六合彩开奖结果

Dave Bunting

2020 was a difficult year for all with the Covid-19 pandemic having the greatest impact on our health service in many years, not to mention the negative effects is has had on the education of children and young people and the lasting effect it will have on businesses and our economy. Never in recent years has the health service had to learn to adapt so quicky and to such a great extent. When I wrote the last editorial of 2020, I hoped that we might by now be seeing some positive effects of widespread coronavirus vaccination. I feel this is starting to be the case and whilst there are fears that current vaccines may not offer full protection to the new Covid variants, as I write this, I have learned the UK has successfully vaccinated over 12 million of its most vulnerable people and looks to be able to reach its target of having offered a first vaccine dose to all of its highest risk patients by mid-February. As we emerge from this era and find new ways of safely providing surgical care during the ongoing pandemic, day surgery units are going to play a huge part in restoring our elective and urgent care services in an effort to keep up with ongoing demand and deal with the inevitable waiting list backlog that has developed in most specialties.

The 六合彩开奖结果 Virtual Conference will be taking place next month on Thursday 18^th March and will focus on how day surgery can be used to recover elective surgery in the Covid-19 era. Importantly, it will be delivered free of charge to all current 六合彩开奖结果 members so please register by following the link on the 六合彩开奖结果 homepage:听

All presented material, including video recordings of invited speaker蝉鈥� lectures and oral prize presentations, will be available online for participants to access free of charge for three months following the conference.

In this edition of JODS, three updated 鈥楬ow I do it鈥� day case guides are presented, this month with an orthopaedic theme. They include guides on Day Case Total Hip Replacement, Day Case Total Knee Replacement and Day Case Anterior Cruciate Ligament Reconstruction.

Please keep your submissions to the Journal coming in and remember 鈥� JODS still offers citable peer-reviewed publication with no author processing fees. Author guidelines and submission instructions can be found in this edition of the journal.

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Kim Russon

I hope you are all safe, well and managed to get some rest over the Christmas period. Unfortunately, 2021 has not started in a way we would have ideally wished, with Covid19 numbers rising and Mr Johnson announcing that the NHS should move to alert level 5 and that the country would begin another national lockdown. Thankfully, the lockdown seems to be working, and hospital Covid19 numbers appear to be stabilising and hopefully will soon start to fall. The NHS is still under tremendous pressure and in many hospitals elective surgery has had to stop again. This causes great concern as we are already aware of growing waiting lists with over 80,000 patients known to have been waiting over 1 year for surgery and over 4 million unreferred patients. It has been reported that even if elective surgery returns to 110 or 120% of pre-covid levels it may take years to 鈥渃atch up鈥�.

Day surgery continues to be recognised as a potential solution and in centres where Covid-secure pathways have been developed, day surgery has been able to carry on. As I mentioned in November, the GIRFT Elective surgery recovery and transformation programme promotes day surgery pathways and is hoped to be able to rolled out nationally. At the recent 六合彩开奖结果/HCC Day case general surgery conference we heard Ms Stella Vig describe how by utilising day surgery pathways, Croydon University Hospital achieved greater than 100% of activity as compared to pre-covid activity to help tackle its growing waiting lists due to the impact of Covid-19 pandemic.

六合彩开奖结果 is delighted to announce that we are continuing our collaboration with Health Care Conferences (HCC) to bring you one day speciality focussed conferences where teams achieving successful day surgery share their knowledge and pathways to enable other centres to learn how to deliver similar services.

• Daycase Major Knee Surgery 鈥�25^th March 2021
• Day Case Total Hip Replacement 鈥�29^th April 2021
• Day Surgery in Gynaecology 鈥� 20^th May 2021
• Day Case General Surgery During Covid19 18^th June 2021
• Breast Surgery as Day Surgery 7^th Sept 2021
• Day case Urology Date TBC

We also have our 六合彩开奖结果 annual conference next month with great speakers and an excellent programme which we hope will assist hospitals to recover elective surgery using day surgery pathways. If you haven鈥檛 already registered then please do soon. Registration is free for 六合彩开奖结果 members and if you are not available on the 18^th March then the recording will be available afterwards for 3months for non-六合彩开奖结果 members and 1 year for 六合彩开奖结果 members.

During this continued time of pressure, both on our working lives and home lives it is important to consider our wellbeing. 六合彩开奖结果 council took a moment during our recent council meeting for #coffeeandagas which is an Association of Anaesthetists campaign to help wellbeing and promote better teamwork. Please look after yourselves and each other.

I look forward to welcoming you all to the 六合彩开奖结果 conference 18^th March 2021.

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See the 2021 Virtual Conference programme here:

Click the image below to find out more about the virtual conference听on our website.

Conference registration is FREE for 六合彩开奖结果 members.

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六合彩开奖结果 would like to thank its Strategic Alliance Partners for supporting the organisation and the 六合彩开奖结果 Annual Conference.

(Click on images to go to the company website.)

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Claire Blandford, Consultant Anaesthetist
David Isaac, Consultant Orthopaedic Surgeon,Torbay & South Devon NHS Foundation Trust, Devon.

Patient Selection

• Symptomatic knee pathology requiring TKR

• Engaged with day case pathway

• No unstable medical co-morbidity requiring in-patient management

• No high dose opioid based analgesia /chronic pain regimen pre-operatively

• Suitable social support

Pre-online Preparation

From booking:

• Pt counselled to expect DC procedure
• Nurse led pre-assessment process completed
• Participation in 鈥榡oint-school鈥� patient education programme

On the day:

• Listed first on theatre list (ideally)
• Withhold ACE inhibitor/ A2RB drug on day of and day before surgery
• Carbohydrate drink 2hrs pre-op
• Pre-medication:
• Paracetamol 1g
• Ibuprofen 1600mg SR (if not contraindicated)
• Oxycodone MR 10mg (5mg dose if age >70)

Anaesthetic听Technique

Spinal:

• 3 鈥� 3.4ml hyperbaric 2% Prilocaine

• NO intrathecal opioid

Sedation:

• Aim to minimise/ avoid. If required then low dose Propofol TCI with capnomask.

