One-Day Surgery - British Association of Day Surgery

The Journal of
One-Day Surgery
VOLUME 19 SUPPLEMENT
Abstracts presented at the
20th Annual Scientific Meeting Southport,
June 2009

Oral Abstracts
PARALLEL 1: ANAESTHESIA
A1 Effects of Changing to a TIVA Anaesthetic Regimen for Day Case Laparoscopic Cholecystectomy
RK Tibble
A2 An Audit of a New Diabetic Management Regime Suitable for Day and Short Stay Surgery
A Modi, A Lipp, K Dhataria
A3 Fewer Tears at Home – Improving pain relief after paediatric day surgery
ME Walters, J Sanderson, JA Short
A4 Interscalene Block for Daycase Shoulder Surgery: Introducing a new technique to suit our patient population
H Du Plessis, MJ Booth, S McKinlay
A5 Current use of Spinal Anaesthesia for Day Surgery in the United Kingdom
S Pangam, B Watson
PARALLEL 1: SURGERY
A6 Improved Communication Between Patients and Medical Staff can Increase the rate of Day Case Laparoscopic
Cholecystectomy
WJ Hawkins, S Mukherjee, JR Isaac, M Ehtisham, FT Curran
A7 Day Surgery Hernia Repair: Open or laparoscopic approach?
DJH Pappin, M Stocker
A8 Nurse-led Ambulatory Hysteroscopy in the UK – A more efficient and cheaper service
JA Smith
A9 Management of Obese Patients for Day Case Procedures
SA Roberts, J Palmer
A10 Talking Trauma
NV Slator, AA Bhangu
PARALLEL 1: EFFICIENCY, TEACHING AND TRAINING
A11 The Price is Right! Knowledge of drug costs amongst anaesthetists performing day surgery
T Heinink, JM Vernon, J Wilkinson
A12 An Uninvited Guest: Presence of medical students in the day surgery unit
A Ratnayake, C Panabokke, M Ahuja
A13 Theatre Efficiency in Ambulatory Surgery: It’s table time that counts!
D McWhinnie, J Ellams, S Naz, M Orchard
A14 Documentation of Operative Notes in Day Surgery – Are we adhering to good surgical practice?
S Das, J Lee, NN Basu, U Parampilli
A15 Interactive e-learning: Development of an online programme
M Weedall, R McMIllan, J Taylor, M Renton, J Bernard, J Alexander, S Hodkinson
PARALLEL 1:THE POSTOPERATIVE PERIOD
A16 ‘Let the Surgeon give the Local’– Implementation of an anaesthetic guideline to reduce the unplanned
admission rate following open inguinal hernia repair
COF Islam, M Stocker, J Montgomery
A17 An Audit of Unplanned Hospital Admission following Elective Paediatric ENT Day Case Surgery in a Tertiary
Referral Centre
S Pickworth, A Patel, D Sethi

Oral Abstracts cont.
A18 An Audit Comparing Home Readiness and Discharge Times in Day Surgery Patients, using Traditional and
PADS Scoring Systems
GA Neilson, S Meldrum, KJ Anderson
A19 Failure to Discharge following Elective Day Surgery – A prospective study
S Vallabhajousula, T Kramer-Taylor, JC Taylor, IG Gunn
A20 Retrospective audit of Day Case Laparoscopic Cholecystectomy – Are strict inclusion criteria necessary?
A Farooq, H Shaker, N Matar
PARALLEL 2: SURGERY – NEW FRONTIERS
A21 EVAR – Reducing length of stay and costs
IR Flindall, S Ward, A Day, P Thomas, A Anjum, A Keane
A22 Day Case or Ambulatory Parathyroidectomy: Safe and feasible in a DGH
R Parameswaran, K Allouni, P Varghese and A McLaren
A23 Day Case Colon and Rectal Cancer Surgery – Are we ready for take-off?
T Wong, A Shekouh, R Wilkin, M Johnson
A24 Intermediate Breast and Axillary Day Case Surgery: Is it feasible?
RM Clancy, RM Watkins
A25 Safe Day Case Upper Urinary Tract Endoscopy
P Erotocritou, N Gravell, P Pietrzak, S Hutchinson, K Anson
PARALLEL 2: THE PATIENT’S PERSPECTIVE
A26 Audit of Patient Information about Anaesthesia
K Sivagnanam, A Lipp
A27 Privacy and Dignity Audit of Patient Care – Day surgery unit Ashford Hospital, Middlesex
J Ryman, E Shepherd
A28 A Patient Survey to Determine how Day Surgery Patients would like Preoperative Assessment to be
Conducted
S Lewis, M Stocker, K Houghton, J Montgomery
A29 Improving Information and Communication Resources for Children with Special Needs Undergoing Day
Surgery
LMA Broxholme, JA Short
A30 “They are Marvellous with you while you are in but the Aftercare is Rubbish”: Carers experiences of their
loved ones undergoing day surgery
A Mottram
PARALLEL 2: SAFETY AND TEAMWORK
A31 Should we Ban Some Anaesthetists from Working in our Day Surgery Centre?
T Viswanathan, MA Skues
A32 Patient Safety in Day Surgery: What’s required for cardiopulmonary resuscitation (CPR) training in this
environment?
A Jervis, J Bethel, MA Skues
A33 Communication in Nottingham City Hospital Day Surgery Unit
H Biswas, J Waring, J Vernon, S Bishop

Plenary Prize Session/Posters
A34 Patient Safety in Day Surgery: Enhancing theatre teamwork and communication
J Thomson, S Rule, J McHale, MA Skues
A35 The World Health Organisation Surgical Safety Checklist – Global to local
JL Doyle, S Lour, H Peskett, R Relano
PLENARY PRIZE SESSION
B1 Day Case Haemorrhoid Banding in a Patient with High Spinal Cord Injury and Severe Autonomic Dysreflexia
A Doyle, A Eley, B Watson
B2 “Out In The Cold?” The incidence of perioperative hypothermia in a district general hospital day surgery unit
T Hinde, M Stocker, J Montgomery
B3 Safe Day Surgery Discharge. Reducing discharge times without compromising patient safety
D Reisel, D Kamming
B4 ‘How to get the most out of 20 Minutes’: The introduction of a one day preoperative assessment training
module for nursing staff
T Hinde, M Stocker
B5 Day Case Laparoscopic Gastric Bandings – Is it really such a big deal?
S Irukulla, M Wattie, M Kubli, M Brown, J Horner
B6 How do we Approach Venous Thromboembolism Prophylaxis in Day Surgery Patients?
N Bhamber, I Ogunrinde, C Shaw, CL Ingham Clark
POSTERS
P1 An Audit of Perioperative Nursing Care for Diabetic Patients Undergoing Day Surgery at Gloucestershire
Royal Hospital 2006–2007
P McCann, J Brown, T Ullahannan
P2 An Audit of Perioperative Temperature Management in Day Surgery
RD Thomas, DE Griffiths
P3 An Audit on Major Complication Rates in Peripheral Angiography at a Large District General Hospital
C P Lim, T L Luk
P4 AO Screw Fixation of Undisplaced Fractured Neck of Femur (Garden Grade I and II) in Patients over 65 Years
of Age
H Sekhar, A Lee, A Kumar
P5 Are Neck Drains a Contraindication to Day Surgery?
J Bhat
P6 Audit of Abdominoplasty as Day Case Surgery
A Salman
P7 Basket of ENT Surgery
AHH Al-Jassim
P8 Day Case Doppler-Guided Haemorrhoidal Artery Ligation for 2nd and 3rd Degree Haemorrhoids –
Intermediate and long-term outcome
T Wong, A Shekouh, J Arthur, P Skaife
P9 Day Case Foot and Ankle Surgery – An audit of patients’ acceptance and analgesic requirements
N Calthorpe, Santra, A Marsh, U Ranasinghe
P10 Day Case Laparoscopic Cholecystectomy in Morbidly Obese Patients
M Ballal, D Raw, M Shrotri

Posters
P11 Day Case Laparoscopic Cholecystectomy: Achievable in peripheral hospitals
LH Lee, E Ghareeb
P12 Day Case Laparoscopic Paraumbilical Hernia Repair
I Shaikh, S Kumar
P13 Day Case Surgery, a Prospective Audit of 796 cases at New Cross Hospital
R Khazaee-Farid, CV Higanbottam, ROC Elledge, M Ahuja
P14 Day Surgery Utilisation – Financial implications
J I Pears
P15 Delayed Discharge after Day Surgery
A Al-Kaysi, J Palmer
P16 Designing a Day Surgery Website: A survey to assess patients’ information requirements and access to
the internet
NT Tarmey, RW Chambers, KM Williamson
P17 ENT Theatre Cancellation on day of Operation
YB Mahalingappa, A Daud
P18 Evaluation of Redesigned Analgesia Regime for Postoperative Analgesia in Day and Short Stay Surgery
M Laye, J Rozentals, JM Vernon
P19 General Anaesthesia and Day Case Patient Anxiety
M Mitchell
P20 Holistic Nursing Care of Day Case ENT Patients
T Lesser, L Brown
P21 How Long Does Preassessment Take?
J Linfield, MA Skues
P22 Impact of Elective Day Surgery Cancellations on Quality of Service Delivery
A Chandran, C Connolly, B Ajakey, M Ragbir
P23 Improving Efficiency: A treatment centre service evaluation
A Weigert, M Pernow
P24 Inadvertent Perioperative Hypothermia in Day Case Patients: ‘Easily done but even easier to rectify’
H Chin, J Kim, V Hariharan
P25 Incidence of Obesity in Patients Presenting with a Primary Abdominal Wall Hernia
I Shaikh, SP Khanolkar, S Kumar
P26 Nasal Surgery and Bleeding
THJ Lesser
P27 “NICE, but not Warm Enough on our Day Surgery Unit!” – A prospective audit
S Gummaraju, I Hall
P28 Outpatient Abdominoplasty! Is it a safe practice?
R Salman, A Salman
P29 Patient Outcomes and Satisfaction Following Day Case Laparoscopic Cholecystectomies
ML Wattie, N Menezes
P30 Patient Satisfaction Survey: Day Surgery Unit Ashford Hospital, Middlesex 2008
J Ryman, E Shepherd
P31 Patient Satisfaction Survey in a Day Case Unit in an Elective Orthopaedic Hospital in the UK
P Banerjee, N Blewitt

P32 Patient Satisfaction within the Portsmouth Day Case Laparoscopic Cholecystectomy Service
AM Walters, K Williamson, D Wainwright, S Sadek, S Toh, T Whitbread
P33 Provision of Appropriate Chairs for Anaesthetists may Reduce Back Pain Related to Theatre Seating
Y Haroon, JM Vernon
P34 Reasons for Cancellations in Day Case General Surgical Procedures
A Hakeem, S Mandal, M Dube, K Badrinath
P35 Routine Ultrasonography: The future in the management of inguinal hernias?
S Alagaratnam, WKB Ranasinghe, TIJ Ranasinghe, AP Zbar
P36 Stapled Haemorrhoidectomy – An effective and feasible day case procedure
N Pranesh, A Saleh, BA Taylor, MJ Tighe
P37 Sub-specialisation and Outcome of Laparoscopic Cholecystectomy in a District General Hospital
AT Clark-Morgan, M Javed, B Swiech, A Jansuz, V Sujendran, M Farouk, S Appleton
P38 The Development of Services for the Treatment of Age Related Macular Degeneration in Aintree NHS Trust
R Mallett, D Ewing, T Myhre, S Wilson, A Kamal, D Clark
P39 The Impact of RTT on Preoperative Screening and Assessment Services Within Poole Hospital
J Hindess, N Roberts

Editorial comment
While we have tried to reproduce all abstracts as submitted, some Editorial discretion has been taken to
correct obvious spelling or grammatical errors. It has also been necessary to reformat tables into a
consistent style and to shorten some abstracts to conform with printing constraints. In these cases, some
Editorial amendments may have been made so as to retain the maximum amount of information possible in
the available space. The Editor hopes that none of these changes will cause any embarrassment or offence.
IAN SMITH

A1
Effects of Changing to a TIVA
Anaesthetic Regimen for Day Case
Laparoscopic Cholecystectomy
RK Tibble
Derby Hospitals Foundation Trust
INTRODUCTION: Day case laparoscopic cholecystectomy has a
high incidence of postoperative nausea and vomiting (PONV)
which can lead to delayed discharge and unplanned overnight
admissions both reducing day surgery efficiency. Total
Intravenous Anaesthesia (TIVA) reduces PONV. We aimed to
discover if using TIVA improved successful day surgery rates for
laparoscopic cholecystectomy in our unit.
METHODS: After auditing rates of PONV, time to discharge
home and unplanned admissions overnight for laparoscopic
cholecystectomies after a volatile anaesthetic technique, a
protocol was introduced based on propofol and remifentanil
TIVA technique with a single dose of morphine 10 mg or
pethidine 100 mg, given 15 minutes before the end of the
operation. Nonsteroidal antiinflammatory analgesics and
paracetamol were also used routinely when no
contraindications existed. 50 patients were followed through
after having the TIVA anaesthetic technique to monitor
postoperative nausea and vomiting and time to discharge or
admission overnight. The two were compared to look for
improvement.
A2
An Audit of a New Diabetic
Management Regime Suitable for Day
and Short Stay Surgery
A Modi, A Lipp, K Dhataria
Norfolk and Norwich University Hospital
INTRODUCTION: Last year our trust developed new guidelines
for improving the management of perioperative blood glucose
control in adult diabetic (type 1 and 2) patients presenting for
elective and day case surgery. The aim was to allow an
increasing number of diabetics (with HbA1C16 yrs, NBM 15 (first
postoperative record) on the new protocol, were found to be
2nd and 3rd on the surgical list. There were 2 patients who were
started on preop. SSI despite being NBM

A3
Fewer Tears at Home – Improving pain
relief after paediatric day surgery
ME Walters, J Sanderson, JA Short
Sheffield Children’s Hospital Foundation Trust
INTRODUCTION: Increasing numbers of surgical procedures
are being performed as day cases in line with government
targets [1] but previous reviews suggest that a significant
number of paediatric patients have pain at home afterwards [2].
The routine practice of our day care ward is to recommend the
use of simple analgesics with which both the child and family
are familiar rather than providing take-home packs. A previous
audit revealed 10% of patients experienced severe pain and
only 44% had mild or no pain. In many cases of
moderate–severe pain the child had not been given regular
analgesia and the doses were frequently inadequate for their
weight. A newly developed protocol gives written instructions
about regular analgesia to every family attending the day unit
and a Patient Group Directive allows nursing staff to
recommend weight-based doses of over-the-counter
analgesics. This re-audit examines whether the new system
improves pain management, ensures delivery of suitable,
regular doses and promotes parental satisfaction.
METHODS: 100 patients were audited prospectively, using local
guidelines and the Royal College of Anaesthetists Audit
Compendium [3] standards, including: 100% discharged with
verbal and written instructions about pain control and
analgesics available at home; 85% reporting mild or no pain
after discharge; >85% parent/carer reporting “satisfied” or
“very satisfied” with pain management after discharge. Data
were collected regarding surgical and anaesthetic details and
A4
Interscalene Block for Daycase
Shoulder Surgery: Introducing a new
technique to suit our patient
population
H Du Plessis, MJ Booth, S McKinlay
Glasgow Royal Infirmary
INTRODUCTION: Interscalene brachial plexus block (ISBPB)
provides superior analgesia for arthroscopic shoulder surgery
(ASS) [1,2] and allows it to be performed as a day case
procedure [3]. Previously patients required a 2 day hospital stay
in our institution. We aimed to perform the surgery under ISBPB
and general anaesthesia as a day case procedure in our
hospital.
METHODS: 73 patients received ISBPB and peripheral nerve
catheter placement prior to general anaesthesia. The ISBPB was
performed with a 30 ml mixture of 1% lignocaine with adrenaline
and 0.25–0.5% levobupivacaine. Postoperatively a 30 ml bolus
of local anaesthetic (0.333%–0.5% levobupivacaine) was
administered prior to nerve catheter removal and hospital
discharge. Discharge analgesia comprised regular and
breakthrough analgesia. Data collected included
demographics, block duration, side effects and patient
satisfaction (1 = very dissatisfied to 5 = very satisfied). Pain
scores (verbal descriptor scale from 0–10) were assessed in
recovery room (RPS), the next day as worst overnight pain score
(WPS) and as best overnight pain score (BPS). Data were
analysed using SPSS statistical programme.
analgesia given in hospital for each participant. Parents were
given a form to record analgesia given, pain severity and
satisfaction with pain relief during the first 48 hours
postoperatively, with an SAE for return.
RESULTS: 94 hospital and 50 parent forms were returned. 96%
of children were discharged with analgesia available at home,
90% received the leaflet and 98% remember receiving verbal
advice about pain control. 94% felt they received adequate
information. Only 62% gave analgesia regularly but
encouragingly 78% and 88% used suitable doses based upon
weight for paracetamol and ibuprofen respectively. Overall,
64% reported mild or no pain while 4% reported severe or
unbearable pain. Of those reporting moderate or worse pain,
analgesia was often only given as needed despite receiving
written and verbal advice. 88% of parents reported “excellent”
or “good” pain control, and 88% were “satisfied” or “very
satisfied” with the system with only 6% unsure, and 4%
unsatisfied.
CONCLUSIONS: The new system of written advice for use with
over-the-counter analgesics has improved pain scores and
helps to ensure paediatric patients are not under-dosed.
However despite advice, a large number of parents still do not
give analgesia regularly and these patients tend to have higher
pain scores. Parent satisfaction overall is good.
REFERENCES
1. Professor Lord Darz. NHS Next Stage Review Interim Report,
Department of Health, 2007
2. Kokinsky E, et al. Paediatric Anaesthesia 1999;9:243–51
3. Royal College of Anaesthetists. Raising the Standard: A
compendium of audit recipes, 2006
RESULTS: The most commonly described procedure was
arthroscopic subacromial decompression (n = 32). Mean age
was 45 (SD 14.2). Gender distribution was 40 male patients and
33 female patients. Mean duration of block was 9.4 hours (SD
3.34). Median RPS was 0/10 (IQR 0–0/10, range 0–4/10).
Median WPS was 4/10 (IQR 1–6/10; range 0–10). Median BPS
was 0/10 (IQR 0–2; range 0–7). Patient satisfaction was median
= 5 (IQR 5–5; range 1–5). Vomiting occurred in 3/73 (4.1%),
nausea in 19/73 (26%) and dizziness in 19/73 (26%). 58.9% of
patients reported the same as or better level of sleep than
normal, on their first postoperative night. Only one patient
required overnight admission due to low oxygen saturations.
CONCLUSIONS: ISBPB achieves excellent pain relief with a low
complication rate and high patient satisfaction. A large
catchment area of patient referral makes it impractical for us to
discharge patients with a nerve catheter in situ. Introducing a
technique of bolus top up rather than continuous infusion has
made day case surgery possible and improved service delivery.
REFERENCES
1. Singelyn FJ, et al. Anesthesia and Analgesia
2004;99:589–92
2. Laurila PA, et al. Acta Anaesthesiology Scandinavica
2002;46:1031–6
3. Russin K, et al. British Journal of Anaesthesia
2006;97:869–73

