1. National policy progress of Ambulatory Surgery in the UK
Dr Ian Jackson
Past President, British Association of Day Surgery
Past President, International Association for Ambulatory Surgery
Editor in Chief, Ambulatory Surgery

2. Declaration
Medical Director for medical software company Refero Software Ltd
Consultancy work for NHS Elect supporting development emergency day surgery
Clinical Safety Officer for York Teaching Hospital NHS Foundation Trust
Contract work for EU supporting day surgery in Hungary

3. Where is York?

4. York Minster

10. Some history to provide context

11. Multidisciplinary membership
Nurses, Theatre staff, Anaesthetists, Surgeons, Managers
To encourage the expansion of day surgery
To promote education and high quality treatment
To conduct research and publish the findings
To organise meetings, seminars lectures and conferences
To provide advice on the construction and management of day units
To maintain high standards of surgical, anaesthetic and nursing care

13. 2000

15. 1700 patients Day Case Inpatient Day Rate (%) 95th centile Extra cases
01 - Orchidopexy 31 8 79 94 6
02 - Circumcision
109 32 77 93 22
03 - Inguinal Hernia
249
309 45 67
124
04 - Excision of Breast Lump 13 30 88 25
05 - Anal fissure dilation/excision
305 64 83 82 -2
06 - Haemorrhoidectomy 37 57 21
07 - Cholecystectomy
342 18 60
08 - Varicose Vein Stripping/Ligation
196
134 59 80 66
09 - Transurethral resection of bladder tumour 70
233 23 43 61
10 - Excision of dupuytrens contracture 73 53
11 - Carpal Tunnel decompression
328 98 14
12 - Excision of Ganglion 86 95
13 - Arthroscopy
806
235 47
14 - Bunion Operations 36
136 78
15 - Removal of metalware 65 99 40 71 51
16 - Extraction of cataract
2116 75 97
100 68
17 - correction of squint 12 11
18 - Myringotomy w or w/o grommets
101
113
19 - Tonsillectomy
490
321
20 - Sub mucus resection
182 3 96
175
21 - Reduction of nasal fracture 9 90
22 - Correction of bat ears 27 89 4
23 - Dilation and curettage/hysteroscopy
1158 54 92
-49
24 - Day surgery Laparoscopy
821
138 5
25 - Termination of pregnancy
579
422 58
393
26 - Total
7277
3270 69
1684
1700 patients

16. Decision we needed to changed direction at BADS

17. 2005

18. One mad evening

22. Some procedures require longer recovery or observation times and so are only possible as a true day case if performed on morning sessions.

23. Some procedures require longer recovery or observation times and so are only possible as a true day case if performed on morning sessions.
Others may require specialised equipment and training for clinicians to achieve their full potential.

24. Some procedures require longer recovery or observation times and so are only possible as a true day case if performed on morning sessions.
Others may require specialised equipment and training for clinicians to achieve their full potential.
Therefore the achievement of these goals may require reconfiguration of day surgery lists, redesign of the clinical pathway and investment in appropriate technology.

26. Now also have National Dataset

27. Specialties
Over 180 procedures

28. 2006 data

34. Day Case Nephrectomy

36. Improvement

37. Problem - variation in practice

38. Laparoscopic Cholecystectomy
75%

39. Inguinal hernia repair
90%

40. Excision biopsy of breast tissue
95%

41. Next phase – drive to improve performance
Financial drive
Feedback of performance
Next phase – drive to improve performance

42. Financial
Tariff for procedures in NHS set by Payment by Results team

43. “How do we provide appropriate payment for Day Surgery activity?”
Payment by Results and day surgery
2009 Approach to BADS by the NHS PbR Team
“How do we provide appropriate payment for Day Surgery activity?”
Reduce tariff?
No... Enhance tariff as a financial incentive

44. Laparoscopic Cholecystectomy

45. Best Practice Tariffs 2015 Breast Surgery: ENT: Orthopaedics:
Mastectomy, Sentinel Node Biopsy, Axillary Clearance
ENT:
Tonsillectomy, Septoplasty, Mastoid Ops
Orthopaedics:
Dupuytren’s, Subacromial decompression, Bunion ops
Gynaecology:
Female incontinence surgery, O/P Hysteroscopy/Sterilisation
Urology:
Resection of Prostate, O/P Cystoscopy
General Surgery:
Laparoscopic Cholecystectomy, Hernia Repair

