lmprovement in perioperative care of the day case patient; logistics and quality of care.

Abstract

Background: The “Day surgery concept” is increasing and nowadays numerous of surgical procedures in patients of all ages, with different comorbidities are performed as day case surgery. Day surgery (DS) is a process; not a procedure. Anaesthetic method, multi-modal analgesia, new surgical minimally invasive techniques and a mind-set to facilitate a rapid recovery are all of importance. Thus, multiple factors influence a safe, effective and successful perioperative course combining high quality of care with rapid recovery, enabling patients to be safely discharged on the day of surgery. Aim: To investigate how different parts of the perioperative care per se affects resource utilisation, logistics and quality of recovery in three common DS procedures. Methods: Paper I; A retrospective observational study in patients scheduled for pelvic organ prolapse (POP) surgery assessing discharge on day of surgery, impact of “annual changes” (2012-14) and anaesthetic techniques in 4 different hospitals. Paper II; A prospective randomised study in male patients scheduled for open hernia repair assessing the impact of surgical scrub/sterile covering before vs. after induction of general anaesthesia on haemodynamic changes, medication, logistics and quality of care. Paper III; A prospective randomised study performed on patients scheduled for surgery of distal radial fractures (DRF) investigating the impact of 3 different anaesthetic methods on postoperative pain, postoperative opioid consumption and logistics the first postoperative week. Paper IV; A subgroup of study III patients, prospectively randomised to 2 different immobilisation methods, brace vs cast, assessing patients self-assessed Quality of recovery (QoR-15), postoperative opioid use and logistics the first postoperative week. Results: Paper I; The use of local anaesthesia and sedation (LAS) significantly increased the by-passing of PACU to a step-down unit and discharge day of surgery during the study period. Paper II; No differences in vasoactive medications was found between groups, but there was a significant decrease in PACU-time in awake patients. Both patients and surgical nurses found the awake procedure acceptable. Paper III; The pain scores and postoperative opioid consumption were significantly higher in the supraclavicular block (SCB) group with long-acting local anaesthetic agent (long-LA) compared to short-acting (short-LA) 24-hours post-surgery and during the first 3 postoperative days. The long-LA-group also had most unplanned healthcare contacts postoperatively. Most SCB-patients could by-pass PACU. Paper IV; The median QoR-15 score increased over time from baseline to 1 week post-surgery with no significant differences between brace/cast-groups of patients. Conclusion: The use of LAS in POP-surgery improved both theatre and PACU efficacy and increased discharge on day of surgery. Surgical scrub/sterile covering before induction can be performed without jeopardizing patient´ quality of care and probably improve the perioperative care. SCB with long-LA for surgical repair of DRF provide effective analgesia during early postoperative course, but the patients that received SCB with short-LA had less pain at 24-hours post-surgery, a better pain profile and consumed less opioids during the first 72 hours postoperatively. An immobilisation with brace instead of cast directly after DRF-surgery appears to be a feasible and attractive option.