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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.
