PATIENT SELECTION PUSHING THE FRONTIERS OF DAY SURGERY. Dr Theresa Hinde Anaesthetic ST7 Council Member British Association of Day Surgery

Transcription

1 PATIENT SELECTION PUSHING THE FRONTIERS OF DAY SURGERY Dr Theresa Hinde Anaesthetic ST7 Council Member British Association of Day Surgery

2 HOW A DAY SURGERY MINDSET CAN TRANSFORM THE OUTCOMES FOR BOTH YOUR PATIENTS AND YOUR HOSPITAL How a your

3 AIMS Is anyone medically inappropriate for day surgery? Additional considerations for urgent/emergency surgery Different approaches to social factors limiting suitability What procedures can we tackle?

4 BACKGROUND: PATIENT SELECTION More complex procedures Patients with significant co-morbidities

5 EMERGENCY AMBULATORY SURGERY Demand for emergency surgical activity increasing Need more effective ways to evaluate and care for patients whilst avoiding unnecessary admissions maximise theatre utilisation improve in-patient access for sickest patients

6 BACKGROUND To maximise day surgery possibilities in your organisation are there Robust assessment systems? Options of Advanced surgical techniques? Advanced anaesthetic techniques? Different ways to care post discharge? Ways to rapidly access urgent lists for certain procedures?

7 ROBUST ASSESSMENT SYSTEMS Appropriate staff making decisions regarding suitability Experienced nurses using well established protocols Experienced clinicians available for advice and support if criteria not clearly met Both will help to overcome perceived barriers Early stages of new pathways

8 WHAT ARE WE TRYING TO ESTABLISH Are this patient s risks increased in any way by treatment on a day stay basis? Would management be different if he/she were admitted as an inpatient?

9 IF THE ANSWER IS NO....the patient is probably suitable for day surgery Consider day surgery as default for elective surgery

10 MEDICAL FACTORS 1980 S Royal College of Surgeons of England: 1985 and 1992 Selection Criteria: Age limit years ASA I & II BMI<30 Max 60 minutes operating time

11 NOUGHTIES Default to Day Surgery Patients should only be excluded from day surgery after full pre-operative assessment shows a contraindication Day Surgery: Operational guide. DoH, London (2002)

12 DAY CASE CRITERIA But: Fatter Population Older Population Therefore expand.. ASA Age BMI Medical conditions ASA 1 and 2 No limit Age 70 No Limit BMI 30 No limit IDDM No Yes

13 ASA CLASSIFICATION (AMERI C AN SOCI ETY OF ANAESTHESIOLOGISTS) ASA I: Normally healthy ASA II: Mild systemic disease ASA III: Severe systemic disease that is not incapacitating ASA IV: Incapacitating disease that is a constant threat to life Most stable conditions can be managed as a day case Most patients with unstable conditions should not be undergoing elective surgery Urgent or emergency surgery in these patients may require inpatient stay

14 ASA III PATIENTS ASA III patients form a disparate group Studies show ASA III does not predict unplanned admissions Ansell and Montgomery (BJA, 2004) Case matched study Admission rate is low (<3%) ASAIII = 2.9% vs non ASA II =1.9% Low incidence of unplanned contact with healthcare services in both groups Low post operative complication rate

15 ASA III PATIENTS Conclusions: ASA III need not be an exclusion criterion Certain ASA III patients can be safely treated with good pre operative assessment and preparation

16 ELDERLY BENEFITS OF DAY SURGERY Decreased impact on patient and family Usually better managed in their own environment Maintains daily routine and autonomy Decreases cognitive dysfunction and delirium Resumption of active mobility

17 PREOPERATIVE ASSESSMENT OF ELDERLY Follow standard protocols for evaluation and preparation Consider frailty scores Use of these is increasing Social planning: involve Family Primary care physicians Other allied health professionals

18 ANAESTHETIC AND SURGICAL TECHNIQUES Schedule early in day Avoid prolonged fasting Employ minimally invasive surgical options Avoid opiates Local anaesthetics as far as possible Maintain temperature