Local Anaesthesia:

• Ultrasound guided saphenous nerve block (0.25% levobupivacaine up to 20mls) + Surgical infiltration (ensure maximal LA dose not exceeded with combined technique)

Antiemetics: (dual agents as standard)

• Dexamethasone 6.6mg IV

• Ondansetron 4mg IV

• Intra Operative Care

Goal directed:

• Normothermia: proactively warm patient with forced air blanket (commence pre-op) & fluid warmer

• Normovolaemia: IV fluids 1000-2000mls (warmed)

Blood Conservation:

• Tranexamic Acid 1g IV start of case + further 1g at end of case (dose reduced for eGFR<50 and or weight <50kg)

• Cell salvage collection routinely

Antibiotic Regimen:

• Teicoplanin (slowly in 100mls n/saline) & Gentamicin [weight adjusted doses]

• Thromboprophylaxis: mechanical- foot pump used intra-operatively & until mobilisation. Dalteparin 5000units (weight adjusted) sc pre-discharge.

Key recovery priorities:

• Manage any PONV aggressively

• Commence oral fluids

• Fortisip 200ml drink

Surgical Technique

• Parapatellar approach

• Tourniquet only inflated for cementation

• Local Infiltration of Anaesthetic to divided tissue, periosteum and subdermal fat layers. 80 ml 0.125% levobupivacaine or 40mls 0.25% levobupivacaine according to individual surgeon鈥檚 preference.

• Careful wound closure in layers to include continuous absorbable suture to skin, plus tissue glue

Take Home Medication

• Paracetamol 1g qds

• Ibuprofen 400mg-600mg po qds 5/7 (if no contraindication) + PPI cover (Lansoprazole 15mg)

• Oxycodone MR 10mg po bd for 5 post op doses (*5mg if age >70) with reinforced non continuation of this via discharge summary (automated process)

  THEN step down on Day 3 to: Codeine 30-60mg po qds OR Tramadol 50-100mg qds if codeine intolerant for 3/7.

  Ondansetron 4mg po tds听 2/7

  Macrogols 1 sachet po bd 5/7
  Dalteparin 5000units sc od for 2/7 (+ sharps bin) then step down onto:
  Aspirin 150mg po od 14/7
  unless other anticoagulation plan in place eg warfarin/clopidogrel/ DOAC听 then usually restart this day 1 post op听

Post Operative Care

• Patient fulfils all standard daycase discharge criteria and demonstrate satisfactory mobilisation/ transfer abilities commensurate with safe discharge

• X-ray taken pre-discharge and reviewed by surgeon

• Day 1 nurse led telephone call from DSU

• In-house 鈥榦rthopaedic outreach鈥� nursing team visit patient in community; days 1,5,10 & 14 to support. Tasks include wound reviews, medication assistance, performing post op blood tests/ vital signs monitoring.

• Direct telephone access to this service for patients

Organisational Issues

• Theatre listing 鈥� patient needs first (or possibly 2^nd) slot on a list

• Consider your facilities estate resources to build your pathway; location of clean air theatres & day case discharge facilities.

• Working hours of MDT support staff eg: physios may not align with time of patients discharge

• Post-operative support for patients; diverse ways this may be able to be provided. Bespoke solution to your unit may be needed.

Common Pitfalls

• Short acting spinal technique required to ensure full offset of sensory/motor block to allow adequate time for mobilisation. If unanticipated complications/ delays occur duration of block may become an issue.

• All staff need to be 鈥榦n message鈥� so that the patient has confidence in the daycase pathway

• First mobilisation hypotension 鈥� we have found the 鈥榝ortisip鈥� drink invaluable in reducing this, alongside good hydration and dual antiemetic regimen

Anticipated Day case Rates

• Not all patients will be suitable for daycase management.
• Estimates indicate approx. 20% of a waiting list cohort may be DC suitable

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Claire Blandford, Consultant Anaesthetist
Mike Kent, Consultant Orthopaedic Surgeon
Torbay & South Devon NHS Foundation Trust, Devon

Patient Selection

• Symptomatic hip pathology requiring THR

• Engaged with day case pathway

• No unstable medical co-morbidity requiring in-patient management

• No high dose opioid based analgesia /chronic pain regimen pre-operatively

• Sufficient social support

• Suitable social support

Pre-operative Preparation

From booking:

• Pt counselled to expect DC procedure

• Nurse led pre-assessment process completed

• Participation in 鈥榡oint-school鈥� patient education programme 鈥� Face to Face education sessions with nursing team and physiotherapist, video presentation, comprehensive information booklet

On the day:

• Listed first on theatre list (ideally)

• Withhold ACE inhibitor/ A2RB drug on day of and day before surgery

• Carbohydrate drink 2hrs pre-op

Pre-medication:

• Paracetamol 1g
• Ibuprofen 1600mg SR (if not contraindicated)
• Oxycodone MR 10mg (5mg dose if age >70

Anaesthetic听Technique

Spinal:

• 3 鈥� 3.4ml hyperbaric 2% Prilocaine

• NO intrathecal opioid

Sedation:

• Aim to minimise/ avoid. If required then low dose Propofol TCI with capnomask.

Local Anaesthesia:

• Surgical Infiltration 0.25% levobupivacaine 50mls (40mls if patient weight <60kg)

• Antiemetics: (dual agents as standard)

Antiemetics: (dual agents as standard)

• Dexamethasone 6.6mg IV

• Ondansetron 4mg IV

Intra Operative Care

Goal directed:

• Normothermia: proactively warm patient with forced air blanket (commence pre-op) & fluid warmer

• Normovolaemia: IV fluids 1000-2000mls (warmed)

Blood Conservation:

• Tranexamic Acid 1g IV start of case + further 1g at end of case (dose reduced for eGFR<50 and or weight <50kg)

  Cell salvage collection routinely

Antibiotic Regimen:

• Teicoplanin (slowly in 100mls n/saline) & Gentamicin [weight adjusted doses]

• Thromboprophylaxis: mechanical- foot pump used intra-operatively & until mobilisation. Dalteparin 5000units (weight adjusted) sc pre-discharge.

