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Dr. Rowan Thomas MBBS FANZCA MPH

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What are the selection criteria? Should the criteria be changed? (A sociological perspective) How can it be changed? (A policy perspective) The importance of follow up and outcome review

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Tertiary referral Hospital Day of surgery discharge not high 25-30% Australian average 60%

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Economic or utilitarian drivers. Lower morbidity Faster mobilisation and recovery Able to be with family Free up resources for other health care areas

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Two components. Day of surgery arrival (DOSA) + Early discharge DOSA requires: Optimisation of co-morbidities and medications Early assessment, communication and consent Timely arrival and fasting Early discharge requires: Good pain management Resolution of unwanted effects of anaesthesia Good social supports Adequate time to assess surgical complications

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Pain (Not enough analgesia?) Nausea (Too much opioid?) Bleeding Unstable co-morbidity Incapable of self care

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Minimally invasive techniques are widening the range of possible surgeries Minimal risk of post-operative Haemorrhage Minimal risk of post operative airway compromise Pain controllable by outpatient techniques Post-operative care that can be managed by a responsible adult or home nursing facilities A rapid return to normal fluid and food intake ANZCA Policy PS15

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A willingness to have the procedure performed and an understanding and an ability to follow instructions Patients place of residence within one hours travelling time from medical attention ASA I or II. Stable ASA III or IV. Careful consideration for higher ASA grades. Infants and children where associated paediatric facilities and experience exist. Should be older than 6 weeks (normal term) or greater than 52 weeks post-conceptual age if premature (< 37 gestation) ANZCA Policy PS15

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A responsible person able to transport the patient home in a suitable vehicle. A responsible person staying at least overnight with the patient. Ensuring that the patient understand the requirements of post-anaesthetic care in regard to public safety. The patient stay within one hour of medical attention until one day after surgery. Ready access to a telephone ANZCA Policy PS15

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Unstable ASA III or IV. Eg. Brittle diabetes, unstable angina, symptomatic asthma. Morbid obesity with haemodynamic or respiratory problems Drugs: Monoamine oxidase inhibitors or acute substance abuse esp. Cocaine. Ex-prem infants