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SHEET 1

Day Surgery Information

Selection criteria and


suitable procedures

Introduction
When patients are referred for day surgery it is essential to ensure that:
✦ the procedure is suitable
✦ the risk of complications (from surgery and anaesthetic) are minimised
✦ admission to an in-patient bed following day surgery is prevented
✦ patients are adequately supported after discharge home.

Selection criteria
Referring to best practice guidelines for day surgery (Royal College of Surgeons of
England, 1992 and 2000), the selection criteria should be defined and collaboratively
agreed by surgeons, anaesthetists and nurses involved in day surgery.
The American Society of Anaesthesiologists’ (ASA) classification of physical status has
been used to assess a patient’s suitability.
Table 1 – The American Society of Anaesthesiologists’ (ASA) classification
of physical status
Class 1: Patient has no organic, physiological, biochemical or psychiatric
disturbance. The pathological process for which surgery is to be performed is
localised and does not entail a systemic disturbance.
Examples: a fit patient with an inguinal hernia; a fibroid uterus in an
otherwise healthy woman.
Class 2: Mild to moderate, systemic disturbance caused either by the
condition to be treated surgically or by other pathophysiological processes.
Examples: slightly limiting organic heart disease; mild diabetes; essential
hypertension; anaemia.
Class 3: Severe systemic disturbance or disease from whatever cause, even
if it may not be possible to define the degree of disability with finality.
Examples: severely limiting organic heart disease; severe diabetes with
vascular complications; moderate to severe degrees of pulmonary
insufficiency; angina pectoris; healed myocardial infarction.

During the 1980s and1990s patients classified in categories ASA 1 and 2 were thought
to be most suitable for surgery. In recent years criteria have expanded to include
patients in category ASA3 provided their disease is well controlled.
For children being considered for day surgery:
✦ they should normally be of physical status ASA 1 or 11
✦ the anaesthetic and operating time should not exceed an hour, and
SHEET 1
Day Surgery Information
Selection criteria and suitable procedures

✦ the procedure should have a low incidence of 11 Carpal tunnel decompression


post-operative complications 12 Excision of ganglion
✦ premature infants who have not reached 44
13 Arthroscopy (all arthroscopic
weeks post conceptual age are not suitable
examinations of joints)
✦ determine ASA classification in children with
underlying disorders and disabilities 14 Bunion operations

✦ infants who are less than 4 weeks old or who 15 Removal of metalware
have been on ventilatory support are not suitable 16 Extraction of cataract with/without
candidates for day surgery. implant
A patient’s body mass index (BMI) is an important 17 Correction of squint
measure when selecting suitable adult patients for
18 Myringotomy
day surgery. Currently a BMI of 35 is acceptable,
however some units have removed the BMI ceiling. 19 Tonsillectomy

A guideline for investigations to be undertaken must 20 Sub mucous resection


be included in the selection criteria to ensure 21 Reduction of nasal fracture
patients are fit for general anaesthesia and surgical
22 Operation for bat ears
intervention.All investigations should be clinically
driven and not done as a matter of routine. 23 Dilatation and curettage/hysteroscopy

Limits for general anaesthesia rely on physical, 24 Laparoscopy


psychological and social criteria when assessing a 25 Termination of pregnancy
patient’s suitability. In children/young people social
Maintaining the supermarket analogy, the
criteria often play a significant part. Selection may
British Association of Day Surgery proposed
depend on the child living a certain distance from the
a “trolley” of procedures, which are suitable
hospital, having more than one parent or carer, having for day surgery in some cases.
access to a telephone and a car to drive the child back
to hospital in an emergency. Two responsible people
should accompany a child home – one to drive the car Table 3
and the other to care for the child. At least half of the following procedures
In 2001 the Audit Commission produced a revised should be performed as possible day cases
“basket” of 25 procedures thought to be suitable for 1 Laparoscopic hernia repair
day surgery on adults and children.
2 Thoracoscopic sympathectomy
Table 2
3 Submandibular gland excision
The Audit Commission “Basket of 25” 2001
4 Partial thyroidectomy
1 Orchidopexy
5 Superficial parotidectomy
2 Circumcision
6 Wide excision of breast lump with
3 Inguinal hernia repair axillary clearance
4 Excision of breast lump 7 Urethrotomy
5 Anal fissure dilatation or excision 8 Bladder neck incision
6 Haemorrhoidectomy 9 Laser prostatectomy
7 Laparoscopic cholecystectomy 10 Trans cervical resection of endometrium
(TCRE)
8 Varicose vein stripping or ligation
11 Eyelid surgery
9 Transurethral resection of bladder
tumour 12 Arthroscopic menisectomy
10 Excision of Dupuytren’s contracture 13 Arthroscopic shoulder decompression
Day Surgery Information
Selection criteria and suitable procedures

14 Subcutaneous mastectomy defined criteria.


15 Rhinoplasty Patients suitable for day surgery will be referred to
16 Dentoalveolar surgery the unit where nurses, through detailed
preoperative assessment, continue the selection
17 Tympanoplasty process. Nurses undertaking this role must be
trained and their competence assessed through an
agreed development programme (usually “in-
Social criteria house”).A multidisciplinary CD-Rom – Pre-
operative assessment: setting a standard through
When selecting patients for day surgery certain
learning – is available in every trust to facilitate
social criteria must be followed.
this training. Staff undertaking pre-operative
✦ Awithresponsible
1 adult/parent/carer must be
the patient for 24–48 hours post
assessment must have the option to contact the
anaesthetist or surgeon if a problem is identified
surgery. that could potentially increase the risk during

