The day-case rate of 60 per cent achieved in the present study could therefore equate to annual savings of at least ��74,700 based on a hospital performing 500 cases per year. Higher day-case rates are therefore desirable, although in the context of randomised controlled trials, with patients selected on the basis of operative fitness Nutlin-3a and proximity to hospital, a day-case rate of only 80 per cent is reported [3, 4, 8�C10]. This relates predominantly to uncontrolled pain, nausea, and vomiting, which are known to affect both hospital stay and patient discharge [3, 4]. The use of intraoperative local anaesthetic, postoperative paracetamol, and nonsteroidal anti-inflammatories, with an avoidance of opiates, have all been suggested as techniques to minimise these problems [1].

Since October 2009 our own institution has therefore introduced a standardised anaesthetic and postoperative analgesia protocol for day-case laparoscopic cholecystectomy, which it is hoped will further increase day-case rates. Additional cost savings are also achievable by using an integrated patient pathway, such as that shown in Figure 2, which can minimise the need for repeat ultrasound studies (��49), blood tests (��10), and outpatient appointments (��88) [7]. The use of nondisposable surgical instruments and limiting the use of intraoperative antibiotics is also important. The gallbladder pathway used in this study adheres to the principles outlined in the ��Focus on Cholecystectomy�� document [1]. Reducing the number of patient visits by providing preassessment at the initial clinic visit and preventing routine outpatient followup resulted in less disruption to patients.

This is particularly important due to the wide geographical distribution of our patients, although these limitations in access to transport may have also led to some patients not being suitable for day-case surgery. Providing patients with a choice of dates for surgery led to fewer cancellations on the day of surgery. Staggered admission times, whilst preventing long periods of waiting or starvation, were not used during this study. These were limited by the need for an anaesthetist or surgeon to see the patient preoperatively, particularly as operating lists were increasingly pooled to meet waiting list targets.

Clerical error, particularly with respect to patients being listed on afternoon operating lists, resulted in a number of patients suitable for day-case surgery requiring an overnight stay. This issue has Cilengitide been previously identified in randomised trials of laparoscopic day-case cholecystectomy versus overnight stay [9]. Following the interim audit in 2008, patients suitable for day-case were predominantly scheduled on a morning list or first on the afternoon list, which resulted in a substantial increase in day-case rates from 30 to over 60 per cent.