures at some in
any predisposing factors contributing to this. Our goal was also    time. Although our study sample size was small, our data
to recommend changes to current practices.                          suggests that the use of prophylactic antibiotics and analgesia
METHODS: This was a retrospective study of 39 cases over a          and elective admission of selective patients with previous
1 year period using a proforma assessing; age, side of              stenting procedures would reduce the readmission rate.
pathology, indication for ureteroscopy, previous stenting,          REFERENCES
reasons for readmission and length of stay.
                                                                    1. Chen JJ, et al. Hong Kong Medical Journal. 2003;9:175–8
RESULTS: Renal tract calculi (27 cases; 11 in lower ureter) were
the commonest indication for ureteroscopy, followed by loin         2. Taylor AL, et al. British Journal of Urology International 2002;
pain (24 cases). 15 cases had both loin pain and calculi. Other        90:477
indications were pelviureteric junction (PUJ) obstruction and       3. Cheung MC, et al. Urology 2001;58:914–8
ureteric stricture. Eight cases were readmitted (20.5%), the
         Analgesia after Shoulder Surgery —                            was the most common intraoperative analgesic (88%). Most
 P5      A need for best practice in daycase                           common surgeries were acromioplasty and shoulder
                                                                       decompression (n=26) followed by rotator cuff repair (n=10).
         surgery?                                                      Only 21/47 (43%) patients had regional blocks (single shot
          R Deepak, JV Edwin, C Pac-Soo                                interscalene brachial plexus block). Local infiltration with
          Wycombe General Hospital                                     bupivacaine was given for all other surgeries. There was
                                                                       considerable variation in the strength and quantity of local
INTRODUCTION: Arthroscopic shoulder surgery has become                 anaesthetic used. The overall average pain score for the first 24
an established daycase operation. Analgesic options vary from          hrs was 3.9 (SD 2.09) and 4.3 (SD 1.96) in the next 24 hrs. The
local anaesthetic infiltration to continuous brachial plexus           average pain score among patients without a block in the first
block. A previous study1 reveals that up to 20% patients have          24 hrs was 4.2 (SD1.98) compared to 3.5 (SD2.45) in the group
inadequate pain relief once the regional block wears off. Our          with a block. In the next 24 hrs, patients who had no block had
practice consisted of a mix of regional and local techniques for       a mean pain score of 4.4 (SD 1.94) versus 4.34 (2.2) with a
surgery followed by oral analgesics at the time of discharge. To       block. There was again considerable variation in the choice of
gain more information on the duration and quality of pain relief       analgesics given to the patients to take home with 4 patients
postoperatively. We conducted a prospective questionnaire              having to go to the GP for further pain relief. 14/21 (75%) of
survey looking into current practice and the utilisation of            patients with blocks were discharged with simple analgesics
regional techniques and investigated the quality of pain relief        which were insufficient once the block wore off.
for 48 hrs postoperatively.
                                                                       CONCLUSIONS: There is a poor quality of postoperative pain
METHODS: The study was performed over four months on                   relief in patients who undergo daycase shoulder surgery. This is
patients undergoing arthroscopic shoulder surgery. One                 irrespective of the utilisation of regional techniques for the
questionnaire, completed by the hospital staff, collected              surgery. Patient education and counselling should be done
patient data and details of analgesic premedication,                   alongside providing effective analgesic medication. A trust
intraoperative analgesia including regional blocks, if used, and       guideline is being drawn up to implement uniform prescribing
postoperative analgesia. A second questionnaire was given to           policy and there is a need for a national guideline regarding
the patient to take home and document the pain experienced,            best practice for suitable postoperative analgesia after daycase
on a scale of 0–10, at three times of the day over the first 48 hrs.   shoulder surgery.
They were called by one of the investigators on day 1 and 2 with
                                                                       REFERENCE
a reminder to post the questionnaire back in the supplied
prepaid envelope.                                                      1. Wilson AT, et al. British Journal of Anaesthesia, 2004;
                                                                       92:414–5
RESULTS: 47 (95%) of the 48 forms were returned. Fentanyl



         Are Anaesthetic Rooms in Day Surgery                          no published evidence suggesting anaesthetic rooms reduce
 P6      Necessary?                                                    morbidity or mortality. On the contrary, there are many
                                                                       anecdotal reports of critical incidents during patient transfer
         P Sultan                                                      between anaesthetic room and theatre, including anaphylaxis,
         Colchester General Hospital                                   profound unrecognised hypotension, cardiac arrest, awareness
                                                                       and equipment problems. The lack of continuity of monitoring
Day surgery is a continually evolving specialty. The NHS plan
                                                                       during the transfer of an unconscious patient and the
target of 75% means day surgery will form a high proportion of
                                                                       distraction of the anaesthetist during this time, can lead to
the work of most departments of anaesthesia and drain a
                                                                       significant delays in recognising the onset of a major
significant percentage of hospital expenditure1. We explore the
                                                                       anaesthetic complication. Transferring the unconscious patient
role of anaesthetic rooms in day surgery and modern clinical
                                                                       can lead to damage to limbs and nerves, inadequate support
practice.
                                                                       for the head, disconnection and displacement of infusions,
The induction of anaesthesia in an anaesthetic room has been a         catheters and tracheal tubes, hypoxia and lightened
traditional feature of UK practice since 1860. A survey in 2002        anaesthesia may result from delayed reconnection of the
identified that 4% of UK anaesthetic departments routinely             breathing circuit. The AAGBI in 1993 recommended
anaesthetise all patients in theatre2. In most other countries,        uninterrupted monitoring throughout anaesthesia which lends
induction takes place on the operating table in theatre without        itself to operating theatre inductions. The money spent on
any apparent disadvantage to the patient. £30 million has been         duplicating equipment also results in double the cost of
spent on equipping anaesthetic rooms in the UK since 19942 in          servicing and checking which is mandatory.
order to comply with minimum standards of monitoring as
                                                                       In summary, the anaesthetic room is the domain of the
outlined by the AAGBI. There has been considerable debate
                                                                       anaesthetist. Throughout training, anaesthetists become
over the past 15 years regarding the use of anaesthetic rooms
                                                                       familiar and confident with anaesthetising patients here. For
particularly given the increasing costs of monitoring
                                                                       this reason many are reluctant to change the practice which is
equipment.
                                                                       safest in their hands. However, increasing financial constraints
Arguments in favour of anaesthetic rooms include the reduction         in and greater accountability in terms of quality is making UK
of fear by separation of the patient from the sights and sounds        practice increasingly difficult to justify.
of the operating theatre, less delay between operations, the
                                                                       REFERENCES
provision of a convenient place for the storage of equipment,
and a better teaching environment. Anaesthetic rooms allow             1. Department of Health. The NHS plan, 2000
theatres to be prepared for the next case while the patient is         2. Broomhead HJ, et al. Anaesthesia 2002;57:850–4
being anaesthetised, potentially improving efficiency. There is
         Assessing the Appropriateness of                              RESULTS: From 1st August to 31st December 2007, there were
 P7      Unplanned Admissions: The Torbay                              4063 daycase procedures. Our unplanned admission rate was
                                                                       1.4%. Of these, 93% were considered appropriate by the ward
         approach                                                      nurses. However, on review of the notes 33% of those had not
          K Stenlake, M Stocker                                        required any interventions necessitating overnight admission.
          South Devon Healthcare NHS Trust                             Reasons for admission were; pain (40%), nausea (14%),
                                                                       surgical (17%), medical (17 %) and social (12%). The highest
INTRODUCTION: We undertake regular audits of Torbay
                                                                       number of admissions was from laparoscopic gynaecological
Hospital’s day surgery services as stipulated by the Royal
                                                                       procedures. There was no overall correlation between time of
College of Anaesthetists.1One such audit examines the
                                                                       surgery and likelihood of admission. However, we have asked
appropriateness of unplanned admissions from the unit, to
                                                                       staff to be vigilant about listing older patients at the start of a
ensure that we remain below the suggested 2% rate.2 As a
                                                                       surgical session due to longer recovery times. An improved
department we are proactive in seeking feedback from
                                                                       postoperative prescribing scheme was introduced in January
discharged patients. We telephone every patient on the day
                                                                       and admissions due to pain and nausea are now being re-
after discharge to ascertain the effectiveness of postoperative
                                                                       audited.
symptom control and satisfaction with our service. However, we
have been missing valuable data from those patients who have           CONCLUSIONS: Our rate of 1.4% certainly meets the target of
‘failed’ to meet discharge requirements and have had to stay in        fewer than 2% unplanned admissions from day surgery. Only
hospital as an unplanned admission. These patients may be              7% were deemed inappropriate by nurses although 40% of
able to offer us a better insight into clinical practices that could   admissions were felt to be inappropriate by medical staff. In
be improved or any system failures. We also wished to audit the        April, we instigated a nurse led process to collate information
appropriateness of our admissions, in particular whether they          and feedback from our admitted patients and ward staff to
received care on the ward which they could not have at home.           generate a new database. We hope to use this to gain further
We asked both patients and ward staff whether the extra night’s        insight into the reasons for admissions. We may then be able to
stay had been beneficial.                                              improve our service and subsequently reduce our admission
                                                                       rate even further.
METHODS: We generated an audit form for each unexpected
admission. These detailed the date, time and type of surgery,          REFERENCES
the reason for admission and interventions required in the             1. Colvin JR. Raising the Standards: A compendium of audit
recovery ward. Further information was then obtained from                 recipes, 2006:1–4
both the patient and ward staff to gauge what (if any)
interventions were required overnight and whether they felt            2. Stocker ME. Raising the Standards: A compendium of audit
that the admission was necessary.                                         recipes, 2006;5.6:116–7




         Attitudes to Music in the Operating                           most (85% of anaesthetists), followed by scrub nurses (80% of
 P8      Theatre — Should it be banned?                                scrub nurses) with surgeons liking music the least (65% of
                                                                       surgeons). Only 20% of all participants felt that music improved
          A Mahdi, V Varadarajan, K Hashaishi
                                                                       their performance in theatre, mainly anaesthetists (58.3%). The
         Manchester Royal Infirmary                                    majority of all participants had no musical genre preference
INTRODUCTION: Music is often played in the operating                   (51.7%). The most popular specific genres were classical music
theatre. However, attitudes amongst different team members             (18.3%) and radio (13.3%). The most unpopular music
regarding this have not been fully researched. Some studies            preference was urban music (0%). Surgeons are generally
have indicated that a surgeon’s performance is not                     viewed as responsible for overall music choice (62% total
compromised by music1. However, the literature regarding this          participants). A total of 35% participants felt that music
is scanty. We therefore undertook a prospective survey of              reduced their performance in theatre–the majority of which
attitudes of consultant surgeons, consultant anaesthetists and         were surgeons (52.4%). A total of 15% of participants felt that
senior scrub nurses to music in theatre. A comprehensive range         music should be banned in theatre, of this group there was no
of viewpoints were evaluated, including whether or not music in        statistically prevalent occupational group (p=0.68)
theatre should be banned altogether.                                   CONCLUSIONS: Our study shows that the majority of theatre
METHODS: This was a prospective study performed between                staff like music in theatre. However, a noticeable minority
February 2008 and March 2008. A paper questionnaire                    would like music banned. Anaesthetists prefer music the most,
addressing various attitudes to music in theatre was randomly          with surgeons preferring it the least. If music is to be played in
distributed to 60 participants; 20 consultant surgeons (from           theatre, the majority of the team have no preference which
different specialties), 20 consultant anaesthetists and 20             genre is chosen. Classical music and radio are the most likely to
senior scrub nurses (with >5 years theatre experience). All            be well received and urban music is most likely to be poorly
participants were employees of our institution, with all               received. Irrespective of how popular music is with the team,
identities kept fully anonymous. The data collated was                 over a third of participants (mainly surgeons) felt it reduced
transferred to a database for analysis by SPSS with p values           their performance in theatre. With the ethos of patient safety in
calculated using Pearson chi-squared and Fisher’s exact tests.         mind, this fact alone would be in favour of banning music in
                                                                       theatre altogether.
RESULTS: The vast majority of all participants liked music to be
played in theatre (76.6%). There was no correlation with gender        REFERENCE
(p=0.71). Anaesthetists were the group who liked music the             1. Moorthy K, et al. Surgery 2004;136:25–30
         Audit of Cancellations in the Day                             blood pressure, 1 BMI of 43 and one high blood sugar. All had
P9       Surgery Unit of a District General                            attended preassessment within two weeks. Recommendations
                                                                       were made to have dedicated day surgery lists, more effective
         Hospital                                                      preassessment, cancellations for anaesthetic reasons to be
          N Purohit, A Tore, H Shien, S Green                          discussed with consultants and formation of a multidisciplinary
          Grantham and District Hospital, Lincolnshire                 group comprising consultant anaesthetist, clinical
                                                                       effectiveness officer and staff from day ward and
INTRODUCTION: Day surgery rates have risen steadily over the           preassessment clinic to address any problems during
past decade1. Although the DOH has set a target of 75% day             preassessment process and admission. A re-audit was
surgery2, many units are not being used to their maximum               conducted subsequently over a 12 month period. Out of a total
capacity3and cancellations vary from 5–20% between trusts3.            2028 cases, 27 cases were cancelled (1.3%). Six each (23%)
We present an audit on the cancellation of daycase surgeries in        were cancelled due to lack of theatre time no longer required,
the Grantham and District Hospital during November                     where as 3% (1 each ) were cancelled by the patient, lack of
2003–December 2007.                                                    theatre staff and need for further investigation. 15% (4 cases)
METHODS: Retrospective audit spanning 18 months. Data were             were cancelled due to upper respiratory tract infections while
collected from cancellation forms in day surgery unit and case         11.5% (3 cases) were cancelled due to lack of surgeon (sick
notes initially for 6 months from November 2003 to April 2004          leave). 7% (two cases) were cancelled in the anaesthetic room
and a re audit subsequently over a 12 month period from Jan            (significant ventricular ectopics and adverse reaction) while
2007 to Dec 2007. Cases done under local anaesthesia were              one case was cancelled due to exacerbation of COPD,
excluded to reflect true day surgery2.                                 pregnancy and high potassium.
RESULTS: A total of 30 (3.9%) out of 784 daycases were                 CONCLUSIONS: The cancellation rate decreased from 3.9% to
cancelled. 12 (40%) were cancelled as patients were not fit for        1.3%.A consultant anaesthetist led day surgery unit and a
general anaesthesia. 4 (13%) were cancelled as the procedure           multidisciplinary group to discuss the preassessment process
was no longer required, one by the patient the day before              and appropriate patient preparation will play a major role in
surgery due to relief of pain and the other 3 on the day after         decreasing the cancellations.
surgical review. 8 cases (27%) were cancelled due to non               REFERENCES
availability of a consultant anaesthetist (required to cover the
                                                                       1. Aylin, P. British Medical Journal 2005;331(7520):803
High Dependency Unit). 3 cases (10%) were cancelled due to
non availability of theatre; patient default, positive pregnancy       2. Department of Health. Day Surgery: Operational Guide,2002
test and no theatre time accounted for the other 3cases. Of the        3. Healthcare Commission. Acute hospital portfolio review —
cancelled cases, 16% (5) were possibly avoidable; 3 had high              Day Surgery, 2005




