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Introduction

Day surgery or Ambulatory Surgery has many definitions across the world, the IAAS recommend the descriptor Ambulatory Surgery defined as ‘an operation/procedure, excluding an office or outpatient operation/procedure, where the patient is discharged on the same working day’.
Another important group are those patients who can be managed with an overnight stay which we suggest should be known as ‘Ambulatory Surgery – Extended Recovery Patient’ defined as ‘a patient treated in ambulatory surgery / procedure centre/unit, free standing or hospital based, who requires extended recovery including overnight stay, before discharge the following day’.

Table 1. IAAS Definitions



When comparing international ambulatory surgery rates for a particular operation it is important to realise that despite our recommendations definitions can still be different around the world. Some countries consider a stay of less than 24 hours as Ambulatory Surgery.
Given the international contributions to this handbook the terms day surgery and ambulatory surgery will be used interchangeably throughout this handbook.


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Day surgery is not new and indeed in 1909 James Nicoll reported his work on nearly 9,000 children who underwent day surgery for such conditions as harelip, hernia, talipes and mastoid disease at the Royal Hospital for Sick Children in Glasgow. This was the work of a gifted enthusiast who was quite simply years ahead of his time, even in those early days he stressed the importance of suitable home conditions and co-operation with General Practitioners.





Three main factors are driving the increase in day surgery
  1. Changes in clinical practice – length of stay following surgery have been steadily reducing over the past decade and this has been accelerated with enhanced recovery programmes that encourage early mobilisation.
  2. Advances in both anaesthesia and surgical techniques have made an expanding number of procedures suitable for day surgery. These advances have also allowed us to offer day surgery to patients who were previously deemed unsuitable due to various co-morbidities. Many hospitals are now moving towards a default option for day surgery for many operations. Instead of the surgeon asking ‘Is this patient suitable for day surgery?’ they are now assumed to be suitable and the question is ‘Is there any justification for admitting this case as an inpatient?’
  3. Countries are struggling to control costs in their health services and the escalation in emergency admissions linked to their aging populations. The ability to treat more surgical patients through less beds means the cost effectiveness of day case surgery has put this mode of care at the top of political agenda.

However it has taken considerable time in many countries to increase day surgery rates. The reasons for this are complex but it is important that these are considered as those wishing to introduce day surgery will experience these issues.

Lack of day surgery facilities

Day surgery is possible without the provision of dedicated day surgery facilities but hospitals that achieve high performance in day surgery have dedicated units – this will be discussed further later in the handbook.

Clinical preference

It is important to acknowledge that many surgeons, anaesthetists and nursing staff have a strong preference for inpatient surgery. Many see day surgery as ‘minor’ and less of a challenge or in some countries surgeons fear the loss of control over hospital beds or ‘their ward’.

Patient preference

Staff often say that the patients don’t want day surgery and it is true that in cultures where day surgery is new that it is important to educate patients on the advantages. When day surgery is explained to patients then it does not matter which country you are working in the universal finding is that most would prefer to recover in their home surroundings.
The expansion of day surgery entails a change in mindset in clinicians, nursing staff, managers and the patient. It might be that changes in national policies and regulations will be necessary, such as the removal of incentives that promote unnecessary hospital stays. However day surgery can be successfully introduced by those who have the drive to achieve change for their patients. In the beginning most hospitals will have to start performing day surgery through their existing facilities. The crucial change in this situation is the patient pathway and that it is clear from the start of the pathway to the patient and all staff that the patient will be going home the same day as the procedure is performed.
Once a service has been started in a hospital you can start to look at how your facilities can be adapted to further support the day case pathway for more and more patients. This handbook will hopefully help through all stages of development of your day surgery service.

We include a series of essays completed by colleagues on the Executive Committee of the IAAS. These are personal views on the management of various aspects of day surgery and contain a large number of useful ideas and information. Each deals with a different part of the patient pathway and we hope you find them useful – we include contact details for those involved so that you can contact them with any questions you may have.