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My name is Doctor Ian Jackson. I'm a consultant anaesthetist by background and I'm the past presidente of the International Association of Ambulatory surgery. In my overview. Today, I would like to cover these topics starting with a look at the website and the is handbook, uh then discuss something about the facilities that are suitable for ambulatory surgery. And so pass on some of the lessons that we've learned over the years and then end with a discussion about pre op assessment. I come from York in the north east of England and this is a picture of my local hospital. This is just to give you an idea of my experience background in day surgery, which I started with managing our day surgery facility in 1989 when I had two theaters and 12 trolleys. Currently following the 2009 redesign, the unit has six theaters and 46 trolley spaces. The is at website is a useful source of information. Uh and there's two main parts to it because the is made major part but also free access to our journal ambulatory surgery, which allows you to download the articles or complete journals for your use. There are several publications on the website today, I'll concentrate on talking about the ambulatory surgery handbook. But the day surgery book on the right hand side, there is downloadable as well and is a much more detailed book about day surgery. The handbook was designed to help with the training program that we undertake in many countries across the world. It covers the full ambulatory surgery pathway but provides a basic level information, a starting point. And as a starting point, it helps all staff reach a basic understanding of the concept of day surgery and what we're trying to achieve. So it's suitable for doctors, nurses and managers. It also has a series of useful essays about various topics from role of the anesthetist through to the role of nursing, an ambulatory surgery. And these can also be useful for you in managing or starting your service. So over the years, we've been seeing that changing pattern and surgery as we've reduced length of stay uh and increased the number of patient's that can be done as a day case or is that even in an outpatient? And this is really being driven by a need certainly in uh the UK to reduce bed numbers, to reduce costs, but also to try and increase access to surgery for our population. And this is just a slide that shows the various levels of day surgery being achieved by day surgery units across the UK. And you can see that they are mostly doing over 60% of their cases, elective surgery as day cases. If we look at single procedures, we can show a huge variation across the UK. Uh This is for, again, for England, each, uh, each bar is a, represents one hospital. But what you can see is the huge increase in day surgery that has been so in green, we have the variation that we saw back in 2008. And then 11 years later, I've got the data showing uh how improved hospitals have become since then. There are still huge variation in activity, but all hospitals have improved in uh their success in providing the laparoscopic cholecystectomy as a day case. So let's have a talk about facilities. There are huge variation in facilities that can be used. Uh Some people have no dedicated facilities and most people who are starting a fresh with day surgery may well start from that point. Uh Some people are using mobile day surgery units and I'll show you a example of that. Uh some people are particularly in the States are keen on freestanding day surgery units which may be free standing some distance away from the main hospital or just free standing within the main hospital site. Or the final part is having a facility as part of your hospital, which in the UK is most of our day surgery facilities. When you have no ambulatory surgery facilities, it is very difficult it can be done, but it is very difficult to manage your day cases because you're managing them through inpatient ward areas and through main theaters. And so it's difficult to manage them. They have a lack of attention and attention and nursing attention in particular is key to getting patient's mobilized and having success in ambulatory surgery. So having no facility, uh it doesn't mean you can't do it, but it makes it more difficult. So we all aspire to having some sort of facility available for our day surgery cases. Now, I mentioned mobile unit, this is an example of a mobile unit in the UK. Uh and these can be useful for bringing surgery closer to your local population when perhaps a small hospital in the locality can be the uh the site that you visit, but it has no suitable facilities for you to be able to perform surgery. And these mobile units are come in a variety of types, but we have used one for hip and knee surgery quite successfully. So it's not part of the hospital, they're often used at a series of set positions around around a large region. And the key to the success with these is it's vital tough controls on the patient selection and on the pre op assessment so that you are only doing procedures that are going to be very successful as a day case and you're ensuring that you are selecting your patient. So they are suitable for sending home at the end of the day. Then when you move on to a freestanding day surgery unit, that's perhaps a separate from the hospital. The efficiency of these depends on the design. If you have some overnight beds, that can increase your flexibility, both for using lists in the afternoon, but also for doing bigger procedures. But we still