FRCA Notes

Principles of Day-Case Surgery

Resources

  • Day surgery is defined by the admission and discharge of a patient on the same day as the surgical procedure, with day surgery as the intended management
    • In 2024 NHS England raised the target for the percentage of surgeries performed as day-case from 75% to 85%
    • UK day surgery rates now exceed this, although wide variation persists between specialties and trusts
    • The increase in minimally invasive surgical techniques has increased the suitability of various procedures for day surgery
    • Increasingly complex procedures are now performed as day cases, e.g. major joint replacement, thyroidectomy, adrenalectomy and radical prostatectomy

Patient benefits Institutional benefits
↓ risk of hospital-acquired infection ↓ cancellations as beds not subject to pressure from emergency work
↓ risk of VTE due to early mobilisation Higher patient throughput per bed
↓ anxiety if hospital stay avoided (esp. paediatrics) ↓ costs of care
Less psychological upheaval ↓ medical/nursing supervision per patient
↑ patient satisfaction Frees inpatient beds for more complex cases
Less disruption to normal routine ↓ elective waiting times and backlog
↓ post-operative delirium and cognitive impairment ↓ environmental impact



Social factors Medical/surgical factors Post-operative factors
Patient understands & consents to day surgery Stable, optimised chronic disease Post-op. pain manageable with PO analgesia & local anaesthetic techniques
Responsible adult to escort home; usually also present for 24hrs post-op. Short duration (<2hrs) No requirement for post-op. monitoring
Appropriate home circumstances & access to a telephone Low risk major haemorrhage No requirement for post-op. IV fluids
Transport home by private car or taxi Low risk delayed airway compromise Allows rapid mobilisation
Oral intake resumed within a few hours

General principles

  • Day surgery should be the default option for all procedures listed in the BADS Directory of Procedures
  • Patients should be placed on a day surgery pathway as early as possible, whether listed from outpatients, via GP referral or as an emergency; this improves patient confidence and allows early discharge planning

  • Selection should be an inclusive process; suitability should not be determined by age, BMI, ASA physical status or physiological parameters alone
    • Instead, suitability is based on an individualised, thorough pre-operative assessment with appropriate investigations
    • Complex patients (due to patient or surgical factors) require pre-operative review by a consultant or autonomously practising anaesthetist with day surgery expertise
    • Patients with uncontrolled comorbidities are not suitable, but once optimised are often fit for same-day discharge

  • Patients at significant risk of serious complications requiring immediate attention (e.g. haemorrhage, cardiovascular instability) may still be suitable for day surgery, but may not be suitable for stand-alone units

Surgical factors

  • The procedure should not carry a significant risk of serious post-operative complications requiring immediate medical attention
  • Post-operative symptoms such as pain and nausea must be controllable with oral medication and local anaesthetic techniques
  • The patient should be able to resume oral intake within a few hours
  • The patient should be able to mobilise before discharge, with mobility aids if necessary
  • VTE risk assessment should be undertaken, with prophylaxis continued after discharge where indicated

Social factors

  • Distance from hospital should not be a limiting factor; distance to any hospital matters more than distance to the discharging hospital, even after tonsillectomy
  • Public transport is not normally acceptable after general or regional anaesthesia

  • A carer at home overnight may not be essential after good recovery from brief or non-invasive procedures, where any bleeding would be obvious and controllable with simple pressure
    • Requires agreement of the whole day surgery team and the patient
    • Standard discharge criteria must still be met and a responsible adult must still escort the patient home

  • Consider the potential need for rapid return to hospital, e.g. after airway surgery or laparoscopic surgery (concealed bleeding)
  • Where no support is available at home, professional or volunteer carer services and post-operative phone calls may be used
  • Virtual wards (remote monitoring at home with community nursing support) can allow patients having more major surgery to go home on the same day

Functional status

  • BADS recommend a patient's fitness for a procedure should relate to their functional status rather than ASA physical status, age or BMI
    • ASA grading is subjective, with variable inter-rater agreement; ASA 3 patients who are functionally dependent have higher post-operative mortality than those who are independent
    • Even ASA 4 patients have successfully undergone day surgery; regional blocks, short-acting spinals or awake local anaesthetic techniques facilitate this
    • Patients with stable, chronic disease do better after day surgery as there is less disruption to their normal lives

