Analysis of the efficacy of pediatric day surgery
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* Mervyn Letts
* Darin Davidson
* William Splinter
* Patricia Conway

## Abstract

**Objectives:** To assess the efficacy and safety of a pediatric day surgery program and its benefits to the child and family.

**Design:** A review and analysis of prospectively gathered data.

**Setting:** The Children’s Hospital of Eastern Ontario (CHEO), a university-affiliated pediatric centre with a referral base of 2.5 million people.

**Patients:** All children undergoing day surgery at CHEO during the 5 years between 1992 and 1997.

**Interventions:** All surgical procedures performed on a day surgery basis.

**Main outcome measures:** Procedures performed, complications and unexpected admissions.

**Results:** An average of 4899 children per year underwent surgical procedures in the ambulatory day surgery program. The 4 commonest procedures performed were myringotomy, tonsillectomy and adenoidectomy, dental procedures, and inguinal hernia repair. The majority of children were between 2 and 7 years of age. Complications were few, averaging 1.6% per year, with postoperative bleeding, primarily secondary to tonsillectomy and adenoidectomy, being the most common. None resulted in permanent disability and there were no deaths.

**Conclusions:** Pediatric day surgery is a safe and cost-effective program that benefits the child, the family and the pediatric surgical program.

The concept of organized day surgery for children was first put forward by Nicoll in 1909.1 Children are good candidates for day surgery because they are typically healthy, and the surgical procedures they require are generally predictable and often of short duration.

Ambulatory surgery over the past decade has become extremely popular, not only because costs are decreased but also, from the patient’s point of view, because it avoids hospitalization and allows the patient to recuperate in a home environment. The latter is especially true for children. Through the institution of pediatric day surgery programs, it has been well recognized that the psychologic trauma of separation during hospitalization is minimized by having the child’s postoperative care managed in the home environment. In recent years, fiscal pressures have popularized adult ambulatory programs in Canada and the United States.2–6 The health care programs in both these countries are being forced to become increasingly more cost-effective, being driven in the United States by the managed care environment and in Canada by decreased funding allocated to hospitals by provincial governments. Although this has been one of the main factors in driving the initiation and expansion of adult day surgery programs, in the pediatric field, day surgery programs have been operating in pediatric hospitals for at least 3 decades.1–7 The program at the Children’s Hospital of Eastern Ontario (CHEO) was incorporated into the planning of the hospital when it was built in 1974 and included a large day surgery unit. It has enlarged from a small percentage of children having their surgery through the day surgery ambulatory program to the current 70% of children having surgery at CHEO through the program.

Although our hospital is not unique in having established a pediatric day surgery program over 20 years ago, we have been a recent leader in instituting a day surgery program for all tonsillectomies and adenoidectomies in children, now having over 6 years’ experience with this aspect of the program. It was the purpose of this analysis to document a 5-year experience with our program, to critically analyze the complications experienced and to determine the feasibility of expanding the program to procedures not traditionally done on a day surgery basis.

## Methods

To analyze the day surgery program at CHEO, we chose a 5-year period from 1992 to 1997 (since this was just after our tonsillectomy and adenoidectomy program was up and running successfully). All records during this time were computerized, facilitating the collection of data and allowing a more accurate evaluation of the common types of surgery done in each of the surgical disciplines. All complications of the day surgery program had also been prospectively recorded, beginning in 1990. This was done by documenting the reasons for all unplanned admissions, either from the day surgery unit itself or any unplanned admission of a child who had had ambulatory surgery and was admitted from home within a week of the surgery. We also have recently reviewed our surgical procedures to identify areas into which we could expand our day surgery program.

## Results

The mean (and standard deviation) number of children treated annually in the CHEO ambulatory day surgery program during the study period was 4899 (153); hence, the total number of children seen each year has been remarkably consistent (Table 1). The otolaryngologic procedures of myringotomy and tonsillectomy and adenoidectomy were consistently the most common procedure done through the day surgery program at CHEO (Table 2). These were followed by dental procedures requiring general anesthesia followed by hernia repair, predominantly in infants and young children, ophthalmologic procedures, and circumcisions. The frequency of circumcision has decreased over the past 2 years owing to the Ontario government’s withdrawal of financial coverage for nonmedically indicated circumcision.

View this table:
[Table 1](http://canjsurg.ca/content/44/3/193/T1)

Table 1 
Children Treated in the Ambulatory Day Surgery Program at the Children’s Hospital of Eastern Ontario, by Service, Between 1992 and 1997

View this table:
[Table 2](http://canjsurg.ca/content/44/3/193/T2)

Table 2 
Most Common Surgical Procedures Performed in the Ambulatory Day Surgery Program at the Children’s Hospital of Eastern Ontario Between 1992 and 1997