         Audit of Day Surgery Attendance                               16 non-attenders giving a non-attendance rate of 1.79%. There
P10      Rates in Plastic Surgery at Selly Oak                         were various reasons for non-attendance including changing of
                                                                       mind, forgetting appointments, miscommunication, being
         Hospital and Associated Cost                                  afraid of surgery and being unwell. The cost to the trust was
         Implications                                                  £4053 with a lost opportunity cost of £13,157, giving a total
         Kok K, Singh S                                                cost of £17,210.
         Selly Oak Hospital, Birmingham                                CONCLUSIONS: Non-attendance to day surgery is a difficult
INTRODUCTION: Patients who fail to attend their day surgery            problem as it wastes NHS resources and has significant
appointments incur an opportunity cost in terms of the                 financial implications as illustrated in this audit. With the
surgeon’s time as well as an economic cost to the Trust. This          introduction of the 18 week referral to treatment (RTT) objective
audit aimed to measure our non-attendance rate and the cost            by the government coupled with the economic difficulties that
implications associated with it.                                       the NHS is facing, it is important that we maintain a low non-
                                                                       attendance rate to maximise theatre utilisation and earnings
METHODS: This was a retrospective audit carried out over 6             via payment by results. As our non-attendance rate is lower
months from January to June 2007. The ward attendance books            than other published figures1–3, we also examine our current
were examined in the day surgery wards at Selly Oak hospital           practice in detail to show how this non-attendance rate was
and the non-attenders for plastic surgery were noted. Their            achieved.
notes were examined, noting down their sex, age, history of
previous non attendance, individual operations and reasons for         REFERENCES
not attending. Where the reason for not attending was not              1. Lee CS, et al. Journal of The Royal Society of Medicine 2003;
noted, patients were telephoned at home to ascertain the                  96:547–48
reason. The financial cost to the trust (cost of theatre facilities,   2. Dockery F, et al. Postgraduate Medical Journal 2001;77:37–9
staff and disposables) and the lost opportunity cost (ie. Lost
income for not performing operations on non-attenders) was             3. Sawyer SM, et al. Journal of Paediatric Child Health 2002;
calculated by obtaining figures from the finance department in            38:79–83
the Trust.
RESULTS: In the 6 months, there were a total of 895 plastic
surgery patients booked for day surgery. There were a total of
         Audit of Postoperative Analgesia by                       RESULTS: In the PD Group, 11/17 (65%) of patients who were
P11      Telephone Follow up and Pain Diaries                      not prescribed codeine recorded constipation for 1–2 days in
                                                                   total. 7/11 (64%) of patients who were prescribed codeine
         M Laye, J Rozentals, JM Vernon                            recorded constipation for 3–5 days in total. 6/28 (21%) of
         Nottingham University Hospital                            patients were nauseous on day 1, on days 4–6 only one patient
                                                                   was nauseous on one day. On day 4, 13/28 patients, and on day
INTRODUCTION: All our daycase general surgery patients             5, 8/28 patients had high pain scores, despite this only one
receive telephone follow-up. This revealed problems with           patient used ibuprofen when the 3 day supply of diclofenac ran
postoperative analgesia at home. A literature and internet         out. On day 5, 2 patients had no pain. The TF Group were
search revealed little specific information on ‘at home’           telephoned 4–10 (median 7)days postop. Constipation was
analgesia following ambulatory surgery, other than recognition     recorded as a problem for 16% of patients and nausea as a
of the need for good patient information. Therefore a pain diary   problem for 5%. 28% of patients were recorded as having no
audit was performed to guide the redesign of our ‘at home’         pain.
analgesia regime. Previously, our anaesthetists had been
prescribing from diclofenac (3 days), paracetamol, co-codamol,     CONCLUSIONS: A single telephone follow up call may
and tramadol. A simple patient information sheet for               underestimate the patient morbidity that has occurred earlier in
diclofenac/paracetamol or diclofenac/co-codamol had been           the postoperative period. More than 3 days supply of NSAID is
used. Telephone follow-up records were analysed to compare         needed for postoperative analgesia. Constipation is a problem,
the information obtained from this source and from a pain          ( some patients stopped co-codamol due to constipation and
diary.                                                             took no analgesia.) Most patients will have had ondansetron
                                                                   which may cause constipation. A new drug chart was devised
METHODS: In the Pain Diary (PD) Group 28 hernia repair or          with a choice of 4 regimens, including Ibuprofen, Paracetamol
laparoscopic cholecystectomy daycase patients were provided        and Codeine. Detailed patient analgesia information booklets
with a 7 day pain diary to record daily pain scores (0–10),        were written. 6 day supply of ibuprofen provided to enable
analgesia consumption and details of nausea and constipation.      patients to seamlessly transfer to their own supply. Codeine is
These patients were telephoned twice, and their diary records      now supplied separately to paracetamol, not as co-codamol.
transcribed over the phone. Daily pain scores were grouped as;     Laxative is now routinely supplied with codeine. A new audit is
High resting ≥ 4, on movement ≥6. Low resting ≤2, on movement      planned to complete the cycle.
≤3. In the Telephone follow-up (TF) group, routine records of
100 other patients having the same surgery were analysed.




         Can Laparoscopic Cholecystectomies                        majority of cases (24; 83%) were performed as elective cases
P12      Feasibly be Performed as a Daycase                        with only five (17%) during the emergency admission; none of
                                                                   these were performed on a daycase basis. Average length of
         Procedure in District General                             hospital stay was 2.8 days. However, of the elective cases
         Hospitals?                                                twenty two of the twenty four patients (92%) spent less than
         J L Morgan, O Tawfiq, M Al-Gailani                        24 hours in hospital. One case was converted to open due to
         Rotherham General Hospital, Rotherham,                    the presence of a unsuspected floating gallbladder. There were
         South Yorkshire                                           no serious complications and only one readmission at the time
                                                                   of data collection due to pancreatitis.
INTRODUCTION: Gallstones are a common surgical problem
                                                                   CONCLUSIONS: We have shown that a large proportion of
with a prevalence of 9% in those over 60 years, equating to 5.5
                                                                   patients undergoing laparoscopic cholecystectomy in a district
million people in the UK1 There were 102, 338 gallstone-related
                                                                   general hospital are discharged within 24 hours of admission.
admissions between 1 April 2005 and 31 March 20062. In this
                                                                   This implies that with adequate patient and staff education,
time 49,077 cholecystectomies were performed, 84% of these
                                                                   careful patient selection, morning operating lists, district nurse
were laparoscopic2,3. Current NHS recommendations include
                                                                   involvement and the use of postoperative advice sheets,
aiming to achieve 70% of elective laparoscopic
                                                                   laparoscopic cholecystectomies can feasibly be performed as a
cholecystectomies as daycase procedures, however at present
                                                                   daycase procedure.
the national average is only 6.4%. We present data from an
audit of laparoscopic cholecystectomies in a district general      REFERENCES
hospital, specifically looking at whether performing these         1. Beckingham I J. British Medical Journal 2001;322:91–4
procedures as a daycase would be feasible.
                                                                   2. NHS Institute for Innovation and Improvement. Focus On:
METHODS: This was a retrospective study of all patients who           Cholecystectomy, 2006
underwent laparoscopic cholecystectomy under a single
consultant at a district general hospital in a 12 month period.    3. Department of Health. Hospital Episode Statistics,
Case notes were reviewed for patient demographics, elective           www.hesonline.nhs.uk
vs. emergency admission, interval from diagnosis to procedure,
technique, conversion, complications and length of stay.
RESULTS: Twenty nine patients underwent laparoscopic
cholecystectomy by a single surgeon during the study period
for gallstone disease. Twenty four (83%) were female and five
(17%) were male (mean age 53 years, range 26–81). The
         Comparison of the Incidence of                           RESULTS:
P13      Unplanned Admission Rate in the First                                               1st 100   Next 98   Total (198)
         100 and the Subsequent 98 patients                       Female: Male                2.6:1     18.6:1   5:1; p<0.01
                                                                  Mean (SD) age              47 (13)   49 (12)    48; p=0.5
         undergoing Daycase Laparoscopic                          Age range                   21–78     16–68       16–78
         Cholecystectomy                                          Patients >55y                 33        67   100; p<0.01
         MI Bhatti, J Sherigarh, A Osman, M                       Patients <55y                67         31     98; p<0.01
                                                                  Conversion                    0         3        3; p=0.1
         Fernando, MA Rathore, MG Brown
                                                                  Admission                    23          6    29; p=0.002
         Causeway Hospital, Coleraine, Northern Ireland
INTRODUCTION: The aim was to compare the incidence of             Seven (3.5%) required readmission. Cystic artery
Unplanned Admission (UPA) in the First 100 and the                pseudoaneurysm (n=1), injury to CBD (n=1), mild postop
Subsequent 98 patients undergoing Daycase Laparoscopic            pancreatitis (n=1) and wound pain and bruising (n=4).
Cholecystectomy (DCLC).                                           CONCLUSIONS: Over the study period there was a statistical
METHODS: Retrospective case series, study period=40m.             and clinical improvement in the unplanned admissions after
Eligibility criteria for DCLC were cholelithiasis, non-acute      DCLC. It was mainly due to bedding in of the process and due to
cholecystitis and ASA I–III. 198 from 253 pts were eligible.      extra caution in the former cohort.
Standard laparoscopic cholecystectomy was performed. All
patients had anti-DVT prophylaxis, antibiotic, orogastric tube,
paracetamol suppository and local anaesthetic to all wounds.
Discharged the same day. The end point was 6 week follow-up.
The First 100 and the Subsequent 98 patients were studied as
two groups. Primary outcome was the Primary outcome was
UPA and secondary outcomes were UPA in >55y, conversion
rate, readmission rate and complications. The end point was 6
week follow up or complications whichever was later.




         Daycase Laparoscopic TEP Hernia                          RESULTS: 101 patients with TEP hernia repair in a Day care
P14      Repair — Outcome and patient                             setting were reviewed. Mean age of the patients at the time of
                                                                  surgery was 52.19 yrs and 170 hernias’ were operated in total.
         satisfaction                                             Two patients (1.9%) were converted to open due to adhesions.
         R Verma, A Hakeem, K Kolar                               There were no major intraoperative complications.
         Doncaster Royal Infirmary                                Postoperative complications were noted in 23 patients
                                                                  (22.7%). These were haematomas (n=8, 7.9%), port site
INTRODUCTION: Of the various types of Laparoscopic Inguinal       infection (n= 2, 1.9%), chronic groin pain (n=2, 1.9%),
Hernia Repair, TEP (Totally Extraperitoneal) method is favoured   recurrence (n= 4, 3.9%) and others (n= 7, 6.9%). Patient
for its lesser recurrence rates and other complications. This     satisfaction was mostly excellent (n=51, 70%) and good (n=22,
study aimed to evaluate outcome and patient satisfaction of       30%) among those who responded during initial follow-up at 4
TEP hernia repair done as a daycase procedure.                    weeks.
METHODS: The case records of Daycase TEP Hernia Repair            CONCLUSIONS: The use of the TEP approach laparoscopic
done in a DGH by a single surgeon from June 2005 until            hernia repair is safe and effective in Day care setting with
November 2007 were reviewed. Patient demographics,                excellent results and high degree of patient satisfaction.
conversion rate, complications, readmission rate and patient
satisfaction level were analysed.
         Direct Access Colonoscopy: A novel                         indication for referrals, findings at colonoscopy and final
 P15     approach                                                   outcomes including complications and cancellations was
                                                                    collected by review of pro-forma and patient case notes.
         J Ahmed, M Rao, A Khan, NN Siddiqi,
                                                                    RESULTS: A total of 330 patients had a colonoscopy. Of these
         CC Mahon, KS Mainprize
                                                                    170 were direct access colonoscopies. Male: Female ratio was
         Scarborough General Hospital                               1:1.5. The two groups were comparable in terms of the age of
INTRODUCTION: Referral for colonic investigations is on the         the patients. 5/160 (3.1%) patients had colonic cancer
rise and introduction of the 18 week targets has further            diagnosed in standard group as against 7/170 (4.1%) in the
increased the workload on endoscopy services. Direct access         direct access group. A further 36 patients had colonic polyps >
colonoscopy could help reduce waiting times and meet the            1cm in the standard group while 21 patients had a similar
targets without compromising on quality of care. Our aim was        diagnosis in the direct group. There was 1 cancellation for social
to assess whether direct access colonoscopy is feasible and         reasons in the direct access group but no complications in
compare PCT direct access colonoscopy with conventional             either group.
colonoscopy referrals.                                              CONCLUSIONS: Direct access colonoscopy is safe and
METHODS: Patient letters sent by general practitioners for          comparable to conventional daycase colonoscopy. It is a
colonic investigation between January and October 2007 were         practical way to reduce waiting times and free outpatient slots.
assessed by 2 Colorectal Consultants for direct access              There is no evidence that it increases inappropriate referrals.
colonoscopy suitability using a standard tick box pro-forma.        Further consideration should be given to this framework.
Patients on anticoagulants, diabetics, those with social
circumstances precluding day surgery and patients referred as
2 week targets were excluded. Data regarding demographics,