19 THE ELDERLY-ADMISSION RATES Admission Rates 80 % of patients >70 < Sinha et al, Hernia,

20 THE ELDERLY SATISFACTION WITH DAY SURGERY Satisfaction with Day Surgery 80 % of patients >70 <

21 OBESITY most potential complications of obesity are limited to the intra and immediate post operative environment and so obese patients can still be managed as a day case The Pathway to Success Management of the Day Surgical Patient BADS Publication 2012

22 OBESITY Even morbidly obese patients can be safely managed in expert hands, with appropriate resources. Obese patients benefit from: short duration anaesthetic techniques early mobilisation decreased hospital stay and associated hospital acquired complications Day Case and Short Stay Surgery (2) Association of Anaesthetists of Great Britain and Ireland British Association of Day Surgery 2011

23 PREOPERATIVE ASSESSMENT Careful assessment mandated Medical case note review Increased incidence of Hypertension Ischaemic heart disease Diabetes Reflux Optimise these conditions Particular attention when assessing for urgent surgery Obesity alone should not preclude day surgery

24 OBESITY Challenges: Problems occur early (induction/primary recovery) Everything may be more difficult and take longer Senior staff required Additional kit Plan for difficult airway, long instruments, special table etc..

25 OBESITY-COMPLICATIONS Retrospective analysis of DSU patients 258 patients with BMI>35 No statistically significant difference in: Unplanned admission rate BMI >35=3.0% vs. BMI<35 = 2.7% (p=0.98) Post operative complications Unplanned usage of community and hospital based services (p=0.59) Conclusion: No evidence that BMI>35 solely an exclusion criterion for day surgery Davies, Houghton and Montgomery, Anaesthesia 2001

26 OBESITY May not be appropriate for surgery in an isolated site, but can still be day cases through main hospital facilities Once they are through primary recovery no increased risk of complications necessitating overnight stay

27 OSA May require CPAP post-op Are they more likely to get this at home or in hospital? Beware of strong opiates Significant OSA in patients undergoing tonsillectomy is a contraindication to day surgery

28 IDDM: AAGBI GUIDELINES(2016) If HbA1c greater than 69mmol.mol -1 delay elective surgery until controlled Diabetics are usually better at managing their own diabetes than we are! Preoperative optimisation from specialist diabetic nursing teams is invaluable for patients with poor control Urgent surgery may require pragmatic approach

29 HYPERTENSION: AAGBI GUIDANCE (2015) BP >180/110: Refer to GP for assessment Aim to control to <160/100 BP >140/90 but less than 180/110: Refer to GP but no reason to postpone surgery Urgent surgery may require pragmatic approach

30 CARDIAC RISK The likelihood of perioperative cardiac complications cannot be entirely predicted. There are major, intermediate and minor predictors for peri-operative cardiac complications. Refer those with major risk factors for further management Assessment of exercise tolerance is fundamental.

31 PREDICTORS OF CARDIOVASCULAR COMPLICATIONS Major predictors Severe/unstable angina Recent MI Uncontrolled heart failure Significant arrhythmia Valvular disease Peripheral vascular disease Intermediate predictors Stable angina Previous MI Controlled heart failure Diabetes Minor predictors Uncontrolled hypertension Non sinus ECG Stroke Increasing age Decreased functional capacity Inherited/social factors Smoking Obesity Alcohol excess Raised lipids Sudden cardiac death in family

32 MEDICAL EXCLUSIONS unstable ASA III, ASA IV/V any poorly controlled abnormality neonates ex-prem infants < 60 wks post conceptual age young sibling of SIDS child Specific to Emergency Surgery pathways: Sepsis or haemodynamic instability

33 CRITERIA IN 2017 Abandon universal selection criteria Adopt an inclusion rather than an exclusion philosophy Apply limitations to the procedure rather than the patient

34 Novel approaches: EMERGENCY AMBULATORY SURGERY University Hospital Bath Emergency ambulatory surgery clinic Careful and timely case and patient selection may allow urgent/emergency day case surgery Preoperative assessment may therefore be required for acutely unwell patients to be operated on the same or next day