Key recovery priorities:

• Manage any PONV aggressively

• Commence oral fluids

• Fortisip 200ml drink

Surgical Technique

General

• Standard THR as per surgeon鈥檚 usual technique
• Techniques/implants allow for full weight bearing as soon as feasible

Intraoperative

• Meticulous haemostasis, use of cell salvage, aim to retransfuse if threshold reached
• Infiltration of high volume/low concentration local anaesthetic into surgical field (capsule/released muscles depending on approach/fascia lata/deep dermal)
• Abductors/Short External Rotators repaired with non-absorbable transosseous sutures depending on approach
• Meticulous multi layer closure with Vicryl absorbable sutures, Skin closure with moncryl and topical skin glue, Opsite dressing

Postoperative

• Patients mobilised by physiotherapist as soon as ready
• Relaxed dislocation precautions

Take Home Medication

• Paracetamol 1g qds

• Ibuprofen 400mg-600mg po qds 5/7 (if no contraindication) + PPI cover (Lansoprazole 15mg)

• Oxycodone MR 10mg po bd for 5 post op doses (*5mg if age >70) with reinforced non continuation of this via discharge summary (automated process)

  THEN step down on Day 3 to: Codeine 30-60mg po qds OR Tramadol 50-100mg qds if codeine intolerant for 3/7.

  Ondansetron 4mg po tds听 2/7

  Macrogols 1 sachet po bd 5/7
  Dalteparin 5000units sc od for 2/7 (+ sharps bin) then step down onto:
  Aspirin 150mg po od 28/7
  unless other anticoagulation plan in place听 听 eg warfarin/clopidogrel/ DOAC听 then usually restart this day 1 post op

Post Operative Care听

• Patient fulfils all standard daycase discharge criteria and demonstrate satisfactory mobilisation/ transfer abilities
• Patient fulfils all standard daycase discharge criteria and demonstrate satisfactory mobilisation/ transfer abilities commensurate with safe discharge
• Check X-ray performed prior to discharge
• Day 1 nurse led telephone call from DSU
• In-house 鈥榦rthopaedic outreach鈥� nursing team visit patient in community; days 1,5,10 & 14 to support. Tasks include wound reviews, medication assistance, blood tests/ vital signs monitoring.
• Direct telephone access to this service for patients

Organisational Issues听

• Theatre listing 鈥� patient needs first (or possibly 2^nd) slot on a list
• Consider your own facilities/ estate resources to build your pathway; location of clean air theatres & day case discharge facilities.
• Working hours of MDT support staff eg: physios may not align with time of patients discharge
• Post-operative support for patients; diverse ways this may be able to be provided. Bespoke solution to your unit may be needed.

Common Pitfalls

• Short acting spinal technique required to ensure full offset of sensory/motor block to allow adequate time for mobilisation. If unanticipated complications/ delays occur duration of block may become an issue.
• All staff need to be 鈥榦n message鈥� so that the patient has confidence in the daycase pathway
• First mobilisation hypotension 鈥� we have found the 鈥楩ortisip鈥� drink invaluable in reducing this, alongside good hydration and dual antiemetic regimen.

Anticipated Day case Rates

• Not all patients will be suitable for daycase management.
• Estimates indicate approx. 20% of a waiting list cohort may be DC suitable

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MICHAEL HOCKINGS & MARY STOCKER

(Original article published 2013, updated 2020)

Patient Selection

• No specific selection criteria

Anaesthetic听Techniques

• Short acting general anaesthetic:
  We use TIVA with propofol and remifentanil
  
  
• Saphenous nerve block which provides a slightly less reliable sensory block than a femoral nerve block but has the advantage of no motor block. This is the preferred technique surgically to enable full weight bearing immediately post operatively
  30 mls. 0.25% Bupivacaine (reduced to 1mg/kg if under 75kg)

Surgical Technique

• Infiltration of local anaesthetic into the skin around the harvest site of patellar听tendon or hamstrings and the arthroscopic portals
  30mls of 0.25% Bupivacaine total (reduced to 1mg/ kg if under 75kg)

Peri-operative analgesia

• Pre-operative: oral paracetamol and ibuprofen

• Intra-operative: iv fentanyl

• Post operative: regular paracetamol and ibuprofen

• Rescue intravenous fentanyl or oral morphine if required

Take Home Medication

• Paracetamol 500 mg/ codeine 30mg po qds, laxido 1 sachet bd, plus ibuprofen 600 mg po qds

Organisational Issues

• Surgeon must write x- ray request form before patient leaves theatre

• Intravenous teicoplanin 400 mg on induction avoids the need for further post operative doses of antibiotics

• Physiotherapist must be available to see patient preoperatively or immediately post operatively to fit knee brace and aid timely discharge

Anticipated Day case Rates

• 90%

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Dr Claire Blandford, Consultant Anaesthetist, Torbay & South Devon NHS Foundation Trust听

Day听case surgery continues to push boundaries and offer huge potential benefit for NHS trusts and patients. However, achieving听total听joint arthroplasty as a day听case procedure is听somewhat of a new frontier for many trusts -听consequently there has been significant appetite听for specific conferences addressing these principles.听Following on from a series of well received conference dates听in 2018/19, HCUK (Healthcare Conferences UK) partnered with 六合彩开奖结果听(British Association of Day Surgery)听to听offer two听dates in Autumn 2020, this time听utilising virtual platforms due to the limitations of the COVID pandemic.听听

The days were specifically themed to allow maximal extractable relevance for delegates and aimed to provide a comprehensive review drawn from听national experts and听shared听experience听across听several centres听in听the UK.听Small group breakouts were included throughout both programmes, along with virtual networking opportunities and an online exhibition. We would also like to thank our sponsors for their contribution to these two events.听听

Day听case Major Knee Replacement (05.10.20)听

This conference included听anterior cruciate ligament (ACL), uni-compartmental knee听(UKR)听and听total knee replacement (TKR)听themes. The conference was chaired by 六合彩开奖结果 council members and delivered via a Zoom facilitated platform. Dr Kim Russon (Consultant Anaesthetist - Rotherham and president of 六合彩开奖结果) chaired the morning sessions.听听The first speaker was Dr Mary Stocker (Consultant Anaesthetist - Torbay and immediate past president of 六合彩开奖结果) who delivered a comprehensive session on optimising day case pathways听and听key elements of suitability & planning.听听This was then followed by two centres giving insights into how they had successfully transitioned their services to facilitate day听case joint听arthroplasty:听Rotherham NHS听Foundation听Trust听and听Torbay & South听Devon NHS Foundation Trust.听听听