         Direct Access Daycase Surgery for                          RESULTS: 56 patients underwent hernia surgery. Of these 33
P16      Primary Inguinal Hernia: A practical                       (59%) patients had DAHS while 23 (41%) patients underwent
                                                                    conventional daycase surgery. All patients were males. Age
         approach                                                   ranged from 20–78 years. 32/33 and 21/23 patients had
         J Ahmed, M Rao, A Khan, NN Siddiqi, CC                     unilateral hernias in the DAHS and conventional daycase
         Mahon, KS Mainprize                                        surgery groups respectively. One patient in the DAHS group
         Scarborough General Hospital                               was cancelled as no hernia was found on the day of operation.
                                                                    There were no intraoperative or postoperative complications or
INTRODUCTION: Coordination between GPs, Surgeons and                readmissions in either group.
patients is required for successful adaptation of direct access
surgery. Direct access hernia repair for symptomatic groin          CONCLUSIONS: Direct access surgery for primary hernia repair
hernias could help reduce waiting times without compromising        is safe and comparable to conventional daycase surgery. It is a
on quality of care.                                                 practical way to reduce waiting times and free outpatient slots
                                                                    for other cases. Further consideration should be given to this
Aim: Compare direct access hernia surgery (DAHS) with               framework.
conventional daycase surgery for treatment of symptomatic
primary inguinal hernias.
METHODS: Patients suitable for primary inguinal hernia
surgery between June 2006 and October 2007 were assessed
by GPs and referred for hernia surgery. A pro-forma agreed
between GPs and Surgical Consultants was completed for
enrolling patients on the appropriate waiting list. Patients were
given written information about the procedure by their GP and
assessed by the operating Consultant on the day of surgery.
Data regarding demographics, complications and readmission
rates was collected by review of patient case notes.
         Does BADS Practice What it Preaches?                                               Q1     Q2      Q3       Q4    Q1    Q2
 P17      MA Skues                                                                         ’06–7 ’06–7    ’06–7   ’06–7 ’07–8 ’07–8

         Jubilee Day Surgery Centre                                 Council Mean          73.9% 72.5% 74.2% 75.7% 75.7% 75.7%

INTRODUCTION: The “Better Care, Better Values” initiative by       95th centile           83.2% 81.2% 82.2% 83.7% 85.9% 85.6%
the NHS Institute1 allows comparative review of Day Surgery        5th centile            62.8% 62.6% 65.2% 64.6% 63.3% 66.7%
Unit performance in England, albeit, by use of the Audit
Commission “Basket of 25” procedures that may not represent        Non council Mean       69.3% 68.6% 69.1% 70.8% 71.6% 70.6%
the full spectrum of 21st century day care and short stay
                                                                   95th centile           82.4% 80.2% 81.2% 83.3% 83.9% 82.2%
practice. A retrospective review of this data has been mapped
to the home hospitals of members of Council of the Association     5th centile            50.0% 51.4% 49.8% 52.2% 58.2% 55.1%
to investigate whether BADS Council members “practice what
                                                                   p values                0.06   0.10    0.04    0.07    0.10   0.06
they preach”.
METHODS: Data downloads from the “Better Care, Better              CONCLUSIONS: BADS Council members, as an aggregated
Values” website were consolidated into an Excel spreadsheet        group, do appear to “practice what they preach”. However,
and a comparison was made of the performance of English
                                                                   ongoing endemic changes in patient care within individual
Council members’ parent hospitals and the rest of the country.
                                                                   hospitals as a response to national imperatives may be outside
Initial analysis evaluated the dataset population to confirm the
                                                                   the influence of even senior members of our Association.
best use of either parametric or nonparametric statistical
methods, from which, the most appropriate analysis was             REFERENCES
conducted to review whether there was a significant difference     1. NHS Better Care, Better Value Indicators; NHS Institute for
between the two groups.                                               Innovation and Improvement.
RESULTS: Dataset review confirmed populations represented a           http://www.productivity.nhs.uk/
normal distribution, allowing parametric methods to be
employed for subsequent statistical analysis. Review of BADS
Council members home hospital performance revealed large
variation between best and worst performing Units, (Table) but
aggregated data indicated that Council members’ hospitals
consistently performed better than the rest of England, at
times, achieving a statistically significant difference.
Performance for Audit Commission “Basket of 25” Procedures
as a Daycase



         Does Timing of Ambulatory General                         (range 26–75 years) compared to 55.0 year s (range 30–87
P18      Surgery affect Delay in Discharge —                       years). There was a marked difference in male: female ratio in
                                                                   the groups–LC 4M:15F compared to the H group 21M:1F.
         An institutional report
                                                                   28/41 (68%) of patients underwent surgery on the AM list (H
         NN Basu, M Hussain, L Miernik, B Kald                     n=19, LC n=9), whereas only 32% underwent surgery on the PM
         Queen Elizabeth Woolwich                                  list (H n=3, LC n=10). 57% of patients operated on the AM list
                                                                   were discharged on the same day, 4/28 discharged within 23
INTRODUCTION: An efficient day care surgery practice
                                                                   hours of surgery and 29% (8/28) had delayed discharge. In the
requires careful planning of the operating list to optimise
                                                                   delayed group, 87% of the patients operated on the AM list
timely discharge within 23 hours. Laparoscopic
                                                                   underwent laparoscopic cholecystectomy. In the PM group,
cholecystectomy and inguinal herniorraphy are two of the
                                                                   1/13 patients were discharged on the same day, 77% (10/13)
commonest performed general surgical operations in the
                                                                   discharged within 23 hours and 2 patients had delayed
daycase setting. The safety and cost-effectiveness of these two
                                                                   discharge.
procedures in the daycase setting are well documented1,2. We
investigated whether timing of surgery in the morning or           CONCLUSIONS: The results of this retrospective audit suggest
afternoon list affected delay in discharge in our hospital.        that performing LC on the AM list is associated with a
                                                                   significantly higher rate of delayed discharge (25%) compared
METHODS: Consecutive patients undergoing laparoscopic
                                                                   to the PM list (8%). A similar correlation is not seen in inguinal
cholecystectomy (LC) or inguinal hernia repair (H) were
                                                                   hernia surgery. To provide an optimal day surgery service,
selected from our day surgery database over a 5 month period.
                                                                   laparoscopic cholecystectomies should be performed on the
Exclusion criteria included any obvious contradictions to day
                                                                   PM operating list. This will enable an overnight stay if required
surgery as well as laparoscopic converted to open
                                                                   at the same time without compromising the 23 hour discharge
cholecystectomy, insertion of drain at laparoscopic
                                                                   target.
cholecystectomy, bilateral inguinal hernia repair and any form
of anaesthesia other than general anaesthesia. Details of time     REFERENCES
and duration of surgery, time in recovery, analgesia used,         1. Gurusamy KS, et al. Cochrane Database of Systematic
surgeon’s postoperative instructions and discharge data were          Reviews 2008;23(1):CD006798
recorded onto a database.
                                                                   2. McGrath B, et al. Canadian Journal of Anaesthsia
RESULTS: 41 patients underwent LC (n=19) and H(n=22)                  2004;51:886–91
during this period. In the LC group the mean age was 51.3 years
         Effectiveness of the Preassessment                         RESULTS:
P19      Service for Day Surgery                                       Preassessed in clinic                   250
                                                                       Referred to Anaesthetists               97 (38.8%)
         I Locker, N Soundararajan, S Mathias,                         Cleared for daycase                     241 (96.4%)
         A Clarke                                                      Discharged as daycase                   234 (93.6%)
         Hull and East Yorks NHS Trust                                 Cleared but did not arrive              4 (1.6%)
                                                                       Cancelled on the day                    1 (0.4%)
INTRODUCTION: This audit looks at the effectiveness of our             Overnight admission                     1 (0.4%)
present multiprofessional preassessment model1. In our                 No data                                 1 (0.4%)
institution, patients who are deemed suitable for daycase
procedures are subjected to pre-screening, referred to the          CONCLUSIONS: Our results show that the present
preassessment team and then given an appointment for a              preassessment service for day surgery is very effective1.
nurse led preassessment clinic. Pre-screening at initial surgical   Previous data showed 30% unsuitability for general
consultation has recently been introduced and this audit            anaesthesia in our day surgery unit. This audit highlights the
sought to additionally quantify its effectiveness in reducing       usefulness of our pre-screening tool and of the guidance
unnecessary, time wasting clinic preassessments. In our day         criteria that we use to determine suitability for general
surgery unit, preassessment nurses can clear patients for day       anaesthesia. Data collection is ongoing and if accepted more
surgery. If in doubt, they seek advice from anaesthetists2, 3.      than 600 patients will be included.
Our aim was to determine the percentage of patients who: were       REFERENCES
deemed unfit at preassessment; were cancelled on the day of
surgery; required overnight admission after day surgery. The        1. The Royal College of Anaesthetists. Raising the standard: a
purpose of collecting this data was to identify the factors that       compendium of audit recipes, 2006
influenced cancellations and overnight admissions. This would       2. Department of Health NHS Modernisation Agency. Day
help us to address these factors, make necessary changes and           surgery: A good Practice guide, 2004.
re-audit our performance against standards1.                        3. Association of Anaesthetists of Great Britain and Ireland.
METHODS: All patients, who were preassessed in November                Day Surgery, 2005
2007, were followed up through surgery to discharge. Relevant
data was collected for every preassessed patient.




         Evaluation of Safety and Efficiency of                     There were no intraoperative complications except bladder
P20      Ambulatory Urogynaecology                                  injury in one patient. 116 (80%) patients were discharged in 23
                                                                    hour ambulatory protocol. Remaining 29 (20%) required
         procedures performed in a 23 hour                          inpatient admission, of which 20 were admitted for anaesthetic
         Daycase Surgery setting                                    complications including (analgesia, medical complication) and
         U Kubal, A Arunkalaivanan                                  9 were admitted for retention of urine.
         City Hospital                                              CONCLUSIONS: Variety of urogynaecology procedures can be
INTRODUCTION: Our objective was to assess the safety and            performed in a 23 hr daycase surgery setting. This practice
efficacy of ambulatory urogynaecology in a 23 hour daycase          appears to be safe and effective, particularly in view of a high
surgery setting.                                                    rate of early discharge. This may have an advantage to both the
                                                                    patients and the health care provider.
METHODS: We evaluated 145 patients who underwent
urogynaecological procedures from April 2006 to March 2007
in a daycase setting. Intraoperative and postoperative
complications were noted. Proportion of patients being
discharged within 24 hours was noted. Readmission rate and
postoperative complications were noted.
RESULTS: Over a period of one year 145 patients underwent
urogynaecological procedures at our unit. Mean age was 57.81
± 14.5 [range: 19–92] and median parity was 2[0–10]. Forty one
(28.3%) patient had hysterectomy previously and 99(68.3%)
were postmenopausal. Various procedures were performed as
illustrated in the table.
  Procedure                                 No (%) cases
  TOT                                       26 (17.9%)
  Prolapse repair ± mesh repair             43 (29.6%)
  TOT + prolapse repair                     12 (8.2%)
  Botox                                     31 (21.3%)
  Cystoscopy                                25 (17.2%)
  Colpoclesis                               8 (5.5%)
        General Practitioners’ Attitude to                      RESULTS: A total of 116 questionnaires were mailed. 70
P21     Vasectomy: Its relevance to the                         completed questionnaires were returned. Of the respondents,
                                                                45 (64%) discuss failure rates, 25 (36%) discuss postoperative
        establishment of a one stop service                     complications, 47 (67%) describe the procedure as irreversible,
        P Erotocritou; S Al-Buheissi; R Lunawat;                whilst 4 (5.7%) were unsure of anaesthesia options for the
        BH Maraj                                                procedure. In addition, only 12 (17%) examined the genitalia
        Whittington Hospital NHS Trust                          prior to referral.
INTRODUCTION: Prior to establishing a one stop vasectomy        CONCLUSIONS: Information given by General Practitioners to
service at our local Trust, we decided to assess the            their patients about vasectomy is pivotal to the establishment
understanding local General Practitioners had about the         of an efficient one stop service. We however, found this
procedure. Additionally, their counselling information was      information to vary widely and lacking in completeness.
recorded to see whether this would affect a new service.        Knowledge of these variations will allow urologists to provide
                                                                appropriate further education to enable a one stop vasectomy
METHODS: A 6 question survey relating to aspects of
                                                                service to be established. To further address this, we now aim
vasectomy surgery and examination of the external genitalia
                                                                to conduct educational meetings with our local primary care
was mailed to the surrounding General Practices. Results were
                                                                colleagues.
processed and appropriate analysis performed.




