Ambulatory & Day Case Nursing — GCC

Take as Normal (with sip of water)

• Antihypertensives — ACE inhibitors, ARBs, beta-blockers, calcium channel blockers (hold ACEi/ARB on day of surgery if consultant directed — discuss)
• Statins
• Thyroid medications
• Anti-epileptics
• Inhaled bronchodilators / steroids — take as usual
• Oral steroids — continue; may need steroid cover if on long-term steroids
• Antiparkinson drugs
• Cardiac antiarrhythmics (amiodarone, digoxin, flecainide)

Hold / Omit

• Metformin — omit on day of surgery and 48h post-op (lactic acidosis risk with contrast/renal impairment)
• SGLT2 inhibitors — hold 3 days before (DKA risk)
• Insulin — adjust dose: usually 50% long-acting the night before; hold short-acting morning of surgery. Check local protocol.
• DOACs (rivaroxaban, apixaban, dabigatran) — omit based on renal function and surgical bleeding risk (typically 24–48h for standard risk, 48–72h for high risk; dabigatran longer if CrCl <50)
• Warfarin — omit 5 days before; check INR day before surgery; bridging if high thromboembolic risk
• NSAIDs / COX-2 inhibitors — usually hold 5 days pre-op (bleeding risk)
• Herbal supplements — hold all for 2 weeks pre-op (bleeding, drug interaction risk)

Allergy & Safety

• Allergy band applied — confirmed by patient
• Latex allergy — first case of day if positive; latex-free equipment
• Drug allergies documented in EMR and on WHO checklist
• Contrast media allergy — inform radiologist/endoscopist
• Blood/blood products consent if applicable

Consent & Marking

• Consent form signed and in notes
• Consent reflects actual procedure planned
• Surgical site marking by operating surgeon using indelible marker
• Mark confirmed with patient while awake and aware
• Laterality confirmed: left vs right

Baseline Observations

• BP (both arms if cardiac/vascular)
• Pulse rate and rhythm
• Respiratory rate
• SpO2 on air
• Temperature
• Blood glucose (diabetics, all ASA 3)
• Weight/BMI (for drug dosing)
• Urine dipstick if indicated

Specific Checks

• Pregnancy test — all women of childbearing age (urine beta-hCG)
• If positive: surgery postponed, obstetric review
• Confirm last menstrual period if test not available

VTE Risk Assessment

• Caprini or RCOG/Trust-specific VTE scoring tool
• Mechanical prophylaxis: anti-embolic stockings or IPC if moderate/high risk
• Pharmacological prophylaxis: LMWH if indicated
• Ambulation plan documented

Pre-Operative Skin Preparation

• Chlorhexidine gluconate 4% shower/wash night before and morning of surgery
• Surgical site hair removal — clippers only (not razors, increases SSI risk)
• Remove nail polish from fingers and toes (SpO2 monitoring)
• Jewellery, piercings removed or taped
• Dentures, prosthetics removed and labelled
• Hearing aids: remove for induction, return in recovery

General Surgery

• Laparoscopic cholecystectomy
• Laparoscopic inguinal / umbilical hernia repair
• Haemorrhoidectomy / anal fissure
• Pilonidal sinus excision
• Breast lump excision / sentinel node biopsy

Orthopaedics

• Knee arthroscopy (diagnostic / meniscal repair)
• Shoulder arthroscopy
• Carpal tunnel release
• Trigger finger release
• Ganglion excision

Ophthalmology

• Cataract surgery (phacoemulsification)
• Pterygium excision
• Lid surgery (entropion/ectropion)
• Strabismus correction (paediatric — with paediatric anaesthesia)

Endoscopy

• Diagnostic and therapeutic colonoscopy
• Upper GI endoscopy (OGD)
• ERCP (endoscopic retrograde cholangiopancreatography)
• Flexible sigmoidoscopy
• Capsule endoscopy (day attendance)

Gynaecology

• Laparoscopic diagnostic / sterilisation
• Hysteroscopy and D&C
• Bartholin's cyst marsupialisation
• LLETZ / cervical biopsy

Plastics / ENT

• Minor skin lesion excision / flap repair
• Tonsillectomy (adult — overnight preferred in some GCC centres)
• Septoplasty / turbinate reduction
• Myringotomy and grommets (paediatric)
• Rhinoplasty (short-stay / 23-hour)