try to minimize admission's from these and overnight states from our day case facilities. And it's vital again still to have controls on patient selection and pre op assessment. Though the controls don't need to be as rigid as you would do with the mobile facility. When you start building a facility as part of a hospital, you actually gain a huge amount. It gives you the maximal ability to push the boundaries. And that means the type of patient's that you undertake, they can be uh more uh less healthy patient's than also the type of surgery on taken can be larger and overnight stay beds can be useful in day surgery. There can be useful for helping testing new procedures that you're wanting to move into your day surgery facility. They're useful for supporting patient's with poor social circumstances who probably can't go home due to poor social circumstances and uh provides you the ability to extend the discharge time when you have overnight stay beds. You actually have a facility where the nursing staff can discharge, you know, up to 10 o'clock at night if the patient wants to be discharged. So, a facility within the hospital in the UK tends to be of two types. Uh The one where they just have a dedicated ambulatory surgery ward, but they're just using normal inpatient theaters. The second is where they actually have a dedicated ambulatory surgery unit, like my own one, which I will describe shortly where you have the, the ward space, admission's area, ward, space, theaters, recovery, and ward space prior to discharge. So starting with a dedicated ambulatory surgery ward, which has no dedicated theaters. This is a useful improvement where you can have a nursing staff looking after the patient's pre operatively and post operatively and encouraging them to mobilize and going home. Uh The use of main theaters means you don't need to create any new theaters and they can be done on mixed list. So they can be done as part of uh inpatient list or they can be done on dedicated ambulatory surgery lists. The evidence is that if you do them as part of dedicated list that provides the best results, but makes the list can work. But you need to ensure that you prioritize the day surgery cases and they're not left to the end of the day. And so that it's difficult for you to discharge them when you start getting to being able to have a dedicated ambulatory surgery unit with theaters and ward area and they're next to each other, then you really start to be able to provide a consistent quality experience for your patient's. It is efficient use of resources and has a much higher success rate for ambulatory surgery. The only other advice we can give is that if you're building a facility, put it on the ground floor, make it easy for patient's to get I/O, ensure that you provide ample drop off and pick up space so that patient's and their carers, the carers can drop off the patient's but also come and pick them up and ensure that you have some parking. For the same reason. We started in my own hospital really with ambulatory surgery ward facility and using main theaters and we managed to make that really efficient. Uh And we demonstrated how good that was. So we were then able to uh to uh develop a new facility with dedicated theaters. As the as the hospital management could see the the advantages in maximizing the surgery activity to achieve our strategy. We basically did it in three phases. We provided a suitable facility for our surgeons in the knee status. Uh We provided an overnight facility to try and help them move in transfer of activity from our inpatient wards. Uh And the important thing was we had an implementation group, we can ignore the slide. So the design of my unit, we've got circular flow ability within the unit. So you have a reception waiting area where patient's come in a ward area that acts as uh the uh the admission area. And the 2nd, 2nd stage recovery, we've got waiting rooms and interview rooms close to the theater block, then we have a theater block with six patient's and then you come to our first stage recovery and then the patient's come back to the ward area for second stage recovery. So we have a circular flow of patient's. So when you're looking at the reception waiting area, you want it to be of a suitable size because you must remember that there are often carers attending with the patient's. You want it to be friendly looking, you want to have good toilet facilities and also to be able to make it child friendly, then we move into our ward area and this is the design of my ward area. We have six bays, the sixth one at the end there is Children friendly. So it's made uh it's all decorated for Children and we've got a waiting area opposite so that we can separate the preop from the POSTOP Children. Each bay has several trolley spaces uh and his direct access to the theaters. So this is just an example of one of the bays in my day surgery facility with oxygen and all services supplied to each trolley space uh and buffers on the walls to protect the walls from uh variable height trolleys. We have a waiting room facilities close to theaters. So for local anesthetic uh procedures, uh such as hand procedures, it's very useful to have these waiting areas uh for ophthalmic ophthalmic cases as well. But always remember that if you've got a waiting facility like that prior to theater, it's you need to ensure that their toilets nearby for the patient's. So local anesthetic cases, cases have very little distance to walk I/O of the theater. In our experience, we group patient's by theater lists. So it's