         How Acceptable is Daycase                              Overall 91% would recommend DCLC to a friend (tDC 93%, eDC
P22      Laparoscopic Cholecystectomy?                          95%). Median postoperative analgesic requirement was 3 days
                                                                (6 days young, 3 days middle aged, 4 days elderly). Only 8%
         S Reshamwwalla, ER Drye, TJ Cahill,                    required analgesia longer than 2 weeks.
         P Bowes, V Vijay, SJ Warren
                                                                Failed DCLCs had a median length of stay of 2 days (young),
         Chase Farm Hospital, Enfield                           5 days (middle aged) and 5 days (elderly). Failures included
INTRODUCTION: Only 6% of laparoscopic cholecystectomies         conversion to open (27%), urinary retention (11%) but never
(LCs) are performed as daycases (DC) in the UK. We assessed     pain (0%). 19% of elderly DCLC patients had medical
feasibility and patient acceptability of DCLC across the age    consultations post discharge, compared with 38% of middle
spectrum, both as true daycase (tDC same day discharge) or      aged and 29% of young; commonest reasons being wound
extended daycase (eDC <24 hour stay).                           check (65%) and umbilical port site infection (12.5%).
METHODS: Data from scheduled DCLC patients from 2003 was        Readmission rates were 3% (young), 3.5% (middle aged) and
analysed for length of stay, complications and readmission      4% (elderly). Normal activity was achieved within 6 weeks of
rate. A telephone questionnaire assessed patient satisfaction   discharge in 86% of patients; 93% were young, 84% middle
(0 to 10), postdischarge consultation, return to normal         aged and 87% elderly.
activities and postoperative analgesic requirements.            CONCLUSIONS: DCLC is successful in 80% of all patients.
RESULTS: 199 patients were included, 146 female. Median age     However, with increasing age there is a decreasing rate of true
was 66 years (range 24–89). 128 patient questionnaires were     DCLCs. In successful DCLC, a low readmission rate is achieved
obtained.                                                       with high satisfaction scoring and over 90% of patients would
                                                                recommend a DCLC. To provide a successful DCLC service, one
                          Young    Middle age   Elderly         must expect one third of elderly patients to fail and anticipate a
                         <50 yrs   50–70 yrs    >70 yrs         higher analgesic requirement in younger patients. DCLC is
Number (n)                  37         85         77            successful and achievable for the majority.
True DC                    54%        29%        17%
Extended DC                38%        60%        51%
Failed DC                  8%         11%        32%
Satisfaction tDC           7.7        8.6         8.6
Satisfaction eDC            9.3        8.4        8.7
         ‘How Are We Doing’? Patient                                 put up in all the clinical and admission areas. An instruction
P23      satisfaction within King’s College                          sheet to the clinical staff was produced to help them explain
                                                                     and administer the questionnaire. A pilot questionnaire was
         Hospital Day Surgery Unit                                   produced with an information sheet to patients explaining the
         J Bush, J Doyle, U Fountain, T Hiles,                       reason for the survey. Patients were also asked to answer a few
         H Peskett, R Sugarman                                       questions about the questionnaire to ensure that the questions
         Day Surgery Unit, King’s College Hospital                   were clear and patients could understand what was being
                                                                     asked of them. The pilot questionnaire was handed out over 5
INTRODUCTION: The National Inpatient Survey is one of the            days in September 2007 and ‘How Are We Doing’ (HRWD) boxes
biggest assessments of views of patients. It provides trusts         were provided in all the clinical areas and patients were
with an independent view of what patients think of the service       encouraged to post the completed questionnaire. Some
they receive while in hospital. The findings allow them to           questions were adapted after reflecting on patients’ comments.
compare their results to the national average and to similar         The survey was run over a 2 week period in November 2007.
trusts across the country. The results also feed into the Health     The questions were split between 4 categories, each with
Care Commission’s annual health check, the system for                several questions attached to it: Category 1: Before your
measuring the performance of NHS organisations. The survey           surgery; Category 2: Cleanliness of the department; Category 3:
enables improvements and changes to be made in order to              The Care you received; Category 4: Going home.
improve patients’ experiences of their time in hospital. The Day
Surgery Unit (DSU) at King’s College Hospital is a stand alone       RESULTS: 232 patients completed the questionnaire. Category
unit with 7 operating theatres, 3 ward areas (adult, paediatric      1: 91% patient were satisfied with the information given to them
and ophthalmic), a dedicated preassessment suite and treats          by admission and clinical staff. Category 2: 84% were satisfied
around 11, 000 patients a year. Views of day surgery patients’       with the cleanliness of the department. Category 3: 93% of
treatment and care were not reflected in the patient satisfaction    patients were satisfied with the courtesy of clinical staff, had
across the trust and in September 2007 the DSU introduced the        confidence and trust in the clinical teams and the teamwork
‘How Are We Doing Survey’.                                           between doctors and nurses. Category 4: 91% of patients were
                                                                     satisfied with discharge information, understanding of who to
METHODS: The inpatient questionnaire was adapted to reflect          contact in case of need and would recommend having their
the nature of daycase patients by the Head of Patient and            procedure done as a daycase. Overall 91% of patients were
Public Involvement, the Patient Survey Coordinator and the           satisfied with the care and treatment they received.
senior team of the DSU. All clinical and admission staff were
briefed during a staff meeting and by letter. Background
information on the inpatient survey was included. Posters were



         Is it Acceptable Practice to Perform                        RESULTS: No patients refused to consent to the survey, in fact
P24      Plastic Surgical Procedures on                              some were very pleased for an opportunity to relate their
                                                                     experiences. Patients’ ages ranged from 16–94 years. 22%
         Patients in a Satellite Day Surgery                         patients were operated on by a middle grade and 72% by a
         Unit? The patients’ perspective                             consultant surgeon. Procedure complexity ranged from simple
         S Hassan, L Ferguson                                        excision with direct closure (90%) to closure with either full
         University Hospital Coventry and Warwickshire               thickness skin graft (7%) or local skin flap (3%). There was a
         NHS Trust                                                   10% rate of delayed wound healing (>2 weeks of dressings to
                                                                     fully heal: range 2–8 weeks) and the rate of infection requiring
INTRODUCTION: There is a major DOH drive to encourage and            antibiotics was 8%. 32% of patients complained of
incentivise performing more plastic surgical dermatological          postoperative bleeding/oozing following discharge, of whom
procedures as day surgical episodes. Many of these procedures        30% required a visit to either their GP or their local A&E
are performed via satellite/bespoke day surgery facilities in        department. There were no significant scar related problems at
small district hospitals. We audited patients’ satisfaction of the   the time of the questionnaire. No patients said that they would
day surgery experience from their initial appointment letter to      not be happy to have another procedure performed in the same
conclusion of the surgical episode.                                  DSU. Overall there were no significant problems with the
METHODS: Over a 3 month, consecutive adult plastic surgery           preoperative workup to their procedure or the amount of
patients who underwent local anaesthetic day surgery                 information given to patients.
procedures at Stratford-upon-Avon Day Surgery Unit (DSU) by          CONCLUSIONS: Overall patients were happy with having their
either middle grade or consultant plastic surgeons were              ‘minor’ surgery performed in the DSU. However there is some
audited by retrospective telephone questionnaire. They were          concern with the level of postoperative wound infection and
asked detailed questions relating to pre-, per- and                  the rate of postoperative bleeding that required some form of
postoperative aspects of their experience. All patients who had      further treatment. This will be discussed in more detail. There
not yet completed their course of treatment were excluded            are no nationally agreed targets for an acceptable level of
unless this related to the treatment of a complication from their    postoperative wound problem available form the DOH.
initial day surgery procedure. Patient were also excluded if they    Performing procedures as a day surgery procedure must be
could not be contacted after three independent attempts. It          carefully evaluated and audited.
was made explicitly clear that patients were under absolutely
no obligation to take part in the audit and that their responses
would be kept entirely confidential. They were told that they
could withdraw their data at any time without consequence to
any aspect of their care.
         Is there a role for Morphine in Modern                     were given morphine, compared to those who did not have
P25      Day Ambulatory Surgery? – A district                       morphine.

         general hospital experience                                58% of patients given morphine had a delayed discharge
                                                                    compared to only 14% of patients not given morphine. In
         NN Basu, B Kald, DI Heath.                                 comparison, 43/50 patients were discharged on time when not
         Queen Elizabeth Woolwich                                   given morphine whereas only 21/50 patients receiving
INTRODUCTION: The provision of an efficient ambulatory              morphine had a timely discharge.
service is dependant on judicious preoperative planning.            Social reasons accounted for almost 30% of delayed discharge
Morphine has been used historically in the day surgery setting.     in both groups.
The side effect profile is well recognised by most clinicians and
                                                                    CONCLUSIONS: This study shows that there is still a tendency
may limit its efficacy in the day surgery setting1,2. The primary
                                                                    to administer morphine in major surgical cases in day surgery.
objective of this study was to assess whether administration of
                                                                    This is associated with increased operative times and time
morphine in the intraoperative or postoperative period resulted
                                                                    spent in the recovery suite. In addition, there is a greater
in delayed discharge following ambulatory surgery in a district
                                                                    chance of delayed discharge in patients who have been
general hospital setting.
                                                                    administered morphine. At present, there are several
METHODS: This prospective, observational study recruited 2          alternative analgesic compounds as efficacious as morphine,
groups of 50 patients undergoing day care surgery. The first        without the side effect profile3. It is likely that these
group were given morphine intraoperatively or in the                compounds will become the mainstay analgesic preparation in
perioperative period. The second group did not receive              ambulatory surgery. Optimisation of day surgery to prevent
morphine, although may have received other non-morphine,            costly delays in discharge may include avoidance of morphine.
opioid analgesics. The primary outcome was whether discharge
                                                                    REFERENCES
was delayed. In addition, reasons for delayed discharge were
noted from the medical records.                                     1. Shirakami G, et al. Journal of Anaesthesia. 2005;19(2):93-
                                                                       101
RESULTS: 73% (24/33)of all major cases received morphine
whereas only 19% (4/21) of all minor cases received morphine.       2. Wong J, et al. Canadian Journal of Anaesthesia 2000;
In the intermediate complexity group almost half the patients          47:1090–3
received morphine. The duration of surgery and time spent in        3. Khan ZU, et al. Pakistan Journal of Medical Science 2007;
recovery was significantly (p<0.05) greater in the group who           23:851–3




         Laparoscopic Cholecystectomy:                              which 4 were DC. 2 out of the 7 postoperative wards had high
P26      Daycase vs. Overnight Stay:                                discharge rates, one of them being Short Stay Ward (23 hour).
         A retrospective audit                                        Reasons for overnight stay               Number (%)
                                                                      Drain in situ                            39 (21.4%)
         M Ahuja
                                                                      Converted to open                        2 (1%)
         New Cross Hospital, Wolverhampton                            Pain                                     6 (3.3%)
                                                                      Pain & nausea                            4 (2.1%)
INTRODUCTION: Day surgery laparoscopic cholecystectomy
(LC) is the procedure of choice in patients with symptomatic          Nausea                                   10 (5.4%)
                                                                      Drowsy                                   4 (2.1%)
gallstones. The aim of this audit was to determine the
                                                                      Social reasons                           2 (1%)
proportion of LC done as daycases at New Cross and to identify        Inability to void urine                  10 (5.4%)
the causes for overnight stay.                                        Patient decision                         1 (0.5%)
METHODS: A retrospective audit of all patients who underwent          Lightheaded                              4 (2.1%)
LC between Jan 2007 and Dec2007 was performed using a                 Oozing                                   2 (1%)
proforma to gather case note data. No daycase criteria were set       Medical complications                    9 (4.9%)
and all patients electively listed for LC were assumed to be          No reason                                57 (31.3%)
daycases (DC).                                                        Surgeon’s practice                       32 (17.5%)

RESULTS: Of 251 cases, 182 (73%) stayed overnight and 69            CONCLUSIONS: The wide variation in discharge rate reflects
(27%) were DC. Most DC were ASA I (51%) or II (45%). The            individual surgical practice. More patients from am list were DC
majority of DC had BMIs of 20–40 (no upper limit). Anaesthesia      (69.5%). Type of anaesthesia for am lists did not influence DC
was administered by 80% consultants, 12% staff grades and 6%        rate. For pm lists, TIVA performed better than inhalational
trainees. 71% received analgesic premedication (NSAID /             techniques. Analgesic premedication and intraoperative
codeine compounds), 22% had antiemetics preop (cyclizine) and       antiemetics reflected lower pain and nausea scores. All
35% H2 blockers. Intraoperatively, 93% DC received opioids,         patients with drains stayed overnight for observation. 30%
12% NSAIDs and 97% antiemetics. 30% received TIVA. Port sites       stayed in for no documented reason. A motivated surgical and
were infiltrated with local anaesthetic in 70% of DC. 80% had no    anaesthetic team with enthusiastic ward staff are the driving
pain in recovery, 10% mild, 7% moderate and 4% severe pain.         force for achieving higher DC rates. Some of the highest
Rescue fentanyl/ morphine was administered for moderate and         performing hospitals in UK achieve 40 to 50% same day
severe pain. Only one patient had nausea in recovery, treated       discharge rate. Considering that no daycase criteria were set
with cyclizine. 9 different surgeons performed LC with wide         for this audit, 27% DC rate is acceptable (national average
variation in DC rate. 3 surgeons achieved 33–37% compared to a      6.4%).
couple with 0%. Biliary leak was documented in 25 cases of
         Medicolegal Implications of                              samples for analysis. Thirteen (28.26%) of these submitted a
P27      Vasectomy; histology and negative                        single semen sample at 12 week whilst two consecutive
                                                                  specimens at 12 & 16 weeks were submitted by only 18
         semen at 4 months may be adequate                        (39.13%) patients. Fifteen (32.60) patients failed to submit any
         to avoid litigation                                      sample at all. Of patients who had postoperative semen
         MS Mirza, K Pattanayak                                   analysis 27 (87.09%) were found to have azoospermia, all at 12
                                                                  week. Three patients were found to have non-motile sperms
         Newham University Hospital
                                                                  whilst one patient had motile sperms. Postoperative
INTRODUCTION: Vasectomy is safe and dependable for male           haematoma developed in 2 patients (4.3%) and 3 (6.52%)
contraception. Operative failure to render sterility results in   patients suffered chronic orchalgia.
unwanted pregnancy and consequent litigation. Compliance
                                                                  CONCLUSIONS: A high percentage of patients are not
with follow up after surgery is low. Histological proof of
                                                                  compliant with the current follow up protocol after vasectomy
vasectomy and a single negative semen specimen may be
                                                                  even if adequately counselled. This can cause medicolegal
adequate to avoid litigation.
                                                                  problems for the surgeon. Histological evidence of the
METHODS: Retrospective analysis of case notes of patients         procedure therefore attains prime importance in litigation
undergone vasectomy over three years from February 2003 to        against surgeons. By simplifying the postoperative follow up to
February 2006 by a single surgeon. Data collected on patient      a single semen analysis at 4 months in addition to histology
demographics, surgical technique and complications, and           may not only improve patient compliance and be cost effective
patient follow up.                                                but could also avoid litigation.
RESULTS: Forty six vasectomies were undertaken as daycase
procedure, 41 under general anaesthesia and 5 under local
anaesthesia. Histological proof of vasectomy was obtained in
45 patients. 31 patients submitted postoperative semen




