1. British Association of Day Surgery www.bads.co.uk How can day surgery be a high quality option for the elderly patient? Dr Anna Lipp President British Association day Surgery

2. British Association of Day Surgery www.bads.co.uk Overview A typical tale of surgery in an elderly patient How might it have been done differently Guidelines for suitability of patients having day surgery

3. British Association of Day Surgery www.bads.co.uk Ivan Edwards and his hernia Mr Edwards is 80 and lives with his 78 year old wife. His daughter lives nearby He has had AF for several years and had a TIA a year ago. He has type 2 diabetes, but is otherwise fairly fit. He can climb the stairs at home He takes Warfarin, digoxin, Humulin 50/50. He also has a hernia.

4. British Association of Day Surgery www.bads.co.uk He goes to his GP about his hernia Diagnosis of Hernia confirmed Surgery suggested and referral to surgeon made …………..Mr Edwards has an inguinal hernia ……….

5. British Association of Day Surgery www.bads.co.uk Surgical OPA Mr Edwards seen by registrar Confirms diagnosis of hernia Books patient for a hernia repair under general anaesthetic Notices patient is elderly, on anticoagulants and insulin so he is booked as an in-patient

6. British Association of Day Surgery www.bads.co.uk Pre op assessment Nurses carry out standard pre-assessment for an in- patient a week before surgery date HbA1C checked – 88mmol/mol Surgery cancelled, referral back to GP for diabetes management to be reviewed. Referral back to surgeon advised when HbA1C < 69mmol/mol

7. British Association of Day Surgery www.bads.co.uk

8. 3 months later…………… HbA1C now 66mmol/mol Repeat nurse assessment Thrombotic risk assessed and instructions to stop warfarin pre-op given Arrangements made for admission night before surgery in view of diabetes on insulin

9. British Association of Day Surgery www.bads.co.uk Day of surgery Mr Edwards is third on the operating list No morning insulin given(NBM), BS 15 by 11 am,FY2 starts VRIII To theatre at 11.30 for a GA Un-eventful hernia repair and recovery Transferred to the ward, feels sick, blood sugar 8. By 20.00 Mr Edwards in pain and cannot PU, in retention, catheterised

10. British Association of Day Surgery www.bads.co.uk Post operative course Blood glucose up and down- remains on VRIII Cannot mobilise because of IVI Develops chest infection- starts antibiotics. Becomes confused Fails trial without catheter

11. British Association of Day Surgery www.bads.co.uk Discharge Day 12 Day 6 diabetes specialist nurse supervises return to usual insulin Day 8 patient ready for discharge with catheter but wife and patient now very anxious about coping at home and need home support arranging Day 12 Home care arrangements in place Referral to urologist for investigation prostate hypertrophy

12. British Association of Day Surgery www.bads.co.uk Could it have been managed differently?

13. British Association of Day Surgery www.bads.co.uk GP Consultation Options for management of hernias with or without surgery Risks and benefits Local anaesthetic vs General anaesthetic Possibility of day case management Check of last HbA1C notes raised level Appointment made with Diabetes nurse to review diabetes management

14. British Association of Day Surgery www.bads.co.uk Surgical OPA Mr Edwards asks about possibility of being a day case patient and whether local anaesthetic repair is possible Hernia repairs default to day surgery intended management Booked on list of surgeon who specialises in LA hernia repair

15. British Association of Day Surgery www.bads.co.uk GA vs LA Risks of GA PONV Urinary Retention Respiratory complications Post operative confusion Benefits LA Low risk PONV Reduces metabolic disruption Low risk respiratory complications Low risk post operative confusion

16. British Association of Day Surgery www.bads.co.uk Is this patient suitable to be a day case? Elderly Diabetes on insulin On anticoagulants

17. British Association of Day Surgery www.bads.co.uk Royal College Surgeons Guidelines 1992 ASA 1 or 2 Age <70 but physiological age rather than chronological BMI <30

18. British Association of Day Surgery www.bads.co.uk AAGBI Guidelines 2011 AAGBI guidelines state “Fitness for day surgery procedure should relate to the patient’s health as determined at pre-operative preparation and not be limited by arbitrary limits such as ASA status, age or BMI” Aldwinckle R, Montgomery J. Unplanned admission rates and post discharge complications in patients over the age of 70 following day case surgery. Anaesthesia 2004;59:57-9

19. British Association of Day Surgery www.bads.co.uk National guidelines state that Day surgery should be offered whenever procedure is appropriate and patient otherwise suitable

20. British Association of Day Surgery www.bads.co.uk

21. Management of diabetes Provide recent HbA1C with referral from primary care Avoid overnight pre-operative admission to hospital wherever possible Identify patients with diabetes so they can be prioritised on the operating list minimising fasting Avoid using VRIII wherever possible

22. British Association of Day Surgery www.bads.co.uk Avoid VRIII VRIIIs are over-used in the peri-operative setting. Patients often return to surgical wards from theatre with an intravenous insulin infusion in place but no directions for its withdrawal. Written guidelines for conversion from the VRIII to the usual diabetes treatment may not be available. Doctors are often unaware of how to do this and infusions are continued or discontinued inappropriately. Continuing a VRIII while a patient is eating often results in poor glycaemic control

23. British Association of Day Surgery www.bads.co.uk Pre-assessment Nurses prepare patient for day case surgery Discuss plans for transport to and from hospital( daughter) Explain what care will be needed at home after surgery Explain how pain can be managed at home Explain when to stop taking warfarin Explain how to manage diabetes pre and post op

24. British Association of Day Surgery www.bads.co.uk Pre op Patient Advice Leaflet

25. British Association of Day Surgery www.bads.co.uk

26. On the day Mr Edwards had last meal evening before and a drink at 6am He injects half usual dose of insulin in the morning On arrival his blood sugar is 7 He is first on the list at 8am, surgery completed by 9am At 10 am he is eating and drinking and blood sugar is 9 By 12 am he has passed urine and got dressed At 1 pm he is ready to go home

27. British Association of Day Surgery www.bads.co.uk Nurse led discharge All criteria for discharge met Analgesia available Diabetes stable Contact numbers for any surgical or diabetic problems Instructions to restart warfarin given Sick day rules given

28. British Association of Day Surgery www.bads.co.uk

29. Could this have been done in Community?

30. British Association of Day Surgery www.bads.co.uk Summary Day surgery can provide a high quality option for the elderly patient Planning early in the pathway avoids delays Written patient instructions enable self management Consider all options for efficient use of resources and high quality outcome

31. British Association of Day Surgery www.bads.co.uk Helpful information