The Rotherham team, comprising Mr Alex Anderson (Consultant Orthopaedic Surgeon), Dr Kim Russon (Consultant Anaesthetist) & Ms Kayleigh Wright (Specialist Physiotherapist)听presented their听work on developing a default to day surgery process for ACLs and how this evolved to facilitate day听case UKR surgery. They noted transitioning their discharge location from inpatient ward to dedicated day surgery unit improved their same day discharge rates.听This session was then听followed by the Torbay team of Dr Claire Blandford (Consultant Anaesthetist), Mr David Isaac & Mr Mike Kent (Consultant Orthopaedic Surgeons) who presented听nine years of听local听experience in achieving day听case ACLs and听UKR听surgery;听progressing more recently听to include听successful听day听case total hip & knee arthroplasty听(>90% same day discharge rates听achieved.) The team presented the transformational process undertaken to achieve this and the precise details of their surgical and anaesthetic pathways.听听

The afternoon session was chaired by Dr Mary Stocker. The first speaker was Dr David Johnston听(Consultant Anaesthetist- Belfast) who covered analgesic aspects of knee arthroplasty surgery presenting various local anaesthetic techniques and multimodal strategies. This was followed by听Dr Robbie Erskine (Consultant Anaesthetist 鈥� Derby)听who听described a 鈥榞olden combination鈥� of听ultra short-acting spinals with long lasting blocks to facilitate day case surgery. His talk provided a wealth of useful information听and the principles he conveyed would听also听have application听to听other surgical听procedures. We then heard from Dr Stocker again who鈥檚听afternoon session听really highlighted the critical value of data- not only in uniting teams in shared ownership of outcomes but also as听a driver听for units听to refine process and performance.听 The final session of the afternoon听was delivered by听a surgeon/ anaesthetist team from Calderdale; Mr Graham Walsh (Consultant Orthopaedic Surgeon) & Dr Nisha Bhuskute (Consultant Anaesthetist). They presented their data, sharing听impressive day case rates in听TKR听surgery and also showed how they utilise digital technology, including wearable tech directly linking discharged patients with hospital physio services to enhance patient experience.听听听

Perhaps you will join us for the next two meetings on 25th听March (Knee) & 29th听April (Hip) 2021?

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Dr Claire Blandford, Consultant Anaesthetist, Torbay & South Devon NHS Foundation Trust听

Day case surgery continues to push boundaries and offer huge potential benefit for NHS trusts and patients. However, achieving total joint arthroplasty as a day case procedure is somewhat of a new frontier for many trusts - consequently there has been significant appetite for specific conferences addressing these principles. Following on from a series of well received conference dates in 2018/19, HCUK (Healthcare Conferences UK) partnered with 六合彩开奖结果 (British Association of Day Surgery) to offer two dates in Autumn 2020, this time utilising virtual platforms due to the limitations of the COVID pandemic.听听

The days were specifically themed to allow maximal extractable relevance for delegates and aimed to provide a comprehensive review drawn from national experts and shared experience across several centres in the UK. Small group breakouts were included throughout both programmes, along with virtual networking opportunities and an online exhibition. We would also like to thank our sponsors for their contribution to these two events.听听

Day case Total Hip Replacement (04.11.21)听

One month later and we had further ascended the lower limb to reach the hip joint as the focus for the day鈥檚 presentations. The morning was chaired by Mr Ed Dunstan (Consultant Orthopaedic Surgeon 鈥� Fife & 六合彩开奖结果 council member) and the afternoon was chaired by Dr Mary听Stocker;听who also delivered the first talk of the morning reprising her well received & highly informative session on optimising day case pathways. The next speaker was Mr Hiren Divecha (Consultant Orthopaedic Surgeon 鈥� Wigan) who presented the pathway by which they as a team had undertaken their first day case total hip replacement (THR). This session also included a personal account from one of Mr Divecha鈥檚 first patients who wholeheartedly endorsed his experience and provided a true insight into the physical & psychological benefits of day surgery to patients. The final session of the morning shared the experience of a surgeon/ anaesthetist team from Torbay; Mr Mike Kent (Consultant Orthopaedic Surgeon) & Dr Claire Blandford (Consultant Anaesthetist). They presented their work on enhanced recovery pathways, how they designed and introduced a day case hip replacement pathway to their trust and the refinements to process undertaken since.听听

The programme had a further 4 sessions in the afternoon. Mrs Hilary Young (Advanced Nurse Practitioner) presented the Northumberland experience. Long recognised as a high-volume centre with low lengths of stay she introduced a new patient education app they had developed and discussed ways that effective teamwork & messaging enables early confident discharge. Hilary specifically highlighted the critical importance of early mobilisation in breaking the cycle of poor mobility/鈫憄ain/鈫憁edication/鈫憇ide effects/鈫搈obility.听 Dr Stocker also spoke in the afternoon delivering valuable advice on measurement and utilisation of data to achieve results.听 We then heard from听Mr Ed Dunstan who described 鈥楾he Scottish Journey鈥� discussing how their pathways have evolved over time, championing positivity in the NHS and sharing the splendid patient feedback their pathway has generated.听 His talk was complimented by Mr Steve Young鈥檚 session (Consultant Orthopaedic Surgeon 鈥� Warwick) who shared insights of development in their unit spanning 15 years+, raised consideration of how we define 鈥榝ailure鈥� and 鈥榮ucces蝉鈥� and proposed six key focal areas for delivering successful outcomes in this field.听听

In summary these two days brought together experts and enthusiasts from across the United Kingdom to share ideas and learning. We heard from many centres who are all achieving excellent outcomes and whilst certainly there are some common core principles in achieving successful day case joint arthroplasty there is also much diversity of practice & 鈥�local听bespoking鈥�听too听-听 which听does draw to mind the lyrics of an 80鈥檚 pop song (if you鈥檒l forgive the bracketed inclusion) 鈥�it听补颈苍鈥檛听(just) what you听do,听 it鈥檚听the way that you do it鈥�.听听听

