1. Impact of Day surgery on Public Hospitals

2. Bhavinder Arora
Department of Surgery
Pt BD Sharma University of Health sciences
PGIMS, Rohtak

3. Introduction The concept of day surgery is not new.
Day surgery is an important part of elective surgery.
About 20% of outpatient surgeries are performed as day surgery in India.
It accounts for 50% of surgery in U.K and more than 60% surgeries in U.S.A.
Indoor surgery is performed in rest of patients.
There is need to grow for decompression of busy hospital beds.

4. The impetus for this has been the high cost of keeping patients in indoor beds, the reduction in availability of these beds, and long surgical waiting lists in publicly funded health-care system.
We present data of day care surgery in a public hospital.
We discuss essentials for success of day surgery and its impact in a public hospital.

5. Day-surgery units (DSUs) are the best way to achieve this.
Day care surgery when well managed is safe, cost effective and acceptable to majority of the people in a public hospital setting.
It is dependent on careful selection, good patient information, skilled surgery, post operative analgesia and effective communication.

6. Day care surgery has generated lot of interest, both among the surgeon and common people.
It has resulted in cropping of ambulatory surgery by a dozens.
The improvement in anesthesia and pain control, minimally invasive surgery and changing attitudes to recovery after surgery have all promoted the expansion of the day surgery.
The renewed interest is due to reduced cost
Besides cost containment there are other factors too allocating for unprecedented growth in day surgery procedures.

7. Aim The feasibility of day care surgery in a public hospital.
The quality care in day surgery should be of same high standards as that of in-patient surgery.
Analyze the cost benefit of care surgery in a public hospital setting
To identify the factors for strengthening the potential of day care surgery.

8. Beginning in public hospitals
In 1951 Eric Farquharson, an Edinburgh surgeon, carried out day-case adult hernia repairs under local anesthesia in order to reduce long waiting lists in the newly introduced National Health Service(NHS).
Hospital-based DSU began to appear in 1960 and UK hospitals followed suit from 1970 and DSU became established in most hospitals.
In India day surgery was started in tertiary care public hospitals, but flourished easily in big five star private hospitals.

9. Day surgery unit in public hospital
The DSU is a self contained dedicated day surgery facility with its own reception and operating and recovery areas.
A compromise is to have day-case ward close to the operating room with dedicated day-case operating sessions with same good organization found in self-contained DSUs
Hospitals without a DSU never achieve high percentage of day cases.

10. The DSU is usually part of a general hospital, and ideally should be purpose built. The design should maximize efficient patient flow. The number of beds and theaters will be dictated by the workload of the specialties using the unit. In general a throughout of patients per-bed day is possible.

11. Types of anesthesia used
Local anesthetic – suitable for day cases; contraindicated in infection.
Regional block – useful in an emergency when the patient is not starved; gives good postoperative pain relief.
Spinal and epidural anesthetic – only to be used by an anesthetist under full sterile conditions; allows ongoing postoperative pain relief.
General anesthetics are now safer and more controllable so still have an important role to play.

12. Surgery included
In a public hospital we are doing day surgery both under local and general anesthesia.
The procedures done under local anesthesia are many.
In comparisons to local anesthesia procedures, general anesthesia procedures are few.

13. Surgery included: local anesthesia
Penile: Preputioplasty, Frenuloplasty, Circumcision, Sapheno-cavernosal shunt for priaprism, Partial amputation of penis.
Scrotal: Bilateral orchiedectomy for carcinoma prostrate, High orchiedectomy, orchiopexy, Hydrocele unilateral and bilateral, Epididymal cyst, Spermatocele.
Inguinal: Inguinal hernia unilateral or bilateral, Varicocele, Lipoma of cord.

14. Surgery included
Anterior abdominal wall hernias- small size, Umblical hernia, Paraumblical hernia, Epigastric hernia, Fatty hernia of linea alba and small incisional hernia.
Large size lipoma
Superficial varicose vein surgery and laser or radiofrequency ablation, Foam therapy.

15. Surgery included: gen. anesthesia
Commonest procedure done under general anesthesia is surgery for gall stone; Laparoscopic cholecystectomy or Minicholecystectomy.
TEPP for inguinal hernia
Skin grafting
UROLOGY, PEDIATRIC SURGERY, BURN AND PLASTIC are also using same model of day surgery in public hospital.
Orthopedics and Ophthalmology operation are done as day surgery procedures.

16. Patients are called in the morning on day of surgery.
Patient are given preoperative instructions.
Informed consent and details of surgical procedure to be done.
Discharge on the same day in evening.
Postoperative instructions and emergency contact information is given to the prime attendant.