A5
Current use of Spinal Anaesthesia for
Day Surgery in the United Kingdom
S Pangam, B Watson
The Queen Elizabeth Hospital Kings Lynn
INTRODUCTION: Spinal anaesthesia is a well-established
technique providing good operating condition for selected
surgical procedures. Although widely used for inpatient
procedures, it is still not routinely practiced in day surgery in
the UK. A survey of 27 day units in 2004 showed that only 1 unit
was routinely performing the technique [1]. This new survey
looked at the current practice of spinal anaesthesia in UK day
surgery units.
METHODS: A simple postal questionnaire was send to 240 day
surgery units in autumn 2008 using names and addresses
listed in the BADS Index of Day Surgery Units [2]. We collected
data regarding frequency of use of spinal anaesthesia,
indications for its use, postoperative problems and follow-up
arrangements. Comments regarding any associated benefits
and difficulties were also canvassed.
RESULTS: We received 124 (52%) replies of which 110 were
suitable for analysis.
Use of spinal anaesthesia
Regularly 13 (12%)
Number (%) of units
Sometimes 52 (47%)
Hardy ever 42 (38%)
Never 3 (3%)
Spinal anaesthesia was most commonly used for orthopaedic
procedures followed by general surgical, urological and
gynaecological procedures. Cardiorespiratory disease was the
A6
Improved Communication Between
Patients and Medical Staff can
Increase the rate of Day Case
Laparoscopic Cholecystectomy
WJ Hawkins, S Mukherjee, JR Isaac,
M Ehtisham, FT Curran
New Cross Hospital, Wolverhampton
INTRODUCTION: Increasingly it is accepted that the gold
standard of care for patients with symptomatic gallstones
should be day case laparoscopic cholecystectomy (DCLC). In
our unit every patient requiring a laparoscopic cholecystectomy
who has an ASA less than III and support at home is admitted
with an intention to treat as DCLC. Our protocol aims to place
them early on the main operating list, be seen by a specialist
nurse pre- and postoperatively and receive a follow-up
telephone call the following day. We aimed to see if we could
increase our rate of DCLC further.
METHODS: A prospective audit of all patients admitted under
our care with an intention to treat as DCLC.
RESULTS: 100 consecutive patients with an intention to treat
as DCLC were recruited into the study. 3 required conversion to
open surgery, all due to dense gallbladder adhesions. Excluding
these, 57 (59%) were successfully discharged the same day
and 40 (41%) the following morning. Further analysis compares
these two groups. Both were similar for age, weight, ASA,
anaesthetic and operative technique, grade of operating
surgeon and time on the waiting list. There have been no major
complications or readmissions following discharge in either
main reason for selecting spinal anaesthesia, followed by
patient preference and then obesity-related considerations.
The majority of respondents (87.%) allowed same-day
discharge of their patients after spinal anaesthesia, but only
25% of units routinely carried out post-discharge follow-up. The
most frequently cited benefit of spinal anaesthesia was
improved access to day surgery for patients with a complex
medical history. The most frequently cited problems associated
with day case spinal anaesthesia were urinary retention and
delayed discharge.
CONCLUSIONS: Spinal anaesthesia is clearly being used much
more extensively in day surgery units than it was in 2004
although it is still the case that 41% of our respondents use it
‘hardly ever’ or ‘never’. The Department of Health target is that
three-quarters of elective operations will be performed on a day
case basis within the next decade. If this is to be achieved,
increasing number of patients presenting to day surgery will be
elderly and/or obese with associated co-morbidities. For many
of these patients spinal anaesthesia will be a suitable option.
Accordingly, we anticipate that the use of spinal anaesthesia in
day surgery will rise further. Rearranging the operative list and
use of established low dose techniques can help to prevent
delayed discharge. However there is a need for further research
into prevention and management of urinary retention in day
surgery setting.
REFERENCES
1. British Association of Day Surgery. Spinal anaesthesia in
day surgery: A practical guide, 2004
2. British Association of Day Surgery. Day surgery unit index,
2008
group. Patients who stayed overnight were more likely to have
originally presented with an admission to hospital (28% vs
12%), to have required a preoperative ERCP (13% vs 5%),
commenced surgery after 2 pm (32% vs 4%) and have had bile
spillage during the operation (33% vs 14%). They were also
observed to have a slightly longer mean operating time (57 vs
49 min). They were slightly less likely to have had a
documented discussion about day surgery by our specialist
nurse or the surgeon than those discharged the same day (55%
vs 63%), although this disparity was greater at the beginning of
the audit period. There was also a slight difference on rates of
DCLC based on which postoperative ward the patient went to.
Of those admitted to the short stay unit 67% were discharged
the same day, compared to 57% if they were admitted to our
main specialist upper GI ward and 40% if they went to another
ward. The DCLC rate was seen to improve on our own ward
during the audit period.
CONCLUSIONS: Our unit is achieving a respectable 60% same
day discharge rate for LC. Perhaps predictably, we have found
that operating late, length of operation, spillage of bile during
the operation and preoperative biliary complications increase
the need for an overnight stay. Early findings from the audit that
were circulated to our staff indicated that admission to the
short stay unit and a discussion about early discharge helped
increase DCLC rates. Subsequent analysis has shown this to be
slightly less significant which probably represents raised
awareness of protocols, if not improved documentation in the
notes. Improving communication between staff and patients
seems to represent the most achievable way of improving DCLC
rates amongst our patients.

A7
A8
Day Surgery Hernia Repair: Open or
laparoscopic approach?
DJH Pappin, M Stocker
Torbay Hospital
INTRODUCTION: A Cochrane Review [1] in 2003 found that
open inguinal hernia repair surgery was associated with fewer
surgical complications, however a laparoscopic approach was
associated with less pain. We conducted a retrospective study
to review outcomes of these two alternatives in day case
inguinal hernia repair in our District General Hospital.
METHODS: All primary unilateral day case inguinal hernia
repairs performed in the unit over a 20 month period (January
2007–September 2008) were included in the study. Operations
involving additional procedures or those for recurrent hernias
were excluded. Data collected included patient demographics
(age, sex, BMI), time to discharge, unplanned admissions and
post-discharge symptoms (assessed by phone 24 hours
postoperatively). A chi-squared test was used for comparison
between the 2 groups with each symptom (* = p

A9
A10
Management of Obese Patients for Day
Case Procedures
SA Roberts, J Palmer
Salford Royal Hospitals NHS Trust
INTRODUCTION: Historically day case surgery was barred to
obese patients, with varying levels of BMI (initially >30, latterly
>35). At our institution the preoperative assessment staff
would request an inpatient bed for obese patients with a BMI
>37 for day case procedures. Our trust wanted to meet targets
for basket and trolley cases through day surgery and wished to
improve the patient experience. One criterion for review was
patients with a high BMI previously excluded from DSU
admission.
METHODS: We surveyed consultant anaesthetists in our trust
to find the reasons why they would not wish to discharge obese
patients after surgery and assessed the prevalence of high BMI
patients in our surgical population. A review of North West
hospitals revealed no consistency for managing these patients:
some had agreed BMI levels ranging from 30 to 37, but many
relied entirely on a clinician’s discretion.
RESULTS: In the consultant survey the main (almost only)
reason for overnight stay was concern about the risk of OSA or
hypoxia. The 2000–2 health survey for England showed the
National proportion of the population with BMI >30 was 21.4%
(Greater Manchester 21.1%, Salford 22.1%). Audit figures at
Salford Royal Hospital show 5.5% of daycases done have BMI
≥37, in keeping with the figure for the whole surgical
population. This percentage could be applied to the total
Talking Trauma
NV Slator, AA Bhangu
Russell’s Hall Hospital, Birmingham
INTRODUCTION: Consent is a dynamic process regulated by the
GMC. In elective surgery we know that retention of information at
time of consent is poor and therefore information leaflets are
widely used, however there is little information relating to
emergency procedures. We aimed to assess patient satisfaction
and retention of information with the consent process.
METHODS: 41 elective days case patients who had been through
a pre-screening clinic and 41 emergency trauma day case
patients were assessed using a questionnaire after surgery.
RESULTS: 100% of elective patients were given patient
information sheets compared to 0% of emergency trauma
patients. When asked to recall complications stated at the time of
consent, 62% of elective patients were able to recall one or more
complication whereas only 22% of trauma patients were able to
recall any complications (p

A11
The Price is Right! Knowledge of drug
costs amongst anaesthetists
performing day surgery
T Heinink, JM Vernon, J Wilkinson
Nottingham University Hospitals NHS Trust,
City Hospital Campus
INTRODUCTION: Appropriate anaesthetic drug selection is
vital for ambulatory surgery to be performed efficiently. General
anaesthetic agents for ambulatory surgery should allow rapid
awakening with minimal hangover; analgesics and antiemetics
should have specific actions with few side effects. Several of
the ‘newer’ drugs have these characteristics (e.g., ondansetron,
desflurane, sevoflurane propofol, remifentanil). The price of
medications may change as their patents end and cheaper
generic alternatives become available. Departments may be
under pressure to reduce their theatre pharmacy budget and to
reduce the use of more expensive volatile agents. For these
reasons it is vital that anaesthetists have an understanding of
drug costs in order to practice cost-effective anaesthesia. Since
2004 we have had an updated anaesthetic drug price list on the
wall of the anaesthetic rooms in our hospital.
METHODS: 20 trainee and consultant anaesthetists were
asked to name the price of 9 drugs and 2 volatile agents at 2
different gas flows.
RESULTS: Mean, median, range and percentage of price
estimations within 50% of the true price were calculated. There
were no major differences in the results of trainees compared
to consultants.
A12
An Uninvited Guest: Presence of
medical students in the day surgery
unit
A Ratnayake, C Panabokke, M Ahuja
Royal Wolverhampton Hospital (New Cross )
INTRODUCTION: Medical students from Birmingham
University do their four weeks attachment in anaesthesia at
New Cross Hospital. During their time in the anaesthetic
department, medical students have to obtain several basic
clinical competencies such as venous cannulation, basic airway
management skills e.g., bag mask ventilation, use of basic
airway adjunct, laryngeal mask insertion, etc. We observed that
the patient consent to the presence of medical students in the
anaesthetic room varied extremely and little is known about
what patients think about participating in medical education.
This survey examines the patients’ attitudes and their
perception of medical student involvement in their care.
METHODS: An 11 point questionnaire survey was distributed
among patients attending the day surgery preoperative
assessment clinic over a two week period (Dec 2008). Every
Drug
True cost
(£)
Mean [median
(range)] (£)
Within 50%
true cost
Propofol 1% 20 ml
Sevoflurane
0.76 1.03 [0.80 (0.20-4.00)] 66%
3% @ 0.5 l/min 2.14 4.81 [5.00 (0.50-10.00)] 11%
3% @ 9 l/min
Desflurane
38.52 58.72 [45.00 (10.00-300.00)] 66%
9% @ 0.5 l/min 3.70 5.49 [4.30 (0.50-15.00)] 39%
9% @ 9 l/min 66.60 57.56 [53.00 (6.00-135.00)] 66%
Ondansetron 8 mg 1.22 1.37 [0.90 (0.10-3.50)] 50%
Remifentanil 1 mg 6.01 5.78 [5.00 (2.00-10.00)] 83%
CONCLUSIONS: Although the mean and median values are
close to the true cost of most of the drugs studied, the wide
range of values quoted demonstrates that the true cost of the
anaesthetic agents used in day surgery is not common
knowledge amongst most anaesthetists. However, for most
drugs, greater than 50% of respondents were within 50% of the
true value, suggesting that the majority of anaesthetists have
some awareness of drug cost. It may be that displaying a price
list in the anaesthetic room has increased this knowledge. The
cost of several drugs has fallen as they reach the end of their
patent protection. For example ondansetron 4 mg iv was £6 but
is now only 76p (14p if oral!), propofol 1% 20 ml was £4 but now
costs 76p. If anaesthetists still perceive these as expensive,
they may underutilise them. By increasing awareness of the
true cost of these agents it is hoped that a barrier to more
efficient use of these agents may be removed. Sevoflurane 250
ml, formerly £144 is now £108. Despite this, along with
desflurane, it is still a relatively expensive drug and
anaesthetists need to be aware of the relative costs at different
fresh gas flows and utilise low-flow anaesthesia where
appropriate.
patient attending the clinic was informed of the anonymous
nature of the survey and was given the choice of accepting or
refusing to fill in the questionnaire.
RESULTS:89 forms were returned. The majority of patients
were positive towards the presence of medical students in the
anaesthetic room. 68% and 70% of patients allow a student to
perform intravenous cannulation and basic anaesthetic
procedures respectively. 20% of patients wanted to be
informed of the procedure that the medical students would
undertake before hand.
CONCLUSIONS: Participation of patients in medical education
is an important tool in undergraduate medical teaching [1].
Although the majority of patients are positive about having
medical students present, this survey emphasise the
importance of informed consent and detailed information of the
procedure before hand. The survey highlights the need for
patient education and information regarding the importance of
medical student participation for the training of future doctors.
REFERENCE
1. Howe A, et al. British Medical Journal 2003;327:326–8

A13
Theatre Efficiency in Ambulatory
Surgery: It’s table time that counts!
D McWhinnie, J Ellams, S Naz, M Orchard
Milton Keynes Hospital
INTRODUCTION: Theatre “efficiency” is often assessed by
recording the number of sessions utilised, overruns, under-runs
or even the number of cases/ session. Such indices can offer
high headline rates of utilisation while masking low levels of
productivity. The operating theatre is only productive when the
operating table is in use i.e., from first incision to the
completion of wound suturing. Our aims were to assess the
theatre efficiency of general surgical sessions in day and short
stay surgery performed under general anaesthesia.
METHODS: Between January and April 2009, 21 ambulatory
(day and 23 hr surgery) theatre lists were analysed with regard
to the time spent in the “anaesthetic room”, “on table
preparation” (time from anaesthetic room to first incision) and
actual “operating time” with any major delays noted.
A14
Documentation of Operative Notes in
Day Surgery – Are we adhering to good
surgical practice?
S Das, J Lee, NN Basu, U Parampilli
University Hospital Lewisham
INTRODUCTION: Accurate documentation is an absolute
requirement in all fields of surgery. Despite day surgery having
a rapid turnover of patients, never has the need for meticulous
surgical record keeping been greater. Assessment of operative
notes has previously focused on non-day surgery cases [1]. We
conducted a retrospective audit on 100 patients who had
undergone surgical procedures as a day case and examined the
quality of documentation of surgical notes.
METHODS: A database was created consisting of 100 patients
who had undergone general surgical day cases procedures over
a 6 month period. A proforma was prepared to include
assessment of legibility, details of operation, details of patient
and surgeon and completeness. All theses parameters were
derived from the Good Surgical Practice [2], published by the
Royal College of Surgeons of England.
RESULTS: For a total of 21 lists, the time in the operating
theatre environment is shown below.
The total list time available was 4,410 min, of which 4,158 min
were utilised, representing 94% “efficiency” according to
conventional measurement. However “true” table time was
only 2,589 min of the 4,158 min of the session utilised
representing theatre usage of only 62.3%. In our ambulatory
sessions approximately a fifth of total list utilisation time is lost
to “on-table preparation”. The reasons include surgeon
unavailability, poor preparation by theatre staff, inappropriate
skill mix, and poor communication.
CONCLUSIONS: “Operating table time” offers a more precise
indication of theatre productivity than the current performance
indicators used by most hospitals throughout the UK. Targeting
a reduction in “on-table preparation time” by implementing
team briefings and addressing the specific reasons for the loss
of time, offers one solution to increasing theatre productivity.
Available time (min)
Time used (min Anaesthetic room (min) On-table preparation (min) Table time (min)
4,410 4,158
804 (19.3%)
765 (18.4%)
2,589 (62.3%)
RESULTS: The grade of the operating surgeon and duration of
surgery was not recorded in 89% and 65% of the records
respectively. In 60% of cases, there was no record of who the
consultant in charge of the patient was. 16% of all operation
notes was deemed illegible and in up to 10% of the patients no
patient name or number, date of operation or name of
operating surgeon and / or assistant was recorded.
CONCLUSIONS: This study shows the standards of good
surgical practice are not being maintained. This has serious
implications in terms of litigation and more importantly patient
care. The introduction of an integrated care pathway for day
surgery and appropriate education of standards may improve
the quality of documentation. This is being reaudited at
present.
REFERENCES
1. O’Mahony JB. Irish Medical Journal 2006;99(7):214–5
2. The Good Surgical Practice Guide 2008.
www.rcseng.ac.uk/publications/docs/good-surgicalpractice

A15
Interactive e-learning: Development of
an online programme
M Weedall, R McMIllan, J Taylor, M Renton,
J Bernard, J Alexander, S Hodkinson
Royal Infirmary Edinburgh
INTRODUCTION: Preoperative assessment ensures patients
are fit for their operation, have all the required information and
reduces the risk of cancellation on the day of surgery. In the
majority of cases this is being undertaken in nurse-led units
with nurses undertaking the role previously undertaken by the
junior doctor. The presentation will explain the development of
an online leaning tool designed to expand nurses’ knowledge
and skills in relation to the practice of preoperative assessment
particularly for nurses new to the specialty. It can also be used
by nurses with experience as an additional resource for
ongoing reference, if required.
METHODS: The Integrated Care Pathway (ICP) is an
assessment tool, which has been designed to guide systematic
enquiry by preoperative assessment staff working in different
A16
‘Let the Surgeon give the Local’ –
Implementation of an anaesthetic
guideline to reduce the unplanned
admission rate following open
inguinal hernia repair
COF Islam, M Stocker, J Montgomery
Torbay Hospital
INTRODUCTION: In 2004, an audit of day case open inguinal
hernia repairs under general anaesthesia revealed an
unacceptably high admission rate. This was due most
commonly to pain or inability to mobilise and, to a lesser
extent, nausea and dizziness. An excess of admissions were
found in the group of patients who had been given local
anaesthetic (LA) either as an ilioinguinal block by the
anaesthetist alone or in combination with the surgeon as
compared to when the surgeon alone had infiltrated LA. A new
anaesthetic guideline was written, advocating infiltration of
local anaesthetic by the surgeon alone, along with a propofolbased
TIVA anaesthetic and an analgesic protocol. This re-audit
looks back at the years since implementation of the guideline
to assess compliance and the corresponding admission rates.
METHODS: A retrospective audit of all patients undergoing
open inguinal hernia repair under general anaesthesia in the
day surgery unit at Torbay Hospital from 2004 to 2008 was
undertaken. Data were obtained from the unit’s Daynamics©
database (Calcius systems). Guideline compliance focused on
two components: whether LA had been administered solely by
the surgeon and whether TIVA had been used.
sites within NHS Lothian. Senior nurses and anaesthetic staff
developed an online interactive educational module to develop
nurse skills of history taking and patient referral using patient
based scenarios related to respiratory, cardiovascular and
respiratory history taking, and incorporating guidance on how
to correctly use the ICP.
RESULTS: The module is being piloted presently and will be
evaluated by participants at the end of April. Following the
evaluation it will be made available to all preoperative
assessment nurses, through the divisions ‘LearnPro’ online
service.
CONCLUSIONS: The module aims to support development of
the history taking and referral skills of nurses throughout NHS
Lothian who practice within preoperative assessment and as a
result increasing the communication between professionals
therefore increasing patient safety.
RESULTS: There has been a reduction in the total number of
cases undertaken per year as the number of laparoscopic
procedures has increased. The timing of the introduction of the
guideline (October 2004) was coincident with a substantial
drop in admission rates.
Year
2003 259
2004
308
2005 187
2006 127
2007 158
2008 164
All cases Unplanned
admissions
27 (10.4%)
28 (9.1%)
12 (6.9%)
3 (1.8%)
5 (3.2%)
5 (3.0%)
LA by
surgeon
41%
66%
89%
96%
96%
98%
TIVA
75%
67%
77%
86%
78%
89%
From 2007 to 2008 a total of 10 patients have been admitted,
though only two of these cited ‘pain’ as the reason for
admission. ‘Inability to mobilise’ prevented discharge in five
cases. ‘PONV’, ‘dizziness’ and ‘feeling unwell’ accounted for
admission of the other three patients. All of these patients had
anaesthetics that complied with the guideline with the
exception of the patient admitted with PONV, who did not have
a TIVA anaesthetic.
CONCLUSIONS: Implementation of guideline-based
anaesthetic practice within the DSU can be associated with a
reduction in admission rates for open inguinal hernia repair.
This may indicate that infiltration of local anaesthetic by the
surgeon alone is associated with a reduced risk of femoral
nerve block and a reduced risk of analgesic failure as compared
to ilioinguinal block performed by the anaesthetist alone or in
combination with the surgeon. In the future, more specific
details on the reasons for admission should be collated in
order to identify any further areas for improvement.

