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Day Care Surgery means that the patient will ordinarily be discharged from the hospital or unit later on the day of the procedure. Anaesthesia for the procedure may require general, regional or local anaesthesia, sedation or a combination of techniques. Almost all ANZCA Professional Standards documents are relevant to day care anaesthesia. The facility should meet the standards set out in the Day Surgery Handbook published by the Australian Day Surgery Council.

SELECTION GUIDELINES

In all cases, the ultimate decision as to the suitability of a patient for day care surgery is that of the procedural anaesthetist. The decision as to the type of anaesthesia must remain in the province of the anaesthetist and will be based on surgical requirements, patient considerations, the experience of the anaesthetist and the facilities and personnel of the day care unit.

1.   PROCEDURES SUITABLE FOR DAY CARE SURGERY MUST ENTAIL:

1.1   A minimal risk of post operative haemorrhage.

1.2   A minimal risk of post operative airway compromise.

1.3   Post operative pain controllable by outpatient management techniques.

1.4   Post operative care managed by the patient and/or a responsible adult and any special post operative nursing requirements met by day surgery, home or district nursing facilities.

1.5   A rapid return to normal fluid and food intake.

1.6   Operative list organisation to achieve early commencement of procedures for which a long recovery period is likely

2.   PATIENT REQUIREMENTS FOR DAY CARE SURGERY INCLUDE:

2.1   A willingness to have the procedure performed, together with an understanding of the process and an ability to follow discharge instructions.

2.2   The patient's place of residence for post-surgery care being within one hour's travelling time from appropriate postoperative medical attention

2.3   Physical status of ASA I or II or medically stable ASA III or IV patients. Physical status alone does not dictate acceptability. Early consultation with the involved anaesthetist is essential.

2.4   Infants and children provided specific arrangements for their treatment are made.

2.4.1   ANZCA Professional Document PS29 Statement on Anaesthesia Care of Children in Healthcare Facilities Without Dedicated Paediatric Facilities is relevant to the management of infants and children for day care surgery.

2.4.2   Normal term infants of over six weeks of age or ex-premature infants (less than 37 weeks gestation) of more than 52 weeks post-conceptual age.

2.4.3   Younger infants may be accepted in units with particular paediatric experience after prior consultation with the involved anaesthetist. Longer postoperative observation may be necessary

3.   SOCIAL REQUIREMENTS FOR DAY CARE SURGERY INCLUDE:

3.1   A responsible person able to transport the patient home in a suitable vehicle. A train or bus is usually not suitable.

3.2   A responsible person staying at least overnight following discharge from the unit. This person must be physically and mentally able to make decisions for the patient's welfare when necessary.

3.3   Ensuring that the patient and/or responsible person understands the requirements for postanaesthetic care and intends to comply with these requirements particularly with regard to public safety.

3.4   The patient remaining within one hour of appropriate medical attention until the morning following discharge.

3.5   The patient having ready access to a telephone in the postoperative dwelling.

3.6   The patient having advice as to when to resume activities such as driving and decision making.

4.   PATIENT PREPARATION:

4.1   ANZCA Professional Document PS7 Recommendations on The Pre-Anaesthesia Consultation describes the essential nature of this consultation for all patients who are to receive anaesthesia.

4.2   ANZCA Professional Document PS26 Guidelines on Consent for Anaesthesia or Sedation is relevant to preparation for day stay surgery.

4.3   Appropriate time for adequate preoperative anaesthetic assessment by the involved anaesthetist must be scheduled for all day case patients.

4.4   Patient assessment can be assisted by:

4.4.1   A standardised patient health/anaesthesia questionnaire.

4.4.2   Prior referral of the patient by the surgeon to the anaesthetist in cases of doubt as to the suitability for day case surgery.

4.4.3   Preliminary nurse assessment according to guidelines approved by an anaesthetist.

4.4.4   Anaesthesia consultation and preparation prior to the day of surgery preferably by the involved anaesthetist

4.5   The patient should be provided with information in an understandable written format which must include:

4.5.1   General information about the procedures to be followed in the day care unit.

4.5.2   Instructions for fasting according to the following guidelines unless otherwise specifically prescribed by the anaesthetist or where other institution guidelines apply:

4.5.2.1   For healthy adults having an elective procedure, limited solid food may be taken up to six hours prior to anaesthesia and clear fluids totalling not more than 200 mls per hour may be taken up to two hours prior to anaesthesia.

4.5.2.2   For healthy children over 6 weeks of age having an elective procedure, limited solid food and formula milk may be given up to six hours, breast milk may be given up to four hours and clear fluids up to two hours prior to anaesthesia.

4.5.2.3   For healthy infants under 6 weeks of age having an elective procedure, formula or breast milk may be given up to four hours and clear fluids up to two hours prior to anaesthesia.

4.5.2.4   Only medications with a little water if required as ordered by the anaesthetist should be taken less than two hours prior to anaesthesia.

4.5.2.5   A proton pump inhibitor or other appropriate agent should be considered for patients with an increased risk of gastric regurgitation.