The ages of children treated in the day surgery program are shown in Fig. 1. The majority of children were between 2 and 7 years, and this was consistent over the study period. Examining the 10 most common procedures of each of the surgical disciplines in more detail provides an overview of the types of procedures amenable to day surgery. Table 3 illustrates the 10 principal types of surgery performed by the otolaryngology service, illustrating the dominance of myringotomy, tonsillectomy and adenoidectomy. Root canal surgery was the most common dental outpatient procedure followed by extraction and application of a crown. Extraocular muscle recessions were the commonest ophthalmolgic outpatient procedure followed by probing of the nasolacrimal duct and examination of the eye in small children. Inguinal hernia and umbilical hernia repairs are currently the commonest procedures done by the general surgery service. Circumcision was the most common procedure done by the urological service, followed by cystoscopy, hydrocelectomy and urethral meatotomy. The orthopedic service has had a lower volume of children pass through the day surgery program. Arthroscopy, removal of fixation devices and cast changes in young children have been the commonest procedures done by this service. The most common plastic surgery procedures done through the program include otoplasty and excision of skin lesions. The neurosurgery and cardiovascular services, because of the nature of their surgery, rarely utilize the program. However, cardiac catheterizations are now routinely done through the day surgery service and have been growing in number since the establishment of the pediatric cardiac program at CHEO in 1991. Cardiac catheterization is an example of a new day surgery procedure introduced successfully to the point at which 95% of all cardiac catheterizations are now performed on a day surgery basis.

![FIG. 1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/44/3/193/F1.medium.gif)

[FIG. 1](http://canjsurg.ca/content/44/3/193/F1)

FIG. 1 
Age range of children treated in the Children’s Hospital of Eastern Ontario surgical day program between 1992 and 1997.

View this table:
[Table 3](http://canjsurg.ca/content/44/3/193/T3)

Table 3 
Principal Surgical Procedures Performed on the Otolaryngology Service in the Ambulatory Day Surgery Program at the Children’s Hospital of Eastern Ontario Between 1992 and 1997

An analysis of the complications of the program was done in a prospective manner beginning in 1990. Unplanned admissions directly from the day surgery unit are listed in Table 4. The average percentage of patients requiring admission over the 5-year period was 1.6%. The largest number of patients requiring admission was in 1992/93, coinciding with the year that the tonsillectomy and adenoidectomy day surgery program was fully instituted. Most patients requiring admission were children who had undergone tonsillectomy and adenoidectomy. As can be seen from Table 4, this decreased significantly over the ensuing 4 years. The commonest reasons for admission continue to be postoperative bleeding, primarily from tonsillectomy and adenoidectomy, as well as nausea and vomiting. Some children who met the criteria for apnea monitoring were kept in the hospital for overnight monitoring. Table 5 illustrates the admissions of children who were sent home and then admitted within a week. This has averaged 0.3% of our day patients over the study period and has varied very little from year to year. Again, postoperative bleeding, primarily delayed bleeding from tonsillectomy and adenoidectomy, was the major reason for admission. During this 5-year period no major untoward experience has resulted in any permanent disability to a child, and there have been no postoperative deaths since the inception of the day surgery program at CHEO among the almost 25 000 children followed up prospectively.

View this table:
[Table 4](http://canjsurg.ca/content/44/3/193/T4)

Table 4 
Unplanned Admissions to Hospital from the Ambulatory Day Surgery Program at the Children’s Hospital of Eastern Ontario Between 1992 and 1997

View this table:
[Table 5](http://canjsurg.ca/content/44/3/193/T5)

Table 5 
Unplanned Admissions to Hospital from Home of Children Treated in the Ambulatory Day Surgery Program at the Children’s Hospital of Eastern Ontario Between 1992 and 1997

## Discussion

There are many advantages of a pediatric ambulatory day surgery program that accrue to both families and hospitals. The child and family are happier and more comfortable with lessened separation anxiety. The child is also not exposed to hospital environmental organisms, with the result that nosocomial infection is reduced. Indeed, postoperative fever accounted for only 3 admissions, cough only 14 patients and wound infection only 6 patients in the entire 5-year experience involving a total of almost 25 000 ambulatory surgical procedures. The program is also extremely cost-effective and avoids expensive admission costs. The real saving, however, comes from the ability to institute actual bed closures; with the development of the tonsillectomy and adenoidectomy day surgery program in 1990, a complete 30-bed ward was able to be closed at CHEO.

Recent advances in anesthesiology have also contributed to the improved results associated with ambulatory surgery. To ensure that children who have other major illnesses are properly assessed before the day of surgery, a preoperative anesthesia clinic to which such patients are referred has been established. Children who fall within a set criteria for referral to this clinic (i.e., associated medical illness, surgery requiring blood transfusions or respiratory or airway malformations) are seen by the anesthetist for a preoperative evaluation within a month before surgery. If necessary, further investigation can be ordered at that time.

Day surgery has become a frequent form of treatment, comprising between 51% and 65% of all surgical procedures.2,3,7 Our volume of day surgery has consistently been over 60% of all surgery performed at CHEO over the past 5 years.

Whereas all surgical services offer outpatient surgery, most centres have reported that ophthalmology, general surgery, dentistry and otolaryngology are the most frequent users,2,7 and this has been our experience.