35 PROCEDURES SUITABLE FOR EMERGENCY AMBULATORY SURGERY Ambulant adults with: General Gynae Trauma ENT Abscesses torso and peri-anal (not breast) ERPC Tendon repair MUA nose Right iliac fossa pain Lap ectopic pregnancy Painful non-obstructed hernia MUA Fracture plating e.g. clavicle Repair fractured mandible Wound problems

36 PATIENTS NOT SUITABLE FOR EMERGENCY AMBULATORY SURGERY Children Evidence of sepsis or haemodynamic instability Significant concurrent illness Condition that cannot safely be left or too painful to manage at home Reduced mobility/no home input/lives alone or some distance away Cognitive or communication difficulties

37 BENEFITS OF EMERGENCY AMBULATORY SURGERY Avoids unnecessary admission and associated in-patient waits Saves bed days Freeing up capacity for emergencies

38 SOCIAL FACTORS Responsible adult Maximum 1 hours drive Adequate facilities inside toilet telephone access heating stairs

39 RESPONSIBLE ADULT How long is 24 hours? Who can provide this care? Are all anaesthetics equal?

40 HOW LONG DO CARERS STAY? B ARKER ET AL J OD S H o u r s Mean time carer stayed (h) Mean time to ADLs (h) Mean time to 'safe' (h) 5 0 All Patients No Pain Mild Pain Moderate Pain Severe Pain

41 WHAT DID PATIENTS THINK? Too Long Not Enough About Right All Patients 29% 12% 59% No Pain Predicted 33% 0% 67% Mild Pain Predicted 57% 0% 43% Moderate Pain Predicted 27% 18% 55% Severe Pain Predicted 20% 15% 65% Survey of 72 patients

42 POSSIBLE SOLUTIONS Torbay Model: provide carers into patients homes Kings Lynn Model: virtual ward Norwich Model: allow some patients home without carers after certain procedures Escort vs 24 hour Care

43 DISTANCE FROM HOSPITAL Rarely a problem (even in mid Wales/rural Devon) 1 hour from a hospital that can treat the condition not necessarily the operating hospital Procedure specific

44 SOCIAL FACTORS The vast majority of patients are socially appropriate for day surgery or can be enabled to be so with proactive management

45 SURGICAL CRITERIA Which Procedures?

46 SURGICAL CRITERIA Can the patient be expected to manage oral nutrition postoperatively? Can the pain be managed by simple oral analgesia supplemented by regional anaesthetic techniques? Is there a low risk of significant immediate post operative complications (e.g. catastrophic bleeding)? Is the patient expected to mobilise with aids post-operatively?

47 LONG OPERATING TIMES Millers Anaesthesia 2010: The duration of surgery in the ambulatory setting was originally limited to procedures lasting less than 90 minutes...however, surgical procedures lasting 3 to 4 hours are now routinely performed on an ambulatory basis.

48 LONG OPERATING TIMES Admissions Total % Ops < 60 min % Ops > 60 min % p = 0.36 No statistically significance difference in admission rates }χ 2 Skues MA, J One Day Surgery, 2011

49 HOW FAR HAVE WE COME? Specialty Procedures in 1990 Procedures in 2016 Ophthalmology Cataract Extraction Vitrectomy Gynaecology Hysteroscopy Hysterectomy Orthopaedics Arthroscopy Uni-chondylar Knee Urology Circumcision Laparoscopic Nephrectomy

50 NEARLY ALL ELECTIVE SURGERY SHOULD BE DAY OR VERY SHORT STAY Lap nephrectomy Prostatectomy Lap hysterectomy Vaginal hysterectomy Thyroidectomy Mastectomy Shoulder surgery Anterior cruciate ligament Lumbar discectomy Abdominoplasty Some emergencies

51 SURGICAL CRITERIA Pushing the frontiers in your own institution: Elective Evaluate existing inpatient procedures with short(ish) LOS What would you need to change to enable them to be day surgery?

52 IN SUMMARY: PATIENT SELECTION Is the patient suitable for day surgery? Medical conditions-pushing the boundaries (safely) Social circumstances-alternatives Surgical considerations-advanced techniques Can the patient or procedure be made suitable? Special considerations for emergency patients Procedure Preoperative issues: Pain Sepsis Haemodynamic stability Can they safely wait?