easy for the surgeon and the status to find the patient's the ward staff in, in managing that group of patient's know the process and it aids a very standard approach and we find that patient's are very supportive of each other when we moved to the theater block. Uh we've got six theatres with the theater corder leading to first stage recovery. As I have already mentioned, we operate on theater trolleys, the patient's walk to the anesthetic room. Usually they're anesthetized on the trolley there operated on the trolley and they go to first staged recovery on the same trolley and then back to the ward area on the same trolley and they move straight to a chair when ready. This means there is no lifting or manual transfer of patient's. So has shown before, this is a picture of the operating trolley showing that it's uh can be put into multiple different positions for different procedures. This is a picture of the theater corridor with three theaters on either side. And this is a picture of one of the theaters which are equipped with a uh laminar flow tent. So we can do more major orthopedic day case procedures from the theater block. We then have direct access to the recovery area. So we provide to recovery spaces per theater. We divide it into also have a Children friendly part to it. And I also included a hoist uh to help our, our staff manage morbidly obese patient. So that's just a picture of the hoist there. And they're used to, uh we don't need to use it very often, but we do a uh large patient sometimes through the day surgery facility, similar hints and tips. Our experience, we move our patient's from first stage two, second stage recovery as soon as they are ready, as soon as they reach the ability to maintain their airway. And we believe they're recovered uncomfortable. We give them IV fluid in theaters about 15 mils per kilo. And we find that helps recovery, local anesthesia cases, bypass first stage recovery. They don't need to uh need to go in to the facility and they go back to a waiting room or they more base. We use short acting IV analgesia were needed in recovery. Uh And we ensure that we provide oral analgesia pre operatively and post operatively for our patient's. So recovery ward area does not use beds. Uh And our experience is very much about using these trolleys to get the patient mobilized as quickly as possible and then finally into a comfortable chair where they do most of their recovery, getting a patient up from the trolley onto the chair, it makes huge difference to that patient's thought process is uh they changed from being a patient who's just had an operation to being someone who is starting to mobilise and is much more likely to be able to be discharged. So, as I mentioned in our experience, mobilization can aid pain relief, funnily enough. Our staff provide empathy but firmness in getting patient's forward into the seating position and getting them mobilized. And we all attend with a really positive attitude. We treat any nausea and vomiting aggressively and I can provide an example of that and uh we use standard discharge analgesia packs so it's very easy for the patient's to be discharged quickly without having to attend pharmacy. So what about changing clinical practice within our hospitals? Really? For our implementation group, we had leadership from our chief executive who made it clear that the move today. Surgery was important for the organization. And what we did is we discussed with each of the surgical teams using what we call the British Association of Day Surgery directory. The directory gives you uh benchmarks for over 100 and 80 procedures, about day, case rate and expected length of stay. And it covers all these surgical subspecialties and what it does is it defines length of stay as a procedure that can be done in a procedure room, a procedure can be done as a day case, a procedure that needs 23 hours a day or one that can be done under 72 hours. And for each procedure, you can say here, uh years, excision of a gangling at the top were saying that 99% can be done as the day case with only 1% needing an overnight stay. Indeed in the UK. Uh It would be very unusual for a excision of a gangling to stay overnight. And similarly, Dupuytren's fasciectomy, which is a major hand procedure in the UK. We're matching 95% of those as a day case. So we use those figures uh in discussions with our directorate so that we developed a default list like hernias, do patrons removal of metal work that moved into the day surgery facility. Uh We agreed a default that procedures that might require a 23 hours stay and then all the patient's from those default list attended pre op assessment through our day surgery facility. And uh so we managed to shift a huge amount of activity into our new day sentry facility. And uh the actual movement of activity was enough for us to be able to close to surgical wards. So when you're first starting out, it's good to start on things that are high volume like hernia repair where there is a good track record internationally of ambulatory care. But it's also good if you look for local uh you know, your own enthusiasts who is enthusiastic about doing day surgery, who are your early adopters amongst your clinicians? And these are just some examples of uh many 180 procedures we have within the ambulatory bads directory of procedures. So I would suggest success requires senior executive sponsorship so that the hospital knows this is important. You need a champion for the day surgery facility. And indeed, it's useful if you have a champion across the