Frailty and the older patient

  • Frailty is a more important risk factor for complications and mortality than age itself
  • Recovery may be slower, but there is no reason this cannot occur at home; GIRFT and the British Geriatrics Society advocate day surgery wherever possible
  • Patients >65 years who stay in hospital and do not walk lose 2–5% of their muscle mass per day

  • Frailty should be recognised early (e.g. in surgical outpatients) so optimisation and prehabilitation can begin while on the waiting list
  • Patients with a Clinical Frailty Score ≥5 can be referred for Comprehensive Geriatric Assessment, e.g. in a POPS clinic, or senior anaesthetic review

Cognitive dysfunction

  • Day surgery is associated with lower rates of post-operative delirium than inpatient surgery
  • Plan pre-operatively for carers to accompany the patient to the anaesthetic room and be present in recovery where this will help
  • Inform next-of-kin/carers what to expect and what to observe for at home

Obesity

  • Obesity itself is not a contra-indication to day surgery; for patients with BMI <50 kg/m2 day surgery is often appropriate once comorbidities are optimised
    • Associated comorbidities must be detected, assessed and treated, e.g. cardiac disease (including right ventricular disease), OSA and diabetes
    • This may require echocardiography or sleep studies, followed by senior anaesthetic review
    • The incidence of intra-operative or early recovery phase complications is higher
    • However, these problems often resolve by the time of discharge and overnight stay may not confer additional benefit
    • Obese patients benefit from short-duration anaesthetic techniques and early mobilisation, but may need prolonged VTE prophylaxis
    • The day surgery team should be forewarned, as extra time, equipment and experienced staff are required

Obstructive sleep apnoea

  • OSA is not an absolute contraindication to day surgery
    • Pre-assessment should identify those with a history of OSA or are at risk on STOP-Bang scoring
    • A STOP-Bang score >5 suggests further investigation with overnight oximetry or limited sleep studies, and referral for CPAP if indicated
    • Those with already diagnosed & treated OSA, and stable co-morbidities, should not be excluded from day surgery; CPAP compliance should be confirmed
    • Those with presumed OSA may still be suitable for minor/intermediate surgery if comorbidities are well controlled and long-acting opioids can be avoided
    • Anaesthetic management should include regional anaesthetic techniques and opioid avoidance where possible
    • Patients should bring their CPAP devices with them in case of failed discharge
    • Patients should be warned about the additional risk at post-operative day 3–4 as REM sleep returns, and of the importance of CPAP compliance

Diabetes mellitus

  • Diabetes is not a contra-indication; day surgery allows rapid return to usual diet and medication, optimising glycaemic control
  • Suboptimal control (HbA1c >69 mmol/mol) should be identified in primary care and referred early, as HbA1c improvements take up to 3 months
  • Patients should be placed first on the list to minimise fasting

  • Medications:
    • SGLT-2 inhibitors should be stopped 24hrs before surgery
    • GLP-1 receptor agonists (and GIP agonists) should be continued; note they may delay gastric emptying

  • Insulin pumps (CSII):
    • Patients may continue to use their pump where only one meal is missed, which applies to most day surgery
    • Care is needed with diathermy and radiological screening, which may damage the pump
    • Pump disconnection or failure risks rapid ketosis
    • Continuous glucose monitors lag behind blood glucose and should not replace capillary glucose and ketone monitoring

Other patient groups

  • Learning difficulties
    • Day surgery is often the best option; input from a learning disability nurse may help
    • Plan for flexible admission times, a quiet area, possible sedation and carer presence at induction and emergence

  • Breastfeeding
    • Breastfeeding can continue peri-operatively without discarding milk ("sleep and keep" rather than "pump and dump")
    • Avoid codeine due to reports of excessive sedation in breastfed infants; favour multimodal and regional analgesia

  • Transgender and gender-diverse patients
    • Use preferred name and pronouns, and offer a pregnancy test to all patients aged 12–55 years with a uterus and ovarian tissue
    • Cricothyroid approximation may remove the cricothyroid membrane, making emergency front-of-neck access impossible
    • Continue hormone therapy unless specifically contraindicated
    • TIVA models are not validated in patients on established hormone therapy; processed EEG monitoring should be used