         “Mini-open” Repair of Acute Tendo-                       were followed up for at least one year. Both Lippeilahti score
P28      achilles Ruptures — The solution?                        for rupture Achilles tendon repair and the American
                                                                  Orthopaedic Foot and Ankle Society for the Ankle-Hind foot
         M El-Husseiny, C Mukundan, F Rayan,                      Clinical Rating System were calculated. The patients (8 males
         A Budgen                                                 and 13 females) had a mean age of 43. Post-operatively leg was
         York Hospitals NHS Trust                                 placed in an air cast boot with 3 heel wedges allowing 30
                                                                  degrees of plantar flexion. Foot is brought into planti-grade
 Achilles tendon rupture is the third most common major
                                                                  position by six weeks with serial removal of heel wedges
tendon rupture. The treatment has been debated since 1888
                                                                  followed by rehabilitative training programme. There were no
when open repair was first performed by Polaillon. The
                                                                  infections, re-rupture or sural nerve involvement noted. All
standard exposure for surgical repair of acute rupture of
                                                                  patients returned to previous work and sports activities. All
Achilles tendon gives favourable results, although such
                                                                  patients scored above 90 in the American Orthopaedic Foot and
extensive exposure increases the possibility of peri-tendinous
                                                                  Ankle Hind foot Clinical Rating System and on the Leppilahti
adhesion which may impair functional outcome. To evade this,
                                                                  Scoring System. Thus Mini open procedure is an excellent
a mini open technique was developed which provide anatomic
                                                                  alternative to open exposures which are extensile.
apposition of the tendon ends and minimal damage to epi-
tendon. We describe a retrospective case series of 21 patients
who were treated with mini open technique as a daycase,
between 2004 and 2007 operated by a single surgeon. They
         Optimal Patient Positioning for                            position. Some anaesthetists still preferred to remove the LMA
P29      Removal of Laryngeal Mask Airways                          in supine (Sup) asleep patients and then turn them lateral for
                                                                    transfer to recovery. Although associated with a higher rate of
         in Children — Results of an audit cycle                    initial complications, the complication rate in recovery was only
         G Thomas-Kattappurathu, JA Short                           5.4% in these patients. Complication rates for awake removal
                                                                    remained higher; 54.5% supine and 24% lateral. \clinically
         Sheffield Children’s Hospital
                                                                    significant complications reduced from 2.2% in the first audit to
INTRODUCTION: Airway complications on removal of the                0.6% on re-audit.
laryngeal mask airway (LMA) after anaesthesia in children are
                                                                                            Audit             Re-audit
well documented. We audited our practice, instituted                 Number                  180                154
recommendations to reduce complications and re-audited to
                                                                     Stage             Deep     Awake    Deep       Awake
assess the outcome.                                                  Number             104      66       105          45
METHODS: The standard for this audit was based on reported           Position        Sup Lat Sup Lat   Sup Lat Sup Lat
complication rates1,2: <10% LMA anaesthetics should be               Number          81 23 40 23       60 43      11    25
associated with postoperative airway complications, defined as       Complications   14 2     17 2     10 1       6     6
                                                                     Comp %          17% 8.7% 43% 8.7% 17% 2.3% 55% 24%
coughing, biting, airway obstruction, laryngeal spasm,
desaturation to SaO2<90%, excessive secretions, retching /           Significance      NS        P<0.01     P=0.03        NS
vomiting and airway trauma. Patient, anaesthetic and surgical
details were recorded over 4 weeks, along with the depth of         CONCLUSIONS: Patient position on removal of the LMA seems
anaesthesia, patient position and the occurrence of                 to have a significant influence on the development of
complications (including their clinical significance) on LMA        complications. The optimal position is lateral at any plane of
removal. Data were analysed by Fisher’s exact test where            anaesthesia; the calibre of the sedated paediatric airway is
appropriate. After recommendations were made for                    larger in the lateral position3 and there is less likelihood of
subsequent practice, a re-audit was performed some months           retained secretions being inhaled in this position. We
later, using similar methodology.                                   recommend that, unless patients cannot be turned, LMAs
RESULTS: The first audit showed a lower incidence of                should be removed in the lateral position.
complications when the LMA was removed in a deep plane of           REFERENCES
anaesthesia compared with awake, and audit standards were           1. Kitching AJ, et al. British Journal of Anaesthesia 1996;
met when the LMA was removed in the lateral (Lat) position at          76:874–6
either depth of anaesthesia. Recommendations were made to
encourage LMA removal in the lateral position and, except for       2. Dolling S, et al. Anaesthesia 2003;58:1224–8
patients with a soiled airway, in a deep plane of anaesthesia.      3. Litman RS, et al. Anesthesiology 2005;103:484–8
On re-audit, more patients had their LMA removed in the lateral



         Oral Morphine: Is it suitable for day                      as first rescue analgesic, only 12% needed another analgesic
P30      surgery?                                                   dose, but when codeine was given as first rescue, 45% needed
                                                                    further analgesia.
         SK Mekala, K Radford, J Vernon
                                                                                                          SA Group    OM Group
         Nottingham University Hospitals, City Campus
                                                                    Number                                   111         121
INTRODUCTION: Codeine phosphate is considered a pro drug;           Nausea
production of its active metabolites is genetically determined      none/mild                             73% / 12% 60% / 4%
and variable, so it may have little or no analgesic effect in       mod/severe                              1% / 0   3% / 5%
approximately 8% of Caucasians 1. It is a widespread                unknown                                  14%      26%
perception that use of oral morphine (OM) may be associated         Vomiting                                  1%       3%
with an increase in nausea and vomiting (PONV), making it           Unplanned admission (non-surgical)        2%       2%
unsuitable for day surgery. OM solution is widely used in our
trust and has recently been introduced to the day surgery unit.     The table shows a trend of increased PONV in the OM group.
We performed an audit on postoperative analgesia using our          The recovery nurse’s observations and opinions concur with
standard regime, and then introduced OM as the preferred            this. The unplanned admissions due to non-surgical reasons
analgesic.                                                          remained similar in both audits. Recovery nurses particularly
                                                                    like OM as it may be given when no medical staff are present on
METHODS: Recovery data were prospectively collected on
                                                                    the unit (unlike IV morphine).
adult patients following operations under general anaesthesia.
Pain and nausea were scored on a scale of 0–3. Analgesics,          CONCLUSIONS: These audits show that patients needed fewer
antiemetics, unplanned admissions and recovery nurse’s              doses of analgesics when OM was used as the first choice
observations were recorded. Patients had a standard analgesia       rescue analgesic in our day surgery unit. However, this may be
(SA Group) prescription of oral codeine, oral tramadol and          combined with a possible increase in PONV. The unplanned
paracetamol. IV fentanyl and IV morphine were available for         admissions rates are similar in both audits. The dose range
severe pain. Some patients were prescribed OM at the nurse’s        given to patients was 10–30mg of OM. It is likely that this
request, The results of this audit were then analyzed. A re-audit   relatively high dose range caused the problems with PONV. We
was started when anaesthetists were requested to prescribe          have designed a dosing protocol that will use a lower dose
OM solution (OM Group) and paracetamol as the standard              range starting with 5mg doses of OM. A re-audit is planned and
recovery analgesia, with IV fentanyl and IV morphine for severe     results should be ready for presentation in June 2008.
pain. The same information was collected as before, over a          REFERENCE
similar timeframe.
                                                                    1. Peck CC, et al. JAMA. 1993;269:1550–2
RESULTS: Age, sex and surgical subspecialty distribution were
broadly similar between the groups. Of the patients given OM
         Outcome of Laparoscopic                                      diameter of cystic duct was greater than 5mm. All the
P31      Cholecystectomy by Harmonic Scalpel                          procedures were done by a single consultant surgeon.

         in Obese Daycase Patients                                    RESULTS: None of the patients needed conversion to open
                                                                      procedure. There was no significant difference (p=0.055) in
         S Ganapathi, S Hassan, R Sewell, T                           operating time between the two groups (Gr. 1: Mean 26.4min,
         Parkinson, H Patel, S Patel, N Marshall                      Median–20min, Range 7–70min; Gr. 2: Mean 34.6min, Median
         Newham University Hospital NHS Trust                         30min, Range 5–90min). There was a significant difference
                                                                      (p=0.004) in hours of inpatient stay (Gr. 1: Mean–21.97,
INTRODUCTION: Traditionally obesity has been seen as a
                                                                      Median–8, Range–3–336; Gr. 2: Mean–27.05, Median–21,
contraindication to day surgery. Laparoscopic cholecystectomy
                                                                      Range–3–192). The incidence of major and minor complications
is still relatively uncommonly performed in day surgery1.
                                                                      were similar in both groups. There was no significant difference
Obesity poses a challenge especially in a daycase setting
                                                                      in operative blood loss, analgesic requirements, return to
because of increased technical difficulty and higher rate of
                                                                      normal activity and readmission rates following discharge.
complications. Advancements in the harmonic scalpel blade tip
now provide reliable ultrasonic division and closure of cystic        CONCLUSIONS: Obese patients were more likely to need
duct in addition to division of vessels and liver bed dissection.     admission following laparoscopic cholecystectomy. But there
The outcome of obese patients who underwent laparoscopic              was no significant difference in terms of complications,
cholecystectomy by harmonic scalpel in the day surgery unit           operating time, operative blood loss, analgesic requirements
was analysed.                                                         and return to normal activity. Dissection with harmonic scalpel
                                                                      improves the overall outcome in obese daycase patients
METHODS: A prospective nonrandomised study was
                                                                      undergoing laparoscopic cholecystectomy in addition to the
conducted on elective daycase patients undergoing
                                                                      reduced operating cost inherent in using a single disposable
laparoscopic cholecystectomy. Among a total of 75 consecutive
                                                                      instrument.
patients 32 patients had BMI<30(Group 1) and 43 patients had
BMI>30(Group 2). The procedure was done using harmonic                REFERENCE
scalpel for division of the cystic artery and cystic duct and liver   1. Smith I. Journal of One-day Surgery 2004;14(2):4–6
bed dissection. Antegrade dissection was employed in all
patients. Cystic duct was secured with an endoloop if the




         Pain and Analgesia Requirements                                                        Pain score       Analgesia score
P32      Following Endovenous Laser Ablation
                                                                         Postoperative day
                                                                                               Median (range)     Median (0–3)
                                                                               1                  3 (0–9)              2
         of Great Saphenous Vein                                               3                  1(0–6)               0
         SC Mckay, NR Banga, SJ Walton, JN Crinnion                            7                  3 (0–6)              1
                                                                               10                 1 (0–3)              0
                                                                               14                 0 (0–3)              0
INTRODUCTION: Endovenous laser ablation (EVLA) is an
effective alternative to surgical ligation and stripping of the
great saphenous vein (GSV), with the benefits of minimal              CONCLUSIONS: Our findings suggest that pain following EVLA
access, reduced trauma and immediate ambulation. However,             of the GSV exhibits a bimodal distribution, peaking on the 1st
we have noted that some patients have significant                     and 7th postoperative days. The aetiology is unclear but may
postoperative pain. Our aim was to determine the pattern and          be due to a delayed inflammatory process. This data is helpful
severity of postoperative pain after EVLA.                            in counselling patients regarding this procedure, and may
                                                                      prevent unnecessary concerns and consultations
METHODS: EVLA was performed in 25 patients with tumescent             postoperatively.
local anaesthesia using an 810nm diode laser (14W continuous
mode) which delivered 50–70 Joules to each cm of GSV vein
treated. The leg was bandaged and patient mobilised
immediately. Nonsteroidal antiinflammatory analgesia was
provided and the patients kept a visual analogue score pain
diary (score 0–10) and analgesia diary (score 0–3) for 2 weeks.
RESULTS: 22 patients provided complete pain and analgesia
diaries at their 2 week follow-up. A duplex scan revealed
absence of flow in all treated veins. The median pain score
peaked on the 1st and 7th postoperative days (see table). 5
patients reported no pain, 1 patient reported severe pain (score
> 5 on days 1–7) and the remainder had moderate symptoms.
There was no relationship between the total power delivered
and the pain or analgesia scores.
         Preemptive Intraperitoneal                                  RESULTS: 15% in group A and 18 % group B had pain scores of 1
P33      Instillation of Large Volume Low                            (mild pain). 71% in group A and 60% in group B had pain scores
                                                                     of 2 (moderate pain). Further, none of the patients in group A had
         Concentration Lidocaine for                                 any injected analgesic on the first postoperative day.
         Postoperative Analgesia after                                                        Group A      Group B     P value
         Laparoscopic Cholecystectomy: An                              Mean age (yr)            48.3         53.5          NS
                                                                       Mean duration (min)      59.1         50.3          NS
         observational study
                                                                       Mean morphine (mg)        7.7         12.3        p<0.05
         G Gopalakrishnan, K Krishnan, M Hemadri,
         M Jaganathan                                                CONCLUSIONS: The use of lidocaine for local anaesthesia has
         Scunthorpe General Hospital                                 conventionally been limited to a maximum dose of 7 mg/kg. The
                                                                     safety and use of large volume low concentration high dose
INTRODUCTION: Laparoscopic cholecystectomy (LC) is                   lidocaine has been established in tissues outside the abdomen2.
associated with moderate to severe postoperative pain. Since         It has also been found that high doses (up to 35 mg/kg)
this surgery is increasingly done as a daycase, good analgesic       administered at low concentrations provide good long term
takes priority to reduce the incidence of admissions. Studies        postoperative analgesia. These effects have not been tested in
have shown that large volume local anaesthetic solutions used        the abdomen. We found that even at slightly higher doses low
intraabdominally offer better postoperative pain relief. We did a    concentration lidocaine improved analgesia. although not
retrospective observational analysis to determine if a large         statistically significant. We suggest that at higher doses, this
volume of dilute lidocaine1 solution reduced postoperative           technique could prove a potent tool in accelerating daycase
analgesic requirement.                                               laparoscopic surgery. In this observational retrospective study,
METHODS: Forty five patients who underwent laparoscopic              we found intraperitoneal instillation of large volume low
cholecystectomy were found to fall into two groups. Group A:         concentration lidocaine reduced postoperative opioid
lidocaine with 1 in 200,000 adrenaline at a dose of 8 mg/kg          requirement. A randomised blinded trial needed to establish its
diluted to 800 ml of normal saline (concentration of 0.1%) was       usefulness and safety.
instilled into the peritoneal cavity before pneumoperitoneum.        REFERENCES
Group B: no instillation. The intraoperative and postoperative
care were standard for our practice. Intraop all patients had 100    1. Elhakim M, et al. Acta anaesthesiologica Scandinavica 2000;
µg fentanyl, 6–12 mg morphine and 5–10 ml of levobupivacine             44:280–4
injected into the portal incision site. Postop patients were given   2. Klein JA. American Journal of Cosmetic Surgery
regular NSAIDS and morphine when required. All patients had             1987;4:263–7
standard monitoring. Morphine use and verbal pain scores
were recorded for the first 24 hours.


