Standard 44: Day Clinic and Day Surgery (Version 11)

Why it matters. Not every patient is safe to go home the same day. A written selection process, applied to each patient before the procedure, stops unsuitable patients from being operated on in a unit that cannot keep them safe.

Sample. Review 20 day-surgery cases from the last 3 months, with the selection, recovery, discharge and pre-procedure records for each.

1. A written selection process exists.

Method. Read the criteria and check the review date.

Evidence to show. Selection policy ( DAY-POL-001 ).

Pass when. Criteria are written, approved and reviewed within 12 months.

2. Each day case is checked against the criteria before the day.

Method. Check the selection checklist for each of the 20 cases.

Evidence to show. Same-day selection checklist ( DAY-FRM-001 ).

Pass when. At least 90% of cases have the checklist completed before the day.

3. Home support and access to care are confirmed.

Method. Check each checklist for home support and access.

Evidence to show. Same-day selection checklist.

Pass when. Every day case has home support and access confirmed.

Immediate fail (any one means the criterion is not met)

• A patient with no home support or no access to care is booked for same-day surgery.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Anaesthesia and sedation carry serious risk, and the level of care depends on who gives them. Each staff member must be trained and credentialed for the level they give, and each patient must be monitored throughout.

Sample. Review the sedation credential register and 10 sedation cases from the last 3 months.

1. Sedation and anaesthesia are given by credentialed staff for the level given.

Method. Match the staff member on each case to the register.

Evidence to show. Sedation credential register ( DAY-REG-001 ).

Pass when. Every sedation case is given by staff credentialed for that level.

2. Monitoring matches the level.

Method. Check the monitoring record for each case.

Evidence to show. Anaesthesia record ( SRG-FRM-002 ).

Pass when. At least 90% of cases have monitoring matched to the level.

3. A written response to complications is in place.

Method. Read the response for each level and check the review date.

Evidence to show. Sedation and complication response ( DAY-SOP-002 ).

Pass when. Each level has a written response, reviewed within 12 months.

Immediate fail (any one means the criterion is not met)

• Sedation is given by a staff member who is not credentialed for that level.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Patients are most at risk in the hour after anaesthesia. Monitoring in recovery until written discharge criteria are met is what finds the complication before the patient leaves.

Sample. Review 20 recovery records from the last 3 months.

1. Each patient is monitored in recovery by trained staff.

Method. Check each record for observations from arrival in recovery.

Evidence to show. Recovery observation record ( DAY-FRM-003 ).

Pass when. At least 90% of records start observations on arrival.

2. Monitoring continues until the written discharge criteria are met.

Method. Check each record for the criteria met before discharge.

Evidence to show. Recovery observation record.

Pass when. Every discharge has all criteria recorded as met.

3. Trained staff carry out the monitoring.

Method. Check the training record for recovery staff.

Evidence to show. Staff training record.

Pass when. Every person recording observations is trained.

Immediate fail (any one means the criterion is not met)

• A patient is discharged from recovery before the written discharge criteria are met.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. A patient who goes home alone after anaesthesia can collapse without anyone to help. An adult escort at discharge, and written advice, is the simplest protection.

Sample. Review 20 discharges from the last 3 months.

1. Every patient leaves with an adult escort.

Method. Check the escort name in each discharge record.

Evidence to show. Discharge and escort record ( DAY-FRM-002 ).

Pass when. Every discharge has an adult escort named.

2. The escort is confirmed on the day.

Method. Check the time of confirmation.

Evidence to show. Discharge and escort record.

Pass when. At least 90% of escorts are confirmed on the day of surgery.

3. Written advice is given to the patient and the escort.

Method. Check the advice record for each discharge.

Evidence to show. Discharge and escort record.

Pass when. Every discharge has written advice recorded as given.

Immediate fail (any one means the criterion is not met)

• A patient leaves day surgery alone, or with no written advice.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. The pre-procedure checks, including the surgical safety check, catch wrong-site, wrong-patient and missing-equipment errors. Each check done and recorded is the proof that it was done.

Sample. Review 20 procedures from the last 3 months, and observe 3 pre-procedure checks on the day.

1. Pre-procedure checks are carried out for every procedure.

Method. Check the pre-procedure record for each of the 20 procedures.

Evidence to show. Pre-procedure check record ( DAY-FRM-004 ).

Pass when. Every procedure has the record completed before theatre.

2. The surgical safety check is completed and recorded.

Method. Check each procedure for the safety checklist record.

Evidence to show. Surgical safety checklist record ( SRG-FRM-001 ).

Pass when. Every procedure has the safety checklist completed.

3. A check not done stops the procedure.

Method. Observe the checks on the day and check any delayed procedure.

Evidence to show. Observed checks and delay record.

Pass when. No procedure started with a check not done.

