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Surgical Same-Day Emergency Care

Second Edition

Professor Douglas McWhinnie, Consultant General and Vascular Surgeon, Milton Keynes University Hospital. Postgraduate Dean of Medicine and Surgery, University of Buckingham. President, International Association of Ambulatory Surgery (IAAS)

Dr Ian Jackson, Editor-in-Chief, Ambulatory Surgery, Past President IAAS

Mr Arin Saha, Consultant in Upper GI, Bariatric and General Surgery, Calderdale and Huddersfield NHS Foundation Trust. National Clinical Lead, Surgical Ambulatory Emergency Care Network

Deborah Thompson, Director, NHS Elect

Dr Kim Russon, President, The British Association of Day Surgery, Consultant Anaesthetist, Rotherham Foundation Hospital Trust

Edited by:
Miss Jo Marsden, Publications Secretary and Editor, The British Association of Day Surgery

Copyright © British Association of Day Surgery 2020. All rights reserved. No parts of this publication may be reproduced, stored or transmitted by any means without the prior permission in writing of The British Association of Day Surgery

ISBN number 978-1-908427-38-0

In recent years, there has been a renewed focus and concern regarding the quality of care provided on the surgical and medical emergency pathways in response to increasing numbers of patients attending and admitted from emergency departments. In 2006 the Royal College of Physicians convened a working party (The Acute Medicine Task Force), to consider in depth the changing landscape of acute medical care in England [1]. It was clear that many patients could be safely managed in an ambulatory setting and relieve pressure on emergency departments. The term, ‘Ambulatory Emergency Care’ (AEC) was used to describe clinical care, including diagnosis, observation, treatment and rehabilitation, but avoiding admission to a hospital bed. The initial success of AEC provided a stimulus to assess the quality of care offered to surgical emergency patients through reports by the Royal College of Surgeons of England and the Association of Surgeons of Great Britain and Ireland (ASGBI) [2,3]. There was a realisation that surgical emergencies should be seen and assessed in a timely manner by a senior member of staff to make an early diagnosis and management plan.

This acceleration of the initial patient assessment allows the patient to be scheduled for theatre more appropriately and thereby reduces the preoperative length of stay. Senior input to determine the timing of discharge also contributes to a reduction in length of the postoperative stay, with patients remaining in hospital no longer than necessary.

Elective day case surgery had been prioritised nationally through the NHS Plan of 2000 where a target of 75% of all elective surgery was to be performed on a day case basis [4]. Day surgery was defined by the Department of Health in 2002 as the admission of selected patients to hospital for a planned surgical procedure, returning home on the same day [5].The success of elective day surgery prompted the development of emergency day surgery. The International Association for Ambulatory Surgery (IAAS) defined emergency day surgery as ‘the management of an emergency patient according to an ambulatory surgical pathway, avoiding overnight stay following their surgical procedure” [6]. The British Association of Day Surgery (BADS) also now include some emergency procedures in their Directory of Procedures [7].

Many emergency surgical procedures are minor and non-life threatening and traditionally have been considered low priority for surgical intervention. Consequently, it was not unknown for these patients to occupy an acute surgical bed for several days as subsequent admissions were prioritised to restricted emergency theatre slots. Indeed, when eventually scheduled for theatre, patients such as these, were often discharged within a few hours of their operation, raising the possibility of an emergency day surgery pathway. However, the concept of emergency surgery on an ambulatory basis without the use of an overnight bed is not new. In his paper, published in the British Medical Journal in 1909, James Nicoll described nearly 9,000 cases performed at the Sick Children’s Hospital in Glasgow on a day case basis. The case mix in this series of children included the elective procedures of hernia repair, operations for cleft palate, hare lip and spina bifida, but also the emergency procedures for congenital pyloric stenosis, depressed birth fracture of the skull, mastoid empyema and ligation of the internal jugular vein in the course of radical mastoid operations or excision of cervical glands [8]. As an early pioneer, James Nicoll is affectionately known as the ‘Father of Day Surgery’.

