DAY CARE MEDICINE SURGERY
Day Care Surgery - The Physicians Viewpoint
The increasing use of day care surgery in hospitals is a boon to the patients, not only from the viewpoint of the surgeon and the patient, from the advantages in overall costs, morbidity, etc., but from a physician’s viewpoint.
In essence, the advantages to the patient of a minimal hospital stay from the physician’s viewpoint are as follows:
1. As local anaesthesia is most commonly used, patients who might be otherwise unsuitable for a general anaesthetic, in view of significant cardio-respiratory morbidity, are capable of having procedures and surgeries that might otherwise not be performed.
2. Extensive investigation to assess medical fitness in the elderly population would be unnecessary when minimal anaesthesia is used. This would help in reducing the cost burden to the patient of the overall procedure.
3. Lack of prolonged stay in a hospital environment would prevent the patient from colonization with multiple resistant hospital pathogens and decrease the overall incidence of nosocomial infection with its attendant costs, morbidity and mortality.
4. The short stay in the hospital prevents disruption in the day-to-day routine of patients, which leads to continued productivity and efficiency in the young, active, working patient.
5. Elderly patients often get disoriented and confused when removed from their home environment and this leads to unnecessary drug therapy and referrals.
6. Patients on multiple medications will have their medication unnecessarily altered or routine dosing of drugs may be missed or duplicated by hospital staff. In the day care surgical setup patients can continue with their routine medication as before, under their own supervision and avoid these problems.
7. Diabetic patients are unnecessarily switched from their oral agents to insulins during their hospital stay, placing them back on previous well established regimens is often not done or made difficult by physicians.
8. In the in-hospital environment, patients tend to be referred to multiple specialists just because they have multiple pre-existing problems. Typically a patient might be referred to a physician, a cardiologist, a diabetologist or a neurologist, simply because they happen to have well controlled previous conditions such as diabetes, epilepsy or ischaemic heart disease. Each of these referrals generates a battery of investigations and treatment, which might be detrimental to an otherwise stable patient, not to mention the lack of co-ordination between the various specialists and the significant increase in the costs of such referrals.
9. Beds in a busy hospital, which might be blocked by patients spending days as in patients for simple surgeries, will now be available for patients with more serious illnesses requiring prolonged admission.
10. Psychologically, the patients and the family are less likely to feel the burden of a major illness as would occur with a hospital admission. Lack of disruption in the work schedule of family members preserves productivity.
However, the day care surgical approach should not encourage a lax or lackadaisical attitude in the care of the patient on account of its seeming ease. Each patient will require careful consideration as to his fitness to undergo the procedure. This, in essence, will consist of a careful evaluation by a physician with stress on any previous cardio-respiratory morbidity, the presence of any symptoms, which might not have previously been thought to require attention and a good physical examination. All basic investigations - viz. a CBC, blood sugar, Chest X-ray and ECG, must be done in addition to those which might be required if the patient has specific problems - such as pulmonary function tests in an asthmatic patient. Special thought must be given to the continuation of routine medications such as antihypertensive, which should be continued or antidiabetic drugs, which should be withheld when the patient is likely to be fasting for some time. The time when these drugs should be suspended or reinstituted should be clearly mentioned to the patient and recorded on paper. Facilities for monitoring patients carefully with regular blood pressure, finger-prick blood sugar, and pulse oximetry, should be available and careful charting of these along with preset systems for attendance by a physician, in case required, should be established, followed and audited carefully. From the surgical viewpoint it is important that the patient have access to proper assistance in case of any worrying new symptoms or complications.
Overall the advantages to the patient of day-care surgery outweigh any disadvantages and it is easy to foresee a time when more and more surgeries will be performed in this manner.
Day-Care Haematology and Transfusion Services : A New Facility
Haematology is a unique branch of medicine, wherein, clinical aspects and lab investigations go hand in hand to create ideal services for patients suffering from haematological problems.
Initially, all haematology patients were treated with whole blood. This, not only increased the side effects, but proved to be ineffective, in most cases. Now, with the blood component technology, one unit of blood can be separated into four components:
1. Packed cells are mainly used in chronic anaemia like thalassaemias, refractory anaemias, aplastic anaemia and anaemia secondary to malignancy and chronic diseases.
2. Fresh Frozen Plasma’s are to be used in congenital and acquired coagulopathies.
3. Platelets are mainly to be used for thrombocytopenia, prophylactically or therapeutically.
4. Cryoprecipitate is to be used in haemophilias or acquired Factor VIII deficient or hypofibrinogenaemias.
Most of these haematology conditions enumerated are chronic cases and patients need treatment almost every month.
What is New?