A17
An Audit of Unplanned Hospital
Admission following Elective
Paediatric ENT Day Case Surgery in a
Tertiary Referral Centre
S Pickworth, A Patel, D Sethi
Royal National Throat, Nose and Ear Hospital, London
INTRODUCTION: In recent years, there has been a trend towards
performing increasing amounts of surgery on children on a day
stay basis. Children make excellent candidates for day surgery as
they are usually healthy, free of systemic disease and typically
require straightforward, minor or intermediate surgical procedures
[1]. In 2000, the NHS plan in the UK set a target of 75% for all
surgical activity to be performed as day cases. The RNTNE hospital
is a tertiary referral centre for ENT surgery. From June 2007, in a
drive to increase efficiency, all elective paediatric ENT surgery was
undertaken within a day case model. We looked at unplanned
admission rates in the 18 months following the restructuring of
services, aiming to identify the incidence, causes of, and common
operations resulting in these. These data represent the largest
audit of elective paediatric ENT day surgery in the literature.
METHODS: Data were collected on the ward database at
admission for all children undergoing elective ENT procedures from
June 2007–November 2008. We looked at age, ASA status and
procedure performed, and for those patients requiring admission,
we reviewed the causes.
RESULTS: A total of 1,044 elective paediatric ENT operations were
performed during the 18 month audit period. 13 patients were
admitted, giving an overall admission rate of 1.24%. The
commonest operative procedure performed was tonsillectomy ±
A18
An Audit Comparing Home Readiness
and Discharge Times in Day Surgery
Patients, using Traditional and PADS
Scoring Systems
GA Neilson, S Meldrum, KJ Anderson
Glasgow Royal Infirmary
INTRODUCTION: With the imminent opening of a brand new
ambulatory care facility and the merging of two day surgery
units, we were keen to evaluate different discharge scoring
systems used in our hospital. The new ambulatory unit will have
a unified discharge protocol. Our “traditional” discharge score is
based on the Aldrete score [1], described in 1970 and modified in
1996 [2] to include pulse oximetry. The traditional system also
includes minimum ward times, which are surgery specific. The
Post-Anesthesia Discharge Score(PADS), described by Chung [3],
provides a more objective score based on five parameters: vital
signs; activity; nausea and vomiting; pain; and surgical bleeding.
Each parameter is scored 0–2, with a score of 9–10/10 indicating
home readiness.
METHODS: We undertook a snapshot audit of all patients
passing through our day surgery unit, over two separate five day
periods. The first snapshot looked at discharge scoring using the
traditional criteria, and the second used PADS . Primary variables
looked for included time to home readiness, actual discharge
time, and reasons for any delay in discharge. Local/regional
anaesthesia, sedation, and general anaesthesia were all included
in the audit. Continuous data were compared using non-paired
t-tests, and categorical data by Chi-squared test.
RESULTS: 229 patients were studied, 108 received traditional
care and 121 PADS care. The mean (SD) time spent in the day
surgery ward before being passed ready for discharge (for all
types of anaesthetic) were shorter with PADS than traditional
adenoidectomy (60%) (Figure) and the largest age group treated
were 5–8 year olds (39%).
700
600
500
400
300
200
100
0
The most common reasons for admission were postoperative
nausea and vomiting, drowsiness and bleeding which accounted
for 30.8%, 30.8% and 23% of all readmissions respectively.
Unplanned admission rates were highest in the 5–8 years age
group. All patients who were admitted overnight were discharged
the next day.
CONCLUSIONS: In keeping with the Royal College of
Anaesthetists standard which suggests that unplanned
admission rates after day surgery of

A19
Failure to Discharge following Elective
Day Surgery – A prospective study
S Vallabhajousula, T Kramer-Taylor,
JC Taylor, IG Gunn
Dr.Gray’s Hospital, Elgin, Scotland
INTRODUCTION: There is consensus amongst clinicians and
NHS managers that the proportion of surgery performed on a
day case basis is suboptimal and could be increased to around
75% [1]. Currently in Scotland 56% of all surgical procedures
are carried out this way with only 39% in NHS Grampian [1]. This
low figure may partially reflect the remote and rural nature of
the population. In our hospital however we achieved a day case
rate of 71% during the term of this study. The aim of this
prospective study was to minimise unplanned admissions and
examine ways to increase day surgery rates.
METHODS: When a patient is not discharged following a
planned day case procedure, the day unit nursing staff
prospectively register data including patient’s age, sex, surgical
specialty, procedure and the reason(s) for failed discharge.
These data were analysed using MS Excel and presented to a
group of day care nurses, anaesthetists and surgeons, followed
by group discussion to identify areas which could be improved.
RESULTS: Between March 2006 and March 2009, 347 patients
out of 17,969 (1.9%) were not discharged after a planned day
case procedure. The majority of these failed discharges were
initially admitted under general surgery and urology (178,
51.2%) followed by gynaecology (82, 23.8%). Patients
undergoing hernia repair (47, 13.5%) represented the largest
group followed by cystoscopy (n = 39, 11.2%), gynaecological
A20
Retrospective audit of Day Case
Laparoscopic Cholecystectomy – Are
strict inclusion criteria necessary?
A Farooq, H Shaker, N Matar
Southport and Formby District General Hospital
INTRODUCTION: Laparoscopic cholecystectomy is the gold
standard treatment for symptomatic gall stone disease and has
been shown to be a feasible day case procedure. The NHS plan
has a target to achieve 75% overall day surgery rates. We
carried out a retrospective audit of our series of day case
laparoscopic cholecystectomies to assess our adherence to
recommended day case inclusion criteria, and assess the
feasibility and safety for inclusion of patients outside of the
present recommended inclusion criteria.
METHODS: We retrospectively reviewed the records of patients
undergoing day case laparoscopic cholecystectomy in a district
general hospital during a 12 month period (May 2007–May
2008). All patients had symptomatic gallstones proven on
imaging, with normal liver function tests and biliary ducts on
ultrasound scan. Patients were informed of discharge criteria
and forewarned that unless these were achieved inpatient stay
would be required. Patients with age >70 years, BMI >35, ASA
III, previous open surgery, or unfavourable ultrasound findings
(e.g., thick walled gall bladder, pericholecystic oedema) were
not excluded, but forewarned of higher chance of failure to be a
day case. Data extracted included biographical data (age,
gender, BMI, ASA grade), and surgical outcomes including
duration of operation, length of hospital stay, postoperative
complications and readmission rates. Reasons for overnight
admission and readmission were analysed.
laparoscopy (27, 7.7%), unilateral varicose veins (27, 7.7%),
gastroscopy (19, 5.4%) and colonoscopy (12, 3.4%). There were
many reasons for unplanned admission: 130 (37.4%) needed
more time to recover; 79 (22.7%) were admitted for pain
control; 43 (12.3%) needed a more extensive procedure; 30
(8.6%) were admitted for social reasons; 23 (6.6%) for
postoperative bleeding and 62 (17.8%) were listed as day cases
but were found to be unsuitable for this. These patients
underwent the procedure and were admitted.
CONCLUSIONS: Our unplanned admission rate is 1.9%
compared to an accepted average of 35 and one with
age >70.
CONCLUSIONS: Day case laparoscopic cholecystectomy is
feasible, not only in patients who fit current selection criteria,
but also in selected patients who lie outside of these i.e., BMI
>35, age >70, previous open surgery, and ASA III. Patients must
be well motivated with attention given to detailed anaesthetic
and surgical technique by experienced staff, and adherence to
strict discharge criteria, to ensure safety.

A21
EVAR – Reducing length of stay and
costs
IR Flindall, S Ward, A Day, P Thomas,
A Anjum, A Keane
St Helier
INTRODUCTION: Abdominal aortic aneurysms are increasingly
being repaired by an endovascular approach. In our district
general hospital, the initial policy was to perform endovascular
aneurysm repair (EVAR) under a general anaesthetic (GA) with a
short stay in a high dependency unit postoperatively. An
assessment of EVAR practice in 2005 by the National
Confidential Enquiry into Postoperative Deaths (NCEPOD)
reported that only 30% procedures were carried out under
epidural anaesthesia with a high dependency or intensive care
unit being the postoperative destination in 95% cases. More
recently we have carried out all EVAR cases under epidural
anaesthesia and have been proactive in limiting high
dependency and total hospital stay.
METHODS: Patients were divided into two groups depending
on the method of anaesthesia. Data were collected
prospectively. So far the data for 22 patients who underwent GA
and 11 patients who underwent epidural anaesthesia have been
analysed. The length of HDU and hospital stay and RETA
A22
Day Case or Ambulatory
Parathyroidectomy: Safe and feasible
in a DGH
R Parameswaran, K Allouni, P Varghese and
A McLaren
Wycombe General Hospital
INTRODUCTION: Day case or ambulatory parathyroid surgery
(

A23
Day Case Colon and Rectal Cancer
Surgery – Are we ready for take-off?
T Wong, A Shekouh, R Wilkin, M Johnson
Countess of Chester Hospital, Chester
INTRODUCTION: Length of stay (LOS) for patients undergoing
colon and rectal cancer surgery has been progressively
declining due to improvement in surgical and anaesthetic
techniques, preoperative and perioperative optimisations, the
Enhanced Recovery after Surgery (ERAS) programme and
laparoscopic colon and rectal surgery. Is it, therefore, possible
to discharge patients within 23 hours of surgery for colon and
rectal malignancy?
METHODS: Data were analysed from a prospective database of
consecutive patients undergoing colon and rectal cancer
resections under one consultant colorectal surgeon between
2004 and 2008. The data, including age, sex, type of procedure,
ASA grade, complications, LOS, mortality and pathological data
were analysed for patients with rectal cancers undergoing
anterior and abdominoperineal resections (Rectum group) and
all other patients undergoing colectomies (Colon group). The
impact of introducing the ERAS programme and laparoscopic
surgery on LOS were examined. The StatView programme was
used to perform the relevant statistical analyses.
A24
Year
2004
2005
2006
2007
2008
Colon
13
12
12
16
Number
Rectum
14
5
12
22
Median (range)
LOS (days)
Colon
9 (4–13)
7.5 (4–41)
5.5 (4–67)
5(2–35)
RESULTS: From 2004 to 2008, data were collected for 137
patients. The ERAS programme was introduced at the COCH in
2004 and laparoscopic colon and rectal surgery from 2008.
Fisher’s exact test showed no statistical significant difference in
the Colon and Rectum resection groups for age and sex
distribution.
There was no significance difference in overall LOS between
2004 and 2008 in the colon and rectal groups (paired t-test p =
0.513). Between 2004 and 2008 one can see a decrease in
median length of stay in both Colon and Rectum groups.
Correlation Z-test analysis shows a significant decrease in LOS
between 2004 and 2008 for the Rectum (p = 0.0034) and the
Colon (p = 0.0161) groups.
CONCLUSIONS: The study shows a significant downward trend
in LOS between 2004 and 2008, so much so that a subgroup of
patients is being discharged at 2 or 3 days. From this study, we
believe that with careful patient selection, education and
support in a specialised Colorectal unit, it may be possible to
achieve day case colon and rectal cancer surgery within the
near future.
12 18 4 (3–15) 5 (2–16) 2 2 1 0
Intermediate Breast and Axillary Day
Case Surgery: Is it feasible?
RM Clancy, RM Watkins
Derriford Hospital, Plymouth
Rectum
11 (4–47)
7(4–83)
6 (4–9)
5(4–57)
INTRODUCTION: Day case surgery compared with standard
inpatient stay has several benefits including reduced
expenditure for each surgical episode. We aimed to assess the
feasibility of performing certain breast and axillary surgical
procedures as day cases rather than with a traditional overnight
stay postoperatively.
METHODS: A prospective study from January 2007 to
December 2008 was performed. Patients included in the study
underwent procedures such as diagnostic open excision biopsy
(wire or ultrasound guided), wide local excision (WLE) of either
palpable or impalpable breast cancers, repeat excision to clear
involved or close margins and axillary node sampling or
sentinel lymph node biopsy. In each case the procedure(s) were
planned as day cases and most had a general anaesthetic.
Colon
0
0
0
2
Resection No Median age (y) Female:male
Colon 66 69.5 (48–88) 30:36
Rectum
71
67 (40–84) 31:40
LOS ≤3 days
Rectum
0
0
0
0
Complications
Colon
2
1
1
7
Rectum
3
1
1
3
RESULTS: 98 operations were performed in 2007. 43 (44%)
took place in the morning and 55 (56%) in the afternoon. 11
(26%) patients undergoing surgery in the morning stayed
overnight compared with 29 (53%) who had their operation in
the afternoon. In 2008, 93 operations were performed. 37
(40%) took place in the morning and 56 (60%) in the afternoon.
For patients having morning surgery 11% (4/37) required an
overnight stay compared with 20% (11/56) who had their
operation in the afternoon. The number of patients requiring
overnight stay was reduced significantly from 41% in 2007 to
16% in 2008 (p = 0.0002). Comparing the total number of
patients operated on in the morning (80) to those having
surgery in the afternoon (111) fewer required an overnight stay
following morning surgery (19%) than after later surgery (36%)
(p = 0.009). Reasons for an unplanned overnight stay included
delayed recovery from anaesthesia and postoperative nausea.
CONCLUSIONS: It is certainly feasible to perform a range of
intermediate breast and axillary procedures as day cases with
unplanned overnight stay in a small number of cases.
Undertaking the procedures in the morning rather than the
afternoon should minimise the number of unplanned overnight
stay episodes.

A25
Safe Day Case Upper Urinary Tract
Endoscopy
P Erotocritou, N Gravell, P Pietrzak,
S Hutchinson, K Anson
St George’s Hospital, Tooting, London
INTRODUCTION: Upper urinary tract endoscopy has
traditionally been considered to be an inpatient procedure.
With miniaturisation of the semi-rigid and flexible
ureterorendoscopes, and utilisation of laser energy the
technique has rapidly evolved and these procedures can now
be performed by skilled endoscopic surgeons in dedicated day
case centres. We present our experience of day case upper
urinary tract endoscopy.
METHODS: 76 patients undergoing day case ureteroscopy for a
range of indications were identified retrospectively from the
theatre log book. Of the study population 50 had complete data
sets to study. The hospital EPR was interrogated for readmissions,
complications, operative details and patient
demographics. Patients received simple analgesia to take
home and were strongly advised to attend casualty with any
postoperative problems.
A26
Audit of Patient Information about
Anaesthesia
K Sivagnanam, A Lipp
Norfolk & Norwich University Hospital
INTRODUCTION: In our hospital most of the elective surgical
admissions come through the Day Procedure unit (DPU) and
Surgical Day Admission unit (SDAU), except obstetrics patients,
thoracic and some major surgical cases. All the patients are
expected to receive some form of information about
anaesthesia prior to the day of admission. We were interested
to know: how much information the patients wanted to know
about their anaesthesia; were they happy with the information
provided; which is the best form of delivering the information
and do we need to add or remove any of the information?
METHODS: For a period of one week all patients were
requested to fill out a questionnaire on arrival to the DPU or
SDAU. Questions were asked about: previous anaesthetic
details; what type of anaesthesia the patients were expecting;
what form of information they had received; patients’
satisfaction about the information provided; any addition or
removal of information; age.
RESULTS: The median age was 44 (20–81) years and median
operation time 40 (15–80) minutes. The indications for
ureteroscopy were stone disease (38 patients), diagnostic (7
patients) and TCC surveillance (5 patients). 38 patients
underwent semi-rigid ureteroscopy alone and 12 went on to
have flexible ureterorenoscopy. No patients required readmission
and there were no documented attendances to the
casualty department postoperatively.
CONCLUSIONS: In a dedicated day surgery unit with a skilled
multidisciplinary team, upper tract endoscopy can be
performed for a number of indications safely.
RESULTS: 208 questionnaire were received ( DPU 98, SDAU
110). 79% had had previous anaesthesia (DPU 86%, SDAU
72%). 74% received information about anaesthesia (DPU 82%,
65% SDAU). 62% expected GA, 27% LA or regional, 11% not
sure about anaesthesia. 36% received written information,
48% verbal, 12% both. 76% received clear information, 14% not
clear, 10% not answered. 77% received adequate information,
6% too much, 17% too little. 32% preferred written information,
47% verbal, 19% both written and verbal, 3% emails. Over 60’s
(36%) prefer both verbal and written information.
CONCLUSIONS: Patients would like to know more about
expected recovery time and details of pain relief, but are not
very keen to know more about complications. Older patients
would like to have both written and verbal information. Email
form of information might be a cost-effective and economical
method for the future.

