This weeks blog is by Archana Shajidevadas (archana.shajidevadas@plymouth.ac.uk ), Lecturer at the  University of Plymouth.

The increasing demand for hospital beds in the National Health Services (NHS) is driven by several factors. The pandemic caused the postponement of many surgeries and treatments, resulting in extended waiting lists further exacerbated by staff industrial actions. Shortage of acute beds often leads to the cancellation of elective surgeries¹, underscoring the critical need for day surgeries where patients can be discharged without overnight admission. Despite this necessity, older adults in day surgery or ambulatory surgery faces significant challenges, including postoperative complications and readmissions. Therefore, proper assessment, planning for successful discharge and follow up are necessary.

Day case surgery criteria focus on functional status rather than age, meaning patients of all ages, including those with multiple comorbidities, are treated in day surgery departments². Older patients undergoing general anaesthesia (GA) for day surgeries require special attention due to risks of altered cognition and frailty, which can lead to impaired quality of life, institutionalisation, and even death³. Many patients also present with undiagnosed baseline cognitive impairments, a significant risk factor for postoperative delirium⁴. Such patients may struggle with post-operative instructions, wound care, medication management, and seeking healthcare if needed. Unfortunately, the NHS lacks a systematic follow-up pathway for day case discharges, typically referring patients to their General Practitioner (GP) for follow-up. This process can be problematic, as GP appointments may take weeks to secure, posing a significant risk for patients with cognitive impairments and other complications.

Many follow-up methods have been trialled globally, with telephone follow-ups being one of the more common approaches. A secretary or registered nurse contacts the patient within 72 hours post-discharge to inquire about safety, post-operative complications, pain management, and general feedback⁵. Another model involves using automated telephone follow-ups to triage patients before a clinician’s call. This method theoretically allows for more effective triaging, ensuring that patients receive timely and appropriate attention from a nurse or a doctor⁶. Additionally, smartphone-based applications have been increasingly utilised in recent years to evaluate patients after day surgery. These applications can help monitor patients’ recovery, manage pain, and identify any complications, providing a convenient and accessible way for patients to stay connected with their healthcare providers. While this method is cost-effective and easy to implement, it has limitations, particularly for the geriatric population. Older adults often face low health literacy, sensory declines, and cognitive impairments that hinder their engagement with follow-up methods like telephone calls or smartphone applications⁷.

Face-to-face visits for each patient are impractical due to resource constraints. Therefore, innovative models such as virtual wards and Artificial Intelligence (AI) technologies should be explored for day surgery follow-up in older adults. Virtual wards are already trialled and implemented for medical and geriatric patients, involve remote monitoring with health devices and telehealth platforms after discharge from the hospital. Training on these technologies should be provided to patients and care givers pre-operatively, with rapid support available for any technical issues. Effective communication between the day surgery team, social services, and other multidisciplinary teams is essential to coordinate care, provide personalised attention, and identify complications early.

AI technologies hold significant potential for personalised follow-up care for older patients undergoing day surgeries. Wearable devices and AI-powered telehealth can enable continuous monitoring of physical activities, vital signs, and patient prognosis, facilitating immediate assistance in case of falls and offering virtual consultations. Smart devices can assist with daily living tasks, medication reminders, and emergency calls via voice assistance. AI-driven chatbots and robots can provide companionship, cognitive stimulation, and mental health monitoring, identifying changes in mood, behaviour, and early signs of depression or cognitive decline.

Application of AI and related technologies must address ethical challenges, including privacy, security, bias, and fairness, to ensure parity in care. Both patients and caregivers, as well as healthcare providers, need training to use these technologies effectively. Financial implications should also be considered to ensure long-term benefits for patients and society.

In summary, while day surgeries offer a solution to the increasing demand for hospital beds, especially amid current healthcare challenges, successful implementation requires a multifaceted approach. Combining innovative follow-up methods with thorough planning and patient support can enhance outcomes, particularly for older adults with complex needs.

1. Hassanzadeh, H., Boyle, J., Khanna, S., Biki, B & Syed, F (2022). Daily surgery caseload prediction: towards improving operating theatre efficiency. BMC Med Inform Decis Mak.22(1):151. doi: 10.1186/s12911-022-01893-8. PMID: 35672729; PMCID: PMC9172609.

2. Nicholas, J and Russon, K, (2020), Day surgery services. https://rcoa.ac.uk/sites/default/files/documents/2020-08/21075%20RCoA%20Audit%20Recipe%20Book_14%20Section%20B.5_p189-208_AW.pdf Accessed on 08/04/24.
3. White, S., Griffiths, R., Baxter, M., Beanland, T., Cross, J., Dhesi, J., Docherty, A B., Foo, I., Jolly, G., Jones, J., Moppett, I K., Plunkett, E and Sachdev, K (2019) Guidelines for the peri-operative care of people with dementia Guidelines from the Association of Anaesthetists. Anaesthesia 74, pp. 357–372. doi:10.1111/anae.14530
4. Tiwary, N., Treggiari, M., Yanez, D N., Kirsch, J., Tekkali, P., Cornelia C and Schenning, K (2021). Agreement Between the Mini-Cog in the Preoperative Clinic and on the Day of Surgery and Association With Postanesthesia Care Unit Delirium: A Cohort Study of Cognitive Screening in Older Adults. Anesthesia & Analgesia 132(4) pp. 1112-1119 DOI: 10.1213/ANE.0000000000005197

5. Berardinelli, A., Sotka, A and Bernhofer, B (2018). Same Day Surgery Follow-up Phone Calls – Return on Investment? Journal of PeriAnesthesia Nursing, 33 (4). e34-e35, https://doi.org/10.1016/j.jopan.2018.06.079.

6. Dahlberg, K., Philipsson, A., Hagberg, L., Jaensson, M., Hälleberg-Nyman, M and Nilsson, U (2017). Cost-effectiveness of a systematic e-assessed follow-up of postoperative recovery after day surgery: a multicentre randomized trial. British Journal of Anaesthesia, 119 (5). Pp. 1039-1046, https://doi.org/10.1093/bja/aex332.
7. Liu, N., Yin, J., Tan, SS., Ngiam, KY and Teo, HH (2021). Mobile health applications for older adults: a systematic review of interface and persuasive feature design. J Am Med Inform Assoc. 28(11). pp. 2483-2501. doi: 10.1093/jamia/ocab151