Plicy N: OP61 Versin: 1.0 Name f Plicy: Day Surgery Operatinal Plicy Effective Frm: 27/01/2010 Date Ratified 22/01/2010 Ratified Patient, Quality, Risk and Safety Cmmittee Review Date 22/01/2011 Spnsr Directr f Nursing and Midwifery Expiry Date 21/01/2013 Withdrawn Date This plicy supersedes all previus issues. 1
Versin Cntrl Versin Release Authr / Reviewer Ratified By / Authrised By Date 1.0 27/01/2010 E Ltt PQRS 22/01/2010 Changes (Please identify page n.) 2
Day Surgery Operatinal Plicy Cntents Page N 1. Intrductin 4 2. Plicy Scpe 4 3. Aim f the Plicy 4 4. Duties Rles and Respnsibilities 7 5. Definitins 8 6. Training 8 7. Dcumentatin 9 8. Patients underging Surgery 9 9. Nurse Led Discharge 9 10. Equality and Diversity 9 11. Prcess fr Mnitring Effectiveness f the Plicy 9 12. Cnsultatin and review f this Plicy 9 13. Implementatin f plicy (including raising awareness) 9 14. References 9 15. Assciated Dcumentatin 10 3
1. Intrductin What is Day Surgery? Day Surgery is when a patient is admitted t hspital, has surgery and is discharged n the same day. There is a wide range f nn-emergency surgical peratins that can be carried ut as day surgery. This has cnsiderable advantages fr patients, the public and the NHS: - Waiting times are shrter. There is less risk f cancellatin There is less disruptin t patient s lives and the cmfrt f recvering at hme There is reduced risk f crss infectin and less stress fr patients if they are nt mixed with the acutely ill It is mre efficient because prcedures can be scheduled mre predictably 1.1 Natinal Guidelines 2. Plicy Scpe The Department f Health NHS Plan (2000) and British Assciatin f Day Surgery (BADS) recmmendatins (www.bads.c.uk fr purchase f the directry) set a target that 75% f elective admissins shuld be perfrmed as a day case. There has been cnsiderable supprt and cmmitment frm the Department f Health in the Day Surgery: Operatinal Guide (Waiting, Bking and Chice, August 2002) and the NHS Innvatin and Imprvement Prgrammes (frmerly Mdernisatin Agency). This plicy cvers the patient jurney frm decisin t admit t discharge f day case patients; it includes referral t pre-assessment, pre-assessment, status n waiting list, admissin planning and admissin prcess, discharge planning and fllw up care. It allws fr patients chice at all pints f the patient jurney. 3. Aim f the Plicy The Aim f the Plicy is t ensure that all emplyees f Gateshead Health NHS Fundatin Trust wh are invlved in Day Case pathways are infrmed and aware f the patient pathway and underpinning prcesses. This will ensure patients all receive equitable access t care and the best pssible experience f day surgery in a safe envirnment, which reflects individual needs and ensures that services are f the highest quality and adhere t the highest standards f care. The patient jurney is shwn at Appendix A. 3.1 Facilities The Unit prvides: - Operating Theatres 12 First Stage Recvery 12 trlley spaces Pd Area 16 curtained cubicle areas Cnsulting/treatment Rm 4
Waiting Areas/ Receptin area Interview Rm Administrative Offices The staffing structure fr Theatres is shwn belw: Divisinal Manager Matrn Educatin Facilitatr Band 7 Senir Sister Band 7 Pds Senir Sister Band 7 Theatres Senir Sister Band 7 Anaes/Rec Pd Area Staff Theatre Staff Anaes/Rec Staff 3.2 Categry f patient All patients will be assessed, using agreed criteria, t ascertain their fitness and apprpriateness fr day surgery. 5
Pre-perative assessment will screen the patient fr suitability bth medically and scially and frms an integral part f the day unit admissin prcess. 3.3 Default Prcedures Each Directrate has identified prcedures that are suitable fr day surgery frm the basket f 25 and the BADS Directry f Prcedures (www.bads.c.uk). These prcedures have a default fr management intent f day case and all patients wh meet the criteria will be treated as a day case. Thse wh need vernight stay will have this prvided but flexibility f discharge times int the late evening is expected t allw mre patients t be discharged hme n the same day than previusly. (See Appendix C fr 23 hur stay prcess) 3.4 Administratin Clerical and Medical Recrd staff frm individual departments and specialities (including external prviders) supprt the Day Case pathway and deal with the administratin and waiting list prcess f the Day Surgery Patients. Please refer t the patient access plicy (OP12) which all services will have agreed t and will adhere t. 3.5 Bking Methd Natinal best practice in relatin t patient administratin is fllwed. Gateshead Health NHS Fundatin Trust Patient Access Plicy (OP12) is fllwed this can be fund n the Trust Intranet at http://www.gatesheadhealth.nhs.uk/freedm-f-infrmatin/plicies-andprcedures/dcuments/live/op12%20patient%20access%20_waitinglist~ WaitingTimes_%20Plicy.pdf 3.6 Preperative assessment All patients underging day case prcedures, requiring either general r lcal anaesthesia, will be apprpriately assessed as per the Trust s current preperative assessment plicy. Please refer t the Infectin Preventin and Cntrl Plicy (IC1) fr guidance n MRSA screening f elective patients. The aim is t ensure all patients attending fr day surgery and treatments will be safe t return hme fllwing their prcedure. As part f the Pre-perative assessment strict criterin is fllwed t ensure this. If it is unsafe t return hme, a bed fr vernight admissin will be fund. Verbal and written infrmatin n hw t access hspital advice and care in the immediate pst discharge perid is given. 3.7 Opening times and timetables The day unit pens at 0800hrs 2000hrs Mnday Friday. 6
Sessins f lists are: - 0900 12:30 1400 17:30 0900 17:30 with apprpriate breaks, t nt exceed 7 hurs 3.8 Surgical Specialities wh access this service Gynaeclgy Urlgy Orthpaedics General Surgery Gynaenclgy Maxill-facial Spinal Dental Plastics ENT Vascular 4. Duties Rles and Respnsibilities 4.1 Divisinal Manager The Divisinal Manager has the verall respnsibility fr plicy decisins and will ensure efficient and effective use f resurces 4.2 Rle f Matrn The Matrn has verall respnsibility fr the Unit especially as regards t the budget. 4.3 Rle f Senir Sister The Senir Sister has respnsibility fr the staffing within the unit including managing the staff and c-rdinating wrk rtas. It is this rle that has peratinal respnsibility t truble sht and interact with ther Directrates fr day-t-day peratinal issues. The senir sister has day-t-day managerial respnsibility fr the running f the centre and the training and develpment f the staff n the pd area. 4.4 Rle f the admitting cnsultant Clinical respnsibility fr the patient is the respnsibility f the admitting cnsultant. 4.5 Rle f the sessin anaesthetist The anaesthetist assesses the fitness and suitability fr anaesthesia fr all patients underging general r reginal anaesthetic. They are respnsible fr administering the anaesthetic and the prvisin f pstperative analgesia. 7
5. Definitins Out Patients Patients referred by a General Practitiner, anther Healthcare prfessinal r self referral, fr clinical advice r treatment. Decisin t Admit The date n which a Healthcare Prfessinal cnfirms that a patient is fit t be admitted fr an prcedure. The DTA date is the effective date when the patient waiting time cmmences. This is the actual date the decisin was made, nt the date the patient was added t the list. Pre Assessment Pre-perative assessment establishes that the patient is fully infrmed and wishes t underg the prcedure. It ensures that the patient is fit fr the surgery and anaesthetic. It minimises the risk f late cancellatins by ensuring that all essential resurces and discharge requirements are identified. Day Cases Patients wh attend hspital fr an interventinal prcedure and are discharged hme within the same day. In Patients Patients wh require admissin t hspital fr treatment and are intended t remain in hspital fr at least ne night. Discharge A multi disciplinary and multi agency activity during which the needs and resurces f patients and carers are at the centre f assessment, planning and implementatin. 6. Training 6.1 New Staff Training requirements f all staff will be assessed as part f their Lcal Inductin and initial CONTACT appraisal. Training will be undertaken as part f the emplyee s Persnal Develpment Plan. 6.2 Existing staff Existing staff require cntinuus prfessinal develpment and this is mnitred by the Educatin Facilitatr and Senir Sister. Mst training requirements fr all staff, either clinical r nn clinical will be identified fr 8
7. Dcumentatin staff at their CONCTACT but als training is identified within the activity f the Unit. All patients attending the Pd are clerked in using the relevant Care Pathways. This care plan begins at pre-perative-assessment and accmpanies the patient thrughut their stay. 8. Patients underging surgery Day Case patients are perated n in the Surgery Centre and Main Theatres. If a patient requires surgery, which has t be dne in main theatres, they are still admitted via treatment centre receptin but may be streamed t theatre thrugh NESC r QE PODS. 9. Nurse Led Discharge The patients are discharged by the qualified nurses fllwing relevant dcumentatin and discharge criteria. (See Appendix B). 10. Equality and Diversity The Trust is cmmitted t ensuring that, as far as is reasnably practicable, the way we prvide services t the public and the way we treat ur staff reflects their individual needs and des nt discriminate against individuals r grups n any grunds. 