C19_Rowan Thomas - Australian and New Zealand College of

Report
Dr. Rowan Thomas
MBBS FANZCA MPH
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What are the selection criteria?
Should the criteria be changed?
(A sociological perspective)
How can it be changed?
(A policy perspective)
The importance of follow up and outcome
review
Tertiary referral Hospital
Day of surgery discharge
not high – 25-30%
Australian average 60%
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Economic or utilitarian drivers.
Lower morbidity
Faster mobilisation and recovery
Able to be with family
Free up resources for other health care areas
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Two components. Day of surgery arrival
(DOSA) + Early discharge
DOSA requires:
◦ Optimisation of co-morbidities and medications
◦ Early assessment, communication and consent
◦ Timely arrival and fasting
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Early discharge requires:
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Good pain management
Resolution of unwanted effects of anaesthesia
Good social supports
Adequate time to assess surgical complications
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Pain (Not enough analgesia?)
Nausea (Too much opioid?)
Bleeding
Unstable co-morbidity
Incapable of self care
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Minimally invasive techniques are widening
the range of possible surgeries
Minimal risk of post-operative Haemorrhage
Minimal risk of post operative airway
compromise
Pain controllable by outpatient techniques
Post-operative care that can be managed by a
responsible adult or home nursing facilities
A rapid return to normal fluid and food intake
ANZCA Policy PS15
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A willingness to have the procedure performed
and an understanding and an ability to follow
instructions
Patient’s place of residence within one hour’s
travelling time from medical attention
ASA I or II. Stable ASA III or IV. Careful
consideration for higher ASA grades.
Infants and children where associated paediatric
facilities and experience exist. Should be older
than 6 weeks (normal term) or greater than 52
weeks post-conceptual age if premature (< 37
gestation)
ANZCA Policy PS15
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A responsible person able to transport the
patient home in a suitable vehicle.
A responsible person staying at least
overnight with the patient.
Ensuring that the patient understand the
requirements of post-anaesthetic care in
regard to public safety.
The patient stay within one hour of medical
attention until one day after surgery.
Ready access to a telephone
ANZCA Policy PS15
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Unstable ASA III or IV. Eg. Brittle diabetes,
unstable angina, symptomatic asthma.
Morbid obesity with haemodynamic or
respiratory problems
Drugs: Monoamine oxidase inhibitors or
acute substance abuse esp. Cocaine.
Ex-prem infants <52 weeks post-conceptual
age.
Lack of responsible adult at home to
transport and care for the patient.
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Sleep apnoea
Morbid obesity
Elderly
Malignant Hyperthermia susceptibility
Anaesthetic technique – regional and
neuraxial.
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Or the application of the criteria?
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Greater use of regional techniques and local
anaesthetic infusion catheters at home.
Better use of analgesic adjuncts.
23 hour stay units
Available inpatient back up facilities
Mobile day surgery
Surgical techniques
◦ Laparoscopic and Robotic surgery
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Better management of co-morbidities
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Structural Functionalism
Society combines to create a
homeostatic system. A change in
one part creates or determines a
corresponding change in another.
Also famous for describing the
doctor-patient relationship and the
‘sick role’. The development of day
surgery is the opposite to the
traditional role he described.
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Every order or change in order
will present a struggle between
the proletariat (workers) and the
bourgeoisie (capitalists).
Exploitation and alienation of the
lower class will be hidden, but
present in every economically
motivated ideology.
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Legitimate authority: Charismatic,
Traditional and Legal-rational.
Local charismatically led systems
grow into bureaucracies with Legalrational lines of authority and
responsibility
Widening selection criteria may be
possible at a local level, however a
greater economic impact is possible
when systems are developed to
establish large scale change,
requiring bureaucratic models to
develop.
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The “care system” must be looked at as a
whole
Greater support, good information and
consistent expectation will lead to a wider
range of day surgical options
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Distance from hospital
Pain management routines
Nausea management routines
Preoperative optimisation and information
Nursing in the home
A number to call
A telephone
Capacity of family
Ability to admit for social reasons
23 hour wards.
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Policy development
Consultation
Iteration
Description
Change through agreement, commitment and
ownership.
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Patients
Government and other funding bodies
Hospital administration
Surgeons
Anaesthetists
Nurses
Other Health providers
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Risk is difficult to evaluate on a small sample
RCTs are not appropriate for low risk
outcomes
Registries and databases are being created to
collect and audit outcomes from medical
interventions.
◦ NSAS – National Survey of Ambulatory Surgery
www.cdc.gov/nchs/nsas.htm
Society of Thoracic Surgery: National
Cardiac Surgery database
American College of Surgeons National
Surgical Quality Improvement Program
(ACS-NSQIP)
Centre for Disease Control and Prevention –
National survey of Ambulatory surgery.
snap shot of aurora
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Applying the criteria more widely is probably
our actual challenge.
Selection criteria applied more widely
through:
◦ Technology – surgical, anaesthetic, pain
management, outcome data collection
◦ Community support
◦ Secondary supports, i.e. inpatient services back-up
◦ Thoughtful, local policy development
◦ Measuring outcomes
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Change can be difficult and it may not be
right in every situation.
There are patient, surgical and social factors
that need individual consideration.
Supports in the community vary from region
to region.
We need to monitor, audit and evaluate
outcomes to assess the work we do, because
our goal of safety and comfort extends
beyond the operating room, it needs to
extend into the home as well.

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