More than a century ago Dr James Nicoll, a Scottish surgeon working at the Sick Children’s Hospital and Dispensary in Glasgow, published a paper in the British Medical Journal about his experiences of approximately 9000 paediatric surgical patients, most of whom he operated on alone in an outpatient setting (Jarrett, 1999). Nicoll believed that much inpatient treatment was a waste of hospital resources because the results obtained in the outpatient department were equally as good but at a fraction of the cost. He believed that carefully selected children recovered better at home, in the care of their family, provided that they were given the necessary education and information to care for their child postoperatively. He also believed that outpatient surgery was cost-effective and, that by removing children from inpatient beds, their treatment and recovery would be of a higher quality. Nicoll could not have realised then the impact that his practice would make in the mid-to-late 20th century, when the rising costs of health care created a trend to the performance of more surgery on an outpatient or day surgery basis. Nicoll is regarded as establishing the foundations for modern day or ambulatory surgery.

Like the impact that is attributed to Nicoll’s work, Hippocrates is noted to be one of the first people who attempted to see inside the gastrointestinal tract by inspecting the rectum with a candle. In 1795 Bozzini used a rigid sigmoidoscope. By the 1870s, Kussmaul was attempting to visualise the stomach with a rigid tube; however, it was not until 1932, when a semi-flexible instrument was designed by Rudolph Schindler to inspect the stomach, that flexible endoscopy began to move into its own domain. Hirschowitz, Curtiss, Peters and Pollard enhanced the design of these instruments in 1958 with their new fibrescope, using fibreoptic bundles to transmit the image. From this point, gastroenterology has evolved into what it has become today (Mays, 2003).

The advent of rapid development in endoscope design, along with procedural advancements, has created a demand for skilled personnel who can manage not only the patient but also care of the equipment. Specialised endoscopy units have developed as free-standing entities as well, as in hospitals, and practice within all of them is underpinned by clinical guidelines, professional standards and specific health department policies. These have been developed collaboratively and some of them are now mandated (Mays, 2003).

Development of day surgery

In the 1950s some day surgery was being performed internationally but the concept of a purpose-designed day surgery unit was not taken up until 1962, with the development of a hospital-based ambulatory surgery unit at the University of California, followed by the first free-standing ‘surgicenter’ opened in 1969 in Phoenix, Arizona (Jarrett & Staniszewski, 2006). In Australia, the first purpose-designed, free-standing day surgery centre was built in Dandenong, Victoria, in 1982, and the first free-standing centre on the campus of a public hospital at Campbelltown, New South Wales, in 1984 (Roberts, 2004). These were followed quickly by the development of other units around Australia.

Initially, this new concept generated little enthusiasm for changing the way health care was provided, as there was no incentive to change at that time. However, since the late 1980s and 1990s, a slow but steady growth of day surgery units has occurred in both the public and private sectors. These units have demonstrated their efficiency, combining good postoperative outcomes with high-levels of patient satisfaction. Factors contributing to the growth of day surgery have included: the continuing need to reduce extensive hospital waiting lists; the rising costs of health care in general; an increasing and ageing population demanding more surgical interventions; advances in surgical and non-surgical techniques and technology; the development of new, shorter-acting anaesthetic agents and drugs; and the commencement of national cancer screening programs.

The advantages offered by day surgery are listed below.

• Day surgery is cost-effective because the unit functions Monday to Friday, and staff normally only work regular morning and afternoon shifts. Units usually close over the weekend and on public holidays.

• Expensive inpatient beds are not required.

• Organised day surgery lists have a high turnover and cases are rarely cancelled.

• When self-contained or free-standing, day surgery frees up valuable operating time in the main perioperative environment.

• There is a reduced risk of hospital-acquired infections.

• Early ambulation reduces the risk of thromboembolism.

• Patients, particularly the elderly, are less anxious, knowing that they can recover in the comfort of their own home.

• Day surgery is associated with less anxiety in paediatric patients (Davidson & Sale,2006).

For most patients, spending minimal time in hospital is a great advantage and day surgery has become accepted as an alternative to lengthy hospital stays. Despite the obvious advantages of day surgery, there has been little encouragement from federal or state governments to increase activity rates. Roberts (2004) estimated that the potential for day surgery had increased from 50% to 75% (possibly more) of all operations/ procedures. However, statistical information from the Australian Institute of Health and Welfare (AIHW) (2007) shows that, in 1996–97, the rate of same-day activity, for all separations, was 44.7%. The rise in activity over the last 10 years has been approximately 1% per annum, as current statistics show (Table 10-1).

