DAY CARE MEDICINE SURGERY
Interventional Radiology in the New Era of Day Care Surgery
Gireesh M Warawdekar, Vimal R Someshwar
Interventional Radiology can be considered as an excellent alternative to various surgeries; in fact, interventional radiology can be considered as a first step towards ‘Pin-Hole Surgery’. Being minimally invasive, various interventional radiological procedures can be performed on a day care basis. Diagnostic angiograms or even complex therapeutic interventions are being performed with the patient being sent home on the same day. As a routine post angiography patients are kept for 6 hours prior to discharge. However, for interventional procedures, the patient may be kept for observation or stabilisation for less that 24 hours before sending them home.
Various Interventional procedures that can be considered as Day Care Procedures are:-
Angiogram Angioplasty + Stenting, Especially Renal, Peripheral, and Sub-clavian Venogram Embolisation: Lymphangiogram Percutaneous Nephrostomy or
Small Bowel Enema Abscess and fluid collection
USG/CT/Fluoroscopy guided biopsies Fallopian Tube Recanalisation
Angiography is used to evaluate the vascular system. Here, needles, guide-wires and catheters are introduced percutaneously into the blood vessel and contrast is injected to study the vasculature in the organ being studied.Day Care in Psychiatry
Venography is a simple out-patient procedure to study the venous system of the limbs. A venous radical over the foot or hand is cannulated with a scalp vein, contrast is injected and its flow monitored on the Image Intensifier, and films are also taken.
Lymphangiography is a study of the lymphatics where an incision is taken on the dorsum of the foot, a lymphatic vessel is catheterised with a fine needle and a radio-opaque oily contrast medium is injected.
USG/CT/Fluoroscopy guided biopsies : With the assistance of the various radiological modalities, tissue samples from the liver, kidney, thyroid and masses at different sites can be obtained by fine needle or true-cut biopsies.
Angioplasty + Stenting, Especially Renal, Peripheral, and Sub-clavian : A blocked or a narrowed artery, normally due to a deposition of cholesterol in the vessel wall, reduces the blood supply to the region, resulting in ischaemia. This obstruction can be relieved by placing a balloon catheter at the site of narrowing and then inflating it. This causes a break, compresses and fragments the cholesterol plaque resulting in an increase in the lumen of the vessel and hence an increase in the blood flow. This site may be stented by placing a metallic spring-like tubular device made of special metal alloys which prevent or delay the re-occlusion of the artery.
Embolisation is performed to occlude blood vessels where the blood flow is more than necessary, especially in cases of bleeding. Patient may require longer post-op. observation to stabilise the patient after cessation of the bleeding.
Percutaneous Nephrostomy or Biliary Drainage is a simple procedure to facilitate drainage of the urine / bile from a dilated pelvic-calyceal or biliary system, respectively, caused mostly due to an obstruction in the form of a calculus, stricture, malignancy, mass or fibrosis.
Abscess and fluid collection drainage : Collections in the abdomen or chest can be drained percutaneously by puncturing the cavity with a needle, advancing a wire into it, and after removing the needle, a drainage catheter can be guided over the wire into the collection so that it drains externally.
Fallopian Tube Re-canalisation : For infertility in women caused by blocked fallopian tubes that prevent sperm from meeting the egg, these blocks can be opened by selectively passing a special hydrophilic wire into the tubes to re-canalise them.
Since the dawn of interventional radiology to the present day, there has been a tremendous advancement in technology with respect to angiography machines, angiographic hardware, as well as intensive care medicine. For example, till a few years ago, angiographies used to be performed using 7Fr or 8Fr catheters, while now angiographies are routinely performed using 4Fr catheters. Percutaneous arterial closure devices are now available to seal the puncture site. Microcatheters (2Fr and 3Fr) are now readily available to reach the smallest of arteries so as to embolise them when treating aneurysms or bleeding vessels. All this progress has ensured that the incidence of puncture site complication are negligible, making these procedures safer, the percentage of success has increased to 80-90 % and finally, the hospitalisation period has reduced drastically. As a result majority of the interventional radiological procedure can be performed on a day care basis.