The roll-out of AEC nationwide was facilitated by the AEC Network, a national programme delivered by a multidisciplinary team skilled in quality improvement working to enable healthcare teams to rapidly expand their ambulatory emergency care services, firstly in medicine and later in surgery [9]. The basis of this large-scale change programme is the Directory of Ambulatory Emergency Care for adults [10]. In 2019 NHS Improvement renamed ambulatory emergency care as ‘SameDay Emergency Care’ (SDEC) with the key components of early consultant assessment and diagnosis, identification of appropriate patients for same day care, rapid treatment and conversion to same-day care management where possible, and early facilitated discharge [11].

Emergency surgical patients present 24 hours per day for advice or treatment. The priorities of Same Day Emergency Care (SDEC) are to provide the surgical patient with a rapid diagnosis and management plan, with immediate discharge where possible, thereby enabling the patient to avoid an overnight inpatient stay in a hospital bed. Treatment may be operative or non-operative depending on the condition. In each case, these underlying principles of care should be provided in a management plan by a surgically qualified senior decision-maker: usually a consultant or experienced middle grade surgeon.

On arrival at the emergency surgical facility, day or night, patients are assessed by a senior decision-maker shortly after arrival. Most hospitals have the provision of a surgical team dedicated to emergency care, devoid of elective responsibilities during the working day, and out-of-hours provision of middle-grade surgeons working shifts. As a result, there is no reason to delay patient assessment by restricting senior input to morning and evening ward rounds. Senior input ensures experienced assessment of the patient, the timely formation of a management plan and that appropriate diagnostics are expedited. Admission avoidance may be enhanced with the default assumption that all surgical emergencies can be treated on an ambulatory basis unless the senior opinion suggests otherwise. If the senior decision-maker suggests a major surgical condition, or there is clinical or diagnostic uncertainty in a patient who is clinically unwell, then the patient should be admitted to an inpatient pathway. In contrast, if the patient requires an intervention for a condition which does not require urgent treatment, then conversion to a delayed but planned emergency procedure the following day with temporary discharge from hospital is an option. If the patient does not require surgical intervention, the patient only requires admission if their condition necessitates close monitoring, IV fluids, IV antibiotics or parenteral analgesia.

The modern surgical assessment suite requires a combination of treatment rooms, a mixture of trolleys and chairs and a patient waiting area. The absence of beds illustrates to the patient the ambulatory nature of the surgical assessment unit which remains functional during times of hospital bed shortages. Triage by an advanced nurse practitioner offers the patient immediate attention and provides the surgical team with the experience of a permanent member of staff. Junior staff are often transient and inexperienced, but the implementation of condition-specific pathways allows the junior doctor to commence an appropriate treatment pathway while awaiting the senior decision-maker. Examples of treatment pathways include protocols for ureteric colic, urinary retention, biliary problems, right iliac fossa pain and diverticular disease.

Restricted facilities for imaging can often slow the flow of patients in the admissions unit. The allocation of dedicated imaging slots each morning for ultrasound, CT or MRI scan offers the senior decision-maker rapid access to diagnostic imaging which in turn improves the speed of patient flow. Access to imaging on demand may reduce preoperative waiting but also identifies early those patients who can be safely discharged or managed daily on an ambulatory basis.

i. Procedure Selection

Patients requiring emergency surgical treatment present in an unscheduled manner and require review or admission 24 hours per day. According to the NCEPOD Classification of Elective and Emergency Surgery, conditions which require a surgical intervention may be classified as ‘immediate’, ‘urgent’, ‘expedited’ or ‘elective’ (Table 1) [2]. An example of a condition requiring ‘immediate’ intervention would be a ruptured aortic aneurysm while peritonitis might be considered ‘urgent’. It is those patients in the ‘expedited’ category who cannot await an interval elective procedure but require their surgical intervention within 48 to 72 hours who offer the possibility of a ‘planned’ emergency procedure.