A27
Privacy and Dignity Audit of Patient
Care – Day surgery unit Ashford
Hospital, Middlesex
J Ryman, E Shepherd
Ashford Hospital Staines Middlesex
INTRODUCTION: The NHS is committed to the provision of
single sex accommodation for all inpatients. This survey aimed
to establish the attitudes of day surgery patients to sharing
accommodation with members of the opposite sex and to
determine the perceived effect on privacy and dignity.
METHODS: A questionnaire was designed and given to
patients attending the day surgery unit for return by post. The
questionnaire was given to all patients who attended over a
period of two weeks. There were 104 responses – a response
rate of 30%.
RESULTS: 45% of patients said that they had “expected”
mixed-sex accommodation before they came to the unit. 51%
“had not thought about it”. 1% of patients were very concerned
about sharing the ward with the opposite sex. 14% were a little
A28
A Patient Survey to Determine how
Day Surgery Patients would like
Preoperative Assessment to be
Conducted
S Lewis, M Stocker, K Houghton,
J Montgomery
Torbay Hospital, South Devon Healthcare NHS
Foundation Trust
INTRODUCTION: Preoperative assessment for day surgery
patients is normally performed at an outpatient appointment
by a nurse. For some patients this additional hospital visit may
be unnecessarily disruptive and lead to loss of earnings. The
‘18 Week Patient Pathway’ guidance [1] suggests that some or
all of preassessment may be conducted by telephone,
questionnaire or IT-supported methods. We therefore
conducted a survey in our Day Surgery Unit (DSU) to explore
patient satisfaction with current arrangements for
preassessment and their preferences for possible alternatives.
METHODS: A two sided survey form was designed in
discussion with several anaesthetic consultants, the patient
services manager and a clinical psychologist. Over a two week
period (14th–25th July 2008) every patient (or parent of young
children) attending the DSU had the opportunity to complete
the form prior to undergoing their procedure, as this was
judged the optimal time for a high response rate whilst
avoiding the immediate postoperative period.
RESULTS: 138 forms were returned from 220 patients
attending during the study period. 75% had undergone
preassessment at a separate appointment, 18% on the day they
met the surgeon and 4% by telephone. The most favoured
option was for assessment on the same day as the surgical
outpatient appointment (52%). Of those for whom it had been
concerned and 85% were “not very” or “not at all concerned”.
50% of patients who commented said that they were happy to
be on a mixed-sex ward for day surgery but would have wanted
to be on a single sex ward if they had stayed overnight. Patients
attending for intimate procedures were the most likely to report
concern – 29% of these patients were “very” or “a little
concerned”. 11% of patients attending for other procedures
reported concern. There was no significant difference between
the attitudes of male and female patients. 99% of patients felt
that they had enough privacy when discussing their procedure
with the surgeon and anaesthetist. When asked if patients were
able to maintain privacy and dignity on the ward, 93%
responded “at all times”; 7% responded “some of the time”.
CONCLUSIONS: Although there was some variation between
types of procedure, most patients expect to share the ward with
the opposite sex for day surgery and are unconcerned by the
prospect. Patients do not feel that a mixed sex ward
compromises their privacy and dignity, and some patients
indicated that this is due to the short amount of time they
spend there.
conducted this way there was a high level of satisfaction and it
would remain the preferred option for 84%. 22% wished to
continue with a separate appointment during normal hours. A
small but significant number (11%) wanted assessment at their
GP surgery. This did not appear to correlate with either old age
or retired status as one might have anticipated. Very few
wished to undergo assessment by telephone or internet. Being
able to visit the unit before the day of surgery was important to
75% of patients; the opportunity to ask questions of nursing
staff was valued, but a majority felt that preassessment should
interfere with their normal activities as little as possible.
CONCLUSIONS: Most of our patients value face-to-face
preassessment with a health professional in the same unit as
their operation will take place. However, it appears that they
also wish to limit the number of visits to the hospital by
combining assessment with the appointment at which they are
listed for an operation. This corresponds to the guidance of the
former NHS Modernisation Agency [2]. As this happens only on
a limited basis at present, the creation of an effective ‘one-stop’
service for day surgery preassessment at Torbay would be a
valid goal. Similar services have been established elsewhere
with considerable success [3].
REFERENCES
1. NHS Elect. The role of Pre-Operative Assessment in
delivering 18 weeks patient pathways, 2007;
http://www.18weeks.nhs.uk
2. NHS Modernisation Agency. National good practice
guidelines on pre-operative assessment for day surgery.
DH, London, 2002
3. B Murthy. Royal College of Anaesthetists Bulletin
2006;37:1885–7

A29
Improving Information and
Communication Resources for
Children with Special Needs
Undergoing Day Surgery
LMA Broxholme, JA Short
Sheffield Children’s Hospital
INTRODUCTION: Children with learning and communication
disability often exhibit extreme anxiety associated with hospital
treatment. This may be due to unpleasant procedures, the
unfamiliar environment, fasting, or loss of routine. They are not
always well served by conventional information resources or
usual methods of explanation. Although day surgery may be
particularly suitable for these children, we need to adapt our
practice to meet their particular requirements and provide
appropriate resources to enhance their understanding and
cooperation.
METHODS: A questionnaire was distributed to all parents of
children attending 7 local special schools (5 primary and 2
secondary), asking about the challenges faced by each child
and the level of parental concern about various aspects of the
hospital process. We also explored methods of assisted
communication used by the child and asked parents to suggest
how we might improve their child’s experience at the hospital.
The survey was approved by the schools and our trust service
evaluation department. Formal ethical approval was not
necessary. Data were analysed anonymously with a Microsoft
Access database.
RESULTS: 629 questionnaires were distributed and 178
(28.3%) were returned, a good response rate from this
A30
“They are Marvellous with you while
you are in but the Aftercare is
Rubbish”: Carers experiences of their
loved ones undergoing day surgery
A Mottram
Pennine Acute Hospital Trust
INTRODUCTION: A study was undertaken to explore the
perceptions of patients and their families undergoing day
surgery.
METHODS: 145 patients and 100 carers from 2 different day
surgery units were interviewed on three occasions: in
preoperative assessment clinic, 48 hours after surgery, and one
month after surgery. Semi-structured interviews were
conducted tape-recorded, transcribed and analysed.
population. The challenges faced by the children, aged 2–18
years, include disabilities of learning 91.6%, communication
85.4%, mobility 38.2%, behavioural control 53.4%, emotional
control 45.5%, sight 20.8%, hearing 9.6% and other medical
conditions including epilepsy and diabetes. 58.5% of children
have had a planned operation in the past. Parents expressed
high levels of concern about anaesthesia, surgery and
postoperative pain, and moderate concern about fasting their
child, inpatient care and hospital acquired infection. Most
parents (79.2%) help prepare their children for new
experiences using their own explanations, but also used story
books (text, pictures or both), DVDs, social stories and symbol
systems. 37.6% of children use Makaton signing, 26.4% use
symbol assisted communication and 21.3% use PECS (picture
exchange communication system). 82% of parents would like
suitable information about anaesthesia and surgery to share
with their child. The most common suggestions for improving
hospital care were to minimise waiting times, provide a quiet,
private waiting area and to ensure staff understood the
implications of learning and communication difficulties in order
to provide appropriate support.
CONCLUSIONS: Communicating with these children presents
a challenge for healthcare workers, but efforts to use
communication resources familiar to the child and parent are
greatly appreciated. Using the survey results, we are
developing symbol assisted resources, for use both before and
after surgery and we provide a home-from-home quiet room for
children with special needs. We hope better communication will
help children be more calm and cooperative and improve both
patient/parent/staff satisfaction and service efficiency.
RESULTS: Overwhelmingly the carers were highly satisfied with
day surgery. However 32 patients raised some concerns. These
centred mainly on the perceived lack of care after the patients
were discharged. Only 9 carers reported negative experiences
they had encountered on the day of surgery. 5 of these involved
incidents related to the anaesthetic and four related to other
unexpected events happening on the day of surgery.
CONCLUSIONS: Although this was a relatively small sample of
patients further studies need to be undertaken to ascertain
patients and carers responses regarding care after discharge.
As the complexity of surgical procedures are set to increase it is
important that patients have access to adequate support
following discharge.

A31
Should we Ban Some Anaesthetists from
Working in our Day Surgery Centre?
T Viswanathan, MA Skues
Countess of Chester NHS Foundation Trust
INTRODUCTION: A recent publication [1] has suggested that
the grade of anaesthetist has an impact on outcome after day
surgery with an increased risk of overnight admission. We have
reviewed our own audit data to see whether our experience
mirrors that reported from this hospital.
METHODS: We conducted a retrospective audit reviewing
27,459 completed episodes requiring general anaesthesia in
our Day Surgery Centre since August 2002. The overnight
admission rate was mapped to individual substantive
anaesthetist, and standardised by speciality rate. Trainees
were considered as one single group. A specific review with a
cohort of patients from November 2004 to January 2009 was
examined in more detail, given the potential confounding
influence of improvement in our preassessment service in the
first two years. Chi squared testing and odds ratio analysis
were used for between and within grade comparison
respectively.
RESULTS: There were 683 unexpected overnight admissions
since 2002 (2.66%) with a progressive reduction to our current
A32
Patient Safety in Day Surgery: What’s
required for cardiopulmonary
resuscitation (CPR) training in this
environment?
A Jervis, J Bethel, MA Skues
Countess of Chester NHS Foundation Trust
INTRODUCTION: Resuscitation training is a requirement for all
clinical staff involved with patient care in acute trusts as
mandated by the NHS Litigation Authority [1]. The level of
competency required is dependent upon needs analysis, that
we have evaluated by a retrospective audit of the incidence of
emergency (“fast bleep” and “cardiac arrest”) calls to our
stand-alone Day Surgery Centre, to assess whether the training
provided is “fit for purpose”.
METHODS: We carried out a retrospective survey counting the
number of emergency calls made from the Jubilee Day Surgery
Centre since the unit opened in August 2002. These data were
then mapped to our day surgery audit database and hospital
electronic patient record to verify the nature of the call and the
patient outcome, from which the incidence of calls was
estimated. We then examined both the level and relevance of
CPR training provided to staff in the centre, in relation to the
perceived requirements needed to ensure safe practice.
RESULTS: In the six and a half year period, 32 emergency calls
were made to the hospital switchboard. (14 fast bleeps, 14 calls
for the cardiac arrest team, 4 calls requesting an emergency
mean rate of 1.46%. From 2004 onwards, the mean admission
rate was 2.03%. Procedures conducted under local anaesthesia
were associated with less risk of overnight admission. There
was a significant difference between the rates of admission for
consultant led general anaesthesia, compared with NCCG or
trainee support (Table ). However, when individual
performance was compared, some consultant and NCCG
anaesthetists performed significantly better than others within
their peer group.
Table 1: Unanticipated admission rate after general anaesthesia
(p

A33
Communication in Nottingham City
Hospital Day Surgery Unit
H Biswas, J Waring, J Vernon, S Bishop
Nottingham City Hospital
ACKNOWLEDGMENTS: This research was funded by the
Economic and Social Research Council (ESRC) as part of the
project ‘Learning across Organisational and Professional
Boundaries’, being conducted at the University of Nottingham.
The data were collected within Nottingham City Hospital Day
Surgery Unit (NCHDSU).
INTRODUCTION: Interpersonal communication is important in
healthcare organisations. For example, recent evidence has
shown how both formal and informal communication contribute
to service efficiency, individual learning, patient safety and
employee satisfaction. However, communication patterns
within healthcare are also often shaped by the type of
professionals involved and the divisions between them. We
studied the relationships within the DSU to identify existing
communication patterns and areas for possible improvement.
METHODS: A mixed quantitative and qualitative Social
Network Analysis (SNA) methodology was used. All nursing,
clerical, managerial and medical staff working in the NCHDSU
were surveyed by SNA questionnaire (n = 48, response rate
83%). A name generator asked respondents to name others
(≤10) that they worked closely with in the unit. Further
questionnaire items measured relational characteristics related
to knowledge sharing, such as willingness to confide and
availability. This was supported by 21 qualitative interviews
exploring work roles and interpersonal relationships.
A34
Patient Safety in Day Surgery:
Enhancing theatre teamwork and
communication
J Thomson, S Rule, J McHale, MA Skues
Countess of Chester NHS Foundation Trust
INTRODUCTION: Improvement of patient safety in the
perioperative environment is a collaborative remit involving all
members of the theatre team. The recent release of the WHO
recommendations for “Safe Surgery Saves Lives” [1] prompted
us to review the potential benefit of preoperative “Team Briefs”
that we introduced in our day surgery centre in October 2008,
as part of our hospital’s involvement with the Safer Patients
Initiative [2].
METHODS: We have carried out a retrospective audit of the
documentation completed during preoperative briefing, a five
minute meeting of the theatre team and clinical staff involved
with the operating theatre session, to review the common
themes and concerns that were raised during the briefing
period. After six months of development, we circulated a
questionnaire to all members of the theatre teams, seeking
views on whether the implementation of “team briefs” was
perceived as being useful in the day surgery environment.
RESULTS: The SNA showed a complex ‘spider’s web’ of
relationships between DSU workers. Taking only peoples’
strongest relationships, the SNA showed a ‘dense’ network with
no more than 2 (rarely 3) degrees of separation between one
another. Although communication was strongest within each
professional group, there were also a number of strong links
between professions. Specialist practitioners and managers
were embedded in the middle of the communication network.
Although identified as the most central members, the network
did not rely completely on any one individual, so was not in
danger of breaking down in the case of a person being absent
or leaving. Accordingly, qualitative data pointed to an open,
non-hierarchical culture of communication and frequent
knowledge sharing between different groups, levels and
professions.
CONCLUSIONS: Rather than limited by professional groupings,
good communication was aided by specific features of DSU
practice and management. The DSU functioned as an
integrated unit in its own building, with its own clerical, theatre
and ward staff. Managerial decisions were made within the
unit, reflecting priorities of practice. Many members of staff are
multi-skilled and able to perform different roles (e.g., HCAs may
act as unit co-ordinator for the day). Groups that are often seen
as on the periphery of communication, e.g., clerical staff, were
integrated into daily practice activity. Possible downsides of the
organisation include that, due to the rather flat non-hierarchical
pattern of communication, and multiple roles of workers, there
may be some confusion amongst visiting workers, as to
people’s roles and who is in charge.
RESULTS:The documentation from five hundred and sixty nine
“team briefs” were reviewed. An anaesthetist attended 85% of
these meetings, and a member of the surgical team, 59%.
Issues with either the ordering or accuracy of the operating list
were identified as a concern for 30% of the sessions, limitations
of equipment provision were cited as an issue in 5%, while
shortfalls in theatre staffing were highlighted for 11% of the
sessions reviewed. Review of the views of theatre staff involved
with team briefing indicated that they were strongly supportive
of the concept as an aid to better communication and improved
patient safety. A consistent response was the perception that
engagement by the surgeon would further enhance the
potential benefit.
CONCLUSIONS: Preoperative team briefing identifies and
helps to address issues with safe care of the patient in the day
surgery theatre environment. Additional input from the surgical
team is perceived as being the current “missing link”.
REFERENCES
1. NHS National Patient Safety Agency. WHO Surgical Safety
Checklist, Jan 2009 (www.npsa.nhs.uk)
2. The Health Foundation. Safer Patients Initiative
(www.health.org.uk)

A35
The World Health Organisation
Surgical Safety Checklist – Global to
local
JL Doyle, S Lour, H Peskett, R Relano
King’s College Hospital NHS Foundation Trust,
London
INTRODUCTION: The WHO Surgical Safety Checklist was
published in June 2008 [1]. A pilot study was conducted at sites
in 8 countries across the world and the results were published
in the New England Journal of Medicine in January 2009 [2]. The
results showed significant reductions in complications and
death following surgery. In January 2009 the National Patient
Safety Agency issued a patient safety alert [3] requiring Health
Care Organisations in England and Wales to begin
implementing the checklist, which will become mandatory by
February 2010.
METHODS: King’s has gone through an extensive consultation
to refine the WHO checklist using feedback from staff. Practice
development staff from the day surgery unit and main theatres
have collaborated to adapt the checklist for trust-wide usage.
The King’s version of the checklist that was launched on 30th
March 2009 has been shared with the trust-wide governance
committees, the anaesthetic department, all surgical
specialities, and through extensive training and
communications with our theatre practitioner colleagues.
RESULTS: The presentation will identify each stage of the
adaptation process from global to local, illustrated by examples
of the learning tools used throughout the process. The launch
version of the King’s Surgical Safety Checklist will be presented,
along with planned strategies for checking ongoing feedback,
audit and compliance.
CONCLUSIONS: Early feedback indicates that use of the
checklist improves multidisciplinary team communications and
a sense of shared responsibility. Staff feedback has contributed
to the development of a robust tool that is customised to
manage potential local risk factors. Our overall aim is to further
reduce the already-rare incidents of patient surgical
complications at King’s.
REFERENCES
1. WHO Safe Surgery Saves Lives:
http://www.who.int/patientsafety/safesurgery/en/
2. Haynes AB, et al. New England Journal of Medicine
2009;360:491–9
3. NPSA: http://npsa.nhs.uk/nrls/alerts-anddirectives/alerts/safer-surgery-alert/

B1
B2
Day Case Haemorrhoid Banding in a
Patient with High Spinal Cord Injury
and Severe Autonomic Dysreflexia
A Doyle, A Eley, B Watson
Queen Elizabeth Hospital, Kings Lynn, Norfolk
INTRODUCTION: There are approximately 40,000 Spinal Cord
Injury (SCI) patients living in the UK [1]. As a result of increasing
life expectancy, SCI patients are increasingly likely to appear on
elective surgery operating lists at non-specialist hospitals [1].
CASE REPORT: A 42 year old man (AS) with a history of SCI 20
years earlier, presented at our day unit for elective banding of
haemorrhoids. AS had limited upper limb motor and sensory
function and was paralysed below the level of the lesion (C7).
He had previously experienced episodes of severe autonomic
dysreflexia following noxious stimuli. His medical history,
preoperative physical examination and laboratory tests were
otherwise unremarkable. On the day of surgery, AS was
accompanied by his regular carers. Our SCI link worker helped
day surgery nurses to assess manual handling and nursing care
requirements. In order to prevent another episode of
autonomic dysreflexia, we opted for low dose spinal
anaesthesia, using 5 mg 0.5% hyperbaric bupivacaine with 10
µg fentanyl. He remained cardiovascularly stable throughout
the 30 minute procedure. Postoperative recovery was
uneventful and AS was discharged home 4 hours after his
surgery. Day surgery contributed significantly to a successful
outcome in this case by offering an accessible environment and
the freedom to use the patient’s usual aids (i.e., wheelchair and
regular carers), rapid admission and discharge and minimal
disruption to bowel, bladder and skin care routines. The use of
“Out In The Cold?” The incidence of
perioperative hypothermia in a district
general hospital day surgery unit
T Hinde, M Stocker, J Montgomery
Torbay Hospital
INTRODUCTION: Hypothermia is a common perioperative
complication causing physiological derangement and the risk
of increased perioperative morbidity. Therefore, NICE have
produced guidelines for the management and prevention of
hypothermia, primarily aimed at inpatient surgery. This
prospective audit aimed to assess our day unit’s adherence to
NICE guidelines, the cost implications of fulfilling these, the
relevance of these guidelines to our cohort of day surgery
patients and the current incidence of complications in our
patient population.
METHODS: The audit was carried out over 2 weeks in
December 2008 in the day surgery unit and included 93 adults.
A questionnaire based on NICE guidelines was used to gather
pre, intra and postoperative information. Additional details
were obtained from our electronic patient record, Daynamix
( © Calcius Systems). Temperatures were taken by staff
perioperatively. Data were entered onto an Excel database for
analysis.
RESULTS: We do not currently provide our patients with written
information on hypothermia avoidance. Nor do we risk score
our patients. Of those audited 7.5% would have required
warming on the grounds of ASA and type of surgery. No
patients would have needed preoperative warming as none had
temperatures of less than 36°C prior to induction. Patients in
regional anaesthesia avoided the dangers associated with
another episode of autonomic dysreflexia. We have now
designed a preoperative checklist to enable optimal
preparation for SCI patients treated in our unit. This includes
plans for anaesthesia, postoperative analgesia, surgical
positioning and manual handling. We are educating our staff in
management of SCI patients, including raising awareness of
autonomic dysreflexia, which can present as a medical
emergency.
CONCLUSIONS: Day surgery units are ideally placed to deal
with the common urological, plastic and orthopaedic
procedures SCI patients require, but these can present
anaesthetic and nursing challenges [1]. The SCI Link Worker
scheme was set up to ensure appropriate care is provided at
non-specialist hospitals and can offer support to day surgery
staff [2]. In a review of SCI services in 2003, the Kent, Surrey
and Sussex local specialist commissioning group
recommended the accreditation of day surgery units capable of
accepting SCI patients but this has not yet come about [3].
However, many of these patients can be successfully managed
provided staff are familiar with the planning and
multidisciplinary approach needed to meet their special
requirements.
REFERENCES
1. Hambly, PR, et al. Anaesthesia 1998;53:273–89
2. SCI Link Worker information available at:
http://www.mascip.co.uk/default.ihtml?step=4&pid=47
3. Kent Surrey and Sussex Local Specialist Commissioning
Group, Standards for patients requiring spinal cord injury
care, 2003
our unit remain mobile and fully dressed until ten minutes
before surgery which minimises the likelihood of preoperative
hypothermia. Combining the 7.5% of patients who were
considered at high risk for hypothermia, and those
anaesthetised for more than 30 minutes, 59% of our patients
met the criteria for intraoperative forced air warming. 76%
received more than 500 ml of fluid which would require
warming under the NICE guidelines. None of our patients
received either of these warming modalities. 6% of patients
arrived with temperatures of less than 36°C. None were
warmed and none had any problems during their recovery from
day surgery. There were no unplanned admissions and no
adverse outcomes at 24 hours in any of the study patients.
CONCLUSIONS: Few of the NICE guidelines are currently
implemented in our unit but patient outcomes remain good.
Preoperative temperature management is good, and all arrive
in the anaesthetic room warm. Forced air warming disposables
for 59% of patients would cost £15,930–£51,330 per annum.
Fluid warming disposables for 76% patients would cost
£34,200 per annum. A minority of patients reach recovery cold.
They had no defining characteristics. Disposable costs to warm
this group would be £1,620 per annum. It is difficult to justify
the cost of implementing all the NICE guidelines in our unit
based on the results of this audit; however we recommend the
following modifications: Information regarding perioperative
temperature control should be added to our patient
information leaflet. A dedicated document is unnecessary;
patients should remain mobilised and fully dressed until 10–15
minutes prior to surgery; routine temperature measurement on
arrival in recovery; subsequent warming if needed.