11. Prcess fr Mnitring Effectiveness f the Plicy This plicy will be mnitred fr effectiveness n a bi-mnthly basis using the day case reprt frm the Infrmatin Department, regular quarterly recrds audit and mnitring f cmplaints and cmpliments. The Day Case grup will reprt t Theatre PAAT and Surgical Divisinal meeting. 12. Cnsultatin and review f this Plicy This plicy has been reviewed in cnsultatin with the Day Surgery Grup. 13. Implementatin f plicy (including raising awareness) The plicy will be cmmunicated buy the Trust Secretary by e mail t all staff members and in additin will be included in the Team Brief t all staff. 14. References a. Day Surgery: Operatinal Guide Waiting, bking and chice, August 2002 b. British Assciatin f Day Surgery, see www.bads.c.uk c. NHS Institute fr Innvatin and Imprvement, available at http://www.institute.nhs.uk/quality_and_service_imprvement_tls/quality_a 9
nd_service_imprvement_tls/day_surgery_- _treat_day_surgery_as_the_nrm.html 15. Assciated Dcumentatin a. Day Surgery: Operatinal Guide Waiting, bking and chice, August 2002 b. British Assciatin f Day Surgery, see www.bads.c.uk c. Gateshead Health NHS Fundatin Trust Patient Access Plicy OP12 available at http://www.gatesheadhealth.nhs.uk/freedm-finfrmatin/plicies-andprcedures/dcuments/live/op12%20patient%20access%20_waitinglist~ WaitingTimes_%20Plicy.pdf d. Gateshead Health NHS Fundatin Trust Discharge and Transfer Plicy OP13 available at http://www.gatesheadhealth.nhs.uk/freedm-finfrmatin/plicies-andprcedures/dcuments/live/op13%20discharge%20plicy.pdf 10
Appendix A Outpatients Preperative assessment Patients are referred t the hspital cnsultant frm the GP. They are given an ut patients appintment. At this appintment the cnsultant decides whether the patient is suitable fr day surgery r nt. Fllwing the decisin t admit fr Day Surgery the pre-assessment request frm is cmpleted and sent with the ntes t pre-assessment, wh review and send ut a appintment t attend pre-assessment. The pre-assessment unit is situated n level 3 at the Nrth East Surgery Centre. The patient arrives at the Pre-assessment unit and is immediately given a preperative assessment frm t fill in. This has been designed t lk at scial needs as well as medical needs. A preperative assessment nurse frm the unit then ges thrugh the frm and makes the relevant cmments. If they feel the patient is nt suitable fr day surgery then they wuld say s at this stage and infrm the relevant secretary. They are able t discuss any issues with the clinical lead if they are nt sure. The assessr makes sure that the patient has 24 hur care pst p and will nt be travelling mre than 1 hur in a car t get hme. Verbal infrmatin is given t the patients regarding their surgery this is fllwed up with written Patient infrmatin leaflets. Admissin letters frm each speciality are sent t the patient cnfirming date and times and fasting instructins fr day f prcedure Admissin Anaesthetic assessment An anaesthetist sees patients pre-peratively, n the day f surgery. Surgery Pre Peri - Pst Current guidelines fr patient mnitring fllwing surgery The guidelines cver the mnitring f patients when returning t the ward frm the 1 st stage recvery unit. (SEE APPENDIX F) Discharge Fllw up Discharge Criteria Nursing staff perfrm an assessment using identified discharge criterin when a patient is ready fr discharge. If required they will see either their anaesthetist r cnsultant surgen fr advice. These need t cnsider scial factrs as well as medical assessment f sufficient recvery fr discharge. (SEE APPENDIX B and C) The discharging nurse gives bth verbal and written infrmatin. Pre-packed analgesia is given with clear verbal and written instructins. Written discharge summaries are cmpleted by the nurse, and are given t each patient befre leaving the unit. A cpy f this summary is given in a sealed envelpe t the patient t be given t the apprpriate GP. Agreed patient grups are fllwed up with a telephne call by Day Unit nursing staff. This allws the patient t discuss any issues r cncerns they may have fllwing their surgery. Patients underging lcal anaesthesia prcedures d nt receive a telephne fllw up frm the unit. A qualified member f staff des the fllw up including apprpriately trained HCAs. 11
a) Admissin Criteria if the Patient Defaults frm a Day Case t an Inpatient. The Surgical and Anaesthetic Team and Senir Nurses make the decisin n day f surgery t admit patients where this is necessary. Patients wh deterirate r thse wh need a lnger stay are transferred t an apprpriate ward as agreed thrugh the Surgical Bed Manager. 12