  • Patients in prison
    • Requires an agreed pathway with local prisons, advance risk assessment (including restraint) and provision for analgesia and overnight observation in prison

General principles

  • There are few absolute contra-indications; most children, even with complex comorbidities, can have safe day surgery with robust pre-assessment and experienced staff in appropriate facilities
  • All hospitals should have their own guidelines on lower age limits and acceptable comorbidities, reflecting local facilities and expertise
  • Children should be on dedicated lists or at the start of the list, and separated from adults on the ward and in recovery
  • Children having non-surgical procedures (e.g. imaging, endoscopy) should receive the same standards of care

Age limits

  • Term infants may be suitable from 44 weeks post-menstrual age (gestational plus chronological age)
  • Those <44 weeks post-menstrual age are unsuitable, although specialist paediatric units may offer care to full-term infants from >1month old

  • Ex-premature infants (born <36 weeks) require careful individual assessment and are not usually accepted if <55 weeks post-menstrual age; they should also have:
    • No recent apnoeas
    • No respiratory or cardiovascular disease
    • No family history of sudden infant death syndrome
    • No adverse social circumstances

Specific conditions

  • Conditions requiring careful individual assessment, which may preclude day surgery in some units:
    • Inborn errors of metabolism
    • Complex cardiac disease
    • Sickle cell disease
    • Active respiratory tract infection
    • Other poorly controlled systemic disease

  • OSA: tonsillectomy should be a "default day case", but children with severe OSA or at high risk of respiratory complications should be managed in a tertiary centre and are not suitable for day surgery
  • Obesity (BMI >98th centile) is not an absolute contraindication, but should inform list order, duration of observation and need for admission; all children should be weighed and measured
  • Diabetes should be established and controlled beforehand; list first, aim CBG 5–10 mmol/L and involve the paediatric diabetes team, especially with insulin pumps

Pre-assessment and parents

  • Focuses more on preparing the child and family than medical screening; most ASA 1–2 children need no investigations
  • Ideally ≥2 weeks before surgery, via a separate nurse-led paediatric pathway with senior anaesthetic support
  • Identifies anxious children; play specialists can help with psychological preparation
  • Establishes parental responsibility and consent, including discussion of gas vs. IV induction
  • Pregnancy status should be ascertained on the day for patients aged ≥12 years

  • Parents must be able to understand instructions, recognise complications (e.g. post-tonsillectomy bleeding) and manage pain at home
  • Tonsillectomy and orchidopexy can cause significant pain for up to 2 weeks; parents need clear verbal and written advice and telephone support

  • Thorough anaesthetist-led, nurse-delivered pre-anaesthetic assessment and preparation, ideally within the same day surgery unit
    • Exposure to the day surgery environment reduces anxiety
    • One-stop clinics minimise patient visits
    • High-risk patients are directed to POPS clinics or consultant-led day surgery clinics

  • Comorbidities and frailty should be identified as early as possible, ideally at GP referral or in outpatients, so optimisation can begin on the waiting list rather than at pre-assessment
    • E.g. treatment of hypertension and anaemia, CPAP for OSA, diabetic control
    • Prehabilitation increases the number of patients suitable for day surgery

  • Aims of pre-operative assessment include:
    • Identifying medical and social risk factors e.g. STOP-BANG scoring
    • Diagnosing conditions with a major impact on anaesthesia that may need treatment first, e.g. OSA, aortic stenosis
    • Allowing time to obtain specialist opinion and optimise those with more complex medical disease
    • Educating patients about the pathway, procedure-specific information and details of post-operative care
    • Shared decision-making, including alternatives such as conservative management, to reduce post-surgical regret

Pre-operative fasting

Admission

  • Staggered admission times minimise waiting while allowing time to finalise consent and laterality
  • Patients should change into a theatre gown only when surgery is imminent, with single-sex bays provided

Management and staffing

  • All day surgery units should have a clinical lead responsible for local policies, guidelines and clinical governance, and a unit manager for daily running
  • All members of the multidisciplinary team should be trained in day surgery practice; multiskilled nursing improves efficiency
  • Resident anaesthetists should be trained in the whole day surgery process and be appropriately supervised; the RCoA Cappuccini test should be applied

