Day case orthopaedic trauma surgery effectiveness: a systematic review

INTRODUCTION

Day case surgery is a well-established way of delivering elective orthopaedic surgical operations safely, cost effectively and has high patient satisfaction.^1-4 Access to dedicated rehabilitation services in dedicated accommodation in America helps day case arthroplasty patients post operatively recover with this type of surgery gaining popularity also in the United Kingdom.^5,6 Day care facilities are less often used to deliver orthopaedic trauma surgery pathways for rapid assessment and patient recruitment can be difficult to coordinate.⁷ However, winter pressures and more recently the covid pandemic have seriously limited a surgeon's ability to offer timely surgery.^8,9 Trauma operations must be delivered within a limited time frame after the injury to lead to positive outcomes for rehabilitating the limb. For instance, The British orthopaedic association standards for trauma care (BOAST) indicate that timely surgery for ankle fractures within 24 to 48 hours and intra articular wrist fractures 72 hours (BOAST standard 12 and 13) improves outcome.^10,11 Achieving these targets can be challenging within the resources currently available to hospitals as the population grows and practice evolves.^12,13

It is not clear how widespread the practice of day case trauma surgery is within orthopaedics in the United Kingdom, nor the pathways adopted to facilitate treatment, or the list of operations performed although surgery appears confined to the appendicular skeleton more distally.¹⁴ During the recent COVID pandemic more complex trauma cases in the proximal appendicular skeleton such as the humeral shaft or proximal humerus have been undertaken by the senior authors without problems.¹⁵

The purpose of this study is to establish the range of practice adopted for day case trauma surgery within the UK and to investigate the possible benefits to patients in terms of safety, satisfaction, and convenience by adopting practice available around the world. Also, to evaluate the cost benefits to the NHS and healthcare providers to facilitate development of these pathways especially where resources are limited.

METHODS

The research question was refined using the population intervention comparison outcome study design (PICOS) framework using an iterative approach to consider whether day case trauma surgery improves clinical outcome, patient satisfaction and how feasible is it to implement within the UK.¹⁶

Search strategy

Eligible studies were found by searching the following databases: Medline, EMBASE, and PsycINFO. All databases were searched up until 10^th December 2021. The following search algorithm was adapted for our chosen databases: (“day surgery” or “day case surgery” or “23-hour surgery” or “ambulatory surgery” or “outpatient”) and (“Orthopaedic trauma”) and (“orthopaedic surgery” or “cost effectiveness” or "patient satisfaction" or "patient reported outcome measures" or “Patient readmission” or “complications” or “length of stay”). The searches were conducted by specialist librarian (within the hospital trust of the lead author) who, while less familiar with the area to research, was skilled at database searches and lists amalgamated. Several iterations were used to maximise sensitivity. In addition to electronic databases reference lists of included studies and relevant reviews were searched to identify missed eligible studies. A "snowballing" method was adopted to include breadth of available literature and contact with study authors to identify any additional or ongoing studies. Additionally, the Royal college of surgeons and British orthopaedic association websites also searched for relevant articles.

Eligibility criteria for study was included in Table 1.

Study selection

Study screening and data collection process

The details of the searches were recorded systematically with the number of studies excluded at the title, abstract and full text screening stage with reasons (e.g., ‘not orthopaedic related' or not in the day case environment) were recorded. Three researchers were involved in the title, abstract and full-text screening stages (DB, JH, NA), and where there was uncertainty in study eligibility, a consensus decision was made by at least two screeners.

Endnote was used to capture and manage the references at each stage of screening.

Only full text articles discussing day case trauma surgery, ambulatory trauma surgery or 23-hour trauma surgery were included.

The same three researchers (DB, JH, NA) extracted the study design, participant characteristics (number of participants/ demographics), intervention characteristics (location of intervention, duration, and type of surgery), details of patient complications, and any outcome measures used such as patient satisfaction (visual analogue score) or assessment score type and value. Finally, any details regarding the cost effectiveness of utilising day case trauma facilities were captured and the rates of readmission and overnight stay.