B3
Safe Day Surgery Discharge. Reducing
discharge times without
compromising patient safety
D Reisel, D Kamming
University College Hospital London
INTRODUCTION: An essential component of efficient day
surgery delivery is optimally timed patient discharge. Day
surgery ward discharge must be safe and a key safety feature is
to ensure that patients have an escort to accompany them
home from hospital. Anecdotal evidence suggested that delay
of the arrival of the escort may contribute to delayed day
surgery discharge which ultimately impacts on day surgical
activity with resource implications. The current audit sought to
clarify the reasons for delayed discharge from our day surgery
unit. We wanted to determine how to improve day surgery
discharge times without compromising patient safety.
METHODS: The study was carried out in two phases. In the first
phase in 2008, 40 randomly selected patients were audited
prospectively. All patients had day surgery operations requiring
general anaesthesia. A random cross section of surgical
specialties were included, equally distributed across morning
and afternoon operating lists. Nursing staff recorded the times
when patients reached three predetermined discharge criteria:
(i) time to tolerating fluids; (ii) time to pass urine; and (iii) time
to discharge from the ward. The second phase was carried out
six months later in 2009. In the intervening period, a new
system was implemented in which patients who had fulfilled all
other criteria for discharge were allowed to wait for their escort
B4
‘How to get the most out of 20
Minutes’: The introduction of a one
day preoperative assessment training
module for nursing staff
T Hinde, M Stocker
Torbay Hospital
INTRODUCTION: Preoperative assessment in our day surgery
unit is performed initially by nursing staff. Referrals are then
made to anaesthetists if required. Our nursing staff receive no
formal education in preoperative assessment and we identified
that courses available nationally are time consuming and costly
which would be a barrier for many of our staff. We wished to
develop a one day course to address this.
METHODS: The course was developed jointly by senior
anaesthetists and nursing staff within our day surgery unit to
provide a one day training package in preoperative assessment
for nurses involved in day surgery. The course is aimed at
experienced staff members as well as those new to
preoperative assessment. The course is teacher facilitated and
evidence based. Included are lectures, problem based learning,
case studies, direct observation in the clinical environment, and
scenarios utilising actors.
Content consisted of four main areas being addressed in the
classroom: patient education around the day surgery
in the separate hospital discharge lounge rather than waiting
on the day surgery ward for their escort to arrive. 40 new
patients were entered into the study, and the same time points
were registered.
RESULTS: The first study found the major rate-limiting factor
for discharge from the day surgery ward was patients waiting
for their escort to arrive. The average time from arrival on ward
until drinking oral fluids (35 min) and time to pass urine (55
min). The average waiting time for the escort to arrive was 152
min. The time from when the patient achieved the discharge
criteria until actual discharge was (152-55) = 97 min. The reaudit
showed similar times for drinking oral fluids (32 min) and
to pass urine (62 min). However, the average waiting time for
discharge from the ward to the discharge lounge was 112 min.
The time from the point where the patient achieved the
discharge criteria until actual discharge was (112-62) = 50 min.
There was an almost 50% reduction in average waiting times
from when all other discharge criteria were met until actual
discharge from ward (97 min vs 50 min). No adverse events
were reported.
CONCLUSIONS: The utilisation of a separate discharge lounge
has led to a significant improvement in day surgery discharge
times. This new system improved day surgery unit service
delivery significantly especially during the busiest time of the
day (early afternoon). Afternoon patients were no longer kept
waiting for a bed space prior to surgery. There was no evidence
of compromised patient safety despite almost a 50% reduction
in ward discharge time. We would therefore recommend
utilising a separate suitable staffed area as a discharge lounge
to optimise day surgery ward bed utilisation.
experience; informed decision making; understanding surgical
procedures and consent; patient selection and medical
evaluation; medical optimisation and making appropriate and
effective referrals.
Afternoon sessions are to be divided between direct
observation in clinics and scenario practice using actors based
on the information learned in the morning. Appropriate
educational material, protocols and references are provided for
candidates to take away.
RESULTS: The course was piloted in April 2009 for internal
delegates. Feedback was excellent and we have now received
national sponsorship enabling us to commence running
courses for external candidates from autumn 2009.
CONCLUSIONS: We identified a gap in the opportunities for
nursing education in preoperative assessment. Other courses
available are modular courses requiring significant time and
financial commitment from the nurses. We wished to develop a
package providing a comprehensive introduction with realistic
time and financial commitments. We believe that the course we
have developed has met these dual requirements and we look
forward to offering the opportunity for this education to other
preoperative assessment nurses throughout the UK.

B5
Day Case Laparoscopic Gastric
Bandings – Is it really such a big deal?
S Irukulla, M Wattie, M Kubli, M Brown,
J Horner
Ashford and St Peters NHS Trust
INTRODUCTION: The publication of NICE guidelines:
“Guidance on the use of surgery to aid weight reduction for
people with morbid obesity” in 2002 established a
recommendation and a need within the UK for need to increase
the capacity to treat and prevent the long term serious
consequences of morbid obesity. Ashford and St Peters trust
became a regional referral centre in 2006. We now conduct 85%
of our gastric bandings as a day case. The two objectives of this
audit were to establish how many laparoscopic bandings were
successfully managed as a day case. Secondly to establish
quality of care and level of patient satisfaction.
METHODS: We report our own experience in gastric band
surgery evaluating patient data, outcomes and readmissions.
We also sampled 30 patients for quality of care and patient
satisfaction.
RESULTS: A total of 201 (non-suture MidBand) gastric bands
were inserted by a single surgeon between July 2004 and March
2009. In addition, on 3 occasions a gastric band was not inserted
due to technical difficulties. Overall 145 (72%) were discharged
on the day of surgery. 33 (16.3%) patients in less than 23 hours.
The remainder stayed in for various reasons, mainly for
management of type 1 diabetes, sleep apnoea or other medical
co-morbidities. BMI ranged from 37–63 (mean 49.2).
B6
How do we Approach Venous
Thromboembolism Prophylaxis in Day
Surgery Patients?
N Bhamber, I Ogunrinde, C Shaw,
CL Ingham Clark
The Whittington Hospital NHS Trust
INTRODUCTION: Clear guidelines exist on the indications for
prophylaxis against venous thromboembolism (VTE) in adult
surgical inpatients. These are based on the Autar scale.
However there are no clear established guidelines for VTE
prophylaxis in day surgery patients, and no validation of the
Autar Scale for this group. In our Day Surgery Unit (DSU) we
give all patients intraoperative intravenous fluids and
encourage early mobilisation for all, but have no other standard
VTE prophylaxis. As indications for day surgery widen to include
longer operations and bigger patients the risk of VTE in day
surgery patients will increase. The aim of this study was to
measure risk factors for VTE and current practice in VTE
prophylaxis in our DSU.
METHODS: 104 patient records were reviewed from among
those attending our DSU in November and December 2008.
Risk factors (according to Autar Scale) and what, if any, VTE
prophylaxis was used were recorded for each patient. Hospital
Episode Statistics were then interrogated for the same group of
patients for the following month to seek any evidence of VTE.
Year Day case rate
2006–7
2007–8
2008–9
No patient was readmitted within 24 hours but 4 patients had a
delayed readmission: 1 port site infection requiring antibiotic
treatment; 1 rectus muscle haematoma; 1 band replaced and
1 band was too tight needing re-operation (replaced 7 days
later). 7 gastric bands were removed: 3 for psychological
intolerance; 2 developed oesophageal dilations and
structuring; 2 patients developed subfibrotic (sub-band
capsule) reactions. We surveyed 30 patients as a sample. These
patients were telephoned the next day to assess pain, nausea
and vomiting, contact with a health professional and level of
satisfaction with their care.
Symptoms
Pain
Nausea
Vomiting
None/mild
45%
96%
100%
Moderate
48%
4%
-
62%
81%
85%
Severe
3%
-
-
Three patients contacted the hospital or their GP: 1 complaining
of pain, 1 couldn’t swallow a tablet and 1 needed diabetic
advice. Patient satisfaction: 85% rated their care as excellent
15% as good.
CONCLUSIONS: Laparoscopic gastric bandings can be safely
conducted as a day case procedure. Of the complications that
did occur none required immediate readmission to hospital.
Overall patients were highly satisfied with being treated as a
day case.
RESULTS: 54 men and 50 women were included. Recording of
body mass index was not always clear. For women taking the
oral contraceptive pill it was not always possible to determine
whether they had been advised to replace it with alternative
contraception until after surgery. 7 patients had surgery lasting
more than an hour. Only one patient had an Autar Score over 10
(indicating moderate risk of VTE), 18 had a score of 6–10
(indicating low risk) and the remainder scored 5 or less,
representing virtually no risk. Intraoperative calf compression
was used in 55 patients including the one at moderate risk.
Graduated calf compression stockings were used in 2 patients,
including the one at moderate risk. No patient was given
chemical prophylaxis against VTE and no patient developed VTE.
CONCLUSIONS: This is a small sample but the results imply
that the risk of VTE in day surgery patients remains low. We
recommend better recording of BMI and contraceptive advice at
preassessment. In terms of VTE prophylaxis, having reviewed
the literature, we recommend the use of intraoperative calf
compression for all our day surgery patients (other than those
having lower limb surgery). This is a low-cost, low-risk
approach. We do not recommend use of chemoprophylaxis with
subcutaneous heparin since there is no evidence that this is
effective as a single preoperative dose. In conclusion, a
standard approach using intraoperative calf compression boots
probably provides appropriate and cost-effective VTE
prophylaxis for day surgery patients.

P1
An Audit of Perioperative Nursing Care
for Diabetic Patients Undergoing Day
Surgery at Gloucestershire Royal
Hospital 2006–2007
P McCann, J Brown, T Ullahannan
Gloucestershire Royal Hospital
INTRODUCTION: This audit was undertaken on thirty diabetic
patients undergoing day surgery over a four month period.
Twenty received general anaesthesia and ten were local
anaesthetic. The diabetic treatments were diet, oral medication
and a combination of tablet and insulin. The aim of the audit
was to improve the standard of care given to diabetic patients.
METHODS: The audit standards were: l. National Service
Framework for Diabetes: Standards which states “that there
should be no delays in discharge resulting from their diabetes,
especially when diabetes was not the original reason for their
admission” and 2. The trust policy for pre/peri operative
management in diabetic patients which states that “diabetic
patients should be first on the morning list if possible.
P2
An Audit of Perioperative Temperature
Management in Day Surgery
RD Thomas, DE Griffiths
City Campus, Nottingham University Hospitals
INTRODUCTION: The National Institute of Clinical Excellence
(NICE) has highlighted the complications of inadvertent
perioperative hypothermia (core temperature 30 min in 21 (38%)
cases, not recorded in 10 cases. The average admission to
surgery wait was 159 (73–285) min. Five patients had received
information on keeping warm. 89% patients had their
temperature recorded on admission to DSU, 18% were found to
be hypothermic; surgery was not delayed and intraoperative
temperature monitoring was not performed in any of these
patients. 9 patients (16%) had intraoperative temperature
monitoring; active forced air warming was used in only 5
patients. 44% adults received >500 ml fluid, a fluid warmer was
never used. Core temperature was measured postoperatively in
recovery in 43 (78%) patients, 33% were found to be
hypothermic – only two were actively warmed. 6 patients
remained hypothermic on discharge to the ward area.
CONCLUSIONS: The present DSU patient information leaflet
does not provide advice on the prevention of hypothermia.
Although only a small proportion of patients were hypothermic
on admission to the unit a significant proportion became
hypothermic during surgery and anaesthesia. This audit
demonstrates that our current practice of perioperative
temperature management in DSU does not meet the standards
recommended by NICE.
REFERENCES
1. National Institute of Clinical Excellence. The Management of
Inadvertent Perioperative Hypothermia in Adults, April 2008
2. Smith CE, et al. The Internet Journal of Anaesthesiology
2007;12(1)

P3
An Audit on Major Complication Rates
in Peripheral Angiography at a Large
District General Hospital
C P Lim, T L Luk
Queen Alexandra Hospital, Portsmouth
INTRODUCTION: Peripheral arterial angiography is the gold
standard for evaluating peripheral vascular disease and serves
as a less invasive alternative to open surgery. We aimed to
identify the complication rates of lower limb arterial
angiography and correlate them with the premorbid condition
of the patient.
METHODS: We included all lower limb arterial angiography
performed in the centre over 4 months (February to June 2008),
collecting data on type of the procedure (elective/emergency),
nature (diagnostic/therapeutic), radiologists/surgeon and
grade, preceding duplex, co-morbidities, renal function pre and
post-procedure and specific complications. The results were
analysed with Microsoft Excel.
P4
AO Screw Fixation of Undisplaced
Fractured Neck of Femur (Garden
Grade I and II) in Patients over 65
Years of Age
H Sekhar, A Lee, A Kumar
University Hospital of South Manchester
INTRODUCTION: Hip fractures affect 1.6 million people every
year with rising incidence. The primary goal of treatment of an
undisplaced intracapsular femoral fracture is the rapid and
uncomplicated recovery of function. Complications of avascular
necrosis (AVN) and non-union have guided treatment towards
primary hemiarthroplasty or a total hip arthroplasty.
Preservation of the femoral head however, would seem to be a
feasible alternative and internal fixation with multiple
cannulated screws may lower mortality and morbidity and
reduce the length of hospital stay (LOS). The aim of this study
was to elicit the rate of reintervention, LOS and morality and
morbidity following AO screw fixation in patients over 65 years
old.
METHODS: A retrospective case study was performed of
patients who had undergone insertion of AO screws for fixation
of an undisplaced (Garden grade I or II) intracapsular fracture of
neck of femur between November 2005 and May 2008. Case
notes of 40 patients were retrieved and reviewed for
information on patient demographics, fracture details,
operative details, LOS and final outcome. Primary endpoints
were mortality, re-intervention and discharge from hospital
follow-up.
Age
92
90
69
78
76
Grade
2
1
1
1
2
Days to surgery
2
1
2
1
2
Weight-bearing
Partial
Partial
Non
Full
Toe-touch
RESULTS: 46 lower limb angiograms were performed over the
4 month period of study. 2 were excluded due to failure to
cannulate. Of these 10 were performed as an emergency. 17 of
these were diagnostic and 27 interventional. 4 were performed
by consultant surgeon and 35 performed by consultant
radiologists and 5 preformed by radiology registrars. 41 had an
arterial duplex study prior to the procedure and 3 did not. 66%
were smokers, 45% had hypertension, 34% had ischaemic
heart disease, 23% had diabetes, 18% had high cholesterol,
and 2% had renal dysfunction. Complications included 1 distal
emboli, 1 perforated vessel, 2 MI, 2 renal failures. Of these, one
patient had both MI and renal failure. One patient also
developed hypoglycaemia during the procedure.
CONCLUSIONS: Our total complication rates are more than
10%. This is partly due to the fact that we included emergency
patients who were generally more unwell and that our
radiologists tend to be more aggressive as most of these
patients were not fit for open surgical intervention.
Nevertheless, peripheral angiogram is an invasive procedure
carrying significant complication rates.
RESULTS: Six (15%) patients were male and 34 (85%) female,
with a median age of 79 years (range 67–95). Nine patients
(22.5%) had a Garden grade I fracture and 31 (77.5%) grade II.
Median time to surgery was 1.0 (0–23) day and all patients had
three screws inserted. Postoperative mobility instructions
varied by operating surgeon. Nine patients (22.5%) were
instructed to stay non-weight bearing, 3 (7.5%) toe-touch, 13
(32.5%) partial weight-bearing, 13 (32.5%) allowed full weightbearing
and 2 (5.0%) had no recorded instruction. Median LOS
was 12.5 (4–51) days. Twenty-one patients (52.5%) were
followed up in outpatients at 11 (2–24) months. There were no
cases of wound infection. Two (5.0%) patients died, one from
an unrelated cause and one suffered a fatal thromboembolic
event within 30 days of operation. Five (12.5%), all female,
required a re-intervention to the hip.
CONCLUSIONS: AO screw fixation of undisplaced intracapsular
femoral fractures results in a low morbidity, mortality, low
failure rate and an early discharge. AO screw fixation appears to
be a safe and feasible alternative to primary hemiarthroplasty
or total hip arthroplasty in the majority of patients. The varied
postoperative weight bearing instructions did not seem to have
a harmful effect on the final outcome. A consensus of
postoperative full weight bearing instruction may expedite
patients’ recovery after surgery and further reduce the length of
stay.
LOS days
9
9
8
9
10
Complications
Fall
AVN
AVN
AVN
AVN
Treatment
Remove screws
Remove screws
Hemiarthroplasty
THR
Remove screws

P5
Are Neck Drains a Contraindication to
Day Surgery?
J Bhat
Southport District General Hospital
INTRODUCTION: We assessed the safety and desirability of
day case surgery for neck masses and whether inserting a neck
drain is a contraindication to being discharged.
METHODS: In a review of day case surgery in Southport it was
noted that concertina drains were inserted into the neck after
certain operations, for example, lymph node biopsy, removal of
branchial cyst abnormality, submandibular gland removal and
in two cases parotid gland removal, as well as numerous
miscellaneous neck operations, including cyst trunk
operations. The patients were sent home and asked to return
the next day for review and removal of the neck drains. On their
return we looked for any complications and assessed patient
satisfaction by asking if they would rather have stayed in and
were there any ill-effects from having the drain insitu.
RESULTS: 28 neck drains were inserted and the patients sent
home the same day for drain removal the following day by the
nurses in the outpatient clinic. There were found to be no ill
effects from this.
P6
Audit of Abdominoplasty as Day Case
Surgery
A Salman
Park West Clinic
NTRODUCTION: It has been our experience that selective
abdominoplasty cases can be preformed safely as day surgery.
METHODS: We have followed a strict selection criteria in order
to achieve maximum aesthetic results with maximum patient
safety and minimal or no discomfort. There are four elements
that must be present in order to carry out abdominoplasty as
day case surgery. We call these the Park West criteria.
1. Patient selection: age/health/mobility/fitness; flap
thickness; future pregnancy/last pregnancy; distance to
travel; comprehension/ cooperation; available support at
home.
2. Day surgery unit set up: full OR; full GA set up (dedicated
anaesthetist); bloods; trained staff; assistant surgeon
present (with skills in general surgery); surgical technique
and limitations (no combined lipo/or other procedure); type
of drains used; availability of overnight stay if needed;
complication prevention.
CONCLUSIONS: Drains are routinely inserted for many types of
surgery, such as breast surgery, including some axillary
clearances. The drains are inserted in a sterile theatre and,
providing they are sealed drains on suction, there is a minimal
risk of introducing infection postoperatively and the district
nurses often take them out. However, neck drains are a
different kettle of fish, the reason for this being that they are
also used to protect the airway. If blood gets into the tissues of
the neck, then this can cause increasing oedema and on
occasions can cause airway problems. Under these
circumstances neck drains have to be considered in a different
category from drains on the limbs or the rest of the body, and
for this reason they have been looked at separately. We are
pleased to say that there have been no issues relating to neck
drains, such as increased infection or airway issues in the
patients treated, so we can say that neck drains are not a
contraindication to day case surgery.
3. Emergency back up: 24/7 emergency availability of the
surgical unit; access to ICU/full hospital facilities; district
nurse support; family involvement; multiple frequent postop
visits.
4. Patient education: extensive information/ preop. education;
mental preparation; true expectation; fully informed
consent.
RESULTS: Over a 36 months period we performed 50 cases of
abdominoplasty as a day case with minimal complications.
CONCLUSIONS: On appropriate compliance with the above
criteria, we found that abdominoplasty can be performed safely
and successfully as a day case in selective patients.