5.   SEDATION AND ANAESTHESIA FOR DAY CARE PROCEDURES

5.1   General, regional or local anaesthesia, sedation or a combination of techniques may be used.

5.2   ANZCA Professional Standards documents should be satisfied where appropriate. ( PS3, PS6, PS 9, PS18, PS 21, PS24, PS 28, PS 31, PS48)

6.   RECOVERY FROM ANAESTHESIA

6.1   ANZCA Professional Document PS4 Recommendations for the Post-Anaesthesia Recovery Room establishes requirements for the facilities and staffing of recovery areas. This document is fully applicable to day care units.

6.2   An area must be provided with comfortable reclining seating for patients during the second stage of recovery prior to discharge home. This area must be adequately supervised by nursing staff and should also have ready access to resuscitation equipment, including oxygen and suction. Patients must not leave this area unaccompanied.

7.   DISCHARGE OF THE PATIENT FROM THE DAY CARE UNIT

7.1   The discharge area should have ready access to wheel chairs, a parking area and ambulance facilities so as to minimise walking for the post-operative patient and to aid transfer of the patient to inpatient hospital care when this is necessary.

7.2   The following criteria apply to patients being discharged home:

7.2.1   Stable vital signs for at least one hour.

7.2.2   Correct orientation as to time, place and relevant people.

7.2.3   Adequate pain control. ANZCA Professional documents PS41 Guidelines for Acute Pain Management and PS45 Statement of a Patients Rights to Pain Management are applicable to day care anaesthesia.

7.2.4   Minimal nausea, vomiting or dizziness.

7.2.5   Adequate hydration and likelihood of maintenance of hydration with oral fluids.

7.2.6   Minimal bleeding or wound drainage.

7.2.7   Patients at significant risk of urinary retention (central neural blockade, pelvic and other surgery) must have passed urine.

7.2.8   A responsible adult to take the patient home. For some patients it may be important to have an adult escort as well as the vehicle driver.

7.2.9   Discharge should be authorised by an appropriate staff member after discharge criteria have been satisfied.

7.2.10   Written and verbal instructions for all relevant aspects of post-anaesthetic and surgical care must be given to the patient and the accompanying adult. A contact place and telephone number for emergency medical care must be included.

7.2.11   Suitable analgesia should be provided for at least the first day after discharge with clear written instructions on how and when it should be used. Advice on any other regular medication is also necessary.

7.2.12   A telephone enquiry as to the patient's wellbeing on the following day should be made whenever possible.

7.3   If the patient is to be transferred to an inpatient facility, the anaesthetist and/or the surgeon will be responsible for the patient until care has been transferred to another appropriate medical officer.

8.   QUALITY ASSURANCE

8.1   Each day care unit must have an established system for audit of the outcomes related to anaesthesia care, and include these outcomes in quality assurance and peer review processes

9.   RELATED DOCUMENTS

PS2 Statement on Credentialling in Anaesthesia

PS3 Guidelines for the Management of Major Regional Analgesia

PS4 Recommendations for the Post-Anaesthesia Recovery Room

PS6 Recommendations on the Recording of an Episode of Anaesthesia Care (The Anaesthetic Record)

PS7 Recommendations on The Pre-Anaesthesia Consultation

PS9 Guidelines on Conscious Sedation for Diagnostic, Interventional Medical and Surgical Procedures

PS16 Statement on the Standards of Practice of a Specialist Anaesthetist

PS18 Recommendations on Monitoring during Anaesthesia

PS19 Recommendations on Monitored Care by an Anaesthetist

PS20 Recommendations for the Responsibilities of an Anaesthetist in the Postoperative period

PS21 Guidelines on Conscious Sedation for Dental Procedures in Australia

PS24 Guidelines on Sedation for Gastrointestinal Endoscopic Procedures

PS26 Guidelines on Consent for Anaesthesia or Sedation

PS28 Guidelines on Infection Control in Anaesthesia

PS29 Statement on Anaesthesia Care of Children in Healthcare Facilities Without Dedicated Paediatric Facilities

PS41 Guidelines on Acute Pain Management

PS45 Statement on Patients’ Rights to Pain Management

PS48 Statement on Clinical Principles for Procedural Sedation

Australian Day Surgery Council Handbook: Day Surgery in Australia: A Report and Recommendations of the Australian Day Surgery Council of the Royal Australasian College of Surgeons, Australian and New Zealand College of Anaesthetists and the Australian Society of Anaesthetists. Revised Edition 2004

COLLEGE PROFESSIONAL DOCUMENTS

College Professional Documents are progressively being coded as follows:

TE Training and Educational
EX Examinations
PS Professional Standards
T Technical

POLICY - defined as 'a course of action adopted and pursued by the College'. These are matters coming within the authority and control of the College.

RECOMMENDATIONS - defined as 'advisable courses of action'.

GUIDELINES - defined as 'a document offering advice'. These may be clinical (in which case they will eventually be evidence-based), or non-clinical.

STATEMENTS - defined as 'a communication setting out information'.

This document is intended to apply wherever anaesthesia is administered

This document has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this document in each case.

Professional documents are reviewed from time to time, and it is the responsibility of the practitioner to ensure that the practitioner has obtained the current version. Professional documents have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that professional documents are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Promulgated (P15): 1987

Reviewed: 1995, 2000

Date of current document: Aug 2006

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