Table 1. NCEPOD classification of elective and emergency surgery

NCEPOD Classification of Elective and Emergency Surgery

Clearly, ‘immediate’ or ‘urgent’ patients requiring surgery are unsuitable for a planned or semi-planned day case pathway, given the need for speed of intervention that their clinical status demands. In contrast patients in the ‘expedited’ group, where the condition can wait 1-2 days to be treated and the patient is clinically stable, they can be sent home and scheduled for surgery in a planned manner. Examples of surgical procedures where a planned emergency intervention might be considered are listed in Table 2.

Table 2. Examples of procedures considered suitable for planned emergency surgery

Examples of procedures considered suitable for planned emergency surgery

ii. Patient Selection

It is imperative to assess each individual patient’s clinical condition before referring to a planned emergency day case pathway. There may be social circumstances which preclude the use of the day case pathway such as lack of carer or transport issues. Most surgical units confine the SDEC operative pathway to the adult patient though specialist paediatric units can utilise the pathway if appropriately resourced.

Clinical factors which dictate a requirement for earlier intervention include patients with systemic sepsis or those with unstable diabetes. Patients requiring parenteral analgesia, antibiotics or fluids are also unsuitable to await their surgical procedure at home.

Criteria for inclusion to the ‘planned’ surgical same day emergency care pathway

  • The proposed surgery is suitable for day care
  • Systemic sepsis is excluded before temporary discharge prior to operation
  • Patients with unstable diabetes that may compromise day surgery are excluded
  • Patients with major comorbidities that preclude day surgery are excluded
  • Ensure oral rather than parenteral analgesia is adequate for patient needs
  • Patients should have suitable social circumstances

iii. Admission

Patients with conditions suitable for planned emergency surgery may follow a predetermined pathway and be discharged on a temporary basis to the comfort of their own home to await their planned emergency procedure, provided specific discharge criteria are met. This concept is widely known as the ‘virtual ward’. Patient details are recorded and added to the ‘virtual ward’ patient list. It is important for the anaesthetic preoperative assessment to be conducted either by the emergency anaesthetist or an appropriately trained nurse before the return home as this will avoid delays on readmission. Prior to discharge home a VTE Risk Assessment should be completed and treatment started if indicated as per local or national guidance.

Patients should be sent home with appropriate fasting instructions and analgesia and instructed to return to the hospital early the next day, either to the day unit or the emergency surgical facility. In some centres the procedure is scheduled first on a morning elective operating or first on the emergency list. In other units a coordinator assigns a theatre slot and communicates the intention to either the Day Surgery Unit Manager or the Emergency Theatre Team. Surgery should be in the morning to allow adequate time for recovery and same-day discharge (Figure 1)

Figure 1. Admission pathway for patients requiring surgery

Admission pathway for patients requiring surgery

Due to delays in getting a more seriously ill patient to theatre it is not unknown for emergency theatre to lie fallow intermittently. There is therefore an opportunity, to utilise the empty CEPOD theatre for a SDEC case before bringing the optimised sick patient to operation. In busy facilities, entire morning lists may be devoted to ambulatory emergencies while in less busy units, an SDEC patient may be routinely added to a day case list, or substitute for any cancelled patient. In each scenario, the patient is discharged on the same day. Overnight bed savings are therefore possible from both the preoperative wait and the postoperative recovery. This balance between clinical and managerial priority can be difficult to achieve without appropriate reflection, but forethought can permit a positive outcome for the quality of emergency patient care and the managerial requirement to shorten duration of stay.

While the patient is best admitted to a dedicated day surgery facility for this pathway, success can also be achieved through a surgical admissions unit or ward. However, post-operatively the patient must not be neglected by conflicting nursing priorities otherwise timely discharge will not occur and the patient will remain in hospital until the next day.

There are many unnecessary admissions to surgical inpatient wards nationwide. Many inappropriate admissions are due to decision-making by junior members of the surgical team, especially out-of-hours. This is often the result of lack of surgical experience and defensive practice. Many of these surgical admissions do not require an intervention and occupy a surgical inpatient bed unnecessarily while awaiting a senior review. With SDEC, senior decision-making at initial assessment allows patients with complex conditions to be appropriately allocated an inpatient bed while others with minor complaints may be treated and discharged. Patients requiring ongoing monitoring but who are not sufficiently unwell to warrant admission, may be discharged home on a temporary basis and reviewed the following day at a ‘hot clinic’ (Figure 2).