Immediate fail (any one means the criterion is not met)

• A procedure starts with a pre-procedure check not done or not recorded.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Surgical site infections are a common, preventable harm. Tracking the rate over time, and reviewing it, shows whether prevention works and where to act.

Sample. Review the surgical site infection register and the bundle compliance record for the last 12 months.

1. Surgical site infections are tracked over time.

Method. Check the register has monthly figures for 12 months.

Evidence to show. Infection surveillance register ( HOS-REG-005 ).

Pass when. Monthly figures are recorded for the last 12 months.

2. Results are reviewed to reduce infection.

Method. Check the review record for each quarter.

Evidence to show. Infection surveillance review ( HOS-SOP-014 ).

Pass when. Each quarter has a recorded review and an action where the rate rose.

3. The bundle is followed for each procedure.

Method. Check the bundle compliance record.

Evidence to show. Bundle compliance record ( SRG-FRM-004 ).

Pass when. At least 90% of procedures have the bundle recorded.

Immediate fail (any one means the criterion is not met)

• No surgical site infection rates are tracked.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. When a patient planned for same-day discharge is admitted, something went wrong in the planning. Reviewing each one shows the cause and stops it happening again.

Sample. Review every unplanned admission from the day unit in the last 12 months.

1. Each unplanned admission is reviewed.

Method. Compare the admissions with the review register.

Evidence to show. Unplanned admission review register ( DAY-REG-002 ).

Pass when. Every unplanned admission has a review.

2. Each review is done within 7 days and states the cause.

Method. Check the review date and the cause for each admission.

Evidence to show. Unplanned admission review register.

Pass when. At least 90% are reviewed within 7 days with a cause recorded.

3. Each finding has an action with an owner.

Method. Check each action for an owner and a closure date.

Evidence to show. Unplanned admission review register.

Pass when. Every finding has an owner, and at least 90% of actions are closed on time.

Immediate fail (any one means the criterion is not met)

• An unplanned admission from the day unit is not reviewed.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Anaesthesia is the highest-risk part of the day for many patients. Continuous monitoring through the whole procedure, matched to the level of anaesthesia, is the standard that finds the problem early.

Sample. Review 10 anaesthesia records and the machine check records for the last 30 days.

1. Anaesthesia follows a written protocol.

Method. Read the protocol and check its review date.

Evidence to show. Anaesthesia safety and monitoring policy ( SRG-POL-002 ).

Pass when. The protocol is current and approved.

2. Monitoring is continuous through the procedure.

Method. Check each anaesthesia record for continuous monitoring.

Evidence to show. Anaesthesia record and monitoring chart ( SRG-FRM-002 ).

Pass when. At least 90% of records show continuous monitoring.

3. Equipment is checked before each list.

Method. Check the machine check record for each list.

Evidence to show. Anaesthesia machine and equipment check ( SRG-FRM-003 ).

Pass when. At least 90% of lists have a recorded check.

Immediate fail (any one means the criterion is not met)

• A patient is anaesthetised with no monitoring, or on equipment that has not been checked.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. The surgical safety checklist works only when the team says it out loud, together, at each pause. A checklist filed after the operation protects no one.

Sample. Observe 5 procedures and check the checklist record for each.

1. The checklist is completed aloud at all three pauses.

Method. Observe the pauses for each procedure and check the record.

Evidence to show. Surgical safety checklist record ( SRG-FRM-001 ).

Pass when. At least 90% of procedures show all three pauses completed aloud.

2. Patient, procedure and site are confirmed aloud at the time-out.

Method. Listen for the confirmation at the time-out.

Evidence to show. Observed time-out.

Pass when. Every observed time-out confirms patient, procedure and site.

3. Identity is checked.

Method. Check the identification log for each procedure.

Evidence to show. Patient identification check log ( ID-FRM-001 ).

Pass when. Every procedure has an identity check recorded.

Immediate fail (any one means the criterion is not met)

• A procedure starts with no time-out, or the checklist is completed after the patient has left the theatre.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Infections after surgery are preventable with a set of checkable practices. A bundle, followed for every procedure and measured, is what makes prevention real.

Sample. Review the compliance record for the last 3 months and 10 procedures.

1. Each procedure follows the bundle.

Method. Check the bundle compliance record for each of the 10 procedures.

Evidence to show. Bundle compliance record ( SRG-FRM-004 ).

Pass when. At least 90% of procedures have every part of the bundle recorded as done.

2. Antibiotic prophylaxis is given within the set window.

Method. Check the antibiotic time against the incision time.

Evidence to show. Anaesthesia record and bundle record.

Pass when. At least 90% of doses are given within the window.

3. Infections are tracked and reviewed.

Method. Check the surveillance register and the review record.

Evidence to show. Infection surveillance register ( HOS-REG-005 ).

Pass when. Every infection is reviewed within 7 days.

Immediate fail (any one means the criterion is not met)

• A procedure starts without the bundle, or a surgical site infection is found with no review.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course