46. Payment..
Daycase (£)
Inpatient (£)
Diff
(%)
Laparoscopic Cholecystectomy
1909
1726
10.6%
Inguinal/Umbilical/Femoral Hernia Repair
1363
1228
11.0%
Ops for urinary incontinence
1181
1067
10.7%
Tonsillectomy (adult)
1094
988
Mastectomy
2123
1928
10.2%
TUR (Prostate)
2127
1931
Septoplasty
1237
1119
10.5%
Tympanoplasty/Mastoid Ops
1842
1664
Dupuytren’s Repair
1715
1547
10.9%

47. 2017 22 more Day Surgery Procedures Gynaecology Orthopaedics Urology
Anterior colporrhaphy, Posterior colporrhaphy, Lap Therapeutic Procedures, Oophorectomy/Salpingectomy
Orthopaedics
Anterior Cruciate Ligament Repair
Urology
Optical urethrotomy, Ureteroscopic extraction calculus, Insertion ureteric prosthesis, endoscopic destruction lesion bladder
ENT
Nasal Polypectomy
General Surgery
Repair of other abdominal hernia, Excision/biopsy of lymph nodes for diagnosis
Ophthalmology
Dacryocysto-rhinostomy + Tube
Vascular/Interventional Radiology
Transluminal procedures on femoral artery, Creation of AV fistula for dialysis

48. Success

49. Feedback of performance
Developed with CHKS – provider of Health Intelligence
Dataset published 12 monthly
Trusts signed up to CHKS can monitor performance against the BADS Directory and their peers

56. Is it all main hospital based?

59. Phone call to going live
Visit and review site – feasibility
Agree plans for upgrade to theatres and wards
Meetings with clinicians
Form - Clinical User Group
Clinical Lead, Nurse Lead, Lead Manager
Regular meetings to agree clinical standards
Day Surgery Unit Operational Policy
Phone call to going live

60. Key developments

61. Key developments Clarity in Operational Policy How many staff
Skill mix of nursing staff
Skill mix of anaesthetists onsite
Skill of primary surgeon for list

62. Key developments Clarity in Operational Policy
Dealing with unplanned admissions
Depends on your facility/staffing
Establish onsite beds for overnight stay
Establish medical cover for those beds

63. Key developments Medical cover Wanted ability for overnight stay
Negotiated senior anaesthetic residency
Monday – Thursday
Furnished flat onsite
Satellite TV
Fresh bread, tea, coffee, milk provided
One evening ward round then only called for emergency.

64. Key developments

65. Key developments Patient Selection Conservative to start BMI < 40
No severe neuromuscular disease with significant functional impairment.
No severe respiratory disease with significant functional impairment.
No history of difficult intubation
No history of MH

66. Key developments

67. Key developments Procedure selection
Depends on structure and confidence
Started with simpler procedures
Complex supported by development of overnight stay
Patient safety paramount consideration

68. Key developments

69. Key developments Dealing with unplanned transfers
Establish transfer protocol to Scarborough Hospital
Clarity on patient assessment and deterioration
Training in recognition of deteroriating patient
Use of national early warning score chart
Agreed threshold for transfer
Agreed transfer team
Team training/practice sessions

70. Key developments

71. Key developments Dealing with major emergencies Escalation protocol
Laparotomy trays/Emergency equipment
Blood bank

73. Key developments
Contract for urgent transfer of blood samples/blood products
Agreed protocol for major haemorrhage
Team training/practice sessions

75. Success? Move of orthopaedic elective surgery
Hip and knee replacement, shoulder surgery etc
Need for second theatre with tent
Quick resolution via mobile modular unit
Looking at provision of ophthalmology theatre

76. Delivered in 8 weeks – working within 12 weeks

78. Standalone - success and safety
Can provide safe quality surgery
Can be with or without overnight beds
Full attention to governance
Clear Operational Policy
Clear emergency pathways
Monitoring of patient outcomes
Requires
Standalone - success and safety

80. Last thoughts to leave you with