specialties, a lead, a surgical laid for general surgery ent guy, any uh but also there needs to be a recognition that this is the right way forward for your patient's. And in our experience, we set up a management team that was a lead clinician in the UK. That's often an anaesthetist, a lead nurse to manage the unit and a lead manager who worked together. And we're responsible for the day to day running and the development of day surgery within the hospital. But you also need a workforce geared to your vision and that's all staffing groups, be it nursing and Easter resurgence or management. And it is really important to have everyone geared to the process. Nursing staff are key to the pro uh success because they make an important contribution in pre op assessment, admission and ward care of patient's. They form a major part of our theater staff and recovery staff and so they are key to the success of the day surgery pathway. Again, an aesthetic staff are key to success. Again, linking into pre op assessment, ensuring that we're doing appropriate patient's and supporting the assessment process. Attention to detail the preop management, the use of drugs in theater and ensuring that their patients' wake up fast, clean and also comfortable surgical staff again, are vitally important because they need to be willing to rise to the challenge. And there is uh techniques that make huge difference. So local anesthesia injection by the surgeon, how they handle the tissues, uh and things like releasing all the gas from the abdomen at the end of a laproscopy makes a huge difference to the success on day surgery. And also managerial staff are vitally important. Helping with the planning of the service is helping the negotiation of transfer of activity with clinical groups. Uh and they can enable change, acting as a change agent and they can help with also ensure that you have the data about activity and outcomes that helps form the transfer of activity. So if you're looking across your health economy, one size does not fit all. There is no toolkit can deal with the wide variability across the world. But support focused where it's needed within your facility can make a huge difference to ensuring that you have success within the day surgery arena. So in summary of this, so far, the model of day surgery you choose, will influence the pre op assessment criteria and influence the procedures that you can undertake. The dedicated facilitate within your hospital. Uh really does increase the type of procedures you can undertake safely. Now to finish off, I'd just like to mention a bit about pre op assessment, pre assessment can be performed in various ways. But in the UK, most of it's done formally at the hospital with a percentage done via a telephone. And in the UK, typically a patient is seen in outpatients where there's a decision that they require surgery, they're sent to our pre assessment facility. And then the decision is made, whether they are suitable or unsuitable for day surgery. And how do we make that decision? Well, most of our units in the UK used nursing staff to help assess the patient's uh the patient's fill in a screening tool and the nurses staff go through that following guidelines of protocols that have been agreed by the anesthetic and surgical colleagues and the nursing staff of direct access to. Underneath this if and when they find any issues that needs discussion. And this is just some pictures of a screening tool which is just uh here is just on a piece of paper which includes social assessment as well as medical assessment. Increasingly, hospitals are using online questionnaires, things that could be completed in the kiosk or can be completed online at home. Now, the important thing about pre op assessment is to remember that it has gotten several functions. The first function is actually screening to ensure your patient is suitable for the procedure and suitable for day surgery. The second part is actually education. So you're answering, the staff are answering questions from the patient and carer about what will happen on the day about the issues around the surgery. And it also gives us an opportunity to provide them with the written information about their operation and the anesthetic. And this helps reinforce the education process and the verbal reinforcement is really important. So this is just uh some examples of uh patient information leaflets that could be very sophisticated, like the cataract surgery one and union uh anesthetic to something much more simple like the circumcision one from Norfolk and Norwich Hospital and pre op assessment. We're aiming to increase the knowledge of the patient and carer. We're trying to reduce their anxiety. We know that it helps increase patient satisfaction and it helps increase the confidence, confidence in the people that will be caring for them. And we know that our patient's who have undergone pre op assessment are less likely to not attend uh and they are less likely to be admitted following surgery. So what areas about patient selection and screening do we need to think about? So, I've just chosen some areas to go through because these are typical points that people want to speak about. So age is something that is often held, do we have an age limit? And the answer is in the UK, we don't, uh we've got evidence from studies done by colleagues in various day surgery facilities that uh unplanned admission rates and discharge complications in patient's over the age of 70 are no higher than in our younger age groups. So we have no upper age limit. Basically, our