ENT Day Surgery at a District General Hospital: A Study of Case Suitability

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1 40 The Journal of One Day Surgery VOL 24 No 2 ENT Day Surgery at a District General Hospital: A Study of Case Suitability TARIK AMER, HOI-YI CHING, SAM GAYA, ANGHARAD JONES, SHUJA KAZMI & PATRICK CUDDIHY Keywords: Day case, ENT, tonsillectomy, patient perception. Abstract: Published data portrays that the overwhelming majority of patients undergoing a basket of ENT procedures do not suffer any post-operative complications, thereby increasing their day case suitability. 1 However, there is limited work on the parental and patient views of same day discharge. Aim: The aims of this study are to: 1) Identify those ENT cases currently performed in an inpatient setting that could be performed in a day case environment. 2) To ascertain patient and parental views on perceived suitability of these cases for day case surgery. Method: We conducted a prospective study over a three month period for all consecutive ENT operations included in the RCS Basket of Cases that are not currently performed as day case procedures. Trainees completed a standard questionnaire for each patient at the time of the postoperative day one ward round to assess day case potential. Results: Day case criteria: 96 cases were included for analysis. 98% fulfilled medical and social criteria for day case surgery. Tonsillectomy: There were 48 paediatric and 21 adult cases of tonsillectomies in the study period. There were no cases of primary hemorrhage requiring return to theatre at time of discharge. 47% of patients and 48% of parents would have opted for day case surgery. 60 % of adeno-tonsillectomy and 100% of adenoidectomy parents had a preference for day case procedures. Functional Endoscopic Sinus Surgery: 85% of patients would have preferred to have gone home on the same day as the procedure despite 5/14 (35%) experiencing bleeding overnight with 2 (17%) required repacking overnight. Discussion: This study shows that whilst patients may fit day case criteria, patient perceptions show that in some ENT procedures, day case surgery is felt to be inappropriate. The low complication rates are reassuring but patients perception of the high risk of bleeding is somewhat at odds with published data. This would appear to be a patient education issue and one that can be addressed in the counseling stage of the operative pathway. Introduction Many ENT procedures are short in duration, have minimal postoperative morbidity and have a low incidence of complications. These characteristics lend themselves to day case surgery. 1,2,3 Day case surgery is acknowledged to have numerous advantages over inpatient surgery; improved efficiency, reduced risk of infection, lower waiting lists and reduced costs. 4 Over the past twenty years there has been a gradual expansion of day case services in the UK. However in 2001 an audit commission report found that there was still scope for further growth, prompting the Day Surgery Strategy in ,5 The above documents and further consultation led to several ENT procedures being included in procedures across specialties that are suitable for day surgery. These include insertion of grommets, tonsillectomy, septoplasty, submucous resection, nasal fracture (manipulation under anaesthesia) and pinnaplasty. Whilst there exists a good evidence base to support the safe performance of 70% of ENT procedures in a daycase setting, the inherent benefits of day case surgery, including considerable financial savings, have yet to be realized in the ENT setting. 1 Authors Addresses TARIK AMER CT1 ENT HOI YI CHING Specialist Registrar ENT SAM GAYA Clinical Fellow ENT ANGHARAD JONES CT2 ENT SHUJA KAZMI CT2 ENT PATRICK CUDDIHY Consultant ENT ENT Department, Royal Gwent Hospital, Cardiff Road, Newport, South Wales NP20 2UB. Corresponding author: TARIK AMER Core Surgical Trainee, ENT Department, Royal Gwent Hospital, Cardiff Road, Newport, South Wales NP20 2UB.

