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Background: Day case haemorrhoidectomy has been shown to be safe and acceptable to patients. The best way to introduce such evidence into clinical practice remains unclear. The aim is to assess the effectiveness of guidelines on the introduction of day-case haemorrhoidectomy in a general surgical unit. Methods: Prospective audit of day-case haemorrhoidectomy and retrospective review of in-patient procedures. The effectiveness of guidelines in encouraging day-case haemorrhoidectomy is assessed by analysis of avoidable admissions. Results: In the year prior to introduction of the guidelines 75 patients had elective haemorrhoidectomy, none as day-cases. In the year following the introduction of the guidelines 80 patients had elective haemorrhoidectomy, 35 (44%) as day cases. There were no complications or re-admissions. Of the 45 in-patients 31 (69%) were eligible for day surgery. Conclusions: The establishment of clear guidelines and their dissemination results in significant changes in practice. However, audit has demonstrated that alternative strategies are needed to encourage changes in clinical practice.
Keywords: Ambulatory care, haemorrhoidectomy
J.R.Coll.Surg.Edinb., 45, December 2000, 369-370
Day-case haemorrhoidectomy is becoming a routine procedure in many centres 1,2 with significant benefits in terms of cost and efficiency. However, in-patient surgery remains the standard practice in many units. Little information is available on how best to encourage changes in surgical practice. In the United Kingdom, surgical routine is based around the preferences of individual surgeons who have substantial autonomy. We have observed the effect of the introduction and circulation of explicit guidelines on the introduction of day-case haemorrhoidectomy in a large surgical unit.
Guidelines were drawn up from the best available evidence. Day cases were premedicated with dioctyl3 for 2 days pre-operatively. The guidelines suggested a general anaesthetic open diathermy haemorrhoidectomy with no pack, infiltration with bupivicaine and a diclofenac suppository.4-7 Post-operatively patients received regular analgesia with co-codamol and diclofenac, fybogel, dioctyl, and metronidazole.8,9 Nursing staff telephoned patients on days 1 and 3 post-operatively to assess complications and satisfaction.
The names of all patients having haemorrhoidectomy one year prior to the introduction of the guidelines were obtained from the coding department. Patients who had in-patient haemorrhoidectomy after introduction of the guidelines were also identified from coding and all notes reviewed. The notes were assessed and patients who would have been suitable for day-case procedures according to day-unit protocols identified. The patients were under the care of 9 general surgeons, 3 being coloproctologists.
In the year prior to introduction of the guidelines 75 patients (36 men), mean age 56 years (range 30-88), had elective haemorrhoidectomy, none as day-cases. Median hospital stay was 3 days (range 1-14).
In the year following the introduction of the guidelines 80 patients had elective haemorrhoidectomy, 35 (44%) as day cases. The 45 in-patients (26 men), mean age 56 years (range 31-91), had a median stay of 3 days (range 2-13). The 35 day cases (15 men) had a mean age of 48 years (range 30-88). There were no complications or re-admissions though one patient attended the day unit for reassurance when he felt his haemorrhoids were still present.
Of the 45 in-patients 31 (69%) would have been eligible for day surgery. (Figure 1) The remainder were unsuitable because of cardiorespiratory disease (12 patients) and diabetes mellitus.2
Figure 1: Day surgery before and after the introduction of guidelines
Published evidence confirms that day case haemorrhoidectomy is safe and acceptable to patients. The optimal way to introduce such evidence into clinical practice is not clear. In this case a treatment protocol produced by a single colorectal surgeon and day unit nurses was circulated on a single occasion to consultant colleagues. The guidelines mapped out a treatment course and raised awareness of the possibility of the day case procedure.
The guidelines without further prompting resulted in 44% of operations being performed as day cases. On the basis that a day unit bed costs £274 a day and an inpatient bed £410 this represents a saving of £33,460 (assuming a 3-day stay). However, 43% of patients having in-patient surgery could have been day-cases. If all had day surgery the savings would total £63,096.
Colorectal surgeons performed 71% of day cases but many were still in-patients. This can be partly explained by patients being listed for surgery prior to the guidelines being published (the surgeon with the longest waiting list performed least day cases). Even the surgeon responsible for the guidelines performed two unnecessary in-patient procedures for this reason. Only one surgeon performed no day case procedures suggesting that the remainder had embraced the idea. Another reason for unnecessary admission is a loss of initiative with replacement of junior staff. Distributing guidelines to junior staff could obviate this problem but some patients will still be inappropriately listed by over cautious medical staff. Pre-assessment of admissions by nursing staff, as occurs in our unit, using agreed protocols could allow unnecessary in-patients to be identified and redesignated.
Our experience adds to the growing evidence that day case haemorrhoidectomy is a well-tolerated and accepted procedure. Common concurrent illness precluded more patients from the day case procedure. This problem may be overcome with the use of regional anaesthesia, allowing a wider spectrum of patients to benefit from day case surgery.
This study has demonstrated that the establishment of clear guidelines and their dissemination results in significant changes in practice. Audit has demonstrated a sub-optimal result; however, there are clear strategies for further improvement including distribution of these results within our unit.
Copyright date: 3 October 2000
Correspondence: Mr SM Plusa, Department of Surgery, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, U.K.
©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb. 45, 6: 369-370