decision on whether to include a patient for day surgery is based on the overall fitness of the patient, not on an age. What about high body mass index? Um Here's a uh abstract from uh study by Frances Cheung uh in Candida, who did a survey of Canadian and anesthesiologists and 91% of Canadian anesthetist uh felt that otherwise healthy patient's with a BM I to for between 35 and 44 were are except for ambulance career and 50% of them actually were quite happy to do people with the BM I of Heart of over 45 in the UK, are guidance from our association of the niece that it says that obesity is not an absolute contraindications for daycare in expert hands. And there's the appropriate thing in expert hands with appropriate resources. So again, to give you an idea of our own experience, we started with a BM I limited of 35 and then gradually expanded, having a small number of larger patient's done by just a small group of anesthetists. And as we gained experience and confidence we then removed the upper BM I limit as long as the patient is having a suitable operation. Uh and is suitable with their overall assessment. We will perform that patient as a day case when I was a young anesthetist hypertension was a common reason for canceling patient's. Uh the interesting thing that came because of uh peri operative cardiac risk. Uh This excellent study published in the British Journal of Anesthesiology in uh 2004, I took away that and provided evidence that there is little evidence for an association between admission blood pressures of less than 1 80 on 110 peri operative complications. So again, in our experience, it's one of the commonest finding pre op assessment. The patient is hypertensive, we manage these patient's as day cases. And the one thing that's important here is to separate out long term gains from the peri operative period. So what we do is we ensure that a patient who we find is hypertension hypertensive, that the primary care team are made aware so that they can be assessed about their need for anti hypertensives. In the long term diabetes is another area where we've made huge increases. Uh and we now manage our diabetic patients' even are insulin dependent diabetes diabetics through our day surgery facility because there is no evidence that using uh GK I infusion is really necessary for minor or intermediate surgery. And in fact, in my hospital, we stopped using GK Eye on any patient that was going to be able to eat within four hours of the surgery. And that was for in patient's as well as day cases. And this is just an example of our diabetic protocol where for type ones, we admit the morning insulin and type twos, we admit the oral hypoglycemics and we monitor the patient's blood sugar, perioperatively and post operatively duration of surgery is another thing that was a hold up in the old days. And traditionally, it was said that we tended to only do procedures that didn't last longer than 60 minutes. But now with modern anesthesias, uh total intravenous anesthesia, modern modern volatile agents, uh we've removed the time limit within our facility. So in reality, it's very few operations take longer than 60 minutes. The other factors you need to consider uh respiratory, look carefully at those with poorly controlled asthma or who are uh dis make on mild exertion. Just think carefully about whether they are suitable to be done in your day surgery facility. And same with cardiovascular issues. History of M I within the last six months, severe angina or poorly controlled cardiac failure or all issues that have potential for poor out perioperative outcome. So again, consider those patients' carefully and I've added in the history of COVID. Now we need to be checking our patient's to make sure they've got no long term sequentially uh from their COVID infection, uh neurological factors, epilepsy, we can usually manage those quite successfully and then an aesthetic issues, malignant hyperpyrexia, schooling, apnea or different history of difficult intubation. We really manage all these patient's through our day surgery facility because we just manage them appropriately. We highlight, highlight them and ensure that they are managed appropriately. So, the important point here is it's important that you remember that patient selection depends on the experience of your clinicians, nurses on the unit, the type of unit you're working on. So whether it's a dedicated unit within a hospital or freestanding unit, and it also also depends on the patient groups that you serve because you will uh in particular populations, you may well have some inherited diseases that you need to consider more than we do in the UK. And the important thing really is you should start conservatively doing the fitter patient's build your experience and then gradually expand to other areas. The only thing to mention really is that it's uh we find it important to follow up our patient's uh immediately uh postdischarge. So we did a standardized phone call. Uh the following day, increasingly there is ability to do telehealth a tele consultation with them uh in the POSTOP period. And that gives you useful information that they're recovering well, but also helps the patient that they know that they're going to get a phone call and they can ask any questions that they have any concerns about so to end. Hopefully, I've given you a bit of overview about the handbook, the facilities that can be used for day surgery, some of the lessons that we've learned over the years and also a bit about pre op assessment. Thank you very much. Indeed.