         Preoperative Fasting on Children                              Table 1                                     Number
P34      Presenting for Plastic Surgery Trauma                         Fluid fast
         I Kannan, R Menon                                             2–3 hours                                       8
                                                                       4–6 hours                                      10
         Royal Victoria Infirmary, Newcastle                           7–12 hours                                     10
INTRODUCTION: Plastic surgery trauma cases are short                   >12 hours                                       6
stay/daycase procedures hence 2–3 hours fasting for fluids             Solid fast
and 6 hours fasting for solids before induction are justified1.        >16 hours                                      34
The Royal College of Anaesthetists in addition states that the
                                                                     Fasting status is summarised in the Table 1. 4 52% of parents
children should be fed as late as possible in the night for
                                                                     were dissatisfied with their management Table 2.
morning surgery and should have breakfast before 7:30 am for
afternoon surgery. RVI, being a regional referral centre for           Table 2                                     Number
paediatric plastic surgery even minor plastic trauma gets
referred from DGH A&Es to the trauma clinic. They are starved          Satisfied                                      10
from 2:30 am and further starved till a slot for theatre becomes       Dissatisfied                                   18
available. This audit was done to determine the fasting times of       No comment                                      6
children presenting for plastic surgery.                               Invalid entry                                   1

METHODS: A prospective audit was conducted from October to
                                                                     CONCLUSIONS: The study clearly showed that children are
December 2007. The ward nurses filled in a questionnaire
                                                                     fasted for prolong periods, causing lot of anxiety and
collecting: Patient details; Surgery; Any relevant medical
                                                                     dissatisfaction to the parents.
condition; Fasting status Time of induction; Parents/Children
satisfaction.                                                        The results were presented in the multidisciplinary meeting
                                                                     consisting of plastic surgeons, anaesthetists and nursing staff.
RESULTS: Out of the total sample of 35 collected, 1 was invalid
                                                                     Decision was taken to admit children directly to ward from
so 34 responses were analysed. 31 children were operated on
                                                                     A&E’s of referring hospitals. The registrar will review the patient
the day of admission. Two children were operated the next day.
                                                                     and book slot in emergency /trauma theatres. They will be fed
One child was done after two days.
                                                                     at the time of arrival and given fluids until 3 hours before
                                                                     surgery by liaising with the anaesthetist. Plastic surgeons will
                                                                     try and actively accommodate the trauma at the end of their
                                                                     elective list. Re-audit to be undertaken after 6 months.
                                                                     REFERENCE
                                                                     1. Phillips S, et al. British Journal of Anaesthesia 1994;
                                                                        73:529–36
         Reducing Waiting Times for Lymph                             RESULTS: During the study period 61 patients had a peripheral
P35      Node Biopsies                                                (i.e. non-breast) lymph node biopsy. All of these patients’ notes
                                                                      were reviewed; 1 set of notes could not be analysed due to
         SAJ Pannick, H King, CL Ingham Clark                         inadequate documentation. The vast majority of the procedures
         Whittington Hospital NHS Trust                               were performed as daycases. Neoplasia (carcinoma or
                                                                      lymphoma) accounted for 43% of diagnoses; infectious disease
INTRODUCTION: General surgeons receive numerous referrals
                                                                      for 10%, including 4 cases of tuberculosis; 33% biopsies
for lymph node biopsies for investigation of lymphadenopathy.
                                                                      showed benign changes or Kikuchi’s disease; 5%
These procedures are usually performed as daycases. Many of
                                                                      lymphadenopathy diagnoses were incorrect; and 8% of biopsy
these patients will subsequently require treatment for
                                                                      results were unrecorded. The predominant referral sources
neoplastic or infectious disease. However, there is little
                                                                      were Haematology (33%) and General Practice (28%). 47%
evidence for specific changes that can speed the diagnostic
                                                                      patients were referred to the surgeons by letter, 45% by
pathway. We sought to explore the variation in waiting times for
                                                                      personal discussion or email, and 8% by fax. Patients referred
lymph node biopsies according to referral source and referral
                                                                      by letter were often seen in clinic (64%) whereas all those
method, and identify opportunities to expedite lymph node
                                                                      referred in person proceeded straight to biopsy. Clinic
biopsy after referral.
                                                                      attendance had no significant bearing on diagnostic accuracy.
METHODS: Patient records for all lymph node biopsies at one           Personal referral was associated with a much shorter time to
hospital in the last two years were identified from Hospital          biopsy than written referral (median waiting time 4 days vs 51
Episode Statistics data. Breast lump referrals were excluded as       days, p<0.001).
a separate referral pathway already exists. Patient notes were
                                                                      CONCLUSIONS: Personal referrals resulted in significantly
then analysed according to criteria established in advance of
                                                                      shorter waiting times before lymph node biopsy compared to
data collection. The notes were assessed for waiting time from
                                                                      written referrals. The speed with which personal referrals arrive
surgical referral to biopsy; referral source; method of referral;
                                                                      at lymph node biopsy should be translated to written referrals.
attendance in surgical clinic; and diagnosis.
                                                                      With 43% of lymphadenopathy (in this study) caused by
                                                                      malignancy, a rapid diagnostic pathway is imperative.




         Scope on Ambulatory Care for                                 No significant wound breakdown occurred in our series, one
P36      Aesthetic Breast Surgery                                     case required revision surgery and another required an
                                                                      evacuation of a haematoma.
         RR Salman, AR Salman
                                                                      Specific surgical factors that contributed to these results
         Park West Clinic, Auralia Hospital
                                                                      included
INTRODUCTION: Interest in day care surgery is on the increase         1 prospective haemostasis techniques with a zero tolerance
world wide, with various surgical specialties embracing this            for even the smallest amount of bleeding,
mode of health service. We develop practices that would allow
patients undergoing breast augmentation to predictably return         2 strict “no touch” techniques for periosteum and implant,
to full normal activities within 24 hours after the operation, free   3 eliminating all blunt dissection,
of postoperative adjuncts
                                                                      4 performing all dissection under direct vision,
METHODS: In a period of 2 years (January 2006–December
                                                                      5 modified and simplified instrumentation, and
2007), 320 patients attending our unit were operated on a day
care basis. More extensive patient information integrated with        6 optimal use perioperative analgesia.
staged informed consent resulted in a more informed and               CONCLUSIONS: We conclude that day care augmentation
confident patient. All patients were treated as outpatients and       breast surgery in our experience is safe and effective when
received general anaesthesia.                                         focuses on the patient education, preoperative planning,
RESULTS: The most frequently performed procedure was                  instrumentation, and surgical technique changes based on
bilateral breast augmentation with implant 201.Readmission            reduced surgical trauma and bleeding and will result in reduced
represents failure of day care surgery and constituted 0 % of all     perioperative morbidity and excellent patient satisfaction.
cases. All patient were followed out on week 1,3,6,10 and 24.
         Senior Anaesthetic Involvement in                          RESULTS: 1022 patients were preassessed for general
P37      Preassessment for Daycase Surgery                          anaesthesia in the specialities of Urology, General Surgery and
                                                                    Gynaecology within the six months.144 (14%) patients were
         SE Taylor, SM Lloyd                                        discussed at the weekly meeting with the Consultant
         St James’s University Hospital, Leeds                      Anaesthetist. Of 116 patients deemed suitable for day surgery,
INTRODUCTION: In our Unit, the nurses responsible for               114 (97%) were managed as such. Of the two cancellations, one
preassessment meet with a specific Consultant Anaesthetist          patient had developed significant co morbidity since
once a week to discuss patients who may not be candidates for       preassessment. The other was a high risk patient. There was
daycase surgery based on the current department exclusion           one unplanned admission for surgical reasons and one
criteria. Management is planned in order to optimise the            inpatient treated as a daycase.
number of daycases, prevent cancellation on the day of surgery      CONCLUSIONS: This weekly meeting allows our Day Surgery
and to produce plans to enable inclusion of higher risk             Unit to manage patients as daycases who would otherwise
patients.                                                           have been considered unsuitable based on the proforma,
METHODS: A six month retrospective analysis was undertaken          guidelines and protocols used by the preassessment nursing
initially from a paper database held at the preassessment           staff. This has benefits to both the patient and the organisation
clinic. This contained the reason for discussion, ASA grading       with approximately four cases per week not requiring an
and management decision reached in each case. Management            overnight stay.
options were daycase, 23hr stay, inpatient or cancellation.
Patient outcomes were retrieved from the hospital
administrative system and case note review.




         Setting up a Single Visit Service.                         METHODS: We undertook Process Analysis and Process Re-
P38      Is this the way forward?                                   engineering whereby visits to secondary care were reduced
                                                                    from 5 plus to 1 plus. Administration contact points were
         M Hemadri, PJ Moore                                        reduced from 12 plus to 5 plus, nurse contact points were
         Northern Lincolnshire and Goole Hospitals NHS FT           reduced from 8 plus to 3 plus and doctor contact points were
                                                                    reduced from 5 plus to 2 plus. This was implemented by: Brain
INTRODUCTION: We introduced a service where daycase and
                                                                    storming (including process analysis and redesign); Initial
short stay surgical patients had all their secondary care
                                                                    patients for observing process and staff working and
services delivered in a single visit. We describe the details
                                                                    responses; Negotiating single visit ward, theatre pathway and
involved in setting it up. From a patient’s perspective our
                                                                    facility; Negotiating patient admin staff and harmonisation of
argument is that improving patient experience while achieving
                                                                    single visit within existing systems (same IT systems and staff
18WDP objectives would need a reduction of visits by the
                                                                    working differently only for the single visit model); Negotiating
patient to secondary care. We proposed that a single visit to
                                                                    managerial and staff agreement on variances; Define inclusions
secondary care would be appropriate for daycase and short
                                                                    and exclusions for Choose and Book; Marketing and training at
stay general surgery patients. The Goole Hospital has an
                                                                    GP practices; Feedback to process development; Audit for
architectural layout where the daycase ward and theatres are
                                                                    benchmarking and quality assurance.
across the corridor. The design within the daycase ward is that
of a corridor with a series of patient contact rooms that lead to   RESULTS: We observed an improved patient experience,
the daycase ward. This enables the single visit model to be         received awards (from Health Foundation, Service
achieved smoothly. The daycase ward is adjoining the regular        Improvement Day Local HSC awards) and invitations (NHS
surgical ward with an interconnecting internal door, enabling       Employers first 18WDP event).
the single visit short stay patients to transfer to the regular     CONCLUSIONS: We propose the following effects: Cost
surgical ward smoothly. The negative infrastructure that            reduction of at least approx £300 / patient. Capacity sparing
facilitates our performance includes Goole Hospital not             effect to enable non-daycase patients to be treated early. We
accepting acute admissions and not having a HDU/ICU facility.       see reducing the number of secondary care visits as key to
This enhances our caution, reduces risk taking behaviours and       improving patient experience and the way forward in delivering
avoids patients or staff being side tracked by more serious         daycase and short stay services. The single visit model is
problems. We were of the view that it would be appropriate to       suitable for adaptation into our non-daycase practice as well,
have dedicated daycase surgical staff rather than the               by providing aligned services with a view to reducing patient
conventional approach of all surgical staff having a daycase        visits to secondary care.
theatre day.
         Single Visit Service for Daycase and                      cholecystectomy were discharged on the same day. There were
P39      Short Stay Surgery: Encouraging                           no DNAs or cancellations due to hospital reasons. There was no
                                                                   mortality. One patient who had laparoscopic cholecystectomy
         preliminary results.                                      had a bile leak but settled on conservative management.
         M. Hemadri, V. Rao, PJ. Moore                             Feedback from the first twenty patients was very positive and
         Goole and District Hospital                               appreciative of this innovative model of service. Initial analysis
                                                                   showed savings to the NHS due to the absence of initial and
INTRODUCTION: Our model involves suitable patients having          follow up OPD appointments.
their first consultation, anaesthetic assessment, nurse
assessment, limited investigations, admission, operative           CONCLUSIONS: We have now reached about 150 patients with
surgery and discharge when appropriate all in a Single Visit to    continuing good results currently being audited. We are now
our unit. No routine follow up is offered. We present our early    available as a separate option in the choose and book directory
results. We propose that the Single Visit model for daycase and    of services. Our main complaint from the patients are having to
short stay surgery is workable, efficient, patient centric and     wait in the daycase unit before going to theatre despite
cost effective.                                                    adequate information being provided; these are sometimes
                                                                   made seriously and sometimes light heartedly and we see it as
METHODS: Retrospective case notes analysis. Retrospective          a side effect of us raising our patients expectations. Our
feedback form analysis. Calculation of estimated costs.            estimated savings are £544 per patient for the NHS. In
RESULTS: 63 patients (age range: 20 to 83; M:F = 43:20) went       conclusion, a wide range of elective operations can be
through the Single Visit model over a 6 month period. 34           performed on the same day as their initial surgical
procedures were done under general anaesthetic and the             consultation. The Single Visit day surgery concept is much liked
remainder under local anaesthetic. The procedures ranged from      by the patients. We believe that compared to the current model
minor surgery (minor surgery n=30) to intermediate/major           Single Visit model has great advantages in terms of efficiency
surgery (inguinal hernia repairs: open: n=7 & laparoscopic:        and cost.
n=11; varicose vein surgery: n=6; ventral hernia repairs: n=3;
laparoscopic cholecystectomy: n=4; and others n=2). All
patients except those who underwent laparoscopic




