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There is an increasing trend towards performing day case procedures both to improve health care efficiency and potentially to enhance social and emotional rehabilitation, especially in the paediatric population. Adenoidectomy and tonsillectomy have been identified as procedures that can be safely performed in this way given certain social and medical criteria. At Booth Hall Children's Hospital, there is already a dedicated day case ward that is currently used by the Department of Otolaryngology for minor ear and nasal procedures. We have prospectively evaluated our paediatric population to assess their suitability for day case surgery regarding adenotonsillectomy.

All patients aged between 3 and 16 years who underwent adenotonsillectomy, tonsillectomy or adenoidectomy between 1 March 2002 and 31 July 2002 under the care of the Department of Otolaryngology at Booth Hall Children's Hospital were prospectively evaluated for suitability for day case treatment. The study included NHS patients admitted to a local BUPA hospital for waiting list initiatives during this period. Both surgeon and anaesthetist preoperatively assessed patients regarding medical contraindications. These included concomitant operations not suitable for day case and ASA grade >II (including haematological abnormalities, obstructive sleep apnoea, epilepsy, moderate to severe asthma and previous anaesthetic complications). Social contraindications were also assessed including the presence of two responsible adults at home, availability of a car and telephone, journey time to hospital of less than 30 min and ability to speak fluent English.

All patients remained in hospital overnight, and, postoperatively, all complications were recorded including any action that was necessary and how long the problem took to resolve. Children were encouraged to take oral fluids as soon as practicable with dietary intake to begin at 4 h postoperatively. Any child who had not had sufficient oral intake by 6 h was considered to be not suitable for day case surgery. Other contraindications were any postoperative haemorrhage, persistent pyrexia, persistent vomiting beyond 6 h postoperatively that required anti-emetic administration, inadequate pain control and inadequate recovery from anaesthesia. The following morning, parents' preference for day case or overnight stay was recorded based on their experience.

Sixty-two patients were admitted to Booth Hall Children's Hospital and 22 were admitted to the local BUPA hospital during this period. In total, 22 patients had adenotonsillectomy, 48 patients had tonsillectomy and 14 patients had adenoidectomy. Fifteen forms were only partially completed (eight forms had incomplete social data and no parental preference recorded, three forms had incomplete social data only and a further seven were missing parental preference only). The age of the patients ranged from 3 to 16 with a mean of 6 years.

Three patients had medical contraindications. One patient had obstructive sleep apnoea. One child had sickle cell trait. One child underwent concomitant microlaryngoscopy for vocal cord nodules. Although three patients had asthma the treating anaesthetist assessed this to be of mild severity and all three were considered suitable for day case surgery. Social contraindications occurred in 17 of the 78 patients with complete data and the details are given in Table 1.

Reactionary haemorrhage occurred in three children within the first hour. Two of them had undergone tonsillectomy, and the bleeding was mild and settled spontaneously. The third child, following adenoidectomy, was returned to theatre and a postnasal pack inserted. No bleeding occurred in any child beyond 1 h postoperatively.

No patient developed persistent pyrexia. One patient had pyrexia noted at 17 h postoperatively. This settled following administration of paracetamol and no further action was necessary. Seventeen children had postoperative vomiting (Table 2). Although vomiting was common after the first 6 h, this was usually self-limiting. Three children required anti-emetic administration beyond 6 h for persistent vomiting causing insufficient oral intake. Two further children were unable to take sufficient oral intake by 6 h because they remained too drowsy following the anaesthetic until the following morning. Both their operations had taken place at late afternoon. Twenty-eight children complained of significant pain (Table 3). In all these cases, this was managed with simple oral analgesia and did not interfere with oral intake or discharge.

Details for parental preference for day case or overnight stay are given in Table 4. It can be seen that although overall approximately 50% of parents went for each category, the proportion opting for day case was greater in those operated on in the NHS hospital.

Overall, a total of 10 out of 84 (12%) patients were identified pre- and postoperatively as contraindicated for day case surgery. When social criteria are included this rises to 23 out of 75 (31%) patients (patients with partially missing data who were otherwise acceptable were discounted from this total). If parental preference is also taken into account then 41 out of 66 (62%) patients were either not suitable or did not wish for day case surgery.

Several countries around the world, most notably the USA and Canada, currently undertake day case adenoidectomy and tonsillectomy, and it has been shown to be a safe alternative to overnight admission [1, 2]. In response to increasing political pressure for improved health care economy in the UK, several studies have examined the possibility of instituting this practice over the past 10 years [3, 4, 5, 6, 7]. These studies have shown varied findings and uptake has therefore been low. Indeed, an audit of tonsillectomy by the Royal College of Surgeons of England in 1997 found that only 3% were performed as day case at that time [8].

The main reasons cited for excluding this practice are preoperative exclusion factors and resistance from parents. In a large study of 500 children, medical conditions were found to exclude around 8% of patients and social factors a further 34% [6]. Two smaller studies of 100 patients have shown that the figures for medical contraindications are highly variable at 15% and 40%, respectively, while social factor exclusions are fairly constant at 35 and 39% [3, 4]. This indicates that there is a significant potential for geographical bias. In our unit, we have found only 4% medical exclusions and 23% social exclusions. Although some forms were incomplete with regard to social factors and so this figure could potentially be slightly larger, approximately three quarters of our patients were suitable for day case preoperatively.

Most studies show postoperative complications to be within acceptable limits for day case surgery. Our findings showed that 8 out of 84 patients would have required overnight admission. This would have been reduced to six patients if all day case surgery were carried out on morning lists. This is in line with a Royal College of Surgeons of England audit of ENT day case surgery, which found 12.7% of tonsillectomies required admission if performed on a morning list, but this rose to 31.2% if carried out on an afternoon list [9].

In order to practice day case adenoidectomy and tonsillectomy, it is essential to have the acceptance of parents. Studies in the UK have shown that resistance to this can be as high as 83% of cases [3]. In this study, parents were provided with the standard literature on adenotonsillectomy followed by overnight stay, as previously approved by our hospital, which highlighted the risks of bleeding. When asked for their preference, no further written advice was given, although it was explained that day case surgery had been shown to be safe. Many parents clearly found this conflicting advice and stated safety as their reason for preferring overnight stay. Despite this, we had an acceptance of 50%.

We feel that day case adenoidectomy and tonsillectomy are an option for the paediatric population at Booth Hall Children's Hospital and plan to initiate this. It will be performed on morning lists only to those patients fulfilling medical and social criteria, and it will be necessary to provide specific written information reassuring parents.