Perhaps you will join us for the next two meetings on 25th听March (Knee) & 29th听April (Hip) 2021?听听

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Vanessa Cubas,听General Surgery Trainee West Midlands,听六合彩开奖结果听Council Member

Friday 4th听of December 2020 saw a joint British Association of Day Surgery (六合彩开奖结果) and Healthcare Conferences UK (HCUK) one- day conference titled 鈥�Daycase听General Surgery During COVID-19鈥�. This virtual conference is a modification of the previously successful 鈥淒eveloping your听Daycase听General Surgery Service鈥�. It saw delegates and presenters from across the UK come听together from different clinical backgrounds for what promised to be an educational and thought provoking day appropriate for the current climate in view of COVID-19.听

The meeting was听chaired听by听六合彩开奖结果 council members:听Mr David Bunting, Consultant Upper GI Surgeon from North Devon District Hospital,听and Ms Vanessa Cubas, General Surgery Trainee. The first session was delivered by听Dr Kim听Russon, Consultant Anaesthetist and 六合彩开奖结果 president. Dr听Russon听presented a听comprehensive overview of the day surgery pathway from GP referral to discharge from hospital and recovery at home, including appropriate patient selection. Importance was placed on dedicated facilities separate from inpatient beds to enable expertise to be developed in managing day case patients. Quality improvement听was introduced as a way of widening the inclusion criteria for day case surgery including those who live alone, the older population, the obese, and more complex surgical procedures. It was also an opportunity to introduce the new听Sixth听Edition of the 六合彩开奖结果 Directory of Procedures, Model Hospital Tool and听六合彩开奖结果 Directory of Procedures National Dataset 2020.听

The next part of the morning session introduced the current effects of COVID-19 on elective surgery and day surgery pathways. This session was presented by Professor Doug听McWhinnie, President of the International Association of Ambulatory Surgery听(IAAS)听and Consultant Surgeon. This was further supplemented by a session by Mr Arin听Saha, Consultant Upper GI surgeon and National lead for The Surgical Ambulatory Emergency Care Network,听who discussed Same Day Emergency Surgery (SDEC). This remains a hot topic across the NHS. Properties of high-functioning surgical ambulatory units were discussed, challenges currently听encountered, options of integration of SDEC units with听the听Think 111 pilot and the future in view of COVID-19. Dr Ian Jenkins, Past President of 六合彩开奖结果 and IAAS and Consultant Anaesthetist, provided the anaesthetic perspective of the challenges encountered in ambulatory surgery care.听

Just before lunch听Mr Charles听Hendrickse, Consultant Colorectal Surgeon, discussed the听setting up of an extremely successful dedicated COVID-19 free unit for elective surgery for University Hospitals Birmingham.听

Following lunch, Mr Graham Lomax (Deputy National Delivery Director), held a session on the Getting it Right the First Time (GIRFT) national programme that addresses national variation on day case services. He also discussed the London recovery of elective surgery in view of COVID-19, the proposed general surgery pathways and the importance of a collaborative approach with managers and clinicians to optimise outcomes.听

Ms Stella听Vig, Consultant Vascular surgeon, gave a session听on听Croydon Health Services NHS Trust听experience on 鈥淐old鈥� site operating and the importance of defaulting to day surgery in the new COVID-19 era and protecting cold/green site pathways. Ms听痴颈驳鈥檚听unit has been so successful that they have achieved over 100% activity compared to 2019.听This was听complemented听by听Senior Charge Nurse Catherine Jack from Queen Margaret Hospital Fife who discussed the units plans to continue with elective surgery during the second wave and gave her valuable experience on encouraging staff wellbeing听during听this difficult time.听

Following afternoon coffee, Mr David Bunting听talked about improving day case laparoscopic cholecystectomy rates and the North Devon experience with the Royal College of Surgeon蝉鈥� Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) project.听Additionally,听tips and advice on how to听maintain a 鈥淗ot Gallbladder鈥� service in the COVID -19 era was discussed.听This was followed by Mr Paul Super, Consultant Upper GI Surgeon from the Heart of England Foundation Trust in Birmingham talking about day case fundoplication and anti-reflux surgery. Nationally, the day case rate for anti-reflux surgery is about 15%, however the rate at Heartlands is in excess of 80%, with an overwhelmingly positive patient feedback. Mr Super outlined the patient pathway and general principles for day case hiatal surgery that have enabled the unit to achieve these impressive results.听

A big thank you to all the speakers and all those involved in organizing a successful day conference, and to all the delegates who attended and contributed to the discussion on the day.听

Due to excellent feedback from this meeting, it is being held once again on听Friday听4th鈥�of June听2021.听

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K Kennedy¹, J Appiah-Ankam², BVS Murthy³听

1 Specialist Registrar in Anaesthetics, Royal Liverpool and Broadgreen University Hospitals,听Liverpool听
2听Consultant Anaesthetist, Royal Liverpool and Broadgreen University Hospitals,听Liverpool听
3听Consultant Anaesthetist, Royal Liverpool and Broadgreen University Hospitals NHS Trust, and Honorary Associate Professor of Health and Life Sciences, University of Liverpool, Liverpool听

Corresponding author:听听Prof. BVS Murthy,听Consultant Anaesthetist,听Preoperative Assessment Unit,听Broadgreen Hospital,听Thomas Drive,听Liverpool听L14 3LB

Email:听Burra.Murthy@rlbuht.nhs.uk听

Abstract听

Introduction:听Shoulder surgery is known to be extremely painful听and yet听it has become successful as a day听case procedure due to the routine use of brachial plexus blocks. Recent work has delineated that patients may be experiencing听pain following discharge once the brachial plexus block has worn off. A service evaluation was undertaken to assess the incidence of听post-operative听pain听in the first 48听hours and patient satisfaction in听patients undergoing听day case arthroscopic shoulder surgery.听听

Methods:听This prospective qualitative service evaluation was conducted听between January听2019听and听June 2019 in patients undergoing day case arthroscopic shoulder surgery on Mondays and Wednesdays with a telephone follow-up interview on Wednesdays and Fridays.听

