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Day-case surgery and family response

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VOL: 96, ISSUE: 43, PAGE NO: 38

Jennifer Pearson, RGN, RSCN, is ward manager, Day Case Surgical Unit, Birmingham Children's Hospital NHS Trust

Adrian Drake-Lee, PhD, FRCS, consultant ENT surgeon, Birmingham Children's Hospital NHS 'Trust

After examining information from patient questionnaires and preoperative interviews in 1995, staff on the day-case surgical unit at Birmingham Children's Hospital NHS Trust decided to introduce a day-case tonsillectomy and adenoidectomy service.

After examining information from patient questionnaires and preoperative interviews in 1995, staff on the day-case surgical unit at Birmingham Children's Hospital NHS Trust decided to introduce a day-case tonsillectomy and adenoidectomy service.

Assessment
Before admission as a day-case patient on the unit, children were assessed in an attempt to ensure their suitability for day-case surgery. The criteria required them to be medically fit, have two adults at home to care for them postoperatively and have a car and telephone available to them in case of emergencies.

Parents and carers were also made aware of the responsibilities that were being placed upon them caring for a child following this type of surgery. These included:

- Managing pain;

- Controlling nausea/vomiting;

- Encouraging the return of a normal diet and fluid intake;

- Knowing when to seek advice either from the ward or GP.

Postoperative care on the ward
Children are monitored for six hours after surgery, as this is the most likely time for complications to occur. It is important to look for any signs of bleeding as this may indicate a potential haemorrhage, which would require surgical intervention and may also be indicative of infection. Signs of postoperative bleeding are:

- Drop in blood pressure;

- Rapid pulse;

- Excessive swallowing;

- Vomiting blood;

- Pallor.

Postoperative observations are recorded half hourly for two hours and hourly for four hours. Routine oral analgesia is administered before diet and fluids are offered in an attempt to make patients more comfortable upon swallowing. The senior paediatric nurse assesses observations, ability to chew, swallow and tolerate diet and fluids before the normal diet is resumed.

Discharge criteria
Our discharge criteria is similar to others in the UK (Tewary and Curry, 1993, and Benson-Mitchell et al, 1996). Parents and carers are given verbal advice and written information when they are admitted to the ward. This includes the ward telephone number for any postoperative enquiries. A member of the nursing team and medical staff are also available to answer questions during the ward round.

Audit
The audit was designed to establish whether children having day-case surgery were more likely to need assistance upon discharge, or whether they recovered postoperatively as successfully as those children who stayed overnight after surgery. It also aimed to discover whether all patients were happy with the service provided.

The parents and carers of 150 children admitted for tonsillectomy and/or adenoidectomy (including 31 who had adenoidectomy alone) were sent a questionnaire (see Box 1). Those who did not reply were mailed a second copy of the questionnaire. Information was collected and collated by nursing staff and entered on to a database.

Results
Thirty-nine of the first 150 patients admitted were felt to be unsuitable for day-case surgery for social reasons and 17 for medical reasons 12 of whom suffered from probable sleep apnoea. In total, 94 children were felt to be suitable for day-case surgery and were admitted with this intention. A further 28 developed postoperative complications so that ultimately 66 were treated as day cases. Haemorrhage occurred in one child. There were 121 replies to the questionnaire. The overall satisfaction was similar for both groups, 97% for the day-case patients and 88% for the overnight stay patients. Parents were also satisfied with the advice given to them on discharge.

Discussion
No patients were readmitted on the day of discharge, nor were any readmitted to the ward during the postoperative recovery period.

Safety factors have had to be built into the scheme for it to operate effectively. Research has shown that families need to be confident in their ability to care for their child following surgery and need to have help and advice from extended family and hospital staff at any time.

Tewary et al (1993) found that 49% of parents would have been happy to have their child treated as a day case, but there was parental anxiety about vomiting or bleeding on the way home or while at home. Nurses must be sensitive to parents' and carer's anxieties and should be available to give support to the child and family as required. In order to minimise calls to the GP, parents are asked to telephone the nurses on the short-stay ward if there are any problems. These calls are now being logged as part of an ongoing study.

Conclusion
This study confirms that day-case tonsillectomy and adenoidectomy are possible, and can be successful in carefully selected cases. The day surgery process encompasses effective pre-admission procedure, parental participation and planned discharge. All these factors combine to achieve a successful outcome.

Further study will be needed to look at both the social factors involved in the postoperative period after day-case surgery and better methods of perioperative management to improve patient recovery.

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