Scrub Nurse Duties

• Sterile field maintenance throughout procedure
• Instrument passing with anticipation of surgeon needs
• Swab, instrument, and needle count (opening and closing)
• Specimen handling — correct labelling, formalin, chain of custody
• Sharps management — hands-free technique, no re-sheathing
• Suture management and irrigation fluid tracking

Circulator Nurse Duties

• WHO Surgical Safety Checklist coordination
• Patient positioning and pressure injury prevention
• Electrosurgery unit (ESU/diathermy) setup and patient plate check
• Documentation of operative record (times, implants, counts)
• Tourniquet management: inflation time recorded, max 2h upper/1.5h lower limb
• Communication with recovery regarding expected patient

Patient Temperature Management

• Peri-operative hypothermia (<36°C) increases: surgical site infection, cardiac events, bleeding, recovery time
• Forced Air Warming (FAW) blankets — pre-warming 15–20 min pre-induction if possible
• Warm IV fluids for large volume cases
• Warm irrigation fluids (intra-abdominal surgery)
• OT ambient temperature ≥21°C for high-risk patients
• Temperature monitoring: oesophageal/nasopharyngeal intraoperatively
• Target normothermia: core temp 36–37.5°C

Blood Loss Estimation

• Visual assessment: swab weighing (1g = 1ml blood)
• Suction canister measurement minus irrigation volume
• Drape/towel soaking assessment
• Communicate cumulative blood loss to anaesthetist at regular intervals
• Trigger transfusion threshold discussion if loss approaching 15–20% EBV

Multimodal Pain Management

• Paracetamol — 1g IV/oral QDS (regular, not PRN) — backbone of multimodal
• NSAID (ibuprofen/diclofenac/ketorolac) — add if no contraindication (renal, GI, bleeding risk)
• COX-2 inhibitors (celecoxib) — preferred over NSAIDs if GI risk
• Local anaesthetic infiltration — surgeon-administered pre/post incision
• Regional nerve blocks — TAP block, femoral block, fascia iliaca as appropriate
• Opioids PRN — tramadol or codeine for breakthrough; morphine/oxycodone if required (monitor sedation)
• Pain score ≤3/10 at rest before discharge

PONV Protocol

• Apfel score risk assessment (female sex, non-smoker, PONV history, opioid use — 1 point each)
• Score 0–1: low risk — no prophylaxis unless requested
• Score 2: moderate — ondansetron 4mg IV at induction
• Score 3–4: high risk — dual therapy: ondansetron + dexamethasone 4–8mg
• Rescue: prochlorperazine 12.5mg IM / cyclizine 50mg IV
• PONV resolved and tolerating oral fluids before discharge

Wound & Drain Checks

• Inspect wound dressing before discharge — confirm dry, intact, no soakthrough
• Pressure dressing: confirm applied, not too tight (neurovascular check distal limb)
• Drains: if present — confirm output volume, output character, patency
• Drains rarely left in day case — if so, patient education on management and drain removal
• Wound care instructions: keep dry 48h, signs of infection to report
• Suture/clip removal date given

Discharge Instructions — Principles

• Written AND verbal — language-appropriate, reading level considered
• Given to patient AND responsible adult escort
• Include: pain management plan, wound care, medications, activity restrictions
• When to seek emergency care (red flag symptoms)
• Contact number for nurse/surgeon queries (24h)
• Next outpatient appointment confirmed before leaving
• Prescription medications dispensed or prescribed before discharge
• No driving for 24h post-GA; no alcohol; no major decisions (cognitive effect of anaesthesia)

Wound Assessment (Wagner Classification)

Nursing Interventions

• Sharp debridement of necrotic/callus tissue (competency-based)
• Wound bed preparation: moist wound healing principles
• Offloading devices: total contact cast (gold standard), removable boot, heel protector
• Vascular assessment: ABI (Ankle-Brachial Index) — ABI <0.9 = PAD, <0.5 = critical ischaemia
• Neurological assessment: 10g Semmes-Weinstein monofilament, vibration sense
• Footwear assessment and prescription referral (orthotist)
• Education: foot inspection daily, footwear, nail care, never walk barefoot
• Multidisciplinary team: podiatrist, diabetologist, vascular surgeon, orthotist

