The
Day Surgery Unit
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
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.