NGH hernia poster .pdf

Day Case Inguinal Hernia Repairs
Are we meeting the guidelines?
D. W. Ferguson, R. A. Wardle, K. D. C. Rees

Background
Recent advances in surgical practice and the resultant performance expectations means the current target
for day case inguinal hernia repairs in Great Britain is an impressive 95%.1 Whilst the 1993 guidelines
were for 30% to be performed as day cases,2 expectations rocketed in less than a decade to 2002 targets
of 75%.3 So, given the recent acceleration in expectations, how does a large district general hospital
perform against today’s 95% target? If it fails, what can be done to achieve 95% success?

Methods
Planned day case inguinal hernia repairs conducted between 1st January and the 31st March 2012 at
Northampton General Hospital (NGH) were considered. All patients admitted overnight on the day of
surgery had their notes reviewed with the reasons for overnight admission extracted and coded.

Results
103 patients were operated on with 83.5% (86/103) of procedures successfully conducted as day cases.
Within the 17 patients admitted, the mean age was 61.5 ± 18.4 years, with 16 males and 1 female. 17.6%
(3) of those admitted had laparoscopic procedures. Of the 17 necessitating inpatient treatment the
reasons for admission were; A. Failure to pass sufficient urine post operatively – a nursing criteria for safe
discharge (6) B. Basic bedside observations unsafe for discharge (4) C. Admission for administration of
analgesia (3) D. No specific reasons given (4).

Conclusions

Three clear reasons for overnight admission were elucidated accounting for 13 (12.6%) patients. We
determine that the single biggest factor resulting in these admissions was insufficient time postoperatively
for physiological function to return to safe values or adequate control of pain. Based on our study, our
recommendation is that elective inguinal hernia repairs are conducted towards the beginning of the theatre
list. We believe the most significant limitation of this study is failure to ascertain the exact time at which
each procedure was conducted.

Pass urine on day of procedure

Bedside observations within safe values

Effective pain management Accept 4 admissions

A Solution?

The schema above suggests a way to increase current day case performance at NGH from
83.5% to above the target of 95.0%.1 Converting 13 of the current 17 admitted patients into day
case procedures by the methods outlined above would enable a success rate of 96.1%. We
believe this is possible and will formulate recommendations to be discussed with NGH.
References

1. British Association of Day Surgery. BADS Directory of Procedures. 3rd edition. London 2009.
2. The Royal College of Surgeons of England. Guidelines for Day Case Surgery. London: RCSE 1992.
3. Modernisation Agency. National good practice guidance on preoperative assessment for day surgical units. London: Operating Theatre Preoperative Assessment Programme 2002.