17. Exclusion Criteria ASA grade IV unfit Obese Multiple recurrent hernia
Large inguinoscrotal hernia
If time required is more than one hour

18. Day care surgery unacceptable to patient
Psychologically unstable
Lives far away from hospital
No competent relative to take care at home for next 48 hours

19. Patient’s selection
For a successful day surgery, selection of patients for surgery is very important.
Selection of patients for a day surgery procedure should consider the patients willing for a day surgery procedure.
Medical and social reasons must be considered and patients should be excluded on these grounds.

20. Patient Information
A comprehensive information using lay man terminologies for patients and their relatives is essential.
Day surgery patients unlike inpatients do not have easy access to doctors and nurses in preoperative and postoperative period to answer their queries and worries.

21. Contd.
A brief description of the disease and surgical procedure to be done as day surgery procedure should be given to patient and attendants.
The oral instructions or printed instructions should be given to the patient before coming for day surgery procedure.

22. Contd.
Instructions regarding post operative use of analgesics should be given.
Alert symptoms should be understood by the patient and attendant.
If any of the alert symptom arises, the patient should contact the doctor for advice regarding self treatment or return to emergency for hospital treatment.

23. Contd.
It is essential that information that all instructions given to patient is correct.
Patient can be worried if a different advice by other doctor and nurse and may loose confidence.
All the surgeons working in a unit must agree on a uniform instructions given to the patient.

24. Postoperative care
Initially the patient is kept in recovery area and then shifted to ward.
All queries of patient must be answered.
A detailed discharge card including details of surgery, postoperative analgesia and removal of sutures and follow up appointments.

25. Medical Audit
As with other fields of practice audit is essential to maintain and improve standards.
Both quality and medical audit should be continued process.

26. Benefits of day surgery
Reduced cost
More efficient high-volume throughput of patients
Reduced waiting lists
In-patient beds free for major surgeries
Fewer cancellation on day of surgery
Low incidence of serious morbidity
Low thrombo-embolism and hospital-acquired infections
Minimal disruption to patient’s life
Patients, particularly children, prefer it

27. Advantages of Day Surgery
Cost containment
Decompression of busy hospital beds
Less nosocomial infections
Smooth recovery in home care with family

28. Cost containment
The expenditure incurred by government on a patient bed is about Rs.1500/- per day.
In a public hospital, the patient is admitted one day prior to surgery and is discharged 2-7 days after surgery.
So the hospital bed cost varies from Rs.4500/- to Rs.12500/-.

29. The public money saving runs in crores in a year depending on number of day surgeries.
If audit is used, the day surgery costs are many time less than surgery done as indoor patient.
Besides public exchequer the money spent by patient on transport, food and material used in day case surgery is much lower.

30. Decompression of Hospital Beds
There is overcrowding of beds in a public hospital due to excess admission rate.
About 20% of these beds in a general surgery ward are occupied by patients in whom surgery can be done as day care procedure.
This overcrowding results in delay in treatment or refusal of treatment.
Day surgery in can provide quick treatment.

31. Decrease Nosocomial Infection
There is cross infection in overcrowded surgical wards.
The infection rate in general surgery wards is high because infected patients are admitted.
The patients undergoing day surgery procedure can not acquire these hospital borne infections as they are not admitted.

32. Factors affecting day surgery in public hospital
Patients’ Acceptability:
It can be judged by
1. Readmissions after have returned home
2. Postoperative complications
3. Complains of early discharge by patient

33. Postoperative morbidity
Major morbidity with the potential for serious harm is rare. In large study from MAYO major morbidity and mortality was %.
Minor morbidity, however is common and apparently minor problems can have significant consequences.
Postoperative morbidity is related to the type of anesthesia used and the surgery itself.

34. Potential problems of day surgery
Initial costs of setting up day-surgery units
Good organization and management needed
Resistance from senior medical staff
Poor patient and procedure selection
Inadequate information given to patients
Morbidity from anesthesia and surgery
Increased community health care workload
Burden of care passed to patient’s family

35. Competition
These large public hospitals are large surgical facilities with several hundred beds in contrast, most of day surgical centres tend to be small with no more than a few dozen beds.
Number of day surgeries performed is much more as the quantum of patients waiting for surgery is more.
Virtually every model of competition, larger market share is associated with more market power. But public hospitals get strong competition from these small day surgery centres.

36. Take Home Message
Day surgery if well managed is both safe, cost effective and acceptable to majority of patients in a public hospital.
High quality day surgery is dependent on careful patient information skilled surgery and anesthesia preferably without complications.
Adequate postoperative analgesia, rapid communication and continued audit.
Because a large number of patients are operated as day surgery, the total number patients operated is much more than total number of beds

37. Take Home Message (contd.)

38. Thanks