RESULTS

In total there were 9956 papers identified within the search (1657 Embase, 798 Medline, and Ovid 7501). The number of studies excluded at the title (8457) and abstract screening stage (1231), and numbers of excluded studies with reasons (e.g., ‘not orthopaedic related' or not in the day case environment) at the full-text screening stage (140). After exclusion of duplicates there were 31 articles relevant to the research question found, four of these were in a foreign language (only two of these were included, one was excluded because it was a review article, and the other did not focus on day case trauma surgery). Two papers on minimally invasive repair of ruptured Achilles' tendon as a day case procedure with early full weight bearing, Bhattacharya and Gerber and Fixation of clavicle fractures: the role of day surgery? were added from the reference lists.^17,18

There were three prospective and twenty-two retrospective studies, three of which were propensity matched to ensure that the groups compared had similar characteristics.^19-21 Two studies were prospective with the retrospective controls.

Overall, 9014 patients had day case surgical procedures to treat orthopaedic trauma patients within the 25 papers identified. The type of anaesthesia was recorded in 6 studies. General anaesthesia was used in 1843 patients, regional or local anaesthesia in 308; the type of anaesthesia was not stated in the other papers. The age of patients was reported in 14 studies with a mean of 37.5 years, the range was (2-83) years. In 11 studies the percentage of males ranged from 29.4-89%. Eight studies involved upper limb procedures, 6 lower limb and 4 were mixed. Looking at the range of cases operated on within the appendicular skeleton all areas had surgery within the upper limb from clavicle to digit apart from the scapula. In the lower limb surgery was confined to the knee (patella fixation, arthroscopy, ligament repair) and below.

The most common upper limb operation was wrist plating and the most common lower limb operations was removal of foreign body and ankle fixation.

Overnight stay was required for 28 (0.003%) patients and a readmission rate in 23 (0.003%) other cases within 28 days of surgery.

Clinical outcomes

There were 40 wound infection complications out of 9014 outpatient operations performed (0.004%) although this varied widely in the papers reported (0-9.3%). In-patient (0.2 -1.3%) and outpatient (0-0.7%) prevalence rates were comparable in the two papers that looked at similar patients in different settings.

Other complications were recorded for 142 patients out of 9014 (0.0156%). Again, the prevalence rates seen ranging from 0.6% to 2.0% in outpatients compared to a comparator of 1.6% to 4% in a similar cohort of the inpatients.

The type of complication being similar ranging from wound problems, failure of fixation and thromboembolic events in both groups.

Patient satisfaction

Only one study quantified patient satisfaction with all but 5.3% of trauma patients being satisfied with the process.² Two other studies indicated that day case trauma surgery patients showed high satisfaction but there were no figures to describe this in more detail.^2,22

Bed occupancy and cost savings

A form of cost benefit analysis was carried out in 9 of the 18 studies. Day case trauma surgery led to savings of £294 to £617 per case by avoiding overnight admission.^2,13

In the US and Canada day case trauma surgery led to savings of $3459 to $5881 per case by avoiding overnight admission.

The total savings of £67450 were reported by Colgate-Stone for 119 upper limb cases and Stull estimated that the health service in the US would reduce costs by $282,529,079.00 if ankle fractures were treated as outpatient or day case trauma procedures rather than being routinely admitted.^13,23

Five studies (Chandratreya, Bhattacharayya, Howells, Qin, Stull) reported on how day case trauma lists affected bed occupancy. Number of bed days saved ranged from 2.1 to 3.9 per case for 1788 cases. Reducing overnight stays reduces the cost of trauma care and makes more beds available for admission of other patients.^7,11,23-25

Howells et al showed that 900 bed days per year could be saved by the efficient day case trauma surgery in one unit.²⁴

Resources

No studies provided a template for a standard operating procedure needed to underpin safe day case surgery. Suitable pre-assessment and anaesthetic evaluation is required to ensure safe surgery in an adequately equipped facility with a structured follow up and emergency contact numbers in case of patient concerns.