P7
Basket of ENT Surgery
AHH Al-Jassim
Southport District General Hospital
INTRODUCTION: The aims of this report are to consider what
the basket of ENT surgery that should be done as a day case
can be.
METHODS: In this paper we will review the different baskets of
ENT surgery that have been considered, review what the
literature has done and compare this with the basket of ENT
surgery that has been undertaken in Southport Day Unit.
RESULTS: The basket of ENT day surgery that is done in
Southport has dramatically increased over the baskets that
have been reported in the literature. In otological surgery, the
basket consists of inner ear drug deliveries, which is inner ear
P8
Day Case Doppler-Guided
Haemorrhoidal Artery Ligation for 2nd
and 3rd Degree Haemorrhoids –
Intermediate and long-term outcome
T Wong, A Shekouh, J Arthur, P Skaife
University Hospital Aintree, Liverpool
INTRODUCTION: The established first line treatments for 1st
and 2nd degree haemorrhoids are oily phenol injections and
rubber band ligations (RBL). The new technique of Doppler-
Guided Haemorrhoidal Artery Ligation (DG-HAL), performed in a
day case setting has been shown to be safe, effective and
associated with minimal postoperative discomfort. Our study
set out to compare symptom resolution and patient satisfaction
of DG-HAL with RBL.
METHODS: Patients with symptomatic 2nd or 3rd degree
haemorrhoids were randomised to either procedure as first-line
treatment. Patient demographics, postoperative complications
and assessment of maximal pain severity within 24 hr of
procedure were recorded. At initial follow-up, endpoints
assessed were symptom resolution, change in continence,
tenesmus and patient satisfaction. Sample size calculations
were performed.
gentamycin, mastoid surgery for cholesteatom in children and
adults, tympanoplasties, ossiculoplasties, stapedectomies, as
well as the grommet insertion and more minor ear procedures.
Nasal surgery consists of septorhinoplasty, medial
maxillectomy, frontal sinus surgery, septotomy, septoplasty,
turbinectomy and endoscopic sinus surgery, as well as the
more common procedures such as polypectomy and DCR.
CONCLUSIONS: With the advent of improved anaesthetic care,
analgesia etc, we can increase the basket of day case surgery
from five procedures to account for 87% of all ENT surgery for
this area. This has caused some problems with the ward and
the facility for emergency admissions, as there are no longer
inpatient beds for the population of over 300,000, as there is
no longer a need for this for routine ENT surgery.
RESULTS: Fifty-one patients opted for DG-HAL (33 F/18 M,
median age 38 yrs, 25 2nd and 26 3rd degree haemorrhoids)
and 103 patients chose RBL (63 F/40 M, median age 43 yrs, 48
2nd and 55 3rd degree haemorrhoids). Patient demographics
and haemorrhoid stage were similar between both groups (p
>0.05). There were no complications. Maximal postoperative
pain within 24 hours of procedure was comparable between the
2 groups (p >0.05). At 12 weeks median follow-up for the 3rd
degree group, 23/25 (92%) of DG-HAL patients had resolution
of bleeding and prolapse compared to 38/55 (69%) of the RBL
group (p = 0.042). At a similar follow-up period for the 2nd
degree group, 25/26 (96%) of DG-HAL patients were symptomfree
compared to 36/48 (75%) of the RBL group (p = 0.03).
There was no tenesmus or change in continence. Ninety-six
percent of DG-HAL patients were satisfied, and would undergo
the procedure again, compared to 76% of RBL patients (p =
0.002).
CONCLUSIONS: DG-HAL is more effective than RBL in
treatment of bleeding and prolapse for 2nd and 3rd degree
haemorrhoids with a similar low incidence of postoperative
discomfort and minimal complications. In the hierarchy of
treatment for haemorrhoids, DG-HAL may and should be
considered as effective first-line treatment.

P9
Day Case Foot and Ankle Surgery –
An audit of patients’ acceptance and
analgesic requirements
N Calthorpe, Santra, A Marsh,
U Ranasinghe
Russell’s Hall Hospital
INTRODUCTION: Historically the majority of foot and ankle
surgery has been performed on an inpatient basis, with patient
generated anecdotes of severe and protracted postoperative
pain. Following the appointment of a specialist orthopaedic
foot and ankle surgeon, a new day case service was established
in our unit. This audit was performed to assess the success of
the perioperative management of these patients and to
objectively establish the acceptability of day case foot surgery
with particular reference to postoperative analgesia.
METHODS: A standardised anaesthetic and analgesic regime
(consisting of propofol, fentanyl, iv paracetamol and diclofenac
plus an ankle block of 20 ml 0.25% Marcain administered by
the surgeon after tourniquet inflation) was used for 51
consecutive procedures. Postoperative pain was assessed at
fixed intervals and patients received a telephone call the
following day to assess pain 24 hr postoperatively. Our
standards were:

P11
Day Case Laparoscopic
Cholecystectomy: Achievable in
peripheral hospitals
LH Lee, E Ghareeb
Erne Hospital, Enniskillen
INTRODUCTION: Laparoscopic cholecystectomy is one of
medicine’s many milestone achievements. Evidences have
shown its safety and superior outcomes in the length of
hospital stay and speed of recovery [1]. Further to this, some
practitioners have advanced their services by introducing
laparoscopic cholecystectomy as a day procedure. Guidelines
and advice are available to help setting up this service for those
who are unfamiliar with its concept [2,3]. This audit is
undertaken in a peripheral hospital, to explore the results of
day case laparoscopic cholecystectomies performed by one
surgeon and to compare the results against national data
reported by the National Institute for Innovation and
Improvement (NIII) [2,3].
METHODS: Retrospective analysis of all patients who
underwent cholecystectomy between 1 January 2005 and 30
April 2007 was performed. These patients were divided into
three groups; elective day procedure, elective inpatient and
emergency. Data collected include age, gender and ASA group.
Main outcomes measured were discharge timings and surgical
complications.
RESULTS: There were a total of 88 cholecystectomies
performed within that period of time for symptomatic
cholelithiasis. All of them were performed laparoscopically. Age
of the patients ranged from 13 to 84 year old (mode 41–50 year
P12
Day Case Laparoscopic Paraumbilical
Hernia Repair
I Shaikh, S Kumar
The Royal Infirmary of Edinburgh
INTRODUCTION: Open repair of paraumbilical hernia is
associated with recurrence rate of 5–7% and surgical site
infection in

P13
Day Case Surgery, a Prospective Audit
of 796 cases at New Cross Hospital
R Khazaee-Farid, CV Higanbottam,
ROC Elledge, M Ahuja
New Cross Hospital, Wolverhampton
INTRODUCTION: The Department of Health produced an
operational guide for day surgery in 2002 in order to improve
efficiency of day surgery units. It has been shown that although
75% of procedures are suitable for day surgery, most trusts are
underperforming and theatre lists usually include procedures
that can be undertaken in a treatment room, endoscopy suite
or primary care. We conducted a prospective audit of theatre
procedures carried out at New Cross Hospital between January
and February 2009 to assess how the day surgery unit is
performing.
METHODS: Over a two week period on a daily basis, data were
recorded prospectively from theatre on patient demographics,
type of operation, hospital coding for the procedure (day case
or inpatient), the speciality involved and the actual outcome of
each patient. We used the British Association of Day Surgery
(BADS) directory of procedures 2nd ed. 2007 to identify
whether the operation was appropriate for day case as a
comparison to hospital coding and actual outcome.
RESULTS:A total of 796 procedures were analysed. Of these,
610 (76.6%) were planned as day case, and 186 (23.3%) as
inpatient. There was a total of 43 (5.4%) cases that were either
cancelled or failed to attend. Therefore, the actual figure for all
day case procedures performed was 513 (68.1%). 80
P14
Day Surgery Utilisation – Financial
implications
J I Pears
Southend University Hospital Foundation Trust
INTRODUCTION: In 2004/2005 the Healthcare Commission
calculated that just by using existing day surgery facilities more
efficiently the number of day surgery admissions could be
increased by 10% [1]. This was supported by a report from the
Secretary of State published in July 2005 that warned “high
levels of investment in the health service won’t continue
indefinitely and that there is “a potential pot of gold” to be
gained through efficiency savings” [2]. Since a review by the
Audit Commission in 2004, Southend’s Day Surgery Unit (DSU)
has exceeded expectations of increasing throughput and in the
last fiscal year admitted an average of 832 patients per month.
However, there is an increasing demand for day surgery
capacity and, without major investment, by questioning and
challenging traditional practices the DSU can work more
efficiently and improve utilisation.
METHODS: A business case proposal was written with three
phases. Phase one was to consider the option of extending the
morning operating theatre session by half an hour to four
hours. This would allow one extra procedure per operating list
and would not require any change to the current shift pattern or
incur additional staff costs. Phase two was to implement this
change to the afternoon session and thirdly, by analysing the
specialities that use the day theatres it may be possible to
further improve the profitability of the service by moving lists
procedures performed (10.6%) were classed as BADS Annex C,
indicating that these could have been performed in the
treatment room, outpatient department or primary care.
Examples included orthopaedic joint facet injections/nerve
blocks; local anaesthetic injections for pain control; flexible
cystoscopy and removal of sebaceous cyst. Ophthalmology
carried out the most number of day case procedures in a
speciality dedicated 2 theatre suite, thus not overcrowding the
day case unit, which was used most frequently by the
orthopaedic team, followed by general surgery. Overall, 275
(32.3%) procedures did not correspond to the correct BADS
coding. Of these, 121 (16.1%) were BADS coded day case
procedures which were done as inpatients. ENT had the highest
number of day case planned procedures converted to inpatient
stay, followed by general surgery (p

P15
Delayed Discharge after Day Surgery
A Al-Kaysi , J Palmer
Salford Royal Hospital
INTRODUCTION: Day surgery units around the UK have
generally become more efficient and more successful in
achieving higher rates of patient turnover and less unplanned
admissions. The day surgery unit in our institution, which is a
large teaching hospital, is a big and independent unit
predominantly consultant-led. The rate of delayed discharge
has gone down from around 3.5% in 2002 to 1% in 2006, but
there was an increase since 2007 due to the expansion of
orthopaedic day case service.
METHODS: As part of a rolling audit of the day unit, we
retrospectively collected one year data looking at day surgery
procedures performed between February 2008 and January
2009, delayed discharges and the associated reasons.
P16
Designing a Day Surgery Website: A
survey to assess patients’ information
requirements and access to the
internet
NT Tarmey, RW Chambers, KM Williamson
Queen Alexandra Hospital, Portsmouth
INTRODUCTION: Timely, comprehensive information provided
in advance of surgery helps to ensure that patients are wellprepared,
improves the patient experience, and is essential for
the consent process [1]. The internet has become increasingly
relevant as a source of medical information for patients as
levels of home internet access grow in the UK [2,3]. We
conducted a survey of day surgery patients to identify
deficiencies in our current means of information delivery, to
assess levels of access to the internet in our patient population
and to assess whether a day surgery website was likely to
improve our patient experience and the quality of our service.
Portsmouth Hospitals NHS Trust is a large DGH providing day
surgery services across three hospital sites.
METHODS: Patients attending for all types of day surgery were
asked to complete a two-part questionnaire. The first part
assessed whether adequate information had been given in five
key areas prior to the day of surgery. The second part assessed
whether patients currently had access to the internet and
whether a day surgery website would be useful to them as a
source of information.
RESULTS: 226 responses were received, of which 188 were
complete. 54% of patients had attended a preassessment
clinic. Patients were most frequently lacking information on
how to find the day surgery unit (inadequate for 23% of
patients), followed by “what to expect when having your
surgical procedure” (inadequate for 14% of patients). 77% of all
patients had access to the internet and 65% thought that they
RESULTS: Sixty nine patients had a delayed discharge. There
was no significant difference in patient gender or patient age.
Surgical factors were the main cause (almost 50% of cases)
mainly due to procedures turning out to be longer or more
complicated than planned, with orthopaedics accounting for
one third. Anaesthetic factors contributed to 30% of cases, with
delayed recovery and pain among the main factors.
Administrative reasons including wrong listing and overbooking
was the cause of delayed discharge in almost 15% of cases
followed by lack of social support which contributed to 5% of
cases.
CONCLUSIONS: We conclude that there was a significant
number of cases of delayed discharge caused by preventable
factors. More careful and efficient preoperative assessment,
patient selection and booking system is required to avoid
unnecessary delay of patient discharge and waste of resources.
would find a day surgery website helpful. Of the 55 patients
aged 60 years or older, 56% had access to the internet and 55%
thought that they would find a day surgery website helpful.
Number
Have access to internet
Would find website helpful
CONCLUSIONS: Overall levels of internet access in our patients
were comparable to data from the Office for National Statistics.
Most patients with access to the internet thought that they
would find a day surgery website helpful. The single most
useful piece of information on a website for our patients was
likely to be travel directions to the day surgery unit. A day
surgery website would be useful to a lesser, but still important,
proportion of patients over the age of 60.
REFERENCES

P17
ENT Theatre Cancellation on day
of Operation
YB Mahalingappa, A Daud
Whiston Hospital
INTRODUCTION: Many elective operations are cancelled on
the day of operation leading to a strain on patients and loss of
valuable hospital resources. This audit looks into reasons for
cancellation and to identify areas for improvement.
METHODS: Retrospective analysis of all planned ENT
operations over 6 months between May 2008 and October
2008 in a district general hospital. Data were collected from
cancellation reports and case notes.
RESULTS: Out of 446 planned operations, 31 (7%) were
cancelled in 6 months. 15 cancelled patients were male, 16
female, 8 children and 23 adults. Cancelled procedures were
tonsillectomy 10, grommets 6, functional endoscopic sinus
surgery septoplasty 5, dacryocystorhinostomy 2,
microlaryngoscopy 1, nasal polypectomy 1, oesophagoscopy 1,
parotidectomy 1, excision neck lump 1 and examination under
anaesthesia of nose 2.
P18
Evaluation of Redesigned Analgesia
Regime for Postoperative Analgesia in
Day and Short Stay Surgery
M Laye, J Rozentals, JM Vernon
Nottingham University Hospitals, City Campus
INTRODUCTION: All our day case and short stay general
surgical patients (DSSGSP) receive telephone follow-up. This
and a series of pain diaries revealed problems with our
postoperative analgesia regime. This regime involved the
anaesthetists prescribing from; diclofenac for 3 days, cocodamol,
paracetamol and tramadol, the ‘old analgesic
regime’. Patients had codeine related side effects of dizziness
and constipation with co-codamol, often causing them to stop
taking the analgesic. In light of this, our postop. regime was
revised. The drugs selected were with the exception of codeine,
available over the counter, allowing the patient to purchase a
further supply if needed. Senna, a laxative, was provided with
codeine. Four combinations of analgesics were provided in this
‘new analgesic regime’ suitable for treating a spectrum of pain,
mild through to moderately severe; 1) paracetamol 1 g qds; 2)
paracetamol 1 g qds, ibuprofen 400 mg qds; 3) paracetamol 1 g
qds, codeine 30–60 mg 4 hourly prn, senna 1–2 tabs; 4)
paracetamol 1 g qds, ibuprofen 400 mg qds, codeine 30–60 mg
4 hourly prn, senna 1–2 tabs. Comprehensive patient analgesia
information booklets were provided.
METHODS: General surgery patients are routinely telephoned
at home by ML or JR. As part of this follow-up call patients are
Operation cancelled by:
Patient
Administration
ENT surgeon
Anaesthetist
Total
Reason for cancellation
Did not want operation
Agitated
Infection
Did not attend
No notes
Error with date
Listed for wrong operation
Insufficient theatre time
Investigations needed
Operation unnecessary
Patient medically unfit
Number (%)
13 (41%)
2
1
7
3
3 (10%)
2
1
12 (39%)
2
5
3
2
3 (10%)
31
CONCLUSIONS: 7% of planned operations were cancelled on
the day of operation. The majority of cancellations were patient
41% and surgeon 39% related due to communication lack prior
to surgery. These can be avoided by identifying problems, while
listing the patient for surgery and at preoperative assessment.
Theatre time can be better utilised by improving coordination
between surgical team, theatre and ward staff and by
streamlining the patient flow to theatre.
asked about symptoms and pain since discharge from hospital.
Telephone follow-up records for 74 DSSGSP, having had hernia
surgery or laparoscopic cholecystectomy treated with the new
analgesic regime were analysed (NA group). The records of 74
DSSGSP, matched for having had similar surgery treated with
the old analgesic regime (OA group) were analysed for
comparison.
RESULTS: Numbers of patients recalling having had nausea
(OA 5, NA 3,) diarrhoea (OA 3, NA 1,) and constipation (OA 20,
NA 26,) were similar for each group. In NA group 15 patients
had taken the senna to treat postop. constipation. No major
morbidity was reported in either group. Time to follow-up, a
mean of 7 days, was similar for both groups. Mean pain score
was 2 (on 0–10 scale) in NA group at 7 day follow-up.
CONCLUSIONS: Prevalence of symptoms that could be
ascribed to being side effects of postoperative analgesics was
similar with both analgesic regimes. Constipation is common
following surgery, as a consequence of opiate use or other
factors. At telephone follow-up this had been a constant
complaint, causing distress, and patients to visit their GP.
Senna, costing 2.5 p a tablet, is now provided with codeine,
20% of all NA patients surveyed took this laxative.
Consideration should be made to routinely supplying a laxative
with opiates in appropriate patients.