Figure 2. Admission pathway for patients not requiring surgical intervention

Figure 2 Admission Pathway for patients not requiring surgical intervention

Hot clinics are best run at a fixed time each morning by experienced team members and are often a natural sequel to the post-take ward round. While they are of great value in offering ongoing treatment and advice to the non-operated non-admitted emergency surgical patient, the hot clinic also offers a ‘safety-net’ for patients with early discharge. Other uses include wound reviews, removal of sutures and performing follow-up diagnostics. Surgical conditions considered suitable for non-operative SDEC care are shown in Table 3.

Table 3. Surgical conditions suitable for a non-operative SDEC pathway

Table 3 Surgical conditions suitable for a non-operative SDEC pathway

i. Abscess Management
Surgical drainage of a superficial abscess is one of the most common surgical procedures performed on an emergency basis in the UK today. Current data suggests that only 36% of superficial abscesses are treated on a day case basis but the BADS directory suggests all superficial abscesses should be considered for day case treatment [7,12]. A superficial abscess requiring surgical drainage is a condition highly suitable for temporary discharge home to await their operation.

In 1997, Loftus and Watkin in Leicester were the first investigators to acknowledge that the pathway for the surgical treatment of superficial abscesses was suboptimal and recognised that emergency patients awaiting surgery were regarded as low priority. The abscess patients were often postponed at the last minute, having been starved, to make way in the emergency theatre for patients considered to have more serious surgical conditions. Indeed, some patients were experiencing multiple postponements, with the resultant blockage of surgical beds. The investigators therefore prioritised the treatment of these abscess patients to allow early treatment and discharge, thereby freeing up surgical beds. In the study, 100 sequential patients with superficial abscesses were audited with times from admission to the operating theatre being less than 6 hours in 92% of patients, and only 4 cases needing overnight stay [13].

The concept was further explored in 2002 by Conaghan and co-workers with a randomised controlled trial comparing length of stay and outcomes for two groups allocated to either day surgery or inpatient intent [14]. The patients scheduled for day surgery had a significantly reduced length of stay compared with the inpatient cohort (median 0 vs 2 nights, p<0.001), with concomitant cost savings. Mayell audited the introduction of an emergency day case service within which 75% of the managed cohort underwent superficial abscess drainage (39% were perianal) over a 20-month period. She found an average reduction in length of stay of 29 hours per patient and estimated that for a population of 100,000 there would be an annual productivity saving of 65 bed days [16]. A similar audit was conducted in Chester in 2015 reviewing the number of acute abscesses managed in day surgery compared with in-patients, before and after implementation of a day case pathway. Day surgery care quadrupled in volume for incision and drainage of superficial abscesses, to a day case rate of 26%, saving an estimated 86 inpatient bed days per year [16].

Patients with abscesses often have diabetes, but rather than excluding all from ambulatory care, Moran and Skues only excluded patients with Type 1 (insulin dependent) diabetes, while those with tablet control were accepted onto the pathway, provided their finger prick blood glucose levels were below 15mMol/L, and they had specific instructions on modulation of blood sugar prior to surgery and for the following day [16]. In New Zealand, Baker and Windsor carried out a large retrospective study of the management of superficial abscesses from 1992–2007, from which they estimated that 59% of the surgical admissions could have been managed on a day case basis, whereas in fact only 6% were. Comparing average costs for inpatient and day case treatment, the authors calculated an average saving of over $3,000NZ per patient for day case treatment [17]. Swift and co-workers assessed abscess data in England from 2010-2012 and in this 3-year period, identified more than 35,000 procedures. Day case rates by provider varied from 10% to 77% with a median value of 35% and the authors concluded that over 9,000 bed days per year could be saved if each provider if activity were undertaken to British Association of Day Surgery suggested rates of day surgery for this procedure [18]. Data published in the BADS National Set for calendar Year 2019 indicates slow progress in the development of emergency day case pathways for abscess treatment with the median rate for perianal abscess drainage at only 28% and drainage of skin abscesses at 36% [12].

