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Innovation and Quality in the Patient Pathway

Madhu Ahuja Consultant Anaesthetist & Lead in Day Surgery & Pre Assessment,  New Cross Hospital, Wolverhampton spoke at today’s Innovation and Quality in Day Surgery conference on: 

• Referral pathways
• Pre operative assessment
• Discharge processes

Abstract of Dr Ahuja's presentation 
The Pathway for day surgery starts with a referral of a patient from primary care for consideration for a surgical procedure. This should take place with knowledge of the procedures that can be carried out on an ambulatory basis leading to referral to a care provider with an intention of day surgery management and an expectation that the provider will accommodate a quality assured process that includes review, booking, the period of admission and provision of follow up support in the immediate period after home discharge.

A simple “fit to refer” check (BP reading, pulse check for AF, recent HbA1c for diabetic patients) at the time of the initial primary care consultation could reduce the numbers of patients who have their operations delayed or cancelled, improving the quality of the pathway for patients and efficient use of operating theatres.

In order to maximize the possibility of day case management, all patients having procedures listed in the BADS Directory of Procedures with a day case rate of >75% should be managed as a day case unless patients are subsequently found at pre-assessment to be unsuitable due to medical or social issues. Patients should be booked as an “intended day case” to ensure they get appropriate information at their preoperative assessment and to ensure the correct tariff is applied for their procedure. 

The pre-operative assessment process is key to successful management of a patient as a day case. It should take place sufficiently in advance of the planned procedure to enable both patient and hospital to make any necessary arrangements to ensure surgery proceeds as planned. Suitably trained nurses provide high quality pre-assessment but having an access to specialist anaesthetic advice ensures patients with complex co-morbidities are assessed without having to make a return visit. Protocols to standardize management of co-morbidities ensure a safe and high quality process.
It is well recognized that patients being managed as a day case receive a higher quality of care and are more likely to be discharged promptly if they are managed through dedicated day surgery facilities. In mixed lists, it is important that the day case procedures are undertaken as early as possible to ensure adequate recovery time. Intended day case management should be clearly recorded on the operating list to ensure the correct pathway is followed.

Management of pain and postoperative nausea and vomiting are key to successful management as a day case and a high quality experience for the patient.

Nurses trained to assess patient’s readiness for discharge, supported by specifically designed protocols are well placed to manage discharge for day surgery patients. Patients should be discharged with appropriate medication to manage pain, documentation describing the procedure they have had, and advice about how to manage common complications and seek further advice. 

Day surgery pathway is a useful tool that can help increase day surgery rates of established procedures. It can also help facilitate converting management of complex patient population or procedure from short stay to day case.
References & Further Reading
1. British Association of Day Surgery. Commissioning Day Surgery: A Guidefor Commissioning Consortia. May 2011. Available from:

2.  BADS Directory of Procedures 4th Edition 2011. Available from

3.  NHS Modernisation Agency. 10 High Impact Changes for Service Improvement and Delivery: Change No 1: Treat day surgery (rather than inpatient surgery) as the norm for elective surgery. Department of Health, London, 2004.

4.  NHS Modernisation Agency. National good practice guidelines on pre-operative assessment for day surgery. Department of Health, London, 2002.

5. British Association of Day Surgery. Ten Dilemmas in Pre-operative Assessment for Day Surgery. 2010. Available from

6.  Kinley H, Czoski-Murray C, George S et al. Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery. Health Technology Assessment 2001;5:No.20

7. One stop service: NHS Modernisation Agency. Day Surgery - A good practice guide. Department of Health London 2005

8. Lewis S, Stocker M, Houghton K, Montgomery JE. A patient survey to determine how day surgery patients would like preoperative assessment to be conducted. Journal of One Day Surgery 2009; 19.2:32–6.

9. British Association of Day Surgery. Nurse led discharge. BADS, 2009. Available from

10.  National Patient Safety Agency Rapid Response Report: Laparoscopic surgery: Failure to recognise post-operative deterioration. NPSA/2010/RRR016. 2010.

11. British Association of Day Surgery. Managing patients with diabetes for day and short stay surgery. BADS, 2011. Available from

Dr Ahuja’s PowerPoint presentation is available for download at the end of this page. 

About Dr Ahuja
I am a Consultant Anaesthetist. I qualified in medicine from Allahabad University and undertook postgraduate studies in anaesthetics at PGIMER, Chandigarh and subsequently at Nottingham, East Midlands Deanery. I was appointed Consultant Anaesthetist at The Royal Wolverhampton Hospitals NHS Trust in 2004. I have been the clinical lead for Day Surgery and Pre-operative Assessment since 2004 and 2006 respectively. 
I have a particular interest in advancing the boundaries of day care treatment. In my trust, I have introduced pathways to allow complex procedures to be done as Day Surgery and designed comprehensive Day Surgery Document incorporating the patient journey during the day surgery episode. 
This is my second term as an elected member of the British Association of Day Surgery Council. I am currently the Chairperson for Editorial Committee and Website Lead.

Future events of interest:

Effective Consent Practice: Implementing the new duty to explain risks to patients
Tuesday 9 February 2016 
Hallam Conference Centre, London

Download: Dr Madhu Ahuja full presentation

26 November 2015


    Partner Organisations

    The Tavistock and Portman NHS Foundation TrustInPracticeClinical Audit Support CentrePlayoutJust For Nurses
    GGI (Good Governance Institute) accredited conferences CPD Member BADS (British Association of Day Surgery) accredited conferences