Nurse-Led Monitoring

• Daily weight monitoring — action if >2kg weight gain in 2 days
• BNP / NT-proBNP monitoring (target reduction from baseline)
• Fluid intake/output diary review
• Functional assessment: NYHA class, 6-minute walk test
• Blood pressure and heart rate targets
• Electrolytes: K+ and creatinine monitoring (diuretics, ACEi)
• Renal function — HF + diuretic use: creatinine trend

Diuretic Titration Protocol

• Nurse-initiated diuresis protocol (consultant-signed standing order)
• Furosemide oral dose escalation algorithm: baseline → +20mg increments
• IV furosemide for decompensation: refer/admit criteria defined in protocol
• Spironolactone monitoring: K+ >5.5 → hold and notify
• SGLT2 inhibitor (empagliflozin/dapagliflozin) monitoring: DKA risk awareness
• Device clinic liaison: pacemaker/ICD/CRT remote monitoring
• Admit criteria: pulmonary oedema signs, K+ <3.0 or >6.0, creatinine rise >50%

Warfarin Management

• INR target ranges: AF/DVT/PE = 2.0–3.0; mechanical heart valve = 2.5–3.5
• Dose adjustment using validated nomogram
• Sub-therapeutic INR: increase dose, assess compliance, identify interactions
• Supratherapeutic INR >5: hold dose, assess bleeding risk, consider Vit K
• INR >9 or active bleeding: urgent physician review, IV Vit K, PCC if major bleed
• Frequency: weekly when initiating / adjusting; monthly when stable in range

Patient Self-Testing (PST)

• CoaguChek XS device training — lancet technique, quality control
• Results reported to anticoagulation nurse via phone/app
• Concordance with lab INR confirmation initially
• Reduces clinic attendance, improves time in therapeutic range

DOAC Patient Management

• DOACs do not require INR monitoring — patient education on this distinction
• Annual renal function check (creatinine/CrCl) — dabigatran dose adjustment if CrCl <50
• Adherence assessment — pill counts, prescription refill records
• Bleeding events: assessment, DOAC reversal agents (idarucizumab for dabigatran; andexanet alfa for Xa inhibitors)
• Drug interactions: amiodarone, verapamil, rifampicin, antifungals

Education Topics (all anticoagulated patients)

• Bleeding recognition and when to seek help
• Dietary considerations (Vit K and warfarin)
• Alcohol interaction
• OTC medication risks (aspirin, NSAIDs, herbal supplements)
• Pre-procedure notification (dental, any surgery)
• Medical alert identification (card/bracelet)

Common Infusions

• IV Iron (Ferinject/Monofer): iron deficiency where oral failed; over 15–30 min (Ferinject) or slow infusion; 30-min post-observation
• Biologic infusions: infliximab, vedolizumab, rituximab, tocilizumab — pre-medication (antihistamine ± hydrocortisone), slow titrated infusion rates, 1h post-infusion observation minimum
• IVIG (Immunoglobulin): slow titration protocol; anaphylaxis kit must be present; observation throughout and 1h post
• Bisphosphonates (zoledronic acid): annual IV infusion; risk of acute phase reaction — pre-hydrate, paracetamol pre-med
• Trastuzumab/Pertuzumab: HER2+ breast cancer maintenance; cardiac monitoring (LVEF)

Pre-Infusion Checks

• Verify patient identity × 2 identifiers
• Check allergy history (previous infusion reactions)
• Confirm pre-medications given as prescribed
• Baseline observations: BP, HR, temp, SpO2 before starting
• IV access confirmed patent, no signs of phlebitis
• Drug label check × 2 nurses (drug name, dose, patient, expiry, rate)

Infusion Reaction Protocol

• STOP infusion immediately
• Maintain IV access — saline flush and keep open
• Call physician to bedside
• Mild/moderate: antihistamine IV, hydrocortisone 100mg IV, monitor
• Severe (anaphylaxis): adrenaline 0.5mg IM (thigh), CPR ready, 999/emergency
• Document reaction in full; complete incident report
• Report to pharmacovigilance if required by local policy

