A ROLE FOR DAY CASE SURGERY IN ORTHOPAEDIC TRAUMA CARE?

Abstract

Introduction: Utilisation of day case surgery units for orthopaedic trauma is an uncommon concept. Limited reports of its use in specific orthopaedic trauma cases have been encouraging. There is currently no formal provision for day case surgery for trauma patients at our institution. The aim of this study was to identify the proportion of trauma patients that would be suitable for daycase surgery and the proportion of these that currently undergo procedures as a day case, with a view to establishing a more formalised daycase trauma service.

Methods: We undertook prospective data collection on all trauma referrals in our institution over a 1 month period in January 2008. Information was recorded for date and time of referral, admission, operation and discharge. Nature of injury, type of procedure performed, grades of surgeon involved and length, nature and reason for any pre or post-operative delay was also recorded. All patients requiring surgery were assessed on their suitability for day case as defined by pre-determined patient-related and surgery-related criteria.

Results: Of all the patients referred during the study period 129 patients required surgery. Of the operated patients 80 (62%) had a procedure suitable to be performed as a day case as defined by surgical factors. Of these, 57 (44%) patients met criteria for day surgery as defined by patient factors. Of those eligible for day case surgery (n=57), only 27% had their procedures performed as a day case. The total number of additional days spent in hospital by day case eligible patients was 69. 34 days were due to pre-operative delay and 35 were due to post operative delay. The mean number of pre operative days in hospital was 1.33(range 0–3) and post operative days 1.85 (range 0–8). There was a wide case mix of procedures performed that were deemed appropriate for day case surgery. 76% were upper limb or soft tissue procedures.The causes for pre-operative delay established two main issues. Limited dedicated operating theatre capacity for day case eligible procedures resulting in their de-prioritisation and limitations on dedicated bed availability. The cause for postoperative delay was more variable but on the whole was for reasons which with appropriate protocols could have been avoided.

Conclusions: This study has identified that a significant proportion of orthopaedic trauma workload would be appropriate to be carried out as a day case. Without an appropriate day case surgery setup, current delays are causing 69 unnecessary bed days per month in our institution. Causes for current delays are related to lack of synchrony between timing of admission and surgery and lack of appropriate discharge protocols. We are in the process of developing a plan for implementation of a dedicated day case trauma service at our institution and suggest that this may be an appropriate use of day case facilities in other trusts.