DAY CARE SURGERY IN A PUBLIC HOSPITAL SET UP
Ravi Bapat*, Chetan V Kantharia** , Satish Ranka *** , Girish Bakshi**** , Anand Iyer****
*Head; **Associate Professor; ***Clinical Research Fellow; ****Resident; Department of General Surgery, Seth GS Medical College and KEM Hospital, Mumbai, India.
The concept of Day Care Surgery is not new to us. Presently about 20% of surgical procedures in India are done as outpatients. However there is a need for the trend to grow for the decompression of busy hospital beds. We present our data of Day Care surgery in a public hospital over last one year and discuss the essentials for the success of Day Care Surgery.
A prospective, single centre, single unit study was carried out over a period of one year from Jan. 1999 to Dec. 1999. The total number of patients studied were 225 of which 30 were females and rest males. Their age ranged from 15-70 years. Surgeries for hernia, hydrocoele, varicocoele, fibroadenoma were included. All the patients underwent anaesthesia fitness prior to surgery and their ASA grade were noted. The patients were admitted on the day of surgery and discharged the same day evening. Patients were analysed with respect to wound infection, duration of stay in ward, approximate cost incurred and post operative pain. 124 patients were treated for hernia, 54 for hydrocoele, 17 for varicocoele and 30 for fibroadenoma. All patients responded to oral analgesics and complained of no pain. None of the patients required post discharge admission for complications. The approximate cost incurred was Rs.300/- per person. Thus 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 patient selection, good patient information, skilled surgeries, adequate post-operative analgesics and effective communication.
Day care surgery has generated a lot of interest, both among the surgeons and the common people. It has resulted in cropping of ĎAmbulatory Surgeons" by a dozens. The renewed interest is most due to the pressure to reduce cost of medical care. Besides the cost containment there are other factors too accounting for its precedented growth.
This is a prospective study carried out at our institute with an aim of :-
1. Assessing the feasibility of Day Care Surgery in a public hospital.
2. To analyse the cost benefit of Day Care Surgery in a public hospital setting.
3. To identify the factors for strengthening the potentials of Day Care Surgery.
MATERIAL AND METHODS
A prospective study of patients undergoing Day Care Surgery over the last one year from 1st January 1999 to 31st December 1999. A total of 225 patients were operated on day care basis. Their age ranged from 15-75 years. All the patients underwent anaesthesia fitness, prior to surgery on OPD basis and their ASA grading was noted.
The surgeries included were :
1) Inguinal hernia repair,
2) Surgery for tunica vaginalis hydrocoele,
3) Varicocoele ligation surgery,
4) Fibroadenoma enucleation.
They were admitted on the day of the surgeryand discharged on the same day in the evening. The patients were analyzed with respect to wound infection, duration of stay in ward, approximate cost incurred and postoperative pain. Local anaesthetic along with sedation was given. Postoperative analgesia was also administered. All the patients were followed up for a period of one month postoperatively.
Patients exclusion criteria :
1. Unfit (ASA IV),
2. Obese : Body mass index > 35,
3. Specific problems : e.g. Multiple recurrent hernias,
4. Size of pathology : Large scrotal hernia (Gilberts III and above),
5. Procedures requiring more than one hour.
1. Concept of Day Care Surgery unacceptable to the patient,
2. Psychologically unstable,
3. Lives far away from the hospital.
C. Social : No competent relative or friend to
i. Accompany or drive patient home after operation.
ii. Look after him or her at home for next 24-48 hours.
All procedures were completed in stipulated time. Table 1 depicts the overall results. No patient required change of technique or an additional anaesthetic. All patients responded to oral analgesics postoperatively and complained of no pain. Only one patient was readmitted post discharge with pain on post operative day two with pain in the leftinguinal region. He was operated for left inguinal hernia. Local examination was unremarkable. He was managed conservatively. Wound infection was not encountered. No written or verbal complain were registered. The approximate cost incurred per person was Rs.300/-.
Average time taken 45 min Change of technique Nil Additional anaesthetic Nil Post operative pain 0.44% Readmission One patient Wound infection Zero
The potential for day care surgery has increased over last few years. The Royal College of Surgeons of England in its "Guidelines for Day Care Surgery" (1992) state that "Day Care Surgery is now considered the best option for 50% of all patients undergoing elective surgical procedure, though the population will vary between specialities". The earliest reference for day care surgery is as early as beginning of 19th Century by James Nicoll and later in 1912 when Ralphwaters from USA described "The Down-Town Anaesthesia Clinic", Sioux City, Iowa, USA, where he gave anaesthesia for minor outpatient surgery. However over the next two decades, it lost its momentum. Patients even for minor surgeries like inguinal hernia repair, hydrocoele surgery etc. were required to spend minimum three days in hospital. At some places this trend still continues.
Past decade has been renewed interest in concept of out patient surgery. A part from cost containment, the other benefits received are decompression of busy hospital beds, less nosocomial infection and early recovery in home environment with the family.