2 The Journal of One Day Surgery 41 Perhaps most emotive in this debate, is the issue of day case tonsillectomy which has wide variation in the UK in terms of uptake. 1,6 In some units, almost all tonsillectomies are performed as day cases. 1 In others, the risk of primary haemorrhage apparently justifies an overnight admission. A meta-analysis of 8,889 patients showed an overall primary haemorrhage of 0.5% in adenoidectomy or tonsillectomy cases. 1,8 As this overrepresented the paediatric population where there tends to be a lower primary haemorrhage rate, further work looked specifically at day-case tonsillectomy in the adult population. 1 Bhatta cites another work that found a primary haemorrhage rate of 0.8%, 95% of which were within 7 hours post operation. 9 This figure is somewhat lower than quoted figures for the Wales Tonsillectomy Surveillance Report. This showed that for 7035 tonsillectomies/adenoidectomies in , there was a bleed rate (primary and secondary) of 1.4%. This figure is a combination of initial returns and readmission returns. This may well be higher as only 30% of return to theatre cases were reported and is lower than the crude bleed rate of 2.3% obtained via Hospital Episode Statistics. 7 This plethora of useful data correctly portrays that the overwhelming majority of patients undergoing this cohort of ENT procedures have no complications post-operatively, thereby increasing their day case suitability. However, there is limited work on patient and parental views of same day discharge. As Dennis stipulates, this must play a key role in establishing such procedures as suitable for day case surgery. 7 A study in Salisbury found that 48% of adults were against day case tonsillectomy on the basis of pain and nausea. 7 The same authors cite work in Bristol and Cumbria where only 28% and 63% of parents would have agreed for their children to have day case tonsillectomies. 10,11 There is a widely held view that in the case of tonsillectomies patients would generally prefer to recover at home in their own surroundings. 12 This study intends to shed light on this in the setting of a District General Hospital to either corroborate or refute this impression. Aim This study was performed in a busy district general hospital (Royal Gwent Hospital, Newport) to review potential expansion of ENT services into day case surgery. The sub-aims are to: 1. Identify those ENT cases currently performed in an inpatient setting that could be performed in a day case environment. 2. To ascertain patient and parental views on perceived suitability of these cases for day case surgery. Method We conducted a prospective study over a 3-month period for all consecutive ENT procedures that could be but were not currently performed as day case. Trainees completed a standard questionnaire for each patient at the time of the post-operative day one ward round to assess day case potential. Patients were matched against rigorous patient selection (medical and social) criteria provided by our Day Case Surgery Department. This is in line with Department of Health /BADS (British Association of Day Surgery) guidelines. 14 Peri and post-operative complications were documented. Medical/nursing interventions conducted overnight were documented. Criteria justifying overnight stay were: haemorrhage, and pain/post op nausea and vomiting (PONV) needing IV/IM treatment. We also asked parents/guardians to express a preference for day case/inpatient management with the insight of having gone through the process as an inpatient. Those patients unwilling for day case management were asked reasons why. Finally, we documented whether patients were operated on a morning or afternoon list as this might influence their preference for the above. Results Day case criteria 102 consecutive cases were assessed. Six cases have been excluded due to incomplete data leaving 96 cases for analysis. 98% fulfilled medical and social criteria for day case surgery. Two patients were excluded; one was a child with Type 1 Diabetes requiring insulin sliding scale for the procedure. The other excluded was an adult who would have been unsupervised in the immediate post-operative phase. Case mix 59 (64%) of cases were aged 18 or under and 35 (38%) were adults. There were 69 tonsillectomies, five adenotonsillectomies, six adenoidectomies and 14 FESS procedures for review. All patients had an overnight stay of at least one night. Tonsillectomy There were 48 paediatric and 21 adult cases of tonsillectomies in the study period. There were no cases of primary hemorrhage requiring return to theatre at time of discharge. Re-admissions were not assessed in this study. All paediatric cases were performed before 3pm and so inference cannot be drawn between preference/suitability based on the time of procedure.

