Day case theatre flow at Royal Manchester Children’s Hospital

Case study summary

Ensuring flow at the paediatric theatre day surgery unit, for both elective and urgent non-scheduled surgery.

This case study is part of a suite of examples designed to support the contents of the children and young people’s elective recovery toolkit.


  • Developed as part of the hospital’s COVID recovery programme.
  • Premise is based on paediatric day case by default (as can be reasonably foreseen).
  • Any unexpected overnight bed requirements immediately escalated to the theatre co-ordinator and clinical co-ordinator.
  • Patient flow occurs entirely within the theatre complex.
  • Reception/waiting area is used for admissions.
  • Walk in walk out (WIWO) lead practitioner attends scheduling meetings to confirm suitable patients four weeks ahead.
  • Children all have a pre-op assessment.
  • A two-stage recovery process is used with nurse led discharge using physiological parameters.


  • Where: Royal Manchester Children’s Hospital (RMCH – part of Manchester University NHS Foundation Trust).
  • Which patients: any patient who is listed for paediatric theatre day surgery unit, for both elective and urgent non-scheduled surgery, but are fit to be at home (including ENT, dental, paediatric surgery, orthopaedics, plastics).
  • When: from August 2020.
  • Staffing: three members of staff, five days a week (7am-7pm). 12-hour shifts of Bands 3 and 4. Currently recruiting to five members of staff. Based on skill set of WIWO competencies, rather than banding.
  • Capacity: Seven trolley spaces recycled through the day (up to 17 patients have been through these trollies on one day – (specifically urology and ENT).

Challenges overcome

  • Culture change: changing mindsets that children need actual ‘beds’ rather than trolleys or chairs. Covid became the enabler, as the hospital had to ensure surgery continued by using staffing and their estate differently. Strong clinical leadership was essential to success.
  • Staffing: finding the right staffing mix was challenging. By developing a set of WIWO competencies, it encouraged band 3/4s looking for career progression to expand their skillset.
  • IT: getting WIWO as a designated “ward” and integrating into their EPIC new electronic system.

Key operational details

  • WIWO lead practitioner works with scheduling to identify and schedule on theatre listing at least four weeks in advance and come directly to WIWO (now a drop-downward on EPIC).
  • Complex cases (e.g., airway procedures) and children with behavioural needs can be considered within this model, e.g., have used the pathway for a long-term ventilation child having minor surgery.
  • Escalation plan in place for unplanned admissions.
  • First patient arrives at 7am – the service currently runs five days a week, aspiration for seven days (7am-7pm).
  • Last patient arrives in time to be discharged home by 7pm.
  • Bedside practitioner has WIWO set of competencies, including nurse-led discharge, so they can work autonomously.

Impact and benefits


  • Reduced waiting times – 2,800 patients through WIWO in 18 months.
  • Improved patient experience, especially for frequent attenders.
  • Streamlined admission process.
  • Reduced length of stay for many procedures*, e.g., adenotonsillectomy length of stay reduced from four hours to three and re-admission rates for adenotonsillectomy reduced to 0.3%.


  • Upskilling staff, improved morale.


  • Has enabled theatres and anaesthetics pathway development.
  • Day case rate increased from 50% to more than 95%.
  • Earlier theatre start times and decreased turnaround times.
  • Two CEPOD lists ring-fenced.
  • Reduced cancellations.
  • Reduced reliance on day case or inpatient beds.

*The WIWO model acts as an enabler for the adenotonsillectomy pathway – see this toolkit on the FutureNHS platform for the Adenotonsillectomy pathway/best practice guidance.

Findings from a study (Improving Safety for Day Case Adenotonsillectomy in Paediatric Obstructive Sleep Apnoea) demonstrated that day case adenotonsillectomy can be safely performed for children aged 2 and over who do not have significant comorbidities.

Key enablers

  • Leadership – make sure there is clarity on responsible owners for the programme. At Manchester Children’s, WIWO sits within the Theatres directorate. The clinical lead is a consultant paediatric anaesthetist, the operational manager is the assistant theatre & scheduling manager, and there is an appropriate AHP lead.
  • Establish a WIWO steering group and ensure key stakeholders are invited so there is buy-in from all involved.
  • Benchmark your current length of stay, day case rates and readmission rates, and measure improvements to show success.
  • Multi-disciplinary involvement in mapping the current patient journey and future vision – all steps in the process from listing the patient to discharge.
  • Process re: booking and scheduling lists – ensure there is effective communication with the scheduling team. List order on the day is also important, for example e.g., that tonsillectomies are listed in the morning – as well as access to patient records.
  • Estates need – ideally a waiting area at the front of theatres and an area at the back of recovery for second stage recovery.
  • Staggered admissions can be considered if it helps the estate.
  • Ensure clear information and communication to parents.