The expenditure incurred by the civic authorities on a patient occupying bed is around Rs.800-900/- per day. Traditionally a patient gets admitted one day prior to surgery, and is discharged the next day of surgery. Thus for his three day stay a total of Rs.2400-2700/- is spent. This does not take into account the drugs, medication and the material used for surgery. In day care surgery, as in our study, patient is called early in the morning for admission on day of surgery, and is discharged by evening the same day. The load of minor surgery in a civil hospital is approximately 50,000 per year. The day care surgery results in saving of Rs.12,50,00,000/- annually. This over whelming evidence that day care surgery has much lower average costs than equivalent inpatient surgery is comparable to the result of audit commission 1990 in UK1 and Heath et al2.
DECOMPRESSION OF BUSY HOSPITAL BEDS
We are all familiar with the phenomenon of over crowding beds in a public hospital. But for day care surgery 15% bed occupancy is taken up by minor cases. This results in refusal and delay in delivery of treatment to a patient with major illness. As seen in our study, the total number of patient undergoing day care surgery per year is 225 against a total of 1320 patients coming to 17.04%.
Decrease in Nosocomial Infections : Overcrowding patients in ward leads to cross infection. The infection late in our hospital is around 8-10%. None of our patients undergoing day care surgery had wound infection.
Factors relevant for success of Day Care Surgery
1. Patient acceptability,
2. Patient selection,
3. Patient information, 4. Postoperative case,
1. Patient acceptability : Method of gauging the acceptability of day care surgery for patients to look for a) Number of unsolicited complaints, b) Readmission later after patients have returned home and c) Postoperative complication rates. In our study there was no verbal or written complain registered. Only one patient was readmitted after discharge. This is in contrast to 3% readmission rates quoted by Ruckey et al3. Thus the overall complication rate once the patient returned home was 0.44%. This statistic is comparable to that of Janet et al4 and Bhutani5 and perhaps better.
2. Patient selection : This is key to the successful day care surgery. Selection is not simply a matter of choosing patients with conditions that may be treated on a day basis, but also involves sifting out those patients who are unsuitable for medical and social reasons. Patients were excluded from our study as per the criteria of medical exclusions and social requirements put forward by Twerskey6 in 1993.
3. Patient information : Comprehensive and well presented information using lay terminologies for patients and their relatives is essential for the success of day surgery. Day patients, unlike inpatients, do not have ready access preoperatively and postoperatively to health care professionals to answer their questions and deal with their worries. As suggested by Baskerville et al7 the information given to patients should commence with a brief description of the condition for which they are being treated and the procedure being undertaken. This is followed by instruction as what patients must do before coming to the unit, what will happen during their stay in the unit, the postoperative analgesic regimen, what they should do on entering home and what is expected in the days following their operation. Finally, patients need advice on when they can return to various activities such as bathing and work. Perhaps the utmost information that must be given is that concern problems, that might arise following surgery at home and how to deal with those. This will includeadvice on self treatment and when to seek professional help. It is very essential that the information patients are given is honest. A patient given different advice by different doctor and nurse becomes worried and loses confidence. Thus all surgeons working in a unit must agree on standard advice to be given to patients for each of the procedures that are undertaken.
4. Postoperative care : After the operation, patients recover in the recovery area and then ward. All the queries of the patient are answered. A detailed discharge is given including the details of the procedure, post operative analgesia, when to remove sutures and follow up appointment.
5. Audit : As in other areas of practice, audit is essential to maintain and improve standards. Both quality and medical audit should be a continued process.
A. Day care surgery when well managed, is both safe and cost effective and is acceptable to majority if patients even in public hospital setting.
B. High quality day surgery is dependent on careful patient information, skilled surgery and anaesthesia, adequate postoperative analgesia, rapid communication and continued audit.
1. Royal College of Surgeons of England 1992. Commission on the provision of surgical services. Guidelines for Day Care Surgery revised edition. RCS, London.
2. Heath PJ, Oqq TW, Hall CA, Brownlie GS. The cost of Day Care Surgery. Health Trends 1990; 22 : 109-11.
3. Ruckley CV, Mcheamin, Ludgate CM, et al. Major out patient surgery. Lancet 1973; 2 : 1193-6.
4. Jarret PEM, Bishop C, Hitchcox K. Day care herniorapphy : early postoperative pain control. In : Wilker E, Ley J. Advances in morphine therapy. International congress and symposium series no. 64. Royal Society of Medicine, London. 1963; 43-6.
5. Bhutiani RP. The impact of a day care surgeon. Journal of one day surgery 1992; 2 : 7-10.
6. Tuverskey RS. To be an outpatient or not to be - selecting the right patients for ambulatory surgery. Ambulatory Surgery 1993; 1 : 5-14.
7. Baskerville PA, Heddle RM, Jarret PEM. Preparation for surgery : Information for the patient. Practitioner 1985; 229 : 677-8.