Key Facts

Day case surgery is the standard of care for most elective surgical procedures in the UK. It offers benefits of reduced hospital-acquired infection risk, faster recovery, improved patient satisfaction, and cost savings to the NHS.

Epidemiology

Over 10 million surgical procedures are performed in the NHS annually, with the majority suitable for day case management. The NHS targets 85% day case rates for basket procedures. Conversion to overnight stay occurs in approximately 2-5% of planned day cases.

Aetiology

The expansion of day case surgery has been driven by advances in:

• Minimally invasive surgical techniques (laparoscopy, endoscopy)
• Short-acting anaesthetic agents (propofol, sevoflurane, remifentanil)
• Improved analgesic techniques (local anaesthesia, regional blocks)
• Enhanced recovery protocols

Pathophysiology

Not directly applicable as a physiological process. The concept relies on selecting procedures and patients where the surgical stress response, pain, and risk of complications can be managed safely without overnight hospital monitoring.

Suitable Patient Characteristics

• ASA grade I-III (stable comorbidities)
• BMI ideally <40 (case-by-case assessment)
• Adequate social support — responsible adult available
• Living within 1 hour of the hospital
• No anticipated need for overnight IV medications or monitoring

Unsuitable Patients

• Unstable comorbidities (e.g., poorly controlled diabetes, recent MI/stroke)
• History of malignant hyperthermia (require extended monitoring)
• Severe obstructive sleep apnoea on CPAP
• Patients requiring post-operative anticoagulation bridging

Common Day Case Procedures

• Inguinal hernia repair, laparoscopic cholecystectomy, excision of lumps
• Arthroscopy, carpal tunnel release, trigger finger release
• Circumcision, cystoscopy, vasectomy

Red Flags

• Uncontrolled pain requiring parenteral opioids beyond 4 hours post-operatively
• Post-operative haemorrhage or expanding haematoma
• Signs of surgical complication: fever, peritonism, inability to void
• PONV unresponsive to antiemetic therapy

Bedside

• Pre-operative assessment: Structured questionnaire, fitness evaluation
• Observations: Baseline BP, HR, SpO2, BMI, airway assessment
• Blood glucose: In diabetic patients — plan insulin management

Bloods

• Targeted blood tests only: Not routine for ASA I patients undergoing minor surgery
• FBC: If anaemia suspected or significant blood loss expected
• U&Es: If on diuretics, ACEi/ARBs, or renal disease
• Coagulation: Only if on anticoagulants or bleeding history
• HbA1c: Diabetic patients — assess glycaemic control
• Pregnancy test: Women of childbearing age (as per local policy)

Imaging

• Procedure-specific — not routinely required for day case selection
• CXR: Not routine; only if clinically indicated
• ECG: If cardiac history, age >65 with comorbidities, or ASA III

Special Tests

• STOP-BANG questionnaire: Screen for obstructive sleep apnoea
• Functional capacity assessment: Can the patient climb two flights of stairs? (≥4 METs)

Non-pharmacological

• Pre-operative optimisation: Smoking cessation, glycaemic control, weight management
• Fasting: 6 hours solids, 2 hours clear fluids (enhanced recovery encourages carbohydrate drinks 2 hours pre-operatively)
• Patient information: Written and verbal discharge instructions, emergency contact numbers
• Discharge criteria: Stable observations, pain controlled on oral analgesia, tolerating fluids, passed urine (if applicable), responsible adult present

Pharmacological

• Multimodal analgesia: Paracetamol 1g QDS + ibuprofen 400mg TDS ± codeine 30-60mg QDS
• Local/regional anaesthesia: Wound infiltration, nerve blocks (reduce opioid requirements)
• Antiemetic prophylaxis: Ondansetron 4mg IV + dexamethasone 6.6mg IV (Apfel score ≥2)
• Short-acting anaesthetic agents: Propofol, sevoflurane, desflurane for rapid recovery
• VTE prophylaxis: Risk-assess per NICE NG89; mechanical ± pharmacological

Surgical/Interventional

• Minimally invasive techniques preferred (laparoscopic, endoscopic)
• Meticulous haemostasis to minimise post-operative complications
• Early morning scheduling for complex cases

Referral Criteria

• Patients not meeting day case criteria — refer to inpatient pathway
• Unplanned overnight stay — document reason and escalate if complication

• Day case surgery has a very low complication rate: unplanned readmission occurs in approximately 1-3%
• Unplanned overnight admission rates are approximately 2-5% (PONV and pain are the commonest causes)
• Patient satisfaction rates exceed 95% for well-run day case units
• Hospital-acquired infection rates are significantly lower than inpatient surgery
• Day case laparoscopic cholecystectomy has a conversion to open rate of 2-5% and readmission rate of 2-4%

BADS Day Case Basket Procedures

Discharge Criteria Checklist