Chemotherapy Day Unit Nursing

• Independent double-check: drug, dose, regimen, BSA calculation, patient identity
• CVAD/PICC/port access — aseptic technique, patency check, blood return confirmed
• Pre-meds: antiemetics (ondansetron, dexamethasone), hydration, mesna (if cyclophosphamide/ifosfamide)
• Toxicity assessment before each cycle: FBC (neutrophils/platelets), LFTs, renal function, mucositis assessment, neuropathy score
• Cycle delay criteria: neutrophils <1.5 × 10⁹/L, platelets <100 × 10⁹/L — hold and review
• Extravasation management: vesicant vs irritant protocol, cold/warm pack, antidote if available (dexrazoxane for anthracyclines)
• CINV management: Aprepitant, ondansetron, dexamethasone protocol
• Patient education: infection signs, neutropenic sepsis 5-day temperature diary

Renal Anaemia Clinic

• Erythropoiesis-Stimulating Agents (ESA): epoetin alfa/beta, darbepoetin alfa
• Target Hb: CKD non-dialysis 100–120 g/L; dialysis up to 120 g/L (avoid >130 — cardiovascular risk)
• Iron status before ESA: TSAT >20%, ferritin >100 (pre-dialysis) before starting ESA
• IV iron sucrose or ferric carboxymaltose if oral iron inadequate
• Monthly Hb monitoring; adjust ESA dose ±25% for response
• Hypertension monitoring — ESA can raise BP; antihypertensive review
• ESA resistance evaluation: iron deficiency, infection, inflammation, hyperparathyroidism, B12/folate deficiency
• Patient self-administration training (subcutaneous ESA injections)

Polyclinic Networks

• Saudi Arabia — MOH polyclinics (primary health care centres) across all regions; parallel private clinic sector (Dallah, NMC, Dr. Sulaiman Al-Habib)
• UAE — DHA-regulated clinics in Dubai; HAAD/DoH in Abu Dhabi; Aster, Mediclinic, American Hospital outpatient networks
• Qatar — PHCC (Primary Health Care Corporation) polyclinics; HMC outpatient centres
• Kuwait — Ministry of Health polyclinics; IBN Sina, Mubarak, Amiri hospital outpatient departments
• Bahrain, Oman — Polyclinic expansion underway under respective MOH development plans
• Government vs private: government sector often free at point of care; private sector typically insurance-based with pre-authorisation requirements

Day Surgery Development & Standards

• JCIA Ambulatory Care Standards — apply to outpatient surgical centres and day surgery units; covers governance, patient safety, QI
• Key JCIA ambulatory standards: patient assessment (AOP), care of patients (COP), ASC (Ambulatory Surgical Care) chapter
• Day surgery units increasingly seeking standalone JCIA accreditation in UAE, Saudi, Qatar
• CBAHI (Saudi) accreditation for ambulatory facilities
• JCI vs DNV vs ACHSI — multiple accreditation bodies operating in GCC
• Nurse-to-patient ratios: typically 1:2 in day surgery recovery; 1:4–6 in day case lounge

Pre-Authorisation Process

• Insurance PA required before most elective outpatient procedures (endoscopy, day surgery, infusions, biologics)
• Documentation required: clinical indication, ICD-10 diagnosis code, CPT procedure code, referring physician letter, relevant investigation results
• PA response time: typically 24–72h; urgent PA pathway for clinical emergencies
• Pre-authorisation does not guarantee coverage — subject to exclusions, policy limits
• Nurse role: ensure PA reference number documented; flag expired PA (most valid 30–90 days)

Insurance Challenges in Day Surgery

• Some insurers prefer inpatient over day case (historical legacy — now changing)
• Day case cost should be presented to insurer as cost-effective alternative
• Coverage for biologics/chemotherapy often requires specialist justification and step therapy evidence
• Uninsured patient pathways: cash payment plans; government referral options
• Nurses must document clinical necessity clearly — supports PA approval and appeals
• Liaise with hospital insurance/billing team for complex PA queries

GCC Language Context

• GCC patient population is highly diverse: Arabic, Urdu/Hindi, Tagalog, Bengali, Malayalam, English, Farsi
• Many nurses in GCC are non-Arabic speaking (South Asian, Southeast Asian, Western) — patient-nurse language mismatch is common
• Arabic is the official language and medical documentation language in government facilities
• Communication failure is the leading root cause of sentinel events globally — and in GCC