ii. Management of Right Iliac Fossa Pain
Right iliac fossa (RIF) pain has many causes and often creates a diagnostic dilemma for the emergency surgeon. Common causes include appendicitis, gynaecological and urological pathologies. Acute appendicitis is the most common cause of the acute abdomen especially in the young, with an estimated lifetime risk in males of 8.6% and 6.7% in females [19]. Failure to identify and treat acute appendicitis may unnecessarily lead to peritonitis and other avoidable complications. Investigations include imaging, haematological and biochemical testing but none offer accurate diagnosis. It is not surprising there is a low threshold among surgeons for early intervention in the patient with an uncertain diagnosis, and this has resulted in high rates for negative appendicectomy [20]. Nevertheless, due to diagnostic uncertainty, patients with RIF pain often block inpatient beds while awaiting a clinical decision and many of these patients are not systemically unwell. Therefore, many RIF patients may be monitored on an ambulatory basis, with daily visits to the hot clinic until the pain has resolved or the diagnosis becomes apparent. Once the surgical decision to perform appendicectomy is made, the patient may then convert to the SDEC pathway and undergo day case appendicectomy.

Although Henry Hancock, President of the Medical Society of London, is credited with performing the first appendicectomy for acute appendicitis in 1848, it was the Surgeon in Chief at the Roosevelt Hospital in New York, Charles McBurney who recognised that the treatment of acute appendicitis was appendicectomy [21,22]. Indeed, the eponymous ‘McBurney’s Incision’ was the incision of choice for many years for the procedure of appendicectomy. The first laparoscopic appendicectomy was performed in 1980 by Kurt Semm, a gynaecologist from Keil in Germany and current guidelines indicate that the laparoscopic approach is the treatment of choice for acute appendicitis [23].

Length of stay after appendicectomy is dependent on several factors including the trauma of the surgical approach, the degree of systemic upset (mainly from sepsis) and the reaction of the individual to the procedure. With the recognition of the benefits of day surgery in the late 1980’s, it was well recognised that some patients were suitable for early discharge after open appendicectomy. In a prospective study of 200 consecutive open emergency appendicectomies performed at the Royal Berkshire Hospital, Reading, 147 patients (73.5%) were discharged home within 24 hours [24]. As the technique of laparoscopic rather than open appendicectomy gained credibility and popularity, subsequent literature reported a progressive improvement in stay, with 75% of operations performed in children as day cases in 1999 and replicated elsewhere by other workers [25,26,27].

Emergency day case appendicectomy in adults has proved rather more problematic [28]. Illness in children often has a rapid onset but an equally rapid recovery. Adults after appendicectomy have an expectation of hospital stay. In a review of 13 studies, published between 1993 and 2012, and involving 1152 adults following appendicectomy, only 27% were discharged within 12 hours, although a total of 53% managed to return home within 23 hours [29]. Patients undergoing appendicectomy may have a ruptured appendix, no ruptured acute appendicitis or a normal appendix removed as a result of right iliac fossa pain. Patients with post-operative sepsis may require ongoing hospital admission while the patient with non-ruptured acute appendicitis offers the most likelihood of early discharge. This can only be achieved if an emergency day case appendicectomy pathway is followed, with adherence to quality day case principles to manage the patient’s expectations.

iii. Management of Biliary Conditions
Acute biliary pathology represents a significant burden on the emergency general surgical take and in many units, there is an ongoing discordance between the accepted standards of ‘best practice’ and the logistical challenges that exist in trying to deliver them [30]. Over the past decade and before, the indications for acute laparoscopic cholecystectomy have increased; it is recommended that all patients who present with acute gallstone pancreatitis, once fit for surgery, should have a laparoscopic cholecystectomy on their index admission or within two weeks though several clinical audits have highlighted the difficulties in meeting these guidelines [30]. For acute cholecystitis, the both the latest Tokyo guidelines and the United Kingdom NICE clinical guidance for the management of gallstone disease (GG188) recommend acute or early cholecystectomy for grade I and II acute cholecystitis though there are recommendations about the expertise and experience of the operating surgeon [31,32].