Appendix B Discharge Criteria all criteria shuld be met Vital signs stable fr at least ne hur Crrect rientatin as t time, place and persn Adequate pain cntrl and has supply f ral analgesia Understands hw t use ral analgesia supplied and has been given written infrmatin abut these Ability t dress and walk where apprpriate Minimal nausea, vmiting r dizziness Has at least taken ral fluids Minimal bleeding r wund drainage Has passed urine (if apprpriate) Has a respnsible adult t take them hme Has agreed t have a carer at hme fr next 24 hurs Written and verbal instructins given abut pstperative care Knws when t cme back fr fllw up (if apprpriate) Emergency cntact number supplied 13
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Appendix C 7.Elective 23 hur Stay Area Scpe The elective 23hr stay area (ESA) is a trlley area fr shrt stay elective surgical patients fllwing surgical interventin. It is used t nurse all apprpriate pst perative patients frm all surgical specialities requiring up t 23hr pst perative care. All Cnsultants within the surgical divisin have equal access t the facility. All patients remain under the care f the admitting cnsultant and surgical teams. Operatinal Management The ESA prvides care fr all apprpriate surgical patients requiring 23hr stay as identified by the BADS directry f prcedures, wh are lder than 16. Current Organisatinal Chart Divisinal Manager ADM Mdern Matrn Elective Ward Managers 15
Staff Staff mstly wrking in the ESA have the necessary experience t nurse all surgical specialities. Any identified staff develpment requirements are dealt with using existing learning and develpment plicies and thrugh c-peratin with the divisin. a) Admissin Criteria The decisin t admit t the ESA is made by the senir nurses at preperative assessment using defined prtcls. The Surgical and Anaesthetic Team and Senir Nurses make the decisin n day f surgery t admit patients t the ESA where this is necessary. Patients wh deterirate r thse wh need a lnger stay are transferred t an apprpriate ward as agreed thrugh the Surgical Team facilitated by the surgical bed c-rdinatr. Patients wh are fit t return hme at the earliest pprtunity fllwing surgery are discharged accrding t the agreed discharge plicy. b) Exclusin criteria The Unit des nt take elective patients r transfers frm ther areas within the Trust. At pre-assessment it will be determined whether patients will be suitable fr the ESA trlleys mbility and size will be a majr factr in this suitability High BMI and high Waterlw scring are used t assess this in cnjunctin with Tissue Viability recmmendatins. Patients with a weight ver 160kg will be excluded frm staying n the ESA the trlleys are nt designed t take patients abve this weight. Patients wh are immbile and are unable t climb nt the trlley will be excluded frm the ESA this is because it is nt pssible t get a hist underneath the trlley. Patients wh are cnsiderably cnfused will be excluded frm the ESA. c) Dcumentatin All adult patients attending PDs are clerked in using the apprpriate Care Pathway. This care pathway begins at pre-perative-assessment and accmpanies the patient thrughut their stay. All paper wrk cnfrms t trust standards. d) Patients underging surgery All ESA patients are admitted via the POD area and then perated n in the designated theatre suite fr their Cnsultant, using the theatre scheduling tl. e) Preperative assessment All patients will be assessed by the pre-assessment team and will receive verbal and written infrmatin abut their stay n the ESA. 16
f) Nurse Led discharge The day unit has a nurse led discharge prtcl. The ESA has the same nurse led discharge prtcl. This is cntinually being refined as discharge requirements are fully understd. g) Utilisatin f Day Unit fr majrs The Day Unit theatre space is nt used fr majr surgical cases. This is due t staffing limitatins there are usually a large numbers f patients being recvered at any ne time. These types f patients remain as inpatients via the same day admissin prcess and are managed by the inpatient waiting list team and g thrugh main theatres. h) Physitherapy cver A physitherapist sees patients as apprpriate (e.g. fllwing lwer limb surgery) and fllw up physitherapy is arranged at the same time if required. The Day Unit (and Extended Stay Area) has the fllwing cver frm physitherapy. Mnday 8am 8pm Tuesday (week 1) 8am 8pm Wednesday (week 2) 8am 8pm Thursday 8am 6pm Any changes t perating lists that require physitherapy cver fr discharge have t be discussed befre being implemented. 8. Mnitring and Auditing Regular audits f varius aspects f patient care are undertaken each year. 9. Data cllectin and strage A cmputer system has been installed that enables the efficient planning f activity and theatre usage and is fully incrprated int the existing Cre Patient Database. 17