Results:听听In the immediate post-operative period, out of 50 patients,听48 had good pain relief with no pain;听2 patients (4%) required听additional analgesia in recovery or on the day-case unit. During the 48-hour follow up we found that 11 patients (30%) reported severe pain and 12 patients (33%) reported moderate pain at rest.听Overall,听the mean patient satisfaction score was 8.43.听Satisfaction听scores were higher for patients experiencing mild to moderate pain compared to severe pain at 48听hours post-operatively听(P > 0.05).听

Conclusion:听We appreciate that patient蝉鈥� experiences of pain could be improved. We hope to make our post-operative pain protocols more robust and to ensure all patients receive a comprehensive written patient education leaflet about their postoperative pain management.听

Keywords:听shoulder surgery;听day surgery;听pain;听satisfaction

Introduction听

Over the past 40 years,听surgery听has听undergone significant developments leading to听widespread听change听to day case听(ambulatory) procedures. This has only been possible with the introduction of听new surgical techniques, advances in anaesthesia, and the collection and publication of comparative data, with financial incentives for hospitals听to do so.1听In 2013-14, 60.7% of finished consultant episodes involved some form of procedure or intervention, with 95.2%听of day case episodes involving a procedure or intervention.¹听As per the NHS quality and service improvement tools 鈥榯he patient must be admitted and discharged on the same day, with day surgery as the intended management鈥�:听it should be听the听norm rather than听the听exception.²听

The development of shoulder arthroscopy has bought it into the realms of day case surgery.听Although shoulder surgery is known to be extremely painful, it has become successful as a day case procedure due to听the routine use of brachial plexus blocks, allowing for听reduced opiate doses.³听With increasing use of regional blocks and multimodal analgesia, day听case shoulder surgery has been widely adopted across the NHS and has been the norm at our听Trust since 2014. Even though it听had become听a norm for the staff,听we wanted to identify听the impact on patient related outcomes听with this change.听We听therefore听conducted a听prospective听qualitative service evaluation to understand the patient蝉鈥� needs, views,听expectations,听and satisfaction on day case听arthroscopic听shoulder surgery.听

Methods听

At听a large tertiary听University Teaching Hospital in the Northwest of England, we conducted a service evaluation听of patients undergoing day case arthroscopic shoulder surgery on Mondays and Wednesdays听between听January听2019听and听June 2019.听This service evaluation was approved by the hospital audit department, and no ethical approval was sought due to the non-interventional nature of the work.听During their听preoperative assessment, all patients were听given听a leaflet with the details of听the听various methods of postoperative pain relief听that would be offered听following shoulder surgery听including听interscalene听brachial plexus听block听(ISB), oral analgesia etc.听During听the听assessment on the day of听surgery, all听patients were consented to both anonymised data collection and a post-operative telephone听follow up听interview.听听

In the intraoperative phase, anaesthetists were requested to听complete听a听data sheet about preoperative analgesics,听ISB听details (including听time of the block,听and听volume and concentration of听local anaesthetic), any other intraoperative analgesia given, antiemetics used and the听volume听of intravenous fluids administered. In the recovery ward and day case unit, staff were requested to complete the data sheet听with听the pain score on admission and at discharge,听and听any analgesia听or听antiemetics听given.听In our unit,听we听routinely听provide one week supply of oral analgesics (codeine and paracetamol) for听post-operative pain relief as听take-home听medication. Occasionally, if the patient is experiencing more听pain,听we tend to prescribe tramadol and / or non-steroidal听anti-inflammatory听medication.听

After听48听hours听i.e.,听on Wednesday and Friday, a telephone follow-up interview was conducted by the day case unit staff听about听the patient蝉鈥�听pain management, their experience, sleep disturbance, nausea and vomiting听(PONV)听and听their听satisfaction.听The overall satisfaction with their pain management was assessed using a visual analogue scale (0 = not happy at all and 10 = extremely happy).听

Results听

We were able to collect the data from 50 patients听(32听males, 18听females)听during their hospital stay.听The听patient ages ranged from 21-77听years (mean听52听years,听and median 56听years). The听details of various听surgical procedures performed听on the shoulder听are listed in Table 1.听

Table 1:听The number patients having various听surgical听procedures and patients who were听not contactable f
or a 48-hour postoperative follow up interview.听

Intra-operative pain relief听

94% of听the听ISB听were performed with ultrasound and听use of a听peripheral nerve stimulator, the remaining听cases听were performed using ultrasound alone.听The agent used for regional anaesthesia was levobupivacaine听mainly听with a strength of听0.375% (27 patients),听however听some anaesthetists used听0.25% (19 patients)听or听0.5% (4 patients). The volume used ranged between 12-35听ml with a median of 20听ml.听45 patients received adjuvant dexamethasone听(6.6 mg),听of which听31听received听it听intravenously听and听the听rest perineurally.听听

The听range of intraoperative听analgesics used was diverse听with听34听patients receiving听paracetamol,听19听had听paracetamol听combined with fentanyl or alfentanil,听and听11听patients received alfentanil听alone.听Other analgesic techniques included听a听combination of those described with听adjuncts of joint infiltration, magnesium听or听morphine/oxynorm.听Only听six听patients received non-steroidal anti-inflammatory drugs (NSAIDs).听听

Post-operative pain relief听

We noted a low incidence of immediate post-operative pain听in our cohort with only听2听patients听(4%)听requiring additional analgesia in recovery or on the day听case unit. Of these two听patients, one had moderate pain following a听subacromial decompression (SAD)听and听one听had severe pain听following听a rotator cuff repair. The patient who had听had听a听cuff repair听and was听in severe pain in recovery then complained of no pain on arrival to the ward following听morphine听2听mg听intravenously in听recovery.听听

Table 2:听Pain scores in first 48 hours听following their听surgery.听

At our 48-hour post-operative follow up, we were able to contact听72% of听patients听(22 males + 14 females)听to assess听their experience,听their听post-operative听pain听relief,听and their satisfaction.听听The mean duration of block in these patients was 20.5 hours (median 21 hours, mode 24 hours).听As demonstrated in table 2, the pain experienced was variable and听did not听appear to correlate with听the听surgical procedure. However, cuff repairs did represent half of听the听patients in severe pain at 48听hours.听

