Not one single factor alone dictates suitability for day surgery. The procedure, patient factors, and discharge destination all must be suitable for safe day surgery.
Patient selection for day surgery requires a comprehensive baseline assessment of the perioperative risk using a validated surgical risk assessment tool. Review of social factors including distance from a hospital and availability of someone to care for the patient overnight need to be considered as part of proactive surgical planning and management.
When selecting suitable patients it is important to consider the following:
Increasingly complex procedures are being performed as day procedures that would have previously been done as inpatient stay.
- have a minimal risk of post-operative haemorrhage
- have a minimal risk of post-operative airway compromise
- be amenable to post-operative pain controllable by outpatient management techniques
- permit post-operative care to be managed by the patient and/or a responsible adult and any special post-operative nursing requirements met by day surgery, home or district nursing facilities
- be associated with a rapid return to normal fluid and food intake
- be scheduled taking into account the anticipated recovery period. Where a prolonged recovery is anticipated, the procedure should be scheduled first on the list or as close to first as feasible.
Patients should be ASA physical status 1 or 2. In certain cases, medically stable patients with ASA status 3 may also be considered, depending on the procedure.
The ASA score alone does not dictate suitability. This is also influenced by surgical and procedure factors, and the facility in which surgery is taking place.
Careful assessment of medical comorbidities should be undertaken with relevant valid screening tools, and with safety consideration of facility resources.
This includes patients with:
- obstructive sleep apnoea and/or a difficult airway
- a body mass index greater than 35 unless the surgery is very minor and superficial.
Once comorbidities are identified, patients should have an active plan put in place to optimise their condition prior to surgery.
Patients should be assessed for cognitive impairment prior to their surgical procedure using a validated tool. The patient or their carer(s) need to have adequate cognitive function and health literacy to appropriately monitor the patient’s recovery and escalate issues if they occur.
A safe discharge plan needs to be considered prior to surgery. This includes:
- pre-arranged transport home
- carer availability and capability
- the arrangement of any additional equipment or supports prior to admission
- appropriate discharge location and environment, including staying within 30 minutes from their nearest health service.
Patient selection should be based on agreed inclusion and exclusion criteria developed by each individual service that takes into consideration the capability of the service providing surgery.
Resources to support implementation
It is crucial to set clear expectations from the initial patient and carer interaction to alleviate anxiety and emphasise that day surgery is the norm, rather than the exception. To achieve this, the healthcare team, including the primary care practitioner, must convey a consistent message from the moment of referral for surgery. One effective way to ensure this is by creating staff question and answer scripts.
Effective communication with the primary care provider is also essential to optimise pre-surgery care and facilitate post-discharge care escalation. They must be informed of the plan for day surgery and given clear expectations of how to support their patient throughout their surgical journey.
Resources to support implementation
Patient optimisation and prehabilitation
Elements of multimodal prehabilitation
Elements of multimodal rehabilitation:
Patient optimisation prior to surgery helps to ensure the best possible outcomes for patients.
Prehabilitation is a process that aims to enhance a patient’s physical and psychological function to support them before, during and after surgery.
Prehabilitation and optimisation of comorbidities pre-surgery can:
- reduce length of stay
- reduce risk of post-operative complications
- enhance recovery post surgery
- improve cardiorespiratory fitness
- improve nutritional status
- encourage the patient to quit smoking and drinking alcohol
- prepare the patient psychologically and emotionally for surgery
- improve surgical outcomes
- improve population health
- improved the patient experience.
The level and type of prehabilitation/pre-surgical care required by the individual patient depends on the surgery risk, patient risk and comorbidities.
Shared decision-making and optimisation programs need to be multimodal to help empower the patient to take control of their perioperative journey. Digitally facilitated prehabilitation is a cost-effective model that can be accessible to a large number of patients, such as via smartphone, tablet or computer. Capitalising on digitally enabled patients who are comfortable with this format for education, resource access and tracking progress can also facilitate self-management abilities.
Reviewed 26 July 2023