Day Care in Diabetes
Hitherto there were just two concepts in the management of patients. These were: out-patients and in-patients. If the patient needed advice and could follow the advice on his own at home, he was termed an ‘out-patient’; and if he was ill and the management was beyond the scope of the infrastructure at home then this patient would be hospitalized for closer care and treatment. In this situation, he was termed an ‘in-patient’.
However, over the years, particularly in the last decade there has been tremendous progress in non-invasive and minimally invasive surgery. This new innovation in science has given rise to a new dimension in patient care: that is, Day Care. Day care entails a visit to a hospital / nursing home / clinic / health centre in the morning, undergoing treatment for the disease and being discharged in the evening.
Most patients are not sick enough to warrant hospitalization and do very well with advice which they can follow at home. Some patients are very sick and need sophisticated investigation and treatment modalities / surgery / expert nursing care / frequent surveillance. These patients are best admitted to hospitals.
With the advent of newer methods of treatment and investigations, there has arisen a third subset of patients who need to be hospitalized for a short time and thereafter can be given ambulatory care from their homes.
With increasing cost of hospitalization, investigation charges, increasing distances between hospital and home, the patient was seen to be overburdened by extremely high hospital bills, thus, discouraging patients from seeking timely advice and delaying treatment till the last stage. To alleviate this inconvenience, the concept of Day Care was created. Day care has brought modern medicine within the reach of the common man without unduly taxing the patients resources, both, financially and supportive.
The advantages of Day Care are largely:-
a. Financial : As hospitalization is only for a day, the cost of hospitalization is minimized.
b. Infrastructural : The patient need not inconvenience family and friends by prolonged in-hospital stay and can make do with lesser help from family / friends. The Day Care centre also benefits as they employ fewer people and hence cut down their expenses too.
c. Responsibility : The physician’s responsibility is reduced to the day-time care of patients and now he need not really be concerned about the provision of optimum responsible staff round-the-clock.
Day Care benefits diabetic patients in several situations:
a. The commonest and most useful function of day care is seen in the Newly Detected Diabetic. In clinics so equipped a diabetic patient can opt for a day long stay in a day care centre. Here, he can be taught about the various aspects of diabetes, viz: symptoms, complications, hypoglycaemia, urine and blood testing, maintenance of appropriate charts and insulin injection, oral medications and other relevant information on diet and exercise. At the end of a day long stay at such a centre, the patient is equipped to deal with his disease much more confidently and completely. Furthermore, the patient can also undergo all his basic tests to establish the extent of diabetes (Fasting and Post Lunch Blood Sugar, Glycosylated Haemoglobin), presence of complications, e.g.: visual, neuropathic or cardiac, for which he can undergo investigations and be suggested treatment.
b. Established diabetics : already on treatment, can use a day care centre in various ways.
i) Periodic admission for complete evaluations, tests and education programmes.
ii) Minor surgeries, e.g.: Cataract surgery, Laser therapy for retinopathy, Laparoscopic surgery on the gall bladder or in the pelvis for gynaecological indications, herniorraphy and hydrocoele surgery.
iii) For the treatment of foot infection requiring debridement, dressing and the administration of parenteral medications.
iv) For the treatment of ENT diseases, e.g.: tonsillectomy, submucous resection for deviated nasal septum, for ear surgery or drainage of sinuses.
v) For the incision and drainage of abscesses at various locations.
vi) For endoscopy of the upper and lower gastro-intestinal tract: both diagnostic and therapeutic.
vii) For life saving procedures like kidney dialysis, pleurocentesis, pericardiocentesis, ascitic tapping when required.
viii) Biopsy of tissues when necessary.
ix) Cystoscopy and other such urological tests, which are short procedures.
x) Coronary angiography and angioplasty cases, where no complications are anticipated.
The list of indications can be expanded further to cover practically every field of medicine.
Day Care has undoubtedly altered the way we look at seriously sick patients who need not now be hospitalized for a prolonged period of time. The decision to admit as day care or to admit as an in-patient depends solely on the treating physician / surgeon as they are in best position to judge the gravity of the situation, the extent of care required by the patients, and the ability of the patient to arrange for the care at his home.