In this cohort,听11听patients (30%) reported severe pain听and 12 patients (33%) reported moderate pain at rest听within the first 48听hours听(Table 2).听Sleep disturbances were experienced by听25 patients on the day of operation due to pain, discomfort and pins and needles. During the follow up only 6 patients had problems with PONV, 3 were female.听听

Table 3:听Mean, median and mode patient satisfaction听scores听about their pain relief听at rest听within first 48 hours听of surgery.听

Patient satisfaction听

Overall,听the mean听patient听satisfaction score was 8.43 (range 5-10, median 8).听Satisfaction听scores were higher听for patients experiencing mild to moderate pain compared to severe pain听(P > 0.05)听at听48听hours post-operatively听(table听3).听The patient who scored 5 had a block duration of 25 hours but severe pain at rest and on movement at 48听hours. She was discharged on paracetamol, NSAID and codeine, but was听receiving gabapentin听preoperatively.听Thirty听patients (80%) felt the length of stay was about right.听All the additional听comments听provided by听patients on their experience are listed in Table 4.听

Table听4:听Additional patient蝉鈥� comments听about听their experience.听听

Discussion听

With advances in surgical techniques and anaesthetic skills,听increasingly arthroscopic shoulder surgery is becoming a day case procedure.听Postoperative pain management after shoulder arthroscopy is a critical factor听in听recovery,听rehabilitation,听and patient satisfaction.听听Even with these advances, optimal pain relief remains a challenge due to considerable individual variations in听the level of pain experienced.4听听

The success of听ISB in 48 patients led to听a听low听incidence of pain听(96%)听in the early postoperative period听within the cohort.听Of听the听two patients,听one听had moderate pain (SAD) and听one had听severe听pain (cuff repair) in recovery,听which听settled quickly with a small dose of morphine听(2 mg)听which suggests it was unlikely听to be听related to block failure.听The benefits of regional anaesthesia for facilitating day听case surgery are widely described in the literature.^5,6,7听We听have听not been able to accurately听identify why some blocks lasted longer than others.听However,听we did find that three听patients who did听not听receive any supplementary dexamethasone (intravenously or perineurally),听due to other comorbid reasons,听had short duration of blocks听(8, 10, 17 hours听respectively).听It is听well-established听that听duration of a single shot ISB can be prolonged by adjunct therapy with听dexamethasone.^{8, 9}听

Follow up听

Our audit has demonstrated that 20 hours of excellent postoperative analgesia may not be sufficient听in some day case shoulder surgical procedures, as observed by Wilson et al.⁵听Regrettably听we noted听a 30%听an incidence of severe pain at 48 hours which is higher than we have seen in previous service evaluations at our trust 鈥�听20%听in 2015 and听11%听in 2012听-听when听we conducted听a听follow up telephone interview at 24 hours.听In a survey of postoperative analgesia following ambulatory surgery, Rawal et al found 35% of day surgery patients experienced moderate to severe pain听during听the听first 48 hours听at home in spite of analgesic medications.¹⁰听At听present our听routine听protocol is to send patients鈥�听home with听paracetamol and codeine, but in selected cases with moderate to severe pain to send听them听home with additional analgesia听such听as tramadol听or听a听NSAID as tolerated or indicated.听In view of these听audit findings, perhaps it is time to modify our protocol about take home medications.听

Our patient听reports of pain were听diverse,听and it is difficult to decipher any correlation听between听pain and听the听surgical procedure. However, cuff repairs听did represent听6 of the 11听patients (54%) in severe pain in the first 48听hours听despite paracetamol, codeine and NSAID,听the听regimen听recommended听in the听PROSPECT guidelines for rotator cuff repair surgery.¹¹听It听is possible these are more painful procedures and would benefit from enhanced analgesia听such as听oramorph for听3-5听days听after surgery.听

Oral take home analgesia is currently the only option for day听case surgery and single shot听ISB听only works听for short periods. It is possible that our patients鈥�听pain scores may be significantly improved if we were able to instigate a protocol to facilitate a brachial plexus catheter and continuous local anaesthetic infiltration at home.听Russon and colleagues听described the provision of continuous brachial plexus blocks at their听Trust and noted it to听produce听good analgesia in 90% of their patients.¹²听Although听this would require robust patient selection and coordination with district nursing teams, this looks to be a promising way to improve听postoperative pain management and听patient satisfaction.听

Sleep听听

It is known that disturbed sleep post-operatively can negatively听affect听a patient鈥�s recovery.¹³听In our cohort, pain satisfaction scores were听affected听by patient experience of听poor听sleep听due to听significant pain.听How do we improve patient鈥檚 post-operative sleep? Perhaps the answer听also听lies in provision of regional anaesthetic catheters and home local anaesthetic infusions.听

Post-operative Nausea and Vomiting听听

We have previously found an incidence of post-operative nausea and vomiting of 2.87% in patients听undergoing听any听day听case surgery at our unit.¹⁴听听听Within the听cohort听we followed, we noted听a lower听incidence of听PONV听(1.67%)听that听may be听due to the lower听emetogenic nature of orthopaedic surgery,听the听higher proportion of males in our cohort and frequent administration of dual antiemetic therapy.听听

Length of stay听

We noted that most patients (80%) were happy with the length of stay which suggests that not only does day听case surgery have an economic benefit to the NHS,听but听patients also prefer day听case surgery.²听听

Patient听Satisfaction听

Patient satisfaction is a complex outcome to assess and is听likely听to be related to a number of variables听within the patient journey.听Some factors听contributing to听satisfaction听in听day听case surgery听are modifiable听like听managing听pre-operative expectations and听optimising patient experience of听pain.15听Our pain satisfaction scores were not as low as may be expected for the prevalence of severe pain in our patient cohort.听Obviously,听patients with lower pain scores had higher satisfaction scores and vice versa; as demonstrated in Table 3,听although there was no statistically significant difference in the means (P > 0.05).听

