The Day Surgery Unit (Tab 69.3)

The DSU is a self-contained dedicated day surgery facility with its own reception, operating and recovery areas, designed to ensure that all of the essentials for good day surgery practice are carried out. While it is possible to use an in­patient ward, and mixed in-patient and day-case operating sessions, in practice this achieves neither efficient throughput nor good-quality care. A compromise is to have a day-case ward close to the operating suite with dedicated day-case operating sessions, with the same good organisation found in self-contained DSUs. Hospitals without a DSU never achieve high percentages of day cases.

The DSU is usually part of a general hospital, and ideally should be purpose built. Nearby parking for escorts collect­ing patients should be provided. The design should maximise efficient patient flow The number of beds and theatres will be dictated by the workload of the specialities using the unit. In general, a throughput of 1.5 patients/bed day is possible, but may be less if more major procedures requiring longer recovery are undertaken. The balance of beds to operating theatres, and the scheduling of the operating sessions, should be planned with this in mind, but there should be flexibility for changing needs. The DSU may also be used for a variety of other procedures that require different facilities and equipment such as gastrointestinal endoscopy, flexible cystoscopy, interventional radiology, and chronic pain or minor medical procedures.

Children-only days or sessions may be planned. Procedures needing longer recovery should be scheduled early in the day, and local anaesthetic cases later. Many units now stay open into the evening to allow later operating sessions.

The unit layout

The reception area

The reception area should be welcoming and large enough to accommodate patients and their escorts on arrival and dis­charge, with adequate space for secretarial and reception staff. Admission procedures are completed here before the patients go to the ward.

The day surgery ward

This may be equipped with beds or trolleys. Preoperative assessment and investigations will already have been carried out, but the patient must be assessed before surgery by the surgeon and the anaesthetist. Basic preoperative checks are carried out, site of surgery marked and consent for the proce­dure signed, if not already done. Time must be allowed for this assessment so that the patient does not meet the anaes­thetist in the anaesthetic room when it is too late to address any problems. Sedative premedication is usually avoided as it may prolong recovery time, and unsedated patients can walk to the anaesthetic room. After leaving the recovery room, the patient will return to this ward area to recover sufficiently to have light refreshment and be taken home.

The anaesthetic room and operating theatres

These should have precisely the same high-quality specification, monitoring, safety and surgical equipment as in-patient operating suites. Trained assistance must be provided throughout the perioperative period. The use of operating trolleys, on which the patients can also recover, can save considerable time and manpower as patients do not have to be moved between trolley and operating table.

The recovery area

The recovery area should be fully equipped to in-patient standards and be adjacent to the theatre. In the UK, patients usually spend only a short time here before returning to the ward to recover, but in the USA this area, called the Post Anesthesia Recovery Unit (PACU), may be used until the patient is ambulant and can to be sent to a ‘step-down area where they remain in a chair until fit to go home. Patients who have had local anaesthesia with no or mild sedation may be able to bypass this area and go straight to the ward.

Personnel

Staffing of the Day Surgery Unit

Experienced day surgery nurses excel at dealing with prob­lems and giving reassurance and information. In many units, multiskilling allows nurses and operating department personnel (ODP) to undertake ward, theatre and anaesthetic assistant duties. Specialised nurses may be needed for children or for certain types of surgery such as ophthalmic. Ancillary staff for portering and domestic duties are also needed.

Record keeping

This must be accurate and complete, often difficult with high-volume fast turnover. Unnecessary paperwork should be mini­mised while ensuring that vital information is logged. A folder containing all of the relevant records is ideal. Computerised systems can help greatly and are now commercially available.

Support services

Although the need for laboratory and radiology services is minimal, these should be available if required. In-patient and resuscitation back-up must be identified for the rare occa­sions when it will be needed.

Medical staff and training

Good-quality treatment with minimal complications means that day surgery must be consultant led and carried out by fully trained medical staff, surgical and anaesthetic, to achieve the best results and reduce complications and risk. However, senior staff may find the work unchallenging and be tempted to delegate it to trainees. Training in day surgery is essential, but trainees should be closely supervised and extra time allowed for this.

Clinical Director

The Clinical Director, usually a consultant surgeon or an anaesthetist, should manage the DSU and implement and audit good standards of care. Regular multidisciplinary meetings with all those using the unit are needed, as is liaison with GPs and community care.