3 42 The Journal of One Day Surgery VOL 24 No 2 Children Parents were asked if they would choose day case tonsillectomy if another child were to have a tonsillectomy. If parents didn t believe that day case surgery was suitable, their reasons were explored. 23/48 (48%) felt that same day discharge was suitable. The remaining 25 (52) felt that day case tonsillectomy was not suitable. Seven parents (15%) cited uncontrollable pain as the deciding factor in their decision and an overnight admission would have been needed if booked as a day case. Seven parents (15%) feared the risk of haemorrhage and so preferred the safety of overnight observation. Three parents cited grogginess or a slow recovery as their preference. Five (10%) preferred the safety blanket of being observed for no other specific reasons. Adult Only three adult tonsillectomies were performed after 3pm. Two out of the three patients felt same day discharge was suitable and the third did not on the basis of pain and difficulty eating. The other 19 (90%) were performed before 3pm. Ten (47%) patients would have preferred to go home on the same day. Of those 53% who didn t, (30%) felt that the pain levels made this arrangement unsuitable. One adult felt as though they were slow to recover from the anaesthetic and an overnight stay was thus warranted. Only one adult tonsillectomy feared the risk of bleeding. Adenotonsillectomy Of the five adeno-tonsillectomy patients in the study, all were performed before 3pm and 60% had a preference for day case and 40% for in-patient procedures. One parent felt the level of pain made the procedure inappropriate and the other cited the fear for bleeding. Adenoidectomy All five adenoidectomy patients were in the paediatric population and parents specified a wish for day case surgery. No overnight complications were noted. Endoscopic cases Fourteen Functional Endoscopic Sinus Surgery cases were included for review. All met day case criteria, nine were on morning lists and five on afternoon lists. 5/14 (35%) experienced bleeding overnight with two (17%) requiring repacking. One patient had a temperature overnight and one patient experienced a fall on the ward. 85% (n=12) of patients would have preferred to go home on the same day as the procedure. Discussion This study has shed light on patient perception in performing tonsillectomies, adenoidectomies and endoscopic procedures on a day case basis. 48% of parents felt that day case tonsillectomies would be safe but clearly a majority feel safe with the current arrangement of inpatient observation post operatively. A key concern for parents was potential suboptimal pain control at home (15%). Another 15% were fearful of the potential for bleeding. There was a similar sentiment amongst adult patients with 30% feeling that pain levels post operatively made this procedure inappropriate to be performed as a day case. In adult patients having endoscopies, the vast majority would have preferred to go home on the same day despite the presence of five cases of post-operative haemorrhage. This study shows that whilst patients may fit day case criteria, patient perceptions show that in some ENT procedures, day case surgery is felt to be inappropriate. The low complication rates are reassuring but patients perception of the high risk of bleeding is somewhat at odds with published data. This would appear to be a patient education issue and one, which can be addressed, in the counseling stage of the operative pathway. Poorly controlled pain is a noteworthy issue hampering a move to a day case model. This should be looked at in future audit of care quality in our ENT department. Pringle and colleagues aptly write that the increased use of day case surgery is justified by reducing costs whilst not compromising care quality. However, quality care also demands patient acceptability; in this study it is clearly not universal. 12 Clearly, there is no overwhelming support for day case surgery particularly in the case of tonsillectomies/ Table 1 Patient preference for day case procedures by type. Procedure Child (<18y) Adult Medical criteria met? Social Criteria met? Morning list Afternoon list Overnight issues/ complications Day case preferences Inpatient preference Tonsillectomy excluded IDDM Yes pain Adenoidectomy 6 - Yes Yes FESS - 14 Yes Yes x bleeding 1 x repacking 12 Adenotonsillectomy 6 - Yes Yes

4 Figure 1 Data collection tool. The Journal of One Day Surgery 43

5 44 The Journal of One Day Surgery VOL 24 No 2 adenoidectomies. However, most patients undergoing functional endoscopic sinus surgery procedures would prefer this arrangement. With appropriate counseling pre-operatively, those patients and parents keen for same day discharge could be carefully selected and booked accordingly to help realize more of the potential benefits of day case surgery. References 1. Bhutta (2006) Adult ENT day surgery, a case for expansion. Ann R Coll Surg Eng (Suppl) 2006; 88: Brown PM, Fowler S, Ryan R, Rivron R. ENT day surgery in England and Wales an audit by the Royal College of Surgeons (Eng.) Comparative Audit Service. J Laryngol Otol 1998; 112: Ganesan S, Prior AJ, Rubin JS. Unexpected overnight admissions following day-case surgery: an analysis of a dedicated ENT day care unit. Ann R Coll Surg Engl 2000; 82: Bradshaw EG, Davenport H. Day Care: Surgery, Anaesthesia and Management. London: Hodder Arnold; Audit Commission. Acute hospital portfolio review of national findings: day surgery. London: Audit Commission; December Dennis, S. Gergallou, M. Eclcok, L. Brockbank, M. (1995) Day case tonsillectomy. The Salisbury experience. Journal of One-Day surgery. 1995; 14[2]. 7. All Wales Annual Tonsillectomy Surveillance Report (2011). Surgical Instrument Surveillance Programme, National Public Health Service for Wales. 8. Tewary AK. Day-case tonsillectomy: a review of the literature. J Laryngol Otol 1993; 107: Moralee SJ, Murray JA. Would day-case adult tonsillectomy be safe? J Laryngol Otol 1995; 109:1,166 1, Benson-Mitchell R., Maw A.R. Assessment of sequelae at home following adenotonsillectomy. A basis for day-case management. Clin. Otolaryngol. 1993; 18: Kubba H., Messersmith R. Is day case tonsillectomy suitable for children in Cumbria? Clin. Perform. Qual. Health Care. 1999; 7(3): Pringle MB, Cosford E, Beasley P, Brightwell AP. Day- case tonsillectomy is it appropriate? Clin Otolaryngol Allied Sci 1996; 21: Kanerva M, Tarkkila P, Pitkäranta A. (2003) Day-case tonsillectomy in children: parental attitudes and consultation rates. Int J Pediatr Otorhinolaryngol. 2003;67(7): Department of Health (2002) Day Surgery: Operational Guidelines. Department of Health