Table 10-1 Current activity, all separations, 2005–06

State/Territory	Day surgery activity
Victoria	58.8%
Queensland	56.9%
Western Australia	55.2%
South Australia	52.2%
New South Wales	51.8%
Tasmania	not published
Northern Territory	not published
Australian Capital Territory	not published
Average	55.3%

AIHW (2007)

The driving force to increase utilisation of day surgery principles in Australia is the Australian Day Surgery Council (ADSC), which is a multidisciplinary body of experts who have been responsible for setting standards and introducing clinical indicators, and who are involved with federal and state government on all aspects of day surgery (ADSC, 2004). The Australian Day Surgery Nurses Association (ADSNA) and the Gastroenterological Nurses College of Australia (GENCA) have also been instrumental in promoting best practice guidelines for ambulatory surgery and procedures, as well as providing educational opportunities for nurses working in day surgery and endoscopy settings. However, notwithstanding the utility of professional guidelines, they are not without limitations, as a systematic review described in Box 10-1 demonstrates.

Box 10-1 Systematic reviews of day surgery

Richardson-Tench, M., Pearson, A., Birks, M. (2005). The changing face of day surgery: using systematic reviews. British Journal of Perioperative Nursing, 15(6), 240–246.

This paper discusses the systematic reviews that resulted in the ADSNA publishing its best practice guidelines for:

• staffing models in day surgery units

• pre-admission procedures for day surgery units

• care of patients while in the day surgery unit.

The article highlights the lack of quantitative evidence to ensure best practice, noting instead that expert opinion underpinned many professional standards. Richardson-Tench et al (2005) strongly recommend the need for primary research in the above areas; it is not only relevant for day surgery practice but also for perioperative practice in general.

A steady increase in day surgery has been carried out internationally; however, this varies between countries, between and within regions, and in the types of procedures performed. Developed countries have performed better than developing countries as there are fewer barriers. Table 10-2 presents data on selected procedures extracted from a survey carried out by Toftgaard and Parmentier (2006) for the International Association for Ambulatory Surgery (IAAS). Table 10-2 shows that there are opportunities for growth in day surgery for some procedures in Australia, whereas for other procedures the limits appear to have been reached.

Table 10-2 Percentage of selected cases completed in day surgery settings by country

Country	Arthroscopic menisectomy	Laparoscopic cholecystectomy
Australia	81%	2%
England	70%	3%
Germany	32.5%	0.5%
United States	96.7%	49.8%
Canada	97.7%	43.9%

Growth of day surgery and endoscopy

Advances in surgical techniques and technology

The availability of endoscopes has been instrumental in changing the face of day surgery, and has required surgeons/proceduralists to learn new skills. Similarly, surgeons have developed techniques of operating via smaller incisions. These techniques have led to less tissue trauma, less postoperative pain and quicker overall recovery from surgery. Advances in wound drainage systems allow the patient to be discharged with a small drain in situ (to be removed the next day). Diagnostic and therapeutic laparoscopy and other forms of endoscopy, removal of simple skin growths/cancers, repair of varicose veins, hernia repair, cataract removal, cystoscopy and in-vitro fertilisation are some examples of procedures commonly performed in day surgery settings.

The development of flexible endoscopes, along with the use of cameras that can be attached to them (resulting in the visualisation of the internal operative site on largescreen monitors), has resulted in a new range of procedures subsequently evolving. Flexible endoscopes are complex, long-lumened instruments that can be used to visualise the lungs, upper and lower intestinal tracts, biliary, gynaecological and urological systems. The small bowel has been difficult to visualise due to its length but this is improving as new technologies evolve, such as the double-balloon endoscope. There is also an ingestible capsule which, during its 8-hour transit through the small bowel, is able to take thousands of photographs. Although most endoscopic procedures are completed within the day surgery or endoscopy unit, lengthy procedures may require an extended or overnight stay for the patient to facilitate the process of monitoring that is required for patients undergoing small bowel investigations.

Another influence on the growth in day surgery procedures is exemplified by the National Bowel Cancer Screening Program. This screening initiative is a preventive measure to improve patient outcomes and to lessen health care costs by diagnosing bowel cancers earlier via a faecal occult blood test. This program evolved because of the development, firstly, of an effective, easy to administer, population-based faecal occult blood test. Subsequently, the Australian government implemented the National Bowel Cancer Screening Program in 2006 (MacLellan, 2006). It is anticipated that this will result in greater numbers of patients undergoing flexible colonoscopy to identify the cause of the bleeding from the bowel previously detected via faecal occult blood test.

De Jong et al. (2006) discuss the role of day surgery in a variety of surgical specialties for frequently performed procedures, and recommend that more complex procedures be introduced in the near future. However, careful patient selection remains the key to success.