P19
General Anaesthesia and Day Case
Patient Anxiety
M Mitchell
University of Salford
INTRODUCTION: General anaesthesia has historically proven
highly anxiety provoking for many patients. With the rise in the
amount of elective day surgery being undertaken, both in the
United Kingdom and across the globe, this aspect of patient
experience has therefore become a prominent issue. Indeed,
with the associated brief hospital stay, limited contact with
healthcare professionals, restricted formal anxiety
management and acute psychological impact of day surgery,
such anxiety may indeed be increasing. Our aims were: i) To
uncover the most anxiety provoking aspects of general
anaesthesia and, ii) determine what interventions may help to
alleviate such anxiety.
METHODS: As part of a larger study investigating anxiety in
elective day surgery, a questionnaire was given on the day of
surgery to 1,250 adult patients undergoing surgery and general
anaesthesia. The questionnaire examined issues of anxiety
regarding the environment, hospital personnel and experience
of general anaesthesia. Participants were requested to return
the questionnaire by mail 24–48 hours following surgery and
460 completed questionnaires were returned.
P20
Holistic Nursing Care of Day Case ENT
Patients
T Lesser, L Brown
Southport District General Hospital
INTRODUCTION: There are many models of day case nursing
care. We would like to present a nursing model which relates to
all aspects of care for the patient on the day case pathway. We
looked at 15 years of using this model with the aim of
demonstrating the benefits of holistic nursing care.
METHODS: In this model nurses work on a dedicated ENT
facility that has its own outpatients, preassessment, operating
theatres, recovery ward and administration office.
Responsibility for the whole of the patient pathway lies with
the same group of nurses. Such that the same nurse will look
after the patient in outpatients, do the preop. and then on the
ward or scrub in theatre. This day case unit has been running
for 15 years and we compare this to a period of 3 years where a
more traditional pathway was followed. For 3 years the patients
are seen in outpatients and if listed for surgery preassessment
is carried out by a central preassessment team, where only a
general health assessment is performed by staff unfamiliar
with ENT. On surgery day patients are admitted to a general day
unit caring for many varied specialities. Main theatre staff
scrub and recover the patient. In this paper we analyse the
difference in patients’ complaints, the nursing and patients’
satisfaction and patient safety issues.
RESULTS: A total of 85% of patients experienced some degree
of anxiety on the day of surgery. Descriptive data revealed
immediate preoperative experiences and concerns regarding
unconsciousness were all highly anxiety provoking. Utilising
factor analysis preoperative anaesthetic information,
anaesthetic catastrophising, final support, personal support,
imminence of surgery, possible adverse events and final
preoperative experiences were identified as central features.
Multiple regression demonstrated preoperative anaesthetic
information, anaesthetic catastrophising and imminence of
surgery were significantly associated with an overall increased
level of anxiety on the day of surgery.
CONCLUSIONS: Focusing on the timely, formal delivery of
information regarding anaesthesia management, emphasising
the notion of ‘controlled unconsciousness’ and dispelling
apparent misconceptions associated with general anaesthesia
might help to considerably limit patient anxiety.
RESULTS: On the dedicated ENT day case unit the
preassessment service is a key part of the pathway and
improves the hospital’s efficiency. During preop. patients are
not only examined to ensure they are medically fit, but the
procedure is explained to the patient and what to expect
postoperatively. This gives them the opportunity to ask any
questions they may have about their surgery. Patients are cared
for by the same team of staff on the ward and in the theatre
environment. During the 3 year period where the patient was
cared for by several different teams and departments the staff
in ENT outpatients found a significant increase in patient
complaints and queries, especially in regards to their
postoperative recovery. Job satisfaction fell for staff as they felt
they were not providing a holistic approach to the ENT patient.
CONCLUSIONS: Patients want to be fully informed about their
surgery and recovery. Familiar staff reduces the patients’
anxiety. Staff want to give a holistic approach to day case care
and are fearful of losing skulls, such as ward/theatre skills. We
should be constantly striving to improve the patients’
experience of surgery by providing as much information as
patients require.

P21
How Long Does Preassessment Take?
J Linfield, MA Skues
Countess of Chester NHS Foundation Trust
INTRODUCTION: The Jubilee Day Surgery Centre runs an
algorithm-directed nurse-led preassessment service
responsible for a workload of over 4,500 day surgery patients
per year. Changes in the complexity and casemix of patients
attending for day surgery prompted a review of the service to
see whether the appointment times for face to face
preassessment were still meeting the requirements of our
service.
METHODS: An audit of 200 patients was carried out evaluating
the time required for baseline observations, patient
assessment / provision of information, and ECG recording or
phlebotomy where indicated. Patient punctuality and
compliance with an internal standard of 90% of
preassessments starting within 15 minutes of appointment
time were also reviewed, together with an overall assessment
of whether the total workload was in accord with guidelines
advocated by the Healthcare Commission [1].
RESULTS: 83% of patients were punctual, arriving on average,
12 minutes early. 89.7% of assessments began within 15
minutes of the appointment time. ECGs were required for 17%
of patients, and phlebotomy for 29%. The time taken for the
various components of the appointment were:
P22
Impact of Elective Day Surgery
Cancellations on Quality of Service
Delivery
A Chandran, C Connolly, B Ajakey, M Ragbir
Royal Victoria Infirmary, Newcastle-Upon-Tyne
INTRODUCTION: Cancelled operations are a major drain on
health resources: 8% of scheduled elective operations are
cancelled nationally, within 24 hours of surgery. The aims of
this study were to define the extent of this problem in our trust
and suggest strategies to reduce the cancellation rate, to
estimate the impact of day surgery cancellations in our
department, to address the issues to improve efficacy in
delivering surgical services with the aim to improve and make
efficient use of resources which is beneficial both for the trust
and patients involved in this care.
METHODS: The hospital IT data system was used to identify
the surgeries cancelled. Also waiting list administration staff
were interviewed from the beginning of the process which
helped us understand the procedure and problems faced with
patients cancelling their procedure. Case notes of all the
patients who were cancelled during the period of Apr 06 to Jul
07 were reviewed to identify the cause and were classified into
patient factors, hospital factors and change in management
plan for illness.
RESULTS: 5,707 elective cases were scheduled (357 / month),
5,513 were performed (345 / month) and 194 cases (12 /
month) were cancelled with a cancellation rate of 3.4%. The
significant rectifiable causes of cancellation were identified as
patient factors 22.7% (social, domestic, childcare, change of
mind, etc) and hospital theatre equipment factors 13.9 % (like
Preassessment activity
Time taken (minutes)
Median IQR Range
Baseline observations 10 5–10 2–25
Patient assessment 35 27–40 10–90
Plus phlebotomy 5 5–5 2–14
Plus ECG 9 5–10 4–20
Complete preassessment 35 30–45 15–95
CONCLUSIONS: A scheduled appointment duration of 45
minutes seems appropriate for our preassessment process to
avoid patient delay. This time is greater than that proposed by
the workforce planning benchmarks from the Healthcare
Commission.
REFERENCES
1. Healthcare Commission. Acute Hospital Portfolio Review:
Day Surgery, July 2005
unavailability of theatre or instrument as shared between other
theatres). Consequently, our recommendations were: to
develop a transparent system to address communication
issues between patients and hospital; creating awareness
through patient education regarding issues leading to
cancellations; to develop a protocol to follow if patients were
cancelled off the list. We delivered the message about this
audit to the staff involved in the process of day case patient
services and proposed our suggestions for improvement in
quality of service provided by addressing the cancellation
issues and obtained feedback during the meeting. Proposed
recommendations from the audit were accepted among the
managers involved in day case patient services.
CONCLUSIONS: The proposed timetable for the planned
changes is currently being audited to measure the
effectiveness of the outcome. But the subjective interpretation
of staff involved suggests that they are following a robust
system on cancellation issues to improve quality of care.
Currently we are running a robust system of reporting
cancellation which is efficiently managed by re-booking the
next patient on the waiting list. Our patients are more aware
about the impact of cancellation issues and the burden on
quality of health care (by distributing leaflets). Proactive
management like telephoning patients to confirm availability
for the day case procedure rather than assuming that they will
turn up after the letter has been sent out. Stringent supervision
by the managers to make sure theatre equipment is available
for procedures has worked well.

P23
Improving Efficiency: A treatment
centre service evaluation
A Weigert, M Pernow
Chelsea & Westminster Hospital NHS Foundation
Trust
INTRODUCTION: Inefficient work practices in day surgery can
have a negative impact on patient care and satisfaction, cost
and staff morale. This evaluation was initiated by senior
nursing staff looking for areas of improvement in our Treatment
Centre. Absence of widely accepted standards precluded a
formal audit.
METHODS: We analysed all elective theatre lists for general
anaesthetic cases over a 4 week period with respect to start
and finish times, downtime between cases, on the day changes
to list order and cancellations. Arrival and waiting times in the
department were noted for each patient, and all critical
incidents and complaints were reviewed.
RESULTS: 1,111 theatre lists were included with a total of 492
patients undergoing procedures. 82 patients were cancelled
(14.3%). The commonest causes of cancellation were failure of
the patient to turn up (24.4%), being considered unfit for
operation (19.5%) and overrunning lists (15.9). 59% of lists
started more than 15 minutes later than scheduled, mostly
because patients were not ready. 44% of lists overran. Changes
to the order occurred in 62% of lists. Overall, changes to list
order were more common on lists that ran on time (65%,
average 1.7 changes per list), than on lists that overran (57%,
average 1.4 changes per list). This suggests that list changes
are unlikely to be the cause of overruns. Rather, it may be that
P24
Inadvertent Perioperative
Hypothermia in Day Case Patients:
‘Easily done but even easier to rectify’
H Chin, J Kim, V Hariharan
Milton Keynes Hospital
INTRODUCTION: Inadvertent perioperative hypothermia is a
common consequence of anaesthesia due to elimination of
behavioural responses to cold and impaired thermoregulatory
responses to heat loss. The National Institute for Clinical
Excellence (NICE) published new hypothermia guidelines in
April 20085 and since then, implementation, at best, has been
inconsistent. We aimed to audit our practice in the day surgery
setting and introduce measures to improve outcome.
METHODS: We conducted a retrospective audit looking at the
adherence rate of our practice to the national guidelines over a
period of 2 months in our day case unit. Data were collected
from patient notes and anaesthetic charts subsequently
analysed using Student’s t-test.
RESULTS: A total of 46 (pre-), 53 (intra-) and 99
(postoperative) day case patients were studied with their pre-,
intra- and postoperative temperature documented. Most
patients (93%) in the preoperative stage were normothermic
list changes can actually lead to more efficient patient
throughput and so avoid list overruns. 23.4% of lists finished
early, and 80% of these had cancellations. Downtime between
patients frequently exceeded 15 minutes (43%, 30.6%, and
24% in urology, orthopaedics, and gynaecology, respectively),
mostly reflecting time required for cleaning and complexity of
setup for the next case. Average waiting time in the department
prior to surgery was 2 hr 35 min (range 24 min to 8 hr 45 min). 4
critical incident forms were completed (0.9% of trust forms in
that period), relating to technical or administrative issues. Two
formal complaints were received, one relating to cancellation
on the day of surgery, the other to the attitude of a staff
member.
CONCLUSIONS: Our Treatment Centre is challenged by high
levels of cancellations, frequent changes to theatre lists on the
day, and a difficulty in having patients ready to start all lists on
time. This service evaluation has prompted a further
investigation into why patients do not turn up for their
procedures on the day, and valuable practical suggestions have
been made by nursing staff with regard to streamlining the
admissions process in the morning. This service evaluation has
generated debate with regard to setting standards relating to
waiting times for patients, the use of critical incident forms and
data collection and extraction issues for quality control
purposes. We are now considering the use of real time patient
survey devices to obtain additional feedback on our services. In
addition, this service evaluation is providing data for a wider
theatre improvement project undertaken at the Chelsea &
Westminster Hospital.
but only 26% were normothermic when they arrived in the
recovery room. Within the intraoperative group, temperaturemonitoring
rate was low (7–13%) and 34 (64%) fell into the
NICE high-risk category. However, only 43% (15/34) were
managed according to the guidelines. Postoperatively, 29%
were hypothermic. Hypothermic patients were found to have a
longer stay in the recovery room compared to the
normothermic group (45.5 vs. 31.9 minutes respectively, p =
0.013).
CONCLUSIONS: There was a poor adherence to NICE
inadvertent perioperative hypothermia guidelines in our day
case unit with only 24% normothermic postoperatively. The
causes are often common and multifactorial. Raising staff
awareness and increasing the availability of basic equipment
has since led to an improved outcome. Hypothermia adversely
impacts on both patient care and NHS resources. Therefore,
maintaining perioperative normothermia should be a high
management priority in all day case units.

P25
Incidence of Obesity in Patients
Presenting with a Primary Abdominal
Wall Hernia
I Shaikh, SP Khanolkar, S Kumar
The Royal Infirmary of Edinburgh
INTRODUCTION: Obesity is on the increase in the general
population and may be a risk factor for developing abdominal
wall hernia. Obesity, specifically when associated with comorbidity
such as cardiac disease, may influence a patient’s
suitability for day surgery. The aim of this study was to
determine the incidence of obesity in patients presenting with a
primary hernia of the abdominal wall.
METHODS: Patients presenting with an abdominal wall hernia
in the outpatient clinic between Oct and Dec 2008 had their
body weight and height measured to determine BMI (body
weight in kilograms / height in meters 2 ). A surgeon examined
the patient and recorded demographic details, type of
abdominal wall hernia and any co-existing medical conditions
on a proforma. Patients with a BMI >30 were considered obese.
The data were analysed with SPSS version 17.0. Statistical
significance was denoted by p value of

P27
“NICE, but not Warm Enough on our
Day Surgery Unit!” – A prospective
audit
S Gummaraju, I Hall
South Warwickshire General Hospitals
INTRODUCTION: In order to prevent the deleterious effects of
inadvertent perioperative hypothermia (core temperature
below 36ºC), NICE has formulated clinical guideline 65 in 2008
[1]. This audit aimed to measure our institutional practice in day
surgical theatres in perioperative hypothermia against NICE
guidelines.
METHODS: We prospectively audited 100 patients undergoing
operations in our day surgery theatres (DSU) during March
2009. Data collected in a structured format included patient
demographics, risk factors for perioperative hypothermia,
nature of surgery, temperatures prior to induction, during
surgery, in postanaesthesia care unit (PACU) and discharge
from PACU and interventions used to warm the patients.
Temperatures were recorded with Braun tympanic thermometer
PRO 4000.
RESULTS: Overall, 52% were females, 43% were aged between
51–84 years and 78% had orthopaedic operations and 47%
were identified to be at risk of developing inadvertent
perioperative hypothermia and 3 patients had temperatures
less than 36ºC prior to induction of general anaesthesia. Forty
percent of patients at risk and 48% with no specific risk factors
became hypothermic in the perioperative period. 14% became
hypothermic in theatres and 35% in PACU respectively.
Intraoperatively, warmed crystalloid was administered to 59%
P28
Outpatient Abdominoplasty! Is it a
safe practice?
R Salman, A Salman
Park West Clinic
INTRODUCTION: Extended abdominoplasty has traditionally
been performed as an inpatient procedure. To date, there have
not been many reports on the safety of outpatient
abdominoplasty. We are presenting our clinical outcomes of
abdominoplasty performed in an outpatient setting over a
three year period by a single surgeon at our unit. We have
followed strict selection criteria in order to achieve maximum
aesthetic results with maximum patient safety and satisfaction.
METHODS: A retrospective chart review was performed of all
patients who underwent abdominoplasty from January
2006–December 2008. Each case was evaluated for
demographic information, patient weight, body mass index
(BMI), and weight of specimen, anaesthesia type, estimated
blood loss, operating room time, length of stay, drain
management and complications.
and 47% were warmed with a forced air warming device. Fifteen
percent of patients at risk were not warmed in theatres.
Interestingly 27% of patients not at risk, despite aggressive
warming in theatres became hypothermic on arrival at PACU.
Temperatures on transfer from PACU were not documented in
the audit forms for 94% of hypothermic patients. Two patients
were discharged from PACU with temperatures below 36ºC.
Grade of anaesthetists and duration of surgery had no impact
upon our findings. Despite inadvertent perioperative
hypothermia, there were no delays in discharge, unplanned
inpatient admissions or any other clinical complications
amongst the audit population.
CONCLUSIONS: Forty five percent of patients undergoing
surgery in our DSU appear to be at risk of perioperative
hypothermia as compared to forty percent in general theatres
in other studies [2]. Some patients tend to be hypothermic
despite preventative measures. Effective team work and
meticulous documentation is necessary to prevent inadvertent
perioperative hypothermia. A forced air warming device adds
another £5.20 per head to patient care in DSU.
REFERENCES
1. http://www.nice.org.uk/nicemedia/media/doc/FinalScopePerio
perativeHypothermiaAdults.doc
2. Williams C, et al. British Journal of Anaesthesia
2008;101:879–80
RESULTS: A total of 48 patients, (47 female and one male),
underwent abdominoplasty. The average patient weight was 78
kg while the average BMI was 38 kg/m 2 . The average estimated
blood loss was 100 ml and average operative time was 180
minutes, while mean specimen weight was 1,000 gram. There
were no perioperative blood transfusions. All patients (100%)
were discharged the same day. There were only two minor
complications one superficial wound infection and one case of
seroma.
CONCLUSIONS: We conclude with our experience that
appropriate patient selection, education and operative
techniques; outpatient abdominoplasty can be performed
safely and successfully.

P29
Patient Outcomes and Satisfaction
Following Day Case Laparoscopic
Cholecystectomies
ML Wattie, N Menezes
Ashford and St Peters NHS Trust
INTRODUCTION: Having introduced day case laparoscopic
cholecystectomies 3 years ago our objective was to assess
quality of care and patient satisfaction.
METHODS: A prospective audit of all day case laparoscopic
cholecystectomies performed in our trust was undertaken over
a 2 year period between May 2006 and May 2008. As per the
established patient pathway all patients were discharged by a
nurse following a medical review. Written and verbal
postoperative instructions were given including the telephone
number of the surgical assessment unit should they experience
any problems. The take home medication was paracetamol or
co-dydramol and a nonsteroidal. Patients with a
contraindication to nonsteroidals were given slow release
tramadol. The day after discharge every patient was
telephoned by a member of the day surgery team to assess
how much pain, nausea and vomiting they had experienced. We
also established readmission rates and satisfaction with their
care.
RESULTS: Over a 2 year period we surveyed 140 patients who
underwent a laparoscopic cholecystectomy as a day case. 43 in
the first year and 89 in the second year.
P30
Patient Satisfaction Survey: Day
Surgery Unit Ashford Hospital,
Middlesex 2008
J Ryman, E Shepherd
Ashford Hospital, Staines, Middlesex
INTRODUCTION: Patient satisfaction is of growing importance
to clinical service providers. This survey aimed to establish
patient satisfaction with issues of communication,
environment, pain control, privacy and dignity.
METHODS: A questionnaire was designed and given to
patients attending the Day Surgery unit for return by post. The
questionnaire was given to all patients who attended over a
period of one month.
RESULTS: Communication: 91% said the pre-admission
information leaflet had told them everything that they needed
to know, and 89% said they were given all the information they
needed by reception. 71% of patients were kept informed of the
length of their wait “fully” or “to some extent”. 94% felt the
surgeon had explained their procedure in a way they could
“completely” understand. The remaining 6% felt they had been
able to understand the explanation “to some extent”. 89% said
that staff explained when the patient could resume their
normal activities “fully” or “to some extent”. 77% had been
told what danger signals to look out for and 76% had been told
who to contact if they had a problem at home. Environment:
100% of patients considered the day surgery unit “very” or
“fairly clean”. 89% considered the toilets “very” or “fairly
Symptom
Pain
Nausea
Vomiting
Four patients contacted the hospital or their GP. Two (0.14%)
were readmitted, both for urinary retention. One had severe
vomiting, the other had pain. Neither wished to be admitted.
There were nine admissions:
Patient satisfaction levels were very high. 78% of patients rated
their care as excellent and 20% rated their care as good. 2%
made no comment.
CONCLUSIONS: Patient satisfaction was high despite a larger
than recommended [1] number of patients expressing moderate
pain. In line with RCOA standards less than 5% expressed
severe pain. Readmission rates were low as were unplanned
admissions. Overall we concluded that day case laparoscopic
cholecystectomies are conducted safely in our trust based on
low readmission rates and high patient satisfaction. However
there is room for improvement in pain relief. Introduction of
protocol driven postoperative prescribing may improve this
outcome measure [2].
REFERENCES
None/mild
70%
95%
92%
Reason for admission
Drain in situ
Surgical decision / complications
Moderate
28%
3%
3%
Severe
2%
2%
5%
Number (%)
3 (14%)
6 (29%)
1. Jackson IJB. Raising the standard, RCOA, 2006
2. BADS Day Case Laparoscopic Cholecystectomy handbook,
2004
clean”. 84% rated the refreshments provided “good” or
“excellent”. Pain control: 79% of patients who reported pain
after surgery thought that staff had done everything they could
to help control the pain. Privacy and dignity: 94% felt their
privacy and dignity had been maintained “all of the time” and
the remaining 6% “some of the time”. 14.5% of patients did not
feel they had enough privacy when discussing their surgery
with the doctor. 90% of patients were “not at all” or “not very”
concerned about sharing the ward with patients of the opposite
sex. Overall, 100% of patients rated their experience as
excellent or good.
CONCLUSIONS: Patients reported a high level of satisfaction
with their care in the day surgery unit although some issues
were raised around communication, particularly the
information given at discharge.