Patients most frequently commented on pain听and it is clearly a focus for patient satisfaction at our听Trust听(Table 4).听While most patient comments听in our study听were positive and suggested a good patient experience, some were clearly dissatisfied with their pain experience.听Overall,听we feel the overriding听patient听positivity听is attribute to our day听case staff and demonstrates our protocols are benefiting patient satisfaction. Nevertheless,听in view of some patients experiencing pain, it is clear we need to address any deficiencies in our protocols.听As听anaesthetists, our ability to influence surgical outcomes is limited. However, we are able to optimise analgesia for our patients听and ensure plans are communicated to patients appropriately.听If we are able听to听minimise the distress caused by post-operative pain, and manage听patient expectations听well听preoperatively, we should be able to have a positive impact on overall satisfaction with day听case shoulder surgery.¹⁵听

Limitations &听Conclusion听

The provision of day听case shoulder surgery at out听Trust is well established and dependent on excellent team working between听the听pre-operative听assessment team, anaesthetists,听surgeons,听and day-case ward nurses.听听As previously noted in the literature,听we have identified that patient satisfaction appears to correlate extensively with patient experience of pain.¹⁵听While we appreciate patient蝉鈥�听experiences of pain could be improved, we are pleased to have听found听relatively high pain satisfaction scores and positive feedback from our patients. Taking听into account听our findings from this听audit, we hope to make our post-operative pain protocols more robust听and听to ensure all patients receive听a听comprehensive听written patient education leaflet about their postoperative pain management including instructions on taking oral pain killers before their听block听wears off. This will empower them to play their part in the recovery period and may enhance听further听patient satisfaction in our service.听听

Acknowledgements听听

We would like to thank all听the patients,听the anaesthetists,听recovery,听and day case staff for their assistance with data collection during the course of this service evaluation.听听

Conflicts of Interest:听The authors have no potential conflicts of interest to declare.听听

References听

1. Appleby J. Day case surgery: a good news story for the NHS.BMJ. 2015 Jul 29;351:h4060. doi: 10.1136/bmj.h4060.听听
2. Same day elective care 鈥� treat day surgery as the norm.听Online library of Quality, Service听Improvement and Redesign tools -听NHS Improvement.听听
3. Conroy BP, Gray BC, Fischer RB, Del Campo LJ, Kenter K. Interscalene block for elective shoulder surgery.Orthopedics. 2003;听26(5):501-3.听
4. 4.White PF. Pain management after ambulatory surgery 鈥� where is the disconnect?Can J Anaesth听2008; 55(4): 201-207听
5. 5.Wilson AT, Nicholson E, Burton L, Wild C. Analgesia for day-case shoulder surgery.Br J Anaesth.听2004; 92:414-5.听听
6. 6.听Joshy, S., Menon, G. & Iossifidis, A. Inter-scalene block in day-case shoulder surgery.鈥�Eur J Orthop Surg Traumatol鈥�2006;16:鈥�327鈥�329.听听
7. 7.Sadashivaiah鈥疛,鈥疓hatge鈥疭. 11.鈥�Interscalene Brachial Plexus Block for Post Shoulder Surgery Pain Relief in Day-Case Patients.Regional Anesthesia & Pain Medicine鈥�2008;听33:听e听
8. 8.Pehora C, Peason AME, Kaushal A, Crawford MW, Johnston B. Dexamethasone asan adjuvant to peripheral nerve block.听Cochrane Database Syst Rev听2017 Nov听9; 11: CD011770.听doi: 10.1002/14651858.CD011770.pub2听
9. 9.Cummings KC 3rd, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, Sessler DI. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine.Br J Anaesth听2011;听107(3):446-53.听
10. Rawal N, Hylander J, Nydahl PA, Olofsson I, Gupta A. Survey of postoperative analgesia following ambulatory surgery.Acta Anaesthesiol Scand1997; 41: 1017-22.听
11. Toma O, Persoons B, Pogatzki-Zahn E, Van de Velde M and Joshi GP. PROSPECT guidelines for rotator cuff repair surgery: systemic review and procedure specific postoperative pain management recommendations.Anaesthesia2019; 74: 1320-1331.听
12. RussonK, Sardesai听AM, Ridgway听S, Whitear听J, Sildown听D, Boswell听S, Chakrabarti听A, Denny听NM, Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure.鈥�Br听J Anaesth听2006; 97:听869-873.鈥�听听
13. Su X, Wang DX. Improve postoperative sleep: what can we do?Curr Opin Anaesthesiol. 2018; 31: 83-88.听
14. Mayhew D, Swaraj S, Murthy BVS.鈥� Nausea and Vomiting in Daycase Surgery - a Quality Indicator.鈥�鈥�Journal of One Day Surgery鈥�2017; 26(3):听9-17.听
15. Jaensson, M., Dahlberg, K. & Nilsson, U. Factors influencing day surgery patient蝉鈥� quality of postoperative recovery and satisfaction with recovery: a narrative review.鈥�Perioper Med鈥�2019;听8:鈥�3. https://doi.org/10.1186/s13741-019-0115-1.听

听

Table 1:听The number patients having various听surgical听procedures and patients who were听not contactable for a 48-hour postoperative follow up interview.听

听

Table 2:听Pain scores in first 48 hours听following their听surgery.听

听

听Table 3:听Mean, median and mode patient satisfaction听scores听about their pain relief听at rest听within first 48 hours听of surgery.

Table听4:听Additional patient蝉鈥� comments听about听their experience.听听

听

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1. Ravikumar R, Williams J. The operative management of gallstone ileus. Ann R Coll Surg Engl 2010;92:279鈥�281.
2. Dybvig DD, Dybvig M. Det tenkende mennesket. Filosofi- og vitenskapshistorie med vitenskapsteori. 2nd ed. Trondheim: Tapir akademisk forlag; 2003.
3. Beizer JL, Timiras ML. Pharmacology and drug management in the elderly. In: Timiras PS, editor. Physiological basis of aging and geriatrics. 2nd ed. Boca Raton: CRC Press; 1994. p. 279-84.
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Mr David Bunting
Editor, Journal of One Day Surgery
British Association of Day Surgery
Consultant Upper GI Surgeon
North Devon District Hospital

[These guidelines were last revised on 03.02.2021]

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