Day Care has eased the burden of expenses of hospitalization, yet supplies the patient the advantage of the use of modern technology and medical expertise in an aseptic organized environment.
Diabetic patients, who, unfortunately, frequently require medical attention, can certainly benefit from this novel modus of
As technology advances more and more people will opt for Day Care. In this way, medical treatment could be made available to a greater number of people.
In last fifty years psychotropic drugs have revolutionized the psychiatric treatment. Majority of the patients with severe psychiatric illnesses used to spend rest of their life in mental hospital. With the advent of drugs these patients could be controlled and be discharged from the hospital. Initial enthusiasm produced by these psychotropic medications was subsequently lost, as many psychiatric patients did not reach their pre-morbid functioning in spite of adequate treatment. Unfortunately, the patients who were discharged from the mental hospital still harbour many deficits, which prevent them from resuming their responsibilities.
Most psychiatric illnesses run a chronic course and require long-term management. These patients were not sick to require specialized care by medical professionals but required help and guidance which could be done by less qualified personnel’s. The common problems encountered in these psychiatric patients are:
1. Partial remission of symptoms of schizophrenia and persistent positive, negative and cognitive symptoms.
2. Bipolar patients with recurrent mild to moderate episodes leading to non-compliance or substance abuse.
3. The incidence of alcohol and substance abuse was significantly high amongst these patients.
4. Non compliance due to various reasons to the prescribed medications
5. Inadequate social skills as early onset of mental illnesses affected their personality development.
6. Families of mental patients also had to get adjusted to these handicaps of chronic patients. Some of the family members reacted to these deficits either by criticism or by overprotecting the patients and thereby creating problems in management.
7. The society was unable to give employment to these patients. They could not create enough jobs and many patients with reasonable control of their mental illnesses could not earn their living.
Even patients who had psychiatric problems which did not require hospitalization (like obsessive compulsive disorder, personality disorder, substance abuse and alcohol disorder, children suffering from autism, ex-patients having problem in adjusting to their family, education or marriage, etc.) needed constant supervision and counselling.
All these factors led to a need of a facility like day care centres, where patients who were not hospitalized, could be cared on regular basis by mental health professionals.
These day care centres could carry out following activities:
1. Increasing the contact with professionals, supervising medications and watching out for long and short-term side effects, improved compliance.
2. Patients could ventilate their feelings in a neutral environment. They could also resort the counsellor for help in making minor and major decisions of life. The professionals were in position to understand and help their difficulty in making decisions because of cognitive deficits. Patients could approach the professionals for handling the difficult family members and resolve their interpersonal problems.
3. In recent years, there are several studies showing significant benefits of day care centres. Centres also could help the individuals to develop social skills like conversational abilities, assertion skills, etc. These skills helped them to participate in society, which helped them to regain back their lost self-esteem. Some specialized centres could teach the patients methods of enhancing their intellectual or cognitive abilities. Studies have shown that combination of cognitive skills training and medications is better than medications alone.
4. Patients having similar psychiatric problems could attend group psychotherapy. This group approach reduced the cost and required less number of professionals. In addition, patients also realized that there are many other people who have similar problems and have different methods of coping, which they can adapt. The patients could also see the long-term harmful effect in other patients who had faulty adaptation. Group environment demonstrated the positive and negative way of solving problems which can result in long lasting experiential learning. This approach was more effective than just theoretical jargon. Patients were also subjected to group pressure to modify their maladaptive pattern of behaviour, accept their illness and medication.
5. Patients having conditions like OCD, panic disorders, social anxiety disorder, schizophrenia, personality disorders, and bipolar disorders could also be given behaviour and cognitive therapy in group settings. This therapy otherwise would be ignored because of its cost.
6. Family members managing long-term psychiatric patients could also ventilate their problems and could learn coping skills from other family members. It also provided an opportunity for the families with the similar mental patients to get together and share many common problems.
Today, day care centres have become integral part of psychiatric management. Majority of psychiatric problems require long-term outpatient management and creating such facilities have improved the outcome and prognosis of many patients.