For the benefit of these patients, Breach Candy Hospital has started a separate ‘Day Care Transfusion Service’, on the lines of most haematology departments abroad. The patient sees us and is investigated in the morning and if component therapy is indicated, he is sent to the day care. His grouping and cross-matching is done immediately and the necessary component is given to him within an hour. The patient is discharged as soon as the therapy is over.
At our Hospital, we fully investigate patients with haematology problems like anaemia, bleeding problems, etc. We take the help of our state of the art Blood Bank and Component facilities to treat specific haematology problems with a definite Blood Component.
We take the help of social workers, who take in-depth family background of the patient and often, in case of chronic patients, helps in acquiring the components without any replacement.
Besides transfusion service, the Day Care services are also open for other haematology treatments like immunoglobulin therapy, I. V. iron therapy and minor chemotherapy for haematology malignancies.
The advantage of such a service is focused mainly for the patient’s convenience and compliance. There is no need for booking or deposit. Also, as the Day Care room is close to the Blood Bank, the Blood Bank staffs are involved with patient care and transfusion services. This ensures results in personalised service to the patient and fast turnover.
Therefore, there is a need for more such ‘Day-Care’ centres to cater to needs of patients.
Providing Oncology Care in Day Care Setting
The number of cancer patient is increasing every year all over the world, including India. This is due to multiple factors, like, environmental agents, inherent susceptibility as well as better diagnostic facilities.
The cost of medical treatment is also rising today. The duration for treatment for a patient with cancer can be any where between six months to one year, including surgery, chemotherapy and radiotherapy. These amounts to a heavy financial burden on the patients; a significant part of which is for frequent hospitalisation for surgery, chemotherapy and other supportive care needed by these patients. This also leads to tremendous pressure on hospitals to provide them with beds as and when needed. The concept of Oncology Day Care Centres is indeed promising as it can help solve many of these problems.
Services of Oncology Day Care Centres
1) Administration of chemotherapy drugs : It is interesting to note, that about 70% of modern day chemotherapy regimens for solid tumours (breast, lung, ovarian cancers), Hodgkin’s disease, Non-Hodgkin’s lymphoma, etc., are of one day only.
These can very well be given in a day care setting. This gives a great relief to the patients and caretakers, as they need not stay overnight in a hospital environment. The formalities of admission and discharge of the patients are reduced to a minimum. Patients can take their planned appointment for day-care admission, directly from day-care personnel. This reduces administrative work for the hospital staff. Once the patients are in the same ward, i.e., day care ward, the task of oncology sister is also made easier as the nurse does not have to move from one ward to another for administering chemotherapy.
Certain equipments like laminar airflow, cooling cap, etc., can be installed in a day care for maximum utilisation.
2) Providing catheter care : Venous access is difficult in many cancer patients. The in-dwelling venous catheters are used frequently to solve this problem. These catheters require regular flushing with heparin and dressing. Blood collection can also be done from these devices. Oncology Day Care centre can be used for catheter care in these patients.
3) Supportive Care : Cancer patients need blood or blood products frequently. They also need IV fluids and / or antiemetics if brought with persistent vomiting after chemotherapy. Growth factors like G- CSF, GM-CSF and Erythropoietin are used to increase WBC counts and haemoglobin, respectively. These injections are given subcutaneously, therefore, can be given in Day Care by the oncology nurse.
4) Public awareness and education : The patients and their relatives coming to oncology day-care are always amenable to suggestions. Various activities to increase awareness regarding cancer, its treatment, management of toxicities, etc., can be held in these day care centres. Cancer screening programme can be promoted at the same time.
5) Record keeping : Good quality data can be monitored regarding number of cancer patients visiting the hospitals, types of cancer seen, treatment offered and its outcome over a long period of time. One can have an official data registry at the day-care centre, which helps the oncologists to learn regarding the epidemiology of various malignancies in their region, treatment results, long term follow up and survival of the patients. This can help in planning better treatment protocols for future.
6) Medical insurance : Today, more and more patients are covered under health insurance where, third party administrators monitor clinicians closely. Day Care facilities definitely reduce financial burdens on them. They should be able to reimburse the day care treatment.
Day Care centres must give equal importance to indoor facilities as far as resuscitative facilities are concerned. A patient can always have an anaphylactic reaction to any chemotherapy drug due to unknown hypersensitivity to that drug or its formulation. This is especially true for drugs like Paclitaxel, Docetaxel, Growth factors, etc. An oncologist should be always available for any medical problem. Qualified oncology nurses should be available, who has adequate knowledge about all the chemotherapy drugs and their reconstitution. It is also advisable to have an intensive care set up available near the day care to deal with any emergency.
Oncology Day care centre are the ideal place to deliver most of the chemotherapy regimens today. They are beneficial for the patients, oncologist, healthcare workers, hospitals and insurance companies as well. Hence, they should be established in all the oncology or multispeciality hospitals.