Strategies

• Professional interpreter service — in-person or telephone (preferred over family for clinical discussions)
• Hospital interpreter lists / language line services (MedInterp, LanguageLine)
• Multilingual discharge instruction leaflets (Arabic, English, Urdu, Hindi, Tagalog minimum)
• Visual aids and pictograms for consent, fasting, wound care
• Teach-back method: patient explains instructions back in their own language
• Avoid using minor children as interpreters

Consent in a Multilingual Environment

• Consent must be in a language the patient understands
• Use qualified interpreter for consent discussions — document interpreter name and ID
• Consent form ideally in patient's language
• Note: some GCC patients may defer to family patriarch for consent decisions — navigate with respect while ensuring patient autonomy is not overridden

Health Literacy

• Assess health literacy early — formal tools (REALM-SF) or informal assessment
• Simplify written materials: grade 6 reading level target
• Reinforce verbal instructions: "chunk and check" technique
• Provide written instructions at discharge — do not rely solely on verbal

Compliance Challenges

• GCC expat workforce is highly transient — patients may leave country before completing follow-up
• Job loss can lead to visa expiry mid-treatment course (biologic, chemotherapy)
• Patients from certain nationalities may return home for surgery or specialist care
• Cultural preferences: some communities prefer traditional medicine alongside biomedical care
• Shift workers and labourers: clinic hours may conflict with work schedules; occupational health clinic integration important

Improving Compliance

• Appointment reminder SMS — multilingual (Arabic, English, Urdu, Hindi)
• WhatsApp-based follow-up (widely used in GCC for patient communication)
• Telemedicine follow-up for stable chronic disease patients
• Community health worker programmes (MOH community health workers in Saudi/Qatar)
• Nurse-initiated telephone follow-up within 24h of day surgery
• Detailed discharge summary emailed to patient and GP
• Cross-border treatment records via e-health platforms (UAE: Malaffi; Saudi: NABIDH)

Post-COVID Expansion

• Telemedicine mandated/expanded during COVID-19 in all GCC states
• Saudi MOH Seha virtual hospital — world's largest virtual hospital (2020)
• UAE: DHA Teleconsultation; Abu Dhabi: telemedicine via DOH-licensed platforms
• Qatar: Hamad Telemedicine; Oman: DIFA telehealth platform
• Post-COVID: telemedicine embedded as permanent care delivery channel
• Video consultation, asynchronous messaging, remote monitoring integration

Nurse Role in Telemedicine

• Triage incoming teleconsultation requests
• Post-operative phone/video review (24h and 7-day calls for day surgery)
• Chronic disease remote monitoring: BP, glucose, weight data review
• Medication adherence follow-up
• Patient navigation — booking, referrals, results communication

Appropriate vs Inappropriate for Telemedicine

Ramadan Impact on Elective Scheduling

• Muslim patients fast from dawn to sunset — impacts medication timing, fasting compliance, hydration
• GCC hospitals typically see reduced elective surgical lists during Ramadan
• Morning surgical slots particularly affected (patients reluctant to break fast for elective procedures)
• Evening / Iftar-time slots may be preferable for day surgery where operationally possible
• Chronic disease management: medication adjustments during Ramadan (particularly insulin, anticoagulants, diuretics)
• Diabetes management during Ramadan: specific GCC guidelines exist (IDF-DAR guidelines)
• Ramadan Clinic — specialised pre-Ramadan medication review appointments increasingly offered in GCC

Same-Day Discharge Culture Differences

• Some GCC patients (particularly nationals) prefer overnight stay even for minor procedures — reassurance, family presence, cultural expectation of care
• Discharge on day of surgery may be perceived as dismissal or insufficient care by some families
• Patient and family education about ambulatory care safety is essential at pre-admission stage
• Family involvement in discharge planning is often essential — address family as well as patient in discharge teaching
• Overnight/23-hour observation beds should be available for patients who clinically or socially require them
• Never discharge a patient against their will to meet throughput targets

GCC-Specific Cultural Sensitivity

• Gender concordance in clinical care — female patients may prefer female nurses/physicians for intimate examinations
• Prayer time schedules — accommodate patient prayer needs in ambulatory settings
• Halal medications — porcine-derived products (heparin, some gelatin capsules) require patient counselling; alternatives where available
• Modesty during examination — always maintain dignity; draping and private spaces