DISCUSSION

Major morbidity and mortality following ambulatory surgery is exceedingly low.³⁸ The government has set targets that 75% of elective surgery should be performed as day cases. Minimally invasive surgery is now well established which has allowed more procedures to be performed as day surgery.¹⁴ Improvements in techniques facilitate reduced surgical time even for quite complex trauma cases including ankle fractures (Bullock et al) or elective surgery enabling procedures such as reverse shoulder replacement (Erickson et al), hip and knee replacements to be done in this setting (Lazic et al).^10,21,39

Patient selection and consideration of timing for surgery must be robust to facilitate a smooth and safe pathway for patients with those up to ASA III being considered suitable for surgery in this setting (Siow et al). The introduction of BOAST standards for ankle trauma recommending same or next day surgery (Morris et al) has helped reduce the issue of swelling and the need for admission or other interventions to reduce this before surgery (Mahmood et al).^40-42

In the postoperative period it is important to observe patients to detect the presence of complications which can occur immediately, early or late and be general in nature or specific to the orthopaedic operation (Shin et al). This includes immediate issues such as pain control, nausea and vomiting which often is determined by the nature of the anaesthetic (McCracken et al) and the needs for readmission for surgical reasons such as swelling, compartment syndrome and continued bleeding or wound problems early after surgery. This review shows that the complications in patients who had day case trauma surgery did not exceed those in patients who had inpatient trauma surgery. Day case trauma surgery is as safe as inpatient trauma surgery (Crawford et al). With careful selection and appropriate home and healthcare support many trauma cases may be safely managed as day case procedures. Patients awaiting surgery for ankle fractures would only be allowed home if they had home support that would allow them to elevate limb, they required strict elevation, mobilising only for self-care.^14,43,44

Infection rates in patients treated as day cases were comparable with (Nylen and Roberts) and in some cases lower than those treated as inpatients. Qin et al in comparing ankle fractures treated as inpatients and outpatients showed that surgical complications, superficial and deep surgical site infections as well as wound disruption were less common in outpatients, but the differences were not significant. Whiting had a 0% infection rate, Schonauer had an overall infection rate of 6.9%; the serious infection rate i.e. those who needed admission for intravenous antibiotics was 4%. Comparison of day case and inpatient cohorts showed comparable infection rates; indeed, the infection rate was sometimes lower in those treated as day cases (Qin, Shen and Whiting).^{25,26,32,45,46}

Also, the overall complication rates were low, ranging from 0% to 12.8% (Schonauer) and did not exceed those for inpatients in similar studies, (Hargreaves). Comparison of inpatient and day case cohorts showed the day case cohorts had lower total as well as major and minor complication rates (Whiting and Shen).^26,32,47

Athar et al showed 94.7% satisfaction with day case surgery. Many of the patients treated on day case trauma lists are non-urgent or low priority cases and are often cancelled when placed on inpatient trauma lists; this has been seen frequently in upper limb surgery. It also facilitates the get it right first time objectives by increasing list availability and flexibility to meet the demands of patients (Hind et al). When placed on day case trauma lists, unnecessary hospitalisation is avoided for patients who prefer the streamlined surgical pathways and clear discharge pathways that day case surgery facilitates provide.^2,48

From the reviews analysed there are clear savings from day case trauma surgery even though the savings vary (Fabricant et al). Estimates of the savings to the NHS vary as the studies span several years; with the increasing tariffs, the increasing cost of healthcare and the greater need to find efficiency savings, the potential cost benefit from day case trauma surgery is even greater. Colgate-Stone showed that their trust saved £67450.00 in one year as a result of day case trauma surgery. Stull estimated that the health service in the US would save $282 million dollars just from treating ankle fractures as outpatients. Imagine the combined total savings that would accrue to the US health service from all outpatient trauma surgery.^13,23,49

Finally, the recent covid pandemic has focussed surgeons’ attention on pathways to improve trauma care in the outpatient setting but also for trauma and elective surgery. Defined green pathways for trauma surgery have facilitated treatment of ambulatory trauma patients.^50-54

There are several limitations in this review. The studies cover a period of almost 20 years. Analysing cost savings is difficult because of the effect of inflation, changes in demographics of the population, healthcare trends, expectation of patients and demand for surgery. Most of the studies were retrospective. In many cases it was not clear what type of anaesthesia was used or whether it was an upper or lower limb procedure. Some studies stated that day case trauma surgery improved patient satisfaction without quantifying it.

CONCLUSION

Day case orthopaedic trauma surgery when planned is effective, well tolerated and facilitates trauma care when facilities are restricted such as during the COVID outbreak and winter pressures. Every hospital should have a standard operating procedure to facilitate this with a suitably resourced theatre and team available to meet the needs of ambulatory trauma patients.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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