Facilities

  • Ideally a dedicated day surgery unit with its own pre-, intra- and post-operative facilities
  • Where inpatient theatres are used, dedicated day surgery admission and discharge areas and a "day surgery mindset" are key
  • Day surgery areas should be ringfenced (e.g. using trolleys) so they cannot be used as escalation beds
  • Standards and equipment must equal inpatient theatres, with pathways for transfer to inpatient or critical care

Stand-alone units

  • Ideally at least two anaesthetists on site at all times
  • The operational policy should define:
    • Patient screening and selection
    • Management of medical emergencies (e.g. cardiac arrest, major haemorrhage) while the anaesthetist is in theatre
    • Transfer agreements with the nearest acute hospital and ambulance service
    • Management of patients who cannot be discharged, or who develop complications after discharge

Urgent day surgery

  • Many acute conditions can be managed via a semi-elective pathway; patients are discharged after initial assessment and return for surgery on a planned list
  • Examples include abscess drainage, appendicectomy, cholecystectomy, ERPC, laparoscopic management of ectopic pregnancy and ORIF of ankle/wrist
  • Requires the condition to be safe to manage at home with pain controlled by oral analgesia, a reliable theatre list and systems to track patients

High-intensity theatre lists

  • Use otherwise idle facilities (e.g. weekends), increased staffing and parallel theatres
  • Aim to have the next patient anaesthetised and ready as the previous operation finishes, minimising theatre downtime

Independent sector

  • Delivers around 20% of NHS elective admissions; day surgery guidelines apply equally
  • May lack laboratory, blood bank, electrophysiology or critical care support, which may limit suitability for some patients

First stage recovery

  • I.e. the theatre recovery area
  • Covers the period of time until the patient:
    • Is fully awake with return of protective reflexes
    • Has controlled levels of pain
  • Patients who meet PACU discharge criteria before leaving theatre (e.g. surgery under regional block) may bypass recovery and return directly to the day surgery unit

Second stage recovery

  • I.e. the day surgery post-operative ward
  • Covers the period from leaving first-stage recovery until the patient fulfils discharge criteria
  • Includes management of early post-operative symptoms including pain, PONV and minor bleeding
  • Patients should be encouraged to drink, eat, mobilise and get dressed

Discharge

  • Protocol-driven, nurse-led discharge should occur based on fulfilment of discharge criteria:
Patient factors Logistical factors
A|B|C - stable for ≥1hr Able to stand, dress and ambulate
D - at baseline cognition and pain controlled Responsible adult accompanying home
E|F - has passed urine Transport by private car or taxi
G - PONV controlled and tolerates PO fluids Responsible adult at home for 24hrs*
H - minimal bleeding Discharge medications and information provided
  • *May not be essential after brief or non-invasive procedures with good recovery (see patient selection)

  • Post-operative information should be provided in verbal, written and/or digital formats, e.g. high-quality, age-appropriate leaflets
  • Information may also be given to the accompanying adult if there are concerns about the patient retaining it
  • Information provided should include:
    • General information post-anaesthetic e.g. no driving, drinking alcohol or operating machinery for 24hrs [or 4 days if isoflurane used]
    • Procedure-specific information e.g. expected symptoms
    • Follow-up appointments e.g. wound care
    • Analgesic advice
    • A contact number for advice in case of problems
    • Discharge summary for patient and GP; the GP should be informed promptly

  • Sufficient analgesia and other medications should be supplied for 5–7 days, ideally in pre-packaged form
  • Best practice is a helpline for at least the first 24hrs after discharge and a follow-up telephone call the next day

  • Overall, specialty-specific and procedure-specific day surgery rates
  • Proportion of patients not booked as day cases
  • Cancellation rate - may reflect poor patient selection
  • DNA rate - may reflect poor administration
  • Unexpected admission (unplanned overnight stay) rate
  • Re-admission rate within 30 days
  • Rates of complications inc. infection
  • Patient-reported outcomes inc. pain, PONV and audit of PONV
  • Patient satisfaction surveys
  • The British Association of Day Surgery BEAT directory and Directory of Procedures; allow comparison vs. national standards and target rates for >300 procedures
  • Benchmarking via the Model Hospital (England) and CHKS
  • The RCoA quality improvement compendium has a dedicated day surgery section