         Social Aspects of Day Surgery: Time                       RESULTS: A major theme to emerge from the study was the
P40      and the day surgery patient                               importance of time to the day surgery patient. What appealed
                                                                   to the patients was the speed of the day surgery service. They
         A Mottram                                                 often placed day surgery within the wider societal context of
         University of Salford                                     speed of service that is fast food, fast internet
                                                                   communications, instant access, and few surprises. They
INTRODUCTION: Although there has been a massive
                                                                   likened it to a MacDonald’s experience with its emphasis on
expansion in Day Surgery provision, both nationally and
                                                                   efficiency, calculability and control. However, a paradox
internationally, there has been little sociological research
                                                                   emerged whereby the patients traded the speed and
concerning this development. Within the space of a few hours a
                                                                   predictability of day surgery for uncertainty and doubt on their
patient is admitted to hospital, undergoes an anaesthetic,
                                                                   discharge from the day surgery unit.
followed by a substantial surgical procedure and is then
discharged home where responsibility for their care, which was     CONCLUSIONS: Patients liked day surgery because of its
previously performed by health service professionals, is now       efficiency, speed and predictability. However anxiety
undertaken by the patient and their families. A study was          sometimes arose on discharge home where support services
devised to gain an understanding of the patient experiences        were not always readily available. This finding is important to
within a sociological framework of analysis.                       enable the future development of day surgery services.
METHODS: 145 patients and their families were interviewed,
utilising semi-structured interviews, on three occasions: in the
preoperative assessment clinic; 48 hours following surgery and
one month following surgery from two different day surgery
units in the north-west of England. Data collection took place
over a two year period.
         Staged Informed Consent for                                4 criteria for whether reoperations were indicated, how many
P41      Aesthetic Breast Surgery gives the                           were indicated, and when implant removal without
                                                                      replacement might be most logical.
         Best Results
                                                                    Our approach that integrates patient education and informed
         AR Salman, RR Salman                                       consent in stages by
         Park West Clinic, Auralia Hospital
                                                                    1 providing detailed, highly specific written and verbal
There are a number of reasons a woman might consider breast           information,
augmentation, including cosmetic improvement, reconstruction
                                                                    2 utilising a staged approach to education and informed
after a mastectomy, or to address a congenital or
                                                                      consent that provides information and requires
developmental abnormality.
                                                                      simultaneous, informed consent in stages,
Informed consent requires surgeons to provide information
                                                                    3 repeating each critical topic at least two or three times during
about all available alternatives and their associated risks and
                                                                      the process, requiring repetitive written documentation by
tradeoffs to every prospective breast augmentation patient.
                                                                      the patient on at least three different occasions,
The informed patient and surgeon then make decisions based
on the information the patient has received, clinical parameters    4 emphasising patient accountability for choices selected, and
that may affect those decisions, and the patient’s willingness to   5 organising the education and informed consent process so
accept specific risks and tradeoffs. Four specific areas of           that it is clinically practical and also increases thoroughness
postoperative issues stimulated major changes in our                  and documentation while conserving surgeon time.
approach to patient education and informed consent:
                                                                    Clearly informed consent is a major issue. We strongly
1 questions or dissatisfaction with implant size                    recommend the use of this staged, integrated system of patient
  postoperatively,                                                  education and informed consent through a comprehensive set
2 questions about financial responsibility for costs associated     of informed consent documents. For some women, the
  with untoward events requiring reoperation postoperatively        potential benefits of this surgery will outweigh the risks.
  including capsular contracture or other problems,                 Surgeons should ensure that patients considering breast
                                                                    surgery understand the risks involved.
3 spouses or other concerned parties rendering opinions
  postoperatively when they had not been involved in the
  informed consent process, and




         Streamlining the Consent Process.                          Result: We found varying compliance with obtaining 1st stage
P42      Can it be done?                                            consent before the day of surgery, that was only minimally
                                                                    improved by the Clinical Governance project (47.8% vs 56.6%).
         AEA Peet, MA Skues                                         The frequency with which 1st stage consent forms were
         Countess of Chester Foundation NHS Trust                   completed appeared dependent upon the individual clinician
                                                                    rather than the surgical speciality.
INTRODUCTION: Our Unit is aiming to improve the quality and
efficiency of the admission process for Day Surgery. To this end    CONCLUSIONS: This cohort of patients has allowed us to
we have empowered nursing staff to facilitate the 2nd stage         instigate nurse led 2nd stage consent affirmation for Day
consent process on the day of surgery. However, success with        Surgery patients. However we are unlikely to be able to extend
this venture is dependent upon the 1st stage consent being          this development further without timely completion of the first
completed before this time.                                         stage process.
METHODS: We conducted an initial audit, evaluating the
frequency with which 1st stage consent was achieved before
the day of surgery for 161 daycase patients. After a Hospital
Clinical Governance initiative to encourage an earlier start to
the consent process, a similar audit (143 patients) was carried
out to evaluate any beneficial effect.
         Surgical Site Marking in Orthopaedic                     departmental criteria, which included the following facets: Use
P43      Daycases                                                 of an indelible marker pen; A mark at/in operative site; Signing
                                                                  of initials in the operative field; Writing the operation name
         A Vasireddy, E Dunstan, R Grewal                         next to the arrow. These criteria were publicised to all the staff
         Basildon University Hospital                             orthopaedic surgeons in the trust by presentation at the
                                                                  Monthly Departmental Audit Meeting. After a period of 2
INTRODUCTION: Prospective assessment of surgical site
                                                                  months, we completed the audit loop by undertaking a similar
marking technique for elective patients in our Orthopaedic Day
                                                                  prospective audit study where the surgical site marking
Surgery Unit was undertaken. Surgical site marking is a
                                                                  technique was analysed and compared to our new
fundamental part of orthopaedic surgery in order to avoid
                                                                  departmental guidelines.
wrong site surgery as well as prevent the wrong procedure from
occurring. In the United Kingdom, the Medical Defence Union       RESULTS: The re-audit indicates that in this study group,
found 306 cases of wrong site surgery during the period form      surgical site marking fulfilled current UK guidelines in 28 out of
1990 to 1999, 20% of which were in Orthopaedics. The National     30 patients (93%) and current departmental guidelines in 17
Patient Safety Agency found 44 incidents of surgical error in     out of 30 patients (57%) with the p value being <0.0005 in both
their pilot study. In the United States of America, further       cases.
studies into wrong site surgery have confirmed the frequency      Discussion: There has been a general improvement in surgical
and severity of errors.                                           site marking standards in our current study. However, the
METHODS: We undertook an initial prospective audit study          signing of initials is an area where there needs to be
where 30 patients were randomly selected on our Orthopaedic       improvement. It is important to ensure continued improvement
Day Surgery Unit over a period of one week. The surgical site     in surgical site marking and the maintenance of high standards.
marking technique utilised was analysed and compared to the       To do this, we would propose re-auditing our practice regularly.
UK, USA and Canadian guidelines with the latter being used as
the gold standard. Overall, only 50% patients of the patients
satisfied the UK criteria. Consequently, we formulated our own




         Tackling Pain Scores after Day                           collected prior to 2000 was used to classify each procedure
P44      Surgery with Protocols for                               according to the level of expected pain (none, mild, moderate,
                                                                  severe) and a stepped analgesic protocol was developed
         Postoperative Prescribing                                ranging from no analgesia required to ibuprofen 600mg QDS
         H Lakshman, JE Montgomery, ME Stocker                    and co-codamol 30/500 i–ii QDS for those procedures in the
         South Devon Healthcare Foundation Trust                  “severe” category. Lists of procedures, their pain categories
                                                                  and the recommended analgesia regime are displayed in all
INTRODUCTION: The Royal College of Anaesthetists                  anaesthetic rooms.
recommends that day surgery units should regularly audit the
pain scores reported by their patients 24–48 hours                In addition to this, in 2002, we introduced a computerised
postoperatively1. They recommend that less than 5% should         anaesthetic record system, Vitatrak (Calcius Systems Ltd), this
report severe pain and more than 85% should report no or mild     enables automatic prescribing of TTAs according to the
pain.                                                             expected pain category of the planned procedure. The
                                                                  prescription is printed along with the anaesthetic chart in the
METHODS: The majority of patients treated in our day surgery      recovery area and the anaesthetist can then sign this. Deviation
unit are telephoned on the day after surgery and asked about      from the protocol requires input from the anaesthetist. This has
their symptoms post discharge. The results of their feedback      increased compliance with our desired prescribing regimen.
are recorded electronically, along with their demographic
details, operative details and in some cases details of their     This audit has highlighted that the postoperative pain scores in
anaesthetic drugs and take out (TTA) medication. We have          our unit greatly exceed those recommended by the college in
reviewed the data for 2007.                                       their audit standards. We feel that protocol driven
                                                                  postoperative prescribing is a major factor in ensuring that
RESULTS: 5540 of the 7956 patients called the following day       patients receive timely and effective analgesia following day
gave feedback on their level of pain (69.6%). Of these 22         surgery. We would like to comment on the college audit recipe
(0.4%) reported severe pain and 189 (3.4%) reported moderate      which sets the standard of less than 5 % of patients with severe
pain. Of those reporting moderate or severe pain 119 (56%)        pain. We do not believe this is acceptable and think the
stated they felt as good as or better than they had expected      standard should be less than 5% moderate pain and less than
and 92 (44%) felt worse than expected however of these only       1% severe pain.
2 were not satisfied with the service they received. Of the TTA
records reviewed 4163 out of 4335 prescriptions (96%)             REFERENCE
followed our unit protocols for analgesia.                        1. Jackson IJB. Raising the Standard. RCOA 2006
CONCLUSIONS: Since 2000 we have had a protocol
recommending appropriate take home prescriptions for all
procedures routinely performed in our day surgery unit. Data
         The Changing Face of Head and Neck                         in the nature of the surgery, with many of the short less
P45      Surgery                                                    complicated operations probably carried out as daycases.
                                                                    Paediatric cases have now all been moved to the Children’s
         KM Ubayasiri, AJ Dickenson                                 Hospital. Other observations include an increased trauma
         University of Nottingham                                   workload and a large increase in the amount of head and neck
INTRODUCTION: A comparative analysis of the number and              cancer work undertaken, probably owing to the availability
types of head and neck (maxillofacial and ENT) operations           nowadays of more advanced and appropriate surgical
conducted in 1986 and 2006 at the Derbyshire Royal Infirmary        techniques.
(DRI). This was completed out of historical interest with a view    CONCLUSIONS: The decrease of 14% in the number of head
to discovering changing trends in both inpatient and day            and neck operations conducted on in patients, compared to 20
surgery.                                                            years previous, is probably partially attributable to longer,
METHODS: A 1986 logbook for the DRI head and neck theatre           more complex operations. This is combined with the fact that
was manually audited, since electronic records were not             many short procedures, which allow quick turnover, have most
available from that time. All operations carried out were divided   likely been moved from main theatres to daycase lists, as
into the area of the head or neck they pertained to, producing a    evidenced by analysis of the actual operations still undertaken
tally. This division was subsequently conducted for the 2006        in the main head and neck theatres.
electronic records for DRI head and neck theatres.
RESULTS: The number of head and neck operations conducted
in 2006 was 14% less than in 1986. This may be explained by an
increased length and complexity of a wider repertoire of head
and neck surgery conducted nowadays. The findings of the
audit support this view. In addition, many new procedures have
appeared over the last twenty years accompanied by a change