Though there are several benefits to early laparoscopic cholecystectomy, including an increased tariff, reduction in incidence of gram-negative biliary sepsis and prevention of recurrent admissions with biliary pain, there have been large population-based studies which have suggested that over 50% of patients in England did not require cholecystectomy following index admission for acute cholecystitis [33]. Further, there have been reported concerns about the increased difficulty of surgical dissection for acute cholecystectomy alongside difficulties in accessing emergency theatre operating lists [34]. In experienced hands however, there is no significant increase in complications for acute laparoscopic cholecystectomy and so the challenge for emergency surgical units is to provide experienced biliary or upper gastro-intestinal surgeons the capacity and time to provide an acute biliary service [35].

There are several strategies within an ambulatory care framework which can be employed to try and meet these standards. Many trusts have implemented dedicated ‘hot’ cholecystectomy lists or a second expedited or CEPOD list where patients are brought in on a semi-elective but urgent basis to minimise the in-patient stay for patients and reduce the impact on the primary emergency theatre. Where possible, a split on-call rota comprising both upper GI and lower GI surgeons can release the upper GI surgeons regularly to manage and operate on acute biliary pathology and having access to elective day surgery recovery and discharge areas can markedly speed up discharge and reduce the burden on in-patient beds.

Aside from acute laparoscopic cholecystectomy for cholecystitis or pancreatitis, the other group of patients that presents a challenge to the acute take are those patients with suspected or confirmed common bile duct stones. There is genuine equipoise in the question of whether or not the bile duct should be imaged in patients with confirmed gallstone disease and the ongoing multi-centre, randomised controlled Sunflower Study aims to provide clarity in this difficult group of patients [36]. Many patients wait several days for MRCP imaging and this group represent another valuable opportunity to convert in-patient care to ambulatory care. Patients who are clinically well with stable or falling jaundice levels and no evidence of biliary sepsis may be considered for urgent ambulatory MRCP imaging organised through a ‘hot’ or ambulatory clinic process.

In summary, biliary pathology represents a significant burden on the emergency general surgical take and many of these patients require surgery. Acute laparoscopic cholecystectomy is indicated on the index admission for gallstone pancreatitis. For patients with recurrent biliary colic admissions or those patients with acute cholecystitis (who after appropriate counselling and explanation wish to undergo laparoscopic cholecystectomy), the opportunities for ambulatory care can benefit both the patient and the surgical team in improving the diagnosis and operative management of these conditions. Further detail about principles underlying safe day case practice can be found in the most recent edition of the BADS 'Day Case Laparoscopic Cholecystectomy' handbook [37].

iv. Management of Orthopaedic Trauma SDEC Patients
Dedicated orthopaedic ‘trauma’ lists have done much to improve the timely management of fractured limbs and urgent orthopaedic cases and release space on NCPOD emergency lists. There are increasing procedures that can be treated as a day case, reduction and fixation (closed or open) of forearm, wrist or hand fractures, repair of tendons in the hand or Achilles tendon, acute knee arthroscopy. Provided adequate analgesia can be provided by the oral route, temporary discharge home, rather than hospital bed occupancy, is an option for these patients while awaiting surgery and some hospitals have developed day case trauma lists which further improves the system. Many orthopaedic procedures may be performed under regional, rather than general anaesthesia offering potential advantages in fasting and recovery

Choice of Anaesthetic for Orthopaedic Procedures
These can be performed under local anaesthesia, regional anaesthesia or general anaesthesia.

Day case spinals and plexus or peripheral nerve blocks are appropriate alternatives to general anaesthetic in the day surgery setting for some operations and may be safer in patients with complex medical conditions. Their use is growing in acceptance and popularity as they are safe, practical, cost-effective and popular with patients. Concern from surgeons that these techniques may slow the lists down or reduce the number of patients that can be accommodated on an operating list are unfounded if there is appropriate personnel and list planning. An additional advantage is the lack of need for a patient to wake up, hence requirement for recovery space is reduced and time can be saved at the end of the procedure. Consideration of awake surgery should be raised with patients during their emergency care management, as appropriate and start with the surgeon, when their surgical pathway is agreed.