P31
Patient Satisfaction Survey in a Day
Case Unit in an Elective Orthopaedic
Hospital in the UK
P Banerjee, N Blewitt
Avon Orthopaedic Centre North Bristol
INTRODUCTION: Day case surgery is becoming more popular
in the surgical care practice in the UK. They receive care that is
better suited for their needs. We conducted a survey among the
nursing staff and patients from the elective orthopaedic day
surgery unit at Avon Orthopaedic Centre April–May 2007. We
compared our practice to the BADS guidelines. The nursing
staffs were asked about the existing patient discharge criteria.
METHODS: Validated questionnaires were prospectively
prepared based on existing guidelines. A set was given to day
case patients about the service they had received. Another set
was circulated among the nursing staff involved in day case
orthopaedic surgery regarding patient discharge which was
based on scoring rather than the existing descriptive criteria
based assessment.
P32
Patient Satisfaction within the
Portsmouth Day Case Laparoscopic
Cholecystectomy Service
AM Walters, K Williamson, D Wainwright,
S Sadek, S Toh, T Whitbread
Portsmouth Hospitals NHS Trust
INTRODUCTION: Day case laparoscopic cholecystectomy has
been shown to be a safe and cost effective way to treat
uncomplicated cholelithiasis in selected patients. The
minimum requirements for such a service must include an
experienced surgical team, dedicated theatre facilities and
appropriate patient selection. Despite this, patient
expectations and satisfaction may vary. Our day case
laparoscopic cholecystectomy service has been pioneered by
four consultant surgeons and a laparoscopic surgical care
practitioner. This service is provided on three separate hospital
sites with the potential for a variable patient experience; as
maintaining consistency of preoperative assessment,
administration and theatre practices can be difficult. The role of
a dedicated laparoscopic surgical care practitioner includes
identifying patients suitable for day surgery, counselling
patients on what to expect from the procedure, assisting in
theatre and close follow-up post-surgery. The importance of
preoperative counselling and postoperative follow-up can be
highlighted by high patient satisfaction across all three sites.
METHODS: Patient satisfaction questionnaires were sent with
pre-paid return envelopes to all day case laparoscopic
cholecystectomy patients during the five month period from
the 1st September 2008 to 31st January 2009. 83
RESULTS: Of the eighty one patients included, 41 (50.61%)
responded. Seven out of eight nurses (87.5%) responded.
Patients admitted from the day unit were excluded. Thirty nine
(95.12%) patients were satisfied with the care. Twenty three
(56.09%) patients were reviewed by the surgeon and 12
(29.26%) were seen by the anaesthetist before they were
discharged. Six (85.71%) out of seven nurses were happy with
the existing criteria for discharging patients. Five (71.42%) of
them thought it was more scientific to use a scoring system.
Lack of privacy, long waiting time and lack of communication
were issues raised by some patients. Nurses were concerned
about a complex calculation of scoring pulse/ blood pressure.
CONCLUSIONS: Recommendations included that the patients
on the afternoon list be called later to avoid long waiting and
patients change their dress in the theatre. All patients should
be reviewed by the surgical and anaesthetic team before
discharge. A printed handout with discharge advice and a
contact phone number to be given to all day case patients.
questionnaires were sent out, and 50 returned (60% response
rate). Questions were formulated to identify patient
satisfaction across the whole patient experience from
admission to postoperative follow-up, using a tick box formula
ranging from strongly agree to strongly disagree. We also
included a section for written comments on what patients felt
we did well, where we could improve and the amount of
information they had been given.
RESULTS: 29 patients strongly agreed that they were satisfied
with the admission process,19 agreed whilst 2 disagreed. 28
patients strongly agreed there was a clean and professional
environment, 21 agreed whilst 1 disagreed. 33 patients strongly
agreed with an approachable and professional staff attitude, 16
agreed, whilst 1 disagreed. 20 patients scored their overall care
received [1 (poor) to 10 (excellent)] at 10; 12 patients scored it at
9; 11 patients gave a score of 8; 4 gave a score of 7, and 2 a
score of 6. Only 1 patient gave a score of 3 out of 10. This
indicates a high level of patient satisfaction. 45 patients said
yes they had received a postoperative phone call and found it
helpful, 3 said yes to some extent and 2 said not applicable.
CONCLUSIONS: These results clearly demonstrate high patient
satisfaction for those individuals following the day case
laparoscopic cholecystectomy pathway in Portsmouth; with
consistent results across the three hospital sites, and the four
consultant surgeons. This consistency demonstrates that the
presence of a dedicated laparoscopic surgical care practitioner
has a significant effect on providing a high quality service with
high patient satisfaction for day case laparoscopic
cholecystectomy patients.

P33
Provision of Appropriate Chairs for
Anaesthetists may Reduce Back Pain
Related to Theatre Seating
Y Haroon, JM Vernon
Nottingham University Hospital, City Campus
INTRODUCTION: The NHS loses 8.2 million working days each
year to sickness absence. Back injury accounts for 40% of this
[1]. In 2005, following concerns over back pain associated with
sitting on theatre stools, consultant anaesthetists at
Nottingham City Hospital were anonymously surveyed
regarding backache associated with theatre seating. This
showed that in the previous three years 55% of the responding
anaesthetists had one or more episodes of backache
associated with sitting on low theatre stools (response rate
65%.) Of the 12 who had an episode of backache related to
sitting on a theatre stool, 7 required more than one dose of
analgesic and 3 would not have been able to work on
subsequent days. Two incidents were recorded when theatre
stools toppled over causing injury. As a result of a risk
assessment, one adjustable swivelling theatre chair was
purchased for each operating theatre for anaesthetist’s use (at
a cost of £1,730 for 17 chairs).
METHODS: The anonymous survey was repeated in 2009, 3
years after the introduction of theatre chairs. This 3 year period
matched that of the initial survey. Additional questions
surveying awareness of three pieces of advice from the
ergonomics department to prevent back pain were included.
RESULTS: The response rate was 66%. 3 out of 23 anaesthetists
had an episode of back pain associated with sitting on a theatre
stool, one of which required medical attention. No anaesthetist
P34
Reasons for Cancellations in Day Case
General Surgical Procedures
A Hakeem, S Mandal, M Dube, K Badrinath
King’s Mill Hospital, Sutton-in-Ashfield,
Nottinghamshire
INTRODUCTION: The cancellation of surgery at the last
moment is an undesirable event not only for the patient, but for
the hospital as well. This leads to unnecessary wastage of
costly theatre time and creates doubt within the patient’s mind
regarding the quality of service provided. The aim of this study
was to examine reasons for on the day cancellation of day case
general surgical procedures, so as to identify rectifiable causes.
METHODS: A retrospective evaluation of cancellation of all day
case general surgical procedures performed between January
to December 2008 was carried out. The reasons for
cancellation were examined and specified as appropriate. The
statistics were carried out using Fischer’s exact test.
had had back pain associated with sitting on a theatre chair.
There was a statistically significant decrease in backache
associated with theatre seating, when the periods before and
after the purchase of theatre seats were compared, Chi square
test p

P35
Routine Ultrasonography: The future
in the management of inguinal
hernias?
S Alagaratnam, WKB Ranasinghe,
TIJ Ranasinghe, AP Zbar
University College London Hospital
INTRODUCTION: Inguinal hernias can present as a wide
spectrum of symptoms ranging from an asymptomatic bulge to
life threatening strangulation. It is seen that indirect inguinal
hernias were more likely to strangulate than direct hernias [1].
The current consensus is that, with advances in repair
techniques and anaesthetics, all hernias should be operated
on. However, some recent evidence suggests conservative
management of asymptomatic inguinal hernias as an option,
with very small strangulation rates even in indirect hernias [1].
Therefore in opting for conservative management of the
asymptomatic hernia, accurate clinical diagnosis between
direct and indirect hernias is essential. Ultrasonography (USS)
has been increasingly used in the diagnosis of inguinal hernias.
We look into the use of USS in aiding the management of
inguinal hernias by identifying the location of the hernia.
METHODS: Separate Medline searches were carried out to
investigate the evidence behind conservative management of
hernias, the accuracy of the clinical diagnosis of inguinal
hernias and the use of imaging in diagnosis.
RESULTS: In data from randomised controlled trials [1,2] where
minimally symptomatic hernias were randomised and followedup
for a period of 2–4.5 years, the rate of hernia strangulation
or incarceration was only 0.0018 events per patient-year [1]. The
demonstrated crossover rate from watchful waiting to operative
surgery was 20% at 12 months [2] and 23% [1] at 2 years, due to
P36
Stapled Haemorrhoidectomy – An
effective and feasible day case
procedure
N Pranesh, A Saleh, BA Taylor, MJ Tighe
Warrington & Halton Hospitals NHS Trusts
INTRODUCTION: Stapled haemorrhoidectomy or Procedure for
Prolapse and Haemorrhoids (PPH) reduces prolapse of
haemorrhoidal tissue by excising a band of prolapsed anal
mucosa above the dentate line. Compared to the Milligan
Morgan open haemorrhoidectomy, it is associated with less
pain up to 14 days postoperatively, a shorter wound healing
time and significantly less pain at 14 days postoperatively.
Moreover, there is no difference in long term rates of recurrence
of prolapse. It is also associated with less faecal incontinence
and is cost effective.
METHODS: We included all cases performed at Warrington and
Halton hospitals from Nov 2006 to Feb 2009. The patient
demographics, symptoms and signs at presentation,
treatments before the definitive procedure, time from
presentation to surgery, postoperative length of stay, patient
satisfaction and postoperative complications were gleaned
from patient records.
RESULTS: 36 patients were included in the study of which 17
were female. The mean age was 51 years (median 48). 22
pain. There were no quality of life adjusted life years gained for
the elective surgery arm [2]. By delaying surgery there was no
increase in surgical complications, difficulty in the surgical
procedure, recurrence rates or reduced patient satisfaction [3].
Published rates of inaccurate diagnoses of inguinal hernias
were between 17–36% for direct and 15–41% indirect hernias
on clinical examination, with the error rate going up to 71% for
femoral hernias. For diagnosis and differentiation of inguinal
hernias the sensitivity was 92.7–100% and specificity
81.5–100% for USS, possibly better than MRI scanning and
herniography. USS is also very efficient in the diagnosis of
notoriously difficult and rare hernias such as Spigelian and
obturator hernias and also revealed other information such as
involvement of bowel and strangulation [4].
CONCLUSIONS: Inguinal hernias may be managed
conservatively, requiring accurate diagnosis of the type of
hernia. USS, with no known side effects, can differentiate
inguinal hernias with high precision and also differentiate from
alternative diagnoses. USS is used widely and integrated into
part of the core-competencies in the emergency department
(FAST) and obstetrics and gynaecology trainees. Use of USS
should be a vital part of future UK surgical training as an aid to
diagnosing hernias, given the current evidence of watchful
management.
REFERENCES
1. Fitzgibbons RJ, et al. JAMA 2006;295:2726
2. O’Dwyer PJ, et al. Annals of Surgery 2006;244:174–5
3. Thompson JS, et al. American Journal of Surgery
2008;195:89–93
4. Yokoyama T, et al. American Journal of Surgery
1997;174:76–8
patients presented with both bleeding and prolapse, 10
patients presented with bleeding only and 4 patients with
prolapse only. 8 patients had undergone both injection
sclerotherapy and banding, 6 patients underwent only
sclerotherapy and 5 patients only banding preoperatively. The
mean time to definitive surgery was 350 days (median 193
days). 17 patients were discharged on the day of the procedure
and 17 patients within 23 hours of the procedure. At follow-up
31 patients were satisfied with the procedure. At 6 weeks
follow-up, 6 patients reported minor bleeding, 4 patients
reported prolapse and 3 patients increased frequency of
defaecation. Only 1 patient required re-intervention in the form
of an open haemorrhoidectomy.
CONCLUSIONS: Stapled haemorrhoidectomy is ideally suited
for a day case procedure. About 50% of patients had
undergone several previous outpatient procedures resulting in
a delay of about a year prior to the definitive operation. Most
patients were satisfied with the procedure and the reintervention
rate was low. The results support the current NICE
recommendations for stapled haemorrhoidectomy – that the
procedure should be considered as primary treatment in
patients with prolapsed internal haemorrhoids.

P37
Sub-specialisation and Outcome of
Laparoscopic Cholecystectomy in a
District General Hospital
AT Clark-Morgan, M Javed, B Swiech, A
Jansuz, V Sujendran, M Farouk, S Appleton
Buckinghamshire NHS Hospitals
INTRODUCTION:Over the past decade in the UK we have
moved towards subspecialisation in general surgery. There are
clear guidelines for gastrointestinal cancer services but only
limited guidelines on benign diseases. The Institute for
Innovation and Improvement recommends 200 laparoscopic
cholecystectomies per surgeon over 5 years, equating to 40
cases per year, furthermore recommending 70% of the elective
cases to be carried out as day cases and 90% as 23 hour
hospital stay.
METHODS: A retrospective analysis of two cohorts of patients
undergoing laparoscopic cholecystectomies in 2006 (1 year)
and 6 months in 2008 (February–July 2008). Analysis was
focused on the subspecialties performing laparoscopic
P38
The Development of Services for the
Treatment of Age Related Macular
Degeneration in Aintree NHS Trust
R Mallett, D Ewing, T Myhre, S Wilson,
A Kamal, D Clark
Walton Hospital Rice Lane Liverpool
INTRODUCTION: The AMD services at Walton day surgical unit,
part of Aintree NHS Trust, has developed and expanded to
meet the needs of the aging population. The patients come
from areas of the Northwest including Sefton, Merseyside,
Lancashire and the Isle of Man. The Day Surgical Unit offers
Avastin and Lucentis injections to patients who are suitable for
treatment as per the criteria. Since the commencement of these
lists we have steadily increased our number of patients per list.
As funding has been secured we now do on average twelve to
eighteen patients per list and three to four lists per week.
METHODS: The injections take place over a period of three
months with one injection per month. The timescale is of vital
importance. Improvements in eyesight are measured by
Logmar assessments in clinic. The ranges of staff involved in
this service are: clerical staff; clinic nurses; ophthalmic
surgeons; optometrists; theatre staff; pharmacy; ambulance
services.
cholecystectomies, perioperative outcomes, day case rates,
overnight stay and readmission.
RESULTS: In 2006 over a period of 1 year 408 laparoscopic
cholecystectomies were performed of which 54% were carried
out by UGI surgeons and 46% by non UGI surgeons. Conversion
rate was 5%, severe adverse events were 8.6% (2 CBD injuries)
and readmission was 3.4%. The day case rate was 25%. From
February 2008 to July 2008 192 cholecystectomies were
performed of which 76% were performed by upper GI surgeons.
The conversion rate was 1% and 92% of the elective
laparoscopic cholecystectomies were performed as either day
case (66%) or overnight stay. Readmission rate was 6.9%.
CONCLUSIONS: With sub-specialisation there is a significant
decrease in conversion rate, perioperative complications and a
significant increase in day case laparoscopic cholecystectomies
being performed. This is mirrored by a small increase in readmission
rate.
RESULTS: The patients who usually attend for this treatment
need a higher level of care than average clinic patients, due to
the fact they are older, have poor eyesight and other medical
problems. Taking all these factors into consideration a
thorough risk assessment has been undertaken.
CONCLUSIONS: Development of this service in the day surgical
unit is vital in providing a new treatment for the AMD patient at
Aintree NHS Trust.

P39
The Impact of RTT on Preoperative
Screening and Assessment Services
Within Poole Hospital
J Hindess, N Roberts
Poole Hospital NHS Foundation Trust
INTRODUCTION: At the BADS conference 2007, we
demonstrated that our preop. screening and assessment
service (POS/A) was running successfully. The Government
have introduced the “Referral to Treatment (RTT)” pathway that
ensures every patient has treatment within a set number of
weeks from primary referral. Currently, our trust is aiming
towards a local target RTT of 13 weeks. POS/A has been proven
to prevent patient cancellations, save inpatient bed days and
reduce DNA rates, so is vitally important in preventing delays to
all elective surgical patient pathways. Although the service has
always been busy, we have identified a direct correlation
between the introduction of RTT at 18 weeks to an increased
throughput of patients through POS/A. As the RTT targets
decrease, the pressures on our service has increased, due to
the same number of patients having to be seen in a shorter
space of time.
METHODS: The POS process has always involved all surgical
patients being directed to day case preassessment
immediately following the decision to admit. By seeing a POS/A
nurse at this point, plans and decisions concerning every
patient’s surgical pathway are made. The POS nurse identifies if
the patient is “Ready, Willing & Able” and that all required tests
and investigations are performed. A data collection tool was
designed to monitor activity and demonstrated the need for
service review in order to improve patient satisfaction and
choice without encroaching on the RTT pathway. Through
change of working practice and as a result of a business plan
submission, we were able to implement more staff, change
clinic working hours, introduce telephone assessments,
evening clinics, pre-booked appointments for those patients
who cannot or choose not to wait and dedicated anaesthetic
support.
RESULTS: In 2005 pilot study, 403 patients were screened over
3 months. April 2007, 427 patients screened. April 2008, 704
patients screened. January 2009, 741 patients screened.
CONCLUSIONS: As our results show, activity has increased
with the implementation of the RTT pathway and continues to
do so, with the expectations of achieving the local targets.
Patients’ assessments have become more complex as have the
operations undertaken as day cases. This has impacted on the
management of our nurse-led clinic with regards to more input
and further resources needing to be designated in order to plan
a safe and successful admission for every patient. Our prebooked
assessment appointments are quickly filled by referrals
from other hospitals that do not offer a POS service for patients
who will be treated at Poole. Further work is required to be able
to offer assessment appointments within 7 days to facilitate the
RTT. This inevitably requires more funding and environmental
space. The trust is investigating if a stand alone centralised
POS/A unit will be a solution to the problems encountered to
date as it should be staffed according to the expected activity.