To minimize the potential for complications, appropriate patient selection is essential, as not all children are good candidates for day surgery. The child should be American Society of Anesthesiologists physical status I or II, and possibly III if the child’s medical condition is well controlled. 8–10 Elective surgery should be postponed if the child presents with or has a recent history of an upper respiratory tract infection. In order for the child to be suitable for day surgery, the family should remain close to the hospital and the parents should be responsible and capable of following postoperative instructions. We are fortunate at CHEO in having both a Ronald McDonald House and Rotel (a Rotary sponsored hotel) close to the hospital. Children under 1 year of age born prematurely have been reported to be at increased risk of thermoregulatory and respiratory complications, in particular apnea, and must be considered on an individual basis and carefully monitored postoperatively.

The choice of procedures for day surgery must also be considered. Typically, the procedure should be brief and involve minimal bleeding and should not require exposure of any major body cavities.8,10 The most common procedures in day surgery include herniorrhaphy, myringotomy, adenoidectomy, circumcision, eye muscle surgery, thyroglossal and first branchial cleft cyst excision, bronchoscopy and gastrointestinal endoscopy.3,8

Another essential factor in day surgery is the discharge criteria. Commonly the criteria include stable vital signs, the ability to tolerate fluids, ability to void, control of pain, absence of nausea, ability to walk, and a responsible parent or guardian to care for the child.11 The criterion that the child can tolerate fluids attempts to decrease the potential for dehydration. However, mandating that children drink liquids increases the probability of vomiting, a complication already prevalent in children.3,12 In response to this dilemma, Schreiner and Nicolson13 stated that children should drink only when they feel ready and may even be safely discharged before drinking. This protocol does not increase the probability of vomiting or dehydration after discharge. 14 We also use this approach and have had similar results.

The frequency of unplanned admissions following day surgery has been reported to range from 0.1% to 5.3%.3,7,9,11,15–17 Ours has averaged 1.7% over the past 5 years. Some studies have noted that complications of anesthesia, such as vomiting and respiratory difficulty have precipitated most admissions,18 whereas others have reported the cause to be surgical, such as a more extensive procedure than was initially planned, unexpected findings, or further treatment. 3,7,11 A combination of surgical and anesthetic complications has also been implicated.6,7 In our study, bleeding (mostly from tonsillectomy and adenoidectomy) was the commonest reason for unplanned admission, averaging 11 children per year, followed by nausea and vomiting.

Vomiting is one of the most common postoperative complications in children,12–14,19 who have an incidence of vomiting twice as high as that of adults.18 Postoperative vomiting has been reported to vary between 0.2% (in a study that did not include tonsillectomy and adenoidectomy17) and 15% (in a study that included tonsillectomy and adenoidectomy20). Of those children suffering this complication, between 33%7 and 88%9 have required admission. Our experience is of a much lower incidence of vomiting and subsequent admission. Propofol-based anesthetic agents have been associated with a decreased incidence of postoperative vomiting.11

The otolaryngology service has been one of the most frequent users of day surgery2,7,9 and was the highest user in our program. The performance of tonsillectomy with or without adenoidectomy on an outpatient basis has been controversial, despite the increasing acceptance of day surgery.21–26 This has been owing to the higher rate of postoperative nausea, vomiting, bleeding and airway obstruction reported in association with these procedures.6,9,18,27–33 Despite this controversy, some American states have legislated that tonsillectomy with or without adenoidectomy must be performed on an ambulatory basis.4 The rate of complications associated with these procedures has been reported to range between 2.2%21 and 20%.25 In the latter study, 81% of the children with postoperative complications required admission. Our experience has been very gratifying in our tonsillectomy and adenectomy day surgery program, with an admission rate of less than 1.5%.

It must be emphasized that to run a large day surgery program requires dedicated, well-trained nursing staff and the cooperation of the anesthetists, surgeons and the surgical office staff. In the CHEO day surgery program, orientation of families and parents begins at the time the surgical procedure is scheduled. At this time a set of guidelines outlining the program is given to the families. It covers essential information such as when the child should begin fasting, what time the family should appear in the day surgery unit, whether a consult to the preanesthetic clinic is required, and the day surgery history and physical form is completed or arrangements are made for the child to see the pediatrician or general practitioner to have this done. The family is also made aware of accommodations close to the hospital at the Rotel or the Ronald McDonald House. Families are also invited to take advantage of the orientation visit managed by the operating room nursing staff on weekdays, whereby families are taken on a tour, conducted in both official languages, of the day surgery unit and the operating room. The program is reinforced by all staff in the clinics, and families are also contacted a couple of days before the procedure by admitting staff to review the time and day of surgery and the fasting instructions.

An essential component for the success of the pediatric day surgery is the postoperative home care program. This is especially necessary for disabled children.

## Conclusions

We have confirmed the safety of a busy pediatric day surgery program. Its acceptance by patients and families is almost universal and its costeffectiveness is unquestioned. More recognition of the pediatric surgical day care program by provincial funding agencies is necessary to recognize the particular needs of the pediatric population. Pediatric day surgery should not be lumped into funding formulas for adults. There needs to be a greater recognition of pediatric day surgery programs by the ministries of health so that these programs will continue to flourish since they are a major contributor to cost reduction and to quality of child care.

## Acknowledgements

We acknowledge the financial support of the Children’s Hospital Research Institute for this project.

*   Accepted December 6, 1999.

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