In the early days of emergency day surgery, a common problem was the sustainability of the service. Early efforts focussed on the ‘abscess pathway’ with the patient sent home with a scheduled return the following day for operation and discharge. Such projects were usually person-centric and driven by individual forward-thinking surgeons or surgical teams [13,14]. Unfortunately, as personnel changed, the service often lapsed as a successful pathway as it required the constant and regular drive of the day surgery enthusiast.

With the recent focus in improving emergency surgery throughout the country, especially out-of-hours and at weekends, there has been a realisation that the ‘abscess’ pathway could be transferred to other minor procedures [38,39]. However, to ensure sustainability, hospital-wide integrated emergency pathways were designed into the system and this led to the concept of AEC for operative and non-operative surgical treatment. Once embedded in an integrated system, the emergency day surgery pathways contribute to admission avoidance, reduce length of stay and most importantly offer the emergency patient the same quality of care formerly reserved for those on the elective pathway.

Sustainability has now been achieved through the efforts of individual Trusts, the NHS Improvement’s introduction of SDEC pathways and the NHS Elect Surgical Ambulatory Emergency Care (SAEC) network programme [9,11]. The SAEC programme supports participating organisations to develop safe and effective ambulatory care for a proportion of all emergency surgical referrals. The pathway should provide streamlined efficient assessment, investigation and treatment (including surgery) avoiding delays in the patient journey through the system (Figure 3). A quality service should avoid unnecessary steps, delays and duplication which add no value to patient care. Where failure of ambulant care is recognised, the patient care should rapidly be converted to traditional in-patient management as required.

Figure 3. The emergency surgery day case pathway

The emergency surgery day case pathway

The key principles to achieve same-day emergency care include:

  • Process-driven referrals
    Referrals to ASU should avoid restrictive protocols
  • Consultant-led and delivered
    Senior decision-making is required throughout the pathway
  • Rapid access to diagnostics
    Diagnostic delays are avoidable if dedicated imaging slots are available for emergency patients. Experience from hospitals adopting SAEC pathways suggests that up to 65% of patients require an abdominal or pelvic ultrasound
  • Rapid access to theatre
    Conversion to surgery is low for ambulatory surgical patients, but timely access to theatres can ensure the patient can still be managed on a day case basis
  • Early supported discharge
    Ambulatory care units can also support the early discharge of patients who have been managed on a traditional inpatient pathway by providing the facility for review of wounds etc post discharge via hot clinics
  • The virtual ward
    This is essential in managing demand and access to surgical treatment. Patients managed at home can include those awaiting surgery, awaiting results or undergoing ambulatory review
  • Documentation and safety-netting
    Information leaflets, documentation and telephone numbers should be given to patients at the first point of contact to ensure they know how to access medical support if they deteriorate while in the virtual ward or awaiting ambulatory review. GP summaries should be created before discharge
  • The Ambulatory Surgical Unit should be based in a designated area
    This protected area should consist of several examining/treatment rooms, with patients accommodated in trolleys and chairs, and collocated with, or be an integral part of the surgical assessment unit. The area should not be utilised for inpatient admissions in times of escalation
  • Nurse practitioner support
    The extended skills of nurse practitioners and other Health Care Professionals support the virtual ward and provide continuity of care
  • Patient experience
    Patient feedback should be collected and used to inform service improvements and monitor the effectiveness of the service
  • Measurement
    Baseline metrics should be established before implementing SAEC to allow any impact of improvements to be assessed
  • Commissioner involvement
    To ensure financial viability of the service, commissioners should be involved early in the development of the ambulatory pathway

The SAEC network has worked with 36 hospital teams to adopt the principles of SAEC listed above. During their work with sites they have seen many examples of good practice developed as these principles are designed into systems. There are many of examples to be found in case studies available from the AEC network. You can access them at https://bit.ly/37irDMq To find out more about the Surgical AEC programme and the work of the AEC network go to their website www.ambulatoryemergencycare.org.uk

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