Advances in anaesthesia

Over the last two decades, significant improvements in anaesthetic techniques have been made owing to the availability of more refined, shorter-acting anaesthetic agents with minimal side-effects. Volatile inhalational agents, such as sevoflurane, desflurane and isoflurane, are popular, and propofol is now commonly used because its properties are such that patients recover rapidly following its use. Total intravenous anaesthesia (TIVA) is ideal for some procedures (Raeder, 2006) and local infiltration, with or without peripheral or regional nerve blocks, may be used and provide good pain relief intra and postoperatively. Fentanyl is another drug with a rapid onset and short duration, making it ideal intraoperatively as well as postoperatively, where it provides excellent analgesia (Gupta, 2006). The variety of antiemetic drugs currently available allows for more effective control of postoperative nausea and vomiting than previously (Bustos et al., 2006; Langton & Gale, 2007).

Equipment used by the anaesthetist has also markedly improved. The laryngeal mask airway has replaced the endotracheal tube for the majority of patients having a general anaesthetic. More sophisticated monitoring equipment records all events and data throughout the anaesthetic and allows for early warning of untoward events, facilitating early intervention. Raeder (2006) states that, ‘The most important aspects of quality in an optimum anaesthetic technique are rapid and clear headed emergence, no postoperative pain, no postoperative nausea or vomiting and absence of any perioperative side effects or discomfort’ (p 186).

Patient acceptance

Patient acceptance of and satisfaction with day surgery is consistently high, providing that their expectations of the experience are met, namely:

• a smooth and trouble-free preoperative admission process

• a successful surgical intervention

• no or minimal postoperative side-effects

• able to go home on the same day with the confidence to cope and recover at home.

The ideal facilities are specifically designed to provide a relaxed, non-threatening, hotel-like ambience where patients receive individualised care. Day surgery is particularly suited to children, who are separated from their parents for as short a time as possible. Given a choice, most paediatric patients and their families would choose day surgery over an inpatient stay (Davidson & Sale, 2006).

However, expectations can be problematic to manage if patients are not given the correct information and explanations during the preoperative consultation. The day surgery experience can seem like a ‘production line’ and patients can feel they are being rushed through the system (Richardson-Tench et al., 2005). Adequate education and care will alleviate these problems, and must be combined with good communication between day surgery and/or perioperative/endoscopy staff, and patients and their families/carers.

Even though patient acceptance of the day surgery experience is mainly positive, acquiescence with the bowel preparation for lower endoscopic procedures can be problematic. Many patients inform staff on admission to the day surgery unit that they were unable to complete the bowel preparation. This is due to its unpalatable nature and/or quantity of medications to be consumed, combined with the (frequent) onset of headache, hunger and diarrhoea caused by the preparation. This, together with the perceived embarrassment associated with the procedure, prevents a number of patients attending for colonoscopy. It is important to educate patients adequately about these matters and their subsequent management prior to the event. This education enhances their overall experience and improves compliance with the necessary preparation. It is often the gastroenterological specialist who gives this information to private patients, which nursing staff reinforce when telephoning the patient on the day before to confirm admission time the following day. Adequate bowel preparation is vital to the success of the procedure and, if this is not completed as directed, then patients need to be aware that the procedure may produce suboptimal results or even be cancelled (Dix, 2007).

Patient selection and assessment

Careful selection and assessment is paramount to successful day surgery and endoscopy, and many factors need to be taken into account in making a decision. It is strongly advised that each facility adopt a team approach to establishing written criteria for patient assessment and selection. This means that all who may be involved in the care of the patient—surgeons, doctors, anaesthetists, nurses, social workers, diabetes educators, pain management consultants, physiotherapists—should be involved. Ensuring this involvement results in all stakeholders taking ownership of the criteria developed, and consequently abiding by them. The criteria should address, but not be limited to, suitability of the procedure, significance of medical history, the minimal physical and anaesthetic assessments to be undertaken, and how the evaluation of social circumstances will be determined. The criteria are then used throughout the selection and assessment process, allowing those patients who do not meet the criteria to be referred for treatment as an inpatient.

Traditionally, patients have been selected following the American Association of Anesthesiologist’s (ASA) physical status classification system, whereby patients classified as ASA 1 and 2 were deemed appropriate for day surgery. This classification is presented in Table 2-2.

However, Gudimetia and Smith (2006) noted that the ASA classification is a simple, albeit crude, evaluation of chronic health and further add that patients with a ranking of ASA 3 do not experience more complications in the medium-to-late recovery period or problems after day surgery. They therefore recommend that patients who are classified as ASA 1–3 should be considered suitable for day surgery unless they have other contraindications, and that some patients classified as ASA 4 may also be acceptable for day surgery under local anaesthetic.