         The effect of Intraoperative DVD on                        one Consultant offered the patients a DVD to watch; the other
P46      Patient Satisfaction during Daycase                        provided a nurse at the table. Patients responded to ten
                                                                    statements (e.g. “I felt pain”) with a mark along a six choice
         Regional Anaesthesia                                       response column (e.g. “Disagree moderately”). The mean of
         LA Penny, OH Whinn, V Rajaratnam,                          their responses provided a single number: a quantitative
         EJ da Silva                                                measure of patient satisfaction.
         Royal Orthopaedic Hospital, Birmingham                     RESULTS: Statistical analysis was carried out using the
INTRODUCTION: Regional anaesthesia in daycase surgery has           Kolmogorov-Smirnov comparison of two data sets. The mean
a number of advantages, such as a reduced incidence of              (SD) satisfaction scores were 2.92 (0.10) and 2.64 (0.115) in the
nausea and vomiting, and improved postoperative pain control.       DVD and nurse groups respectively. The satisfaction scores
As its use becomes more widespread, it is important to ensure       were higher in the group watching DVDs (p=0.01).
that patient satisfaction with regional anaesthesia is              CONCLUSIONS: Watching a DVD intraoperatively improves
maintained, and perhaps improved. A number of issues                patient satisfaction.
governing satisfaction with regional anaesthesia have been          REFERENCES
identified such as preoperative preparation, psychology and
communication, regional anaesthetic technique, intraoperative       1. Hu P, et al. Journal of Clinical Anesthesia 2007;19:67–74
warming and good postoperative analgesia1. The                      2. Cruise CJ, et al. Canadian Journal of Anaesthesia
intraoperative environment also plays a significant role:              1997;44:43–8
patients who have their hand held or listen to music report less
                                                                    3. Dexter F, et al. Anesthesiology 1997;87:865–73
anxiety2. As technology becomes more advanced, other
methods of distraction therapy have become available: we
conducted an audit to evaluate whether watching a digital
video disc (DVD) increases patient satisfaction.
METHODS: Adult patients undergoing upper limb daycase
surgery under brachial plexus axillary block completed a
modified Iowa Satisfaction with Anaesthesia Scale (ISAS)
questionnaire3 before being discharged from the daycase unit.
Patients from two individual Consultant lists were questioned:
         The Financial Implications of                              severe phimosis). 96 (79%) referrals were deemed essential
P47      Nonessential Flexible Cystoscopy                           (43 haematuria, 36 check cystoscopies, 7 flexible cystoscopies
                                                                    aided ureteric stent removal, 5 to evaluate presence of urethral
         R Nair, C Kerali, D Pearce, J Abbaraju,                    stricture, 5 for recurrent urinary tract infections), and 22 (18%)
         PL Acher, S Madaan, IK Dickinson                           were deemed nonessential (15 lower urinary tract symptoms, 4
         Darent Valley Hospital, Dartford and Gravesham             urinary tract infections, 2 elevated prostate specific antigen, 1
         NHS Trust                                                  suprapubic abdominal pain). Of the essential flexible
                                                                    cystoscopies performed 10 (10%) revealed suspicious bladder
INTRODUCTION: Flexible cystoscopic examination is a useful          pathology. However, nonessential cystoscopies yielded no
diagnostic tool. Absolute indications include bladder tumour        suspicious bladder lesions. There were 4 (3%) post procedural
surveillance and the investigation of haematuria. Although          complications including 3 urinary tract infections and 1 episode
carried out as a daycase procedure under local anaesthetic, the     of clot retention.
examination is invasive and not without morbidity. The purpose
of this audit was to assess the appropriateness of referrals for    Based on costs incurred for each procedure (£494 for
flexible cystoscopy.                                                cystoscopy without biopsies) and extrapolation of data;
                                                                    eliminating non essential flexible cystoscopy can save the
METHODS: Prospective data collection was performed                  trust/PCT up to £130,416 per annum.
examining all flexible cystoscopies conducted over a four week
period. Indication, outcome, complications and subsequent           CONCLUSIONS: There is increasing dependence on flexible
auxiliary procedures were all assessed. Indications for             cystoscopy as a first line investigation. We have developed a
cystoscopy were classified as essential or nonessential by two      referral pro-forma whereby nonessential investigation requires
consultant urologists and any discrepancies corrected by a          discussion with a senior urologist. In addition, an educational
third consultant. A cost analysis eliminating nonessential          programme for urological trainees and specialist nurses in the
flexible cystoscopy was performed and the data extrapolated to      indications for flexible cystoscopy and the alternative
calculate financial benefits from their omission.                   investigations available has been developed. It is hoped the
                                                                    resultant financial savings for our trust will lead to appropriate
RESULTS: 142 patients (mean age 66 years; 101 M, 41 F) were         redistribution of resources, reduction in complication rate,
referred for flexible cystoscopy. 21 patients were cancelled (17    waiting times and delayed cancer diagnosis.
urinary tract infections, 1 did not attend, 1 unfit, 1 anxiety, 1




         The Impact of Multi-skilled Staff                          to develop a multi-skilled workforce from existing staff groups1
P48      Availability on Day Surgery Operating                      including the impact of job satisfaction and morale; 2. The
                                                                    proactive measures undertaken by unit to improve the
         Theatre Session Cancellations
                                                                    recruitment and development of multi-skilled staff. Analysis of
         HA Lloyd                                                   the data was undertaken to determine the others reasons for
         Cromer Hospital, Norfolk and Norwich University            operating lists being cancelled2.This area provided the most
         Hospital Trust                                             interesting and informative data for discussion and analysis.
                                                                    The Healthcare Commission report3 recommended a system to
INTRODUCTION: This research project was undertaken as part
                                                                    reallocate planned cancelled sessions to other surgeons. It was
of a MBA (Healthcare Management) The purpose was to assess
                                                                    not clarified or explored how this system should be managed.
the impact of the availability of qualified and competent multi-
                                                                    Between April 2006–March 2007 the allocated surgeon not
skilled nursing and technical staff on reducing the number of
                                                                    being available (usually a planned event), was identified in this
operating sessions cancelled in ‘stand alone’ day surgery
                                                                    research, as the predominant reason for an operating session
facilities in England and Wales.
                                                                    not taking place and was responsible for 63.1% of all cancelled
METHODS: A postal questionnaire was sent to 244 day surgery         sessions. The anaesthetist not being available was responsible
facilities in May 2007.Both qualitative and quantitative            for 4.7% of all cancelled sessions. The number of sessions
research methods were used to obtain data and commentaries          cancelled due to lack of available nursing and technical staff
about the operating time, staffing establishments, session          was 0.06% (not significant).
usage, reasons for list cancellation and skill shortages within
                                                                    CONCLUSIONS: A national review should be undertaken to
the day surgery facilities. Feedback was also obtained about
                                                                    review underutilisation of day surgery facilities and nursing
the availability of training for staff and issues of morale and
                                                                    staff due to lack of surgical cover. In the ‘business’ of
motivation.
                                                                    healthcare this waste of available resources is unacceptable
RESULTS: The overall response rate was 27.4%. However the           and would not be tolerated in other areas of industry and
responses provided a large amount of data which was analysed        commerce.
and coded. Data analysis concentrated on the following key
                                                                    REFERENCES
areas: Six day surgery units which reported cancelled operating
sessions due to lack of appropriately skilled staff and nine        1. Mac Donald M, et al. Journal of Advanced Nursing 1999;
facilities with only one dedicated operating theatre. Analysis of      29:859–68
the qualitative data provided key emerging themes. These            2. Cole B et al. Journal of the Royal College of Surgeons 1998;
included: 1. The challenges which have faced these units in            43:87–8
terms of recruitment and development of multi-skilled staff and
consideration of what internal change management is required        3. Healthcare Commission. Day Surgery: Acute Portfolio
                                                                       review, 2005
         Unplanned Admissions Following                            1.9%), haematomas (n=8, 7.9%), port site infection (n= 2,
P49      Daycase Laparoscopic TEP Hernia                           1.9%), chronic groin pain (n=2, 1.9%), recurrence (n= 4, 3.9%)
                                                                   and others (n= 7, 6.9%). Ten patients (9.9%) stayed overnight
         Repair                                                    after the procedure. Reasons for unplanned admissions were
         R Verma, A Hakeem, K Kolar                                Urinary retention (n=4), Drain inserted (n=2), Haematoma
         Doncaster Royal Infirmary                                 (n=1), Non-cardiac chest pain and low BP (n=2) and social
                                                                   causes (n=1). Grade of the surgeon, unilateral or bilateral
INTRODUCTION: TEP (Totally Extraperitoneal) method of
                                                                   hernia repair or patient demographics had no influence on
laparoscopic hernia repair is gaining popularity because of
                                                                   patient stay rate.
lesser complications and recurrence rates. This study aimed to
evaluate unplanned admissions following a daycase TEP              CONCLUSIONS: TEP hernia repair as a daycase procedure has
procedure and to identify preventable causes.                      excellent advantages for the patient with rapid recovery and
                                                                   low complication rate. Our study shows that it is potentially
METHODS: The case records of TEP Hernia Repair done by a
                                                                   difficult to reduce the unplanned admissions rate as these are
single surgeon from June 2005 until November 2007 were
                                                                   mostly due to difficult procedure or postoperative urinary
studied. Patient demographics, complications, overnight stay
                                                                   retention.
rate and reasons for such stay were studied.
RESULTS: Our study had 101 patients who underwent TEP
hernia repair as a daycase procedure and in total 170 hernias
were operated upon. Mean age (52.19 yrs), Minimum Age (18
yrs) and Maximum Age (74 yrs). Conversion to open (n=2,




         Unplanned Admissions Following                            Age sex and past          Procedure       Reason for admission Postop
P50      Daycase Procedures — A prospective                        medical history (PMH)                                          stay

         study                                                     1 76 M hypertension       Lap chole       Converted to open &   4 days
                                                                     asthma COPD                             drain
         A Hakeem, K Nagpal, J Muen
                                                                   2 69 M hypertension       Recurrent ing   Bleeding &            1 day
                                                                     angina COPD             hernia          haematoma
INTRODUCTION: Admission for overnight or longer hospital           3 4 M no PMH              Circumcision    Bleeding              1 day
stay from a daycase unit is an undesirable outcome. This audit
was designed to examine the reasons for unplanned overnight        4 74 F hypertension       Lap chole       Past medical          1 day
hospital admission in General Surgical Daycase procedures and        chronic renal failure                   problems
to identify preventable causes.                                    5 62 F arthritis          Lap chole       Analgesia (NSAID      1 day
METHODS: All daycase general surgical procedures done over                                                   allergy)
a 4 week period (Oct–Nov 2007) were studied. Data was              6 62 M COPD               Lap incisional Low saturation         1 day
collected prospectively from patient notes and theatre                                       hernia
documentation. Patient demographics, surgical procedure,
                                                                   7 72 F hypertension       Lap chole       Slow recovery (late   1 day
mode of anaesthesia, ASA grade, immediate complications,
                                                                                                             afternoon case)
overnight and further stay, reason for such stay and duration of
stay were recorded.                                                8 51 M no PMH             Lap chole       Slow recovery (late   1 day
                                                                                                             afternoon case)
RESULTS: 61 patients were operated in our unit over 4 week
period. Total overnight stay was 13% (n=8), of which immediate     CONCLUSIONS: The reasons for unplanned admissions are
complications were 5% (n=3) and overnight stay due to              multifactorial. Overnight stay due to problems unrelated to
problems unrelated to surgical procedures were 8% (n=5).           surgery like past medical history needs stringent preoperative
Immediate complications were excess bleeding (n=2) and             assessment to bring appropriate patients for Daycase
laparoscopic cholecystectomy converted to open                     procedures. Operations which need extended recovery period
cholecystectomy (n=1). Unplanned admissions due to other           (like laparoscopic cholecystectomy) should be done early in the
problems were past medical history (n=2), for extended             list.
recovery due to late afternoon procedure (n=2) and pain relief
(n=1). Grade of surgeon or the anaesthetist had no effect on
the overall outcome.
         Waiting for the Operation — A study of                     RESULTS: During the study period 407 patients were treated in
 P51     patients’ attitudes to waiting in a                        the DSU. 8 children and 18 patients who spoke no English and
                                                                    had no interpreter were excluded. 205 patients (57%) were
         dedicated day surgery unit                                 contacted and agreed to take part in the study. The mean
         H Jones, J Machin, J Johnson, C Shaw,                      waiting time between arrival and the procedure was 2.75 hrs
         CL Ingham Clark                                            (SD 1.9 hrs). Most people passed this time by reading or talking
         The Whittington Hospital NHS Trust                         with friends or family. Most patients (60%) did not wish to go
                                                                    home and be recalled, even though they lived near the hospital.
INTRODUCTION: It is custom and practice for all patients on a       Patients who favoured this option commented that they would
day surgery operating list to be asked to attend the Unit at the    like to eat or smoke while waiting! 65% of patients overall, and
same time, usually an hour before the list is due to start. This    76% who had to wait more than 2 hours for their procedure,
facilitates the preoperative interaction between surgeon,           would have preferred to have been asked to arrive for
anaesthetist and patient. However it means that patients who        admission at a time closer to their operation.
have been placed towards the end of the list may wait a long
                                                                    CONCLUSIONS: The majority of patients attending DSU do not
time between arriving in the Unit and having their procedure.
                                                                    like the current “batch” approach to admission for day surgery.
The aim of this study was to determine how long people had to
                                                                    They would prefer more individualised arrival times closer to
wait, and what they thought about alternative ways of
                                                                    the time of their procedure. The challenge for DSU teams is to
managing this time.
                                                                    deliver this without compromising efficiency.
METHODS: A telephone survey was carried out with patients
treated in one DSU over a 4 week period using a standardised
questionnaire. This was administered by two medical students
who had not been directly involved with the patients’ care.
Patients were asked about how long they had waited in the
DSU before their procedure, how they spent this time and what
their views were on the options of either being sent home after
the admission process and recalled half an hour before their
operation, or of being asked to arrive for admission at a time
closer to their anticipated procedure time.




         Ward Facilitator — Who is that!                            managed the communication between theatre, recovery and
P52      D Frederiksen                                              ward as the trolley space continue to change from minutes to
                                                                    minutes. As the unit returned to its new facilities, it became
         King’s College NHS Trust Foundation Hospital               clear that the ward facilitator had become a very important role
INTRODUCTION: During a major refurbishment programme                within the ward structure by being a steeping stone for ward
within Day Surgery Unit at King’s College Hospital; we created a    staff to consult if there was matter they were not sure about, to
nurse role to oversee and facilitate communication between          escalate issues to and to relieve for breaks. The ward facilitator
theatre, recovery and ward area to ensure a safe and sound          also provide a cushion for nurse in chare of the unit by being
patient care pathway through the unit during the patient’s stay.    able to dealing and resolving with issues locally instead of
                                                                    overburden one person with small issues they may spend 1/2
METHODS: The ward facilitator role during the period of             hour to understand.
refurbishment became a vital tool in ensuring that the unit still
treated patients within a professional caring environment by        CONCLUSIONS: The ward facilitator is here to stay. The ward
coordinating where nursing staff was allocated to, where the        facilitator is a vital tool in ensuring a clinical safe and sound
patient was allocated to and to direct the medical staff in the     conduct of providing care pathway for patient, relatives, and
right direction when arriving to the ward. The ward facilitator     staff.

				
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