Abstract
Recent Department of Health guidelines have recommended that bunion surgery should be performed as a day case in a bid to reduce hospital costs, yet concurrently improving patient outcomes. Following an audit in 2012/3, we implemented a number of measures in a bid to improve the rates of day case first ray surgery. In this paper, we look to see if these measures were effective in reducing the length of stay in first ray surgery.
We performed a prospective case note review of all patients undergoing first ray surgery between 01/01/2012 and 01/02/2013, and found the rates of same day discharge in this group to be lower than expected at just 24.19%. We recognised that the most commonly cited reasons for delayed discharge were that patients not being assessed by physiotherapy, and were unable to have their take home medication (TTO's) dispensed as pharmacy had closed. To address this, we implemented a pre-operative therapy led foot school, and organised ward analgesia packs which may be dispensed by ward staff, thus bypassing the need for pharmacy altogether. Together, we coined the term “care package” for these measures. We then performed a post implementation audit between 01/01/2014 to 01/01/2015 to ascertain if these measures had been effective.
We identified 62 first ray procedures in the preliminary audit, with an average age of 50.5 years (range 17–78 years) and a M:F ratio of 1:5. The most commonly performed procedures were Scarf osteotomy, 1st MTPJ fusion, and distal Chevron osteotomy. We compared this to 63 first ray procedures post implementation of the care package. The average age was 55.3 years (range 15–78 years) and the M:F ratio was 1:2.5, and there was a similar distribution in terms of specific procedures. We found the length of stay had reduced from 1.00 to 0.65 days (p= 0.0363), and the rate of same day discharge had increased from 24.6% to 44.6% (p= 0.0310). We also noted that St Helens Hospital (SHH), the dedicated day case surgery unit, had a significantly increased rate of same day discharge than Whiston Hospital (WH- the main hospital) at 87.5% and 28.89% respectively (p= 0.0002).
Preoperative physiotherapy assessment is an important tool in reducing length of stay for first ray surgery. The use ward analgesia packs has a synergistic effecting in increasing day case first ray surgery. We therefore commend its use to other centers. Additionally, we have shown dedicated day case surgery units are more effective at achieving same day discharge than general hospitals.