✦ Anaccompany
2 escort must be available to drive or
them home in a taxi.
anaesthetic or surgical intervention.
For children, initial assessment is again usually by

✦ Patients/parents
3
private telephone.
must have access to a
the surgeon in outpatients. Referral is then made
to a pre-admission programme. Pre-assessment of
children is carried out by a registered children’s
✦ The
4 journey home should not take longer
than one to one and a half hours.
nurse with specialist day care knowledge. This
nurse must have the option to contact the
anaesthetist or surgeon if a problem is highlighted
It is essential that patients have support from
that renders the child/young person or family
carers and a means of contacting the hospital
unsuitable for surgery.
should the need arise.
In the case of children:
✦ the parent/carer must be able to cope with the Additional selection of
pre-procedure instructions and with the care procedures suitable for day
of the child/young person after treatment surgery
✦ the parent/carer must agree to day treatment
after receiving adequate information, and an General surgery/urology
opportunity to discuss any anxieties. Ligation of communicating hydrocoele
✦ the parent/carer must be able to stay with the Separation of preputial adhesions
child/young person throughout the day Meatotomy
✦ the parent/carer must be able to make Minor repair of hypospadias
arrangements for the practical care of the Hypospadias fistula
child/young person at home for a named Removal of JJ stents
period of time following discharge. Division of tongue tie
✦ facilities in the home must be taken into Examination under anaesthetic and
account when selecting suitability, i.e. access to vaginoscopy
telephone. Separation of labial adhesions
Gastroscopy ± biopsy
✦ travel on public transport following a general
anaesthetic is inappropriate – arrangements Oesophageal dilatation
for suitable transport must be available. Change of tracheostomy
Change of gastroscopy button
Proctoscopy: Sigmoidoscopy ± biopsy
Who should select? Anal dilatation
Manual evacuation
When a patient requires surgical intervention, the
Excision of local skin lesions
initial assessment often takes place in the out-
Lymph node biopsy
patient department by the surgeon using the
Excision of sebaceous cysts
SHEET 1
Day Surgery Information
Selection criteria and suitable procedures

Branchial sinus/fistula Minor revisions of nose Further reading


Thyroglossal cysts and lip following cleft lip
Removal of long lines and palate surgery Excision Action for Sick Children (2002)
Partial or complete removal and revision of various Setting standards for children
of toenails hamartomata undergoing surgery, London:
Pulsed dye laser treatment Action for Sick Children.
Orthopaedics
Manipulations of portwine stain Caring for Children in the
birthmarks Health Service (1991) Just for
Change of plaster
Release of trigger thumb the day – a study of services for
Serial casting for scoliosis Summary children admitted to hospital for
Tenotomy day treatment. London: Action
It is proven that effective for Sick Children
Dental patient selection will:
Conservation Hodge, D. (ed) (1999) Day
✦ prevent patient
Extractions Surgery – A Nursing Approach.
cancellations on the day of
(especially children with Kent: Churchill Livingstone.
surgery
special needs, Penn, S., Davenport, H.T.,
✦ improve holistic family-
mental/physical handicaps) Carrington, S. and
centred patient care
Excision or biopsy of oral Edmondson, M. (1996)
lesions ✦ ensure adequate support
and education for pre- and Principles of day surgery
Lingual/labial frenectomy nursing. Oxford: Blackwell
post-operative care
Enucleation of simple cysts Science.
Removal of direct bone ✦ maximise the use of the
plates and wires operating list Sutherland, E. (1996) Day
✦ contribute to the overall Surgery – A handbook for
ENT
efficiency of the day unit nurses. Kent: Baillière Tindall.
Adenoidectomy
✦ increase patient
Nasal polyps Audit Commission (1990) A
satisfaction.
Suction clearance including shortcut to better services – day
removal of foreign bodies surgery in England and Wales.
Electrcochleography HMSO: London.
Fat graft myringoplasty Royal College of Surgeons of
Aural polypectomy England (1992) Guidelines for
Change of mastoid dressing day case surgery (revised
Endoscopy edition), London: RCS.
Fracture of nasal bones
Cautery The Royal College of Surgeons
of England (2000) Children’s
Dilatation of choanae
surgery: A first class service.
Antral washouts
London: RCS.
Drainage of septal
haematoma The Royal College of Surgeons
Tonsillectomy (some) of England (1992) Guidelines
March 2001 Ophthalmic for day case surgery (revised
Revised December 2004 Tear duct probing edition). London: RCS.
Published by the Excision of chalazion and
Royal College of Nursing
Miller, J, Rudkin, G. E. and
20 Cavendish Square other benign lid lesions Hichcock, M. (1997) Practical
London Plastic and dermatological anaesthesia and analgesia for
W1G 0RN day surgery. Oxford: Bios
Incomplete simple
Tel: 020 7409 3333 Scientific
syndactyly
www.rcn.org.uk
RCN Direct 0845 772 6100
Excision of accessory
24 hour information and auricles and digits
advice for RCN members. Dermoid cysts
Publication code 001 436

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