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DAY CARE MEDICINE SURGERY

Setting Up A Day Care Centre
T Naresh Row, MG Nariani, MM Begani, Niranjan Agarwal
This last article in the Day care section briefly deals with setting up of a centre.
Having decided to start your own Day Care Centre, how does one go about it? What does one need for an Ideal Set up?
There are several books and recommendations on how to set up a day care centre, we have tried to adapt them to suite our conditions, especially for a metropolitan city, based on our requirement.
Basically, you will need to provide for Reception, waiting room, Changing room, Operation theatre, recovery and beds. Depending on the space available, you can provide for a pantry and store room.

Introduction
In the metropolitan cities, restriction of space
makes you innovative. Here one tries to provide every necessary detail required, in the minimum of space, without compromising on the quality. At present, countries like UK, USA and France, where Day Care or Ambulatory Surgery is well established, there is a two-tire system. One, where the Day Care centre is attached to a fully functioning hospital or institute; second, where the centre is ‘free standing‘, situated at some distance from the hospital, that is, independent to the hospital itself and / or not related to it in any way.

The first modern day unit was established in 1969, in Phoenix, Arizona, USA. This ‘Surgicenter’ was the prototype of a ‘free standing’ unit, on which are based centres all over the USA.1
No individual or a group of individuals, however dynamic or dedicated they might be, can successfully plan, build, and operate a major ambulatory unit without broad-based support.2
While recommending standards for setting up of an Ideal Day care centre, care has been taken to allow the bare minimum requirements. Variations are encountered depending on your speciality, city of practice, type of patients you would be catering to, and resources available. A very brief synopsis has been presented, as any detailed description would be beyond the scope of this article.

The criteria’s of patient selection, case selection, anaesthesia selection, discharge instructions, etc. remain the same as has been described in the earlier articles.


We should keep in mind

1. To deliver a state of the art medical treatment to a group of patients who desire day care surgery, therefore, keep up with the latest and modern innovations in your field.
2. How many patients from your daily operating list would be able to utilise the day are facilities. This includes patient education.
3. How will you generate more patients to opt for ambulatory surgery? Here again, increasing the awareness of Ambulatory surgery among the medical and patient population at large. This can be achieved by circulating patient information pamphlets, holding talks and workshops for the medical professionals, specially the family physicians or general practitioners.
4. Feasibility study of your area, to find out the presence of an existing centre of the same speciality, type of patient population you would cater too. That is, educated patients, who are not living very far from your centre, would agree to Day care option.
Reception and registration of the patient, with consent and other formalities of administration. This should be as minimum as possible, because the patient is fasting and has come for surgery to you, should be least troubled.
Waiting room for the relatives, if you do not have separate room for each patient.

Pre-operation preparation room : Changing of cloths, shaving of the surgical area, administration of enemas, checking of BP, Blood sugar in diabetics; sometimes the patient is drowsy due to the anxiolytic administered the previous night, would like to sleep if there are cases scheduled ahead of him.
Surgery : A fully equipped, well-lit and spacious operating theatre is mandatory. Your OT should be able to handle any unforeseen emergencies that can arise during the surgery. Therefore, ample floor space should be provided for movement. Complete monitoring of the patient from the anaesthetic point of view, a fully functioning Anaesthetic machine, even if you operate under local anaesthesia; Pulse Oximeter with or without Capnograph; Cardioscope; BP apparatus; emergency drug trolley; Suction machine and Electrocautery, as per your speciality. In short, even though you are planning on a small centre, your OT should have enough equipment to handle any major calamity.
Recovery : Usually, the pre-operation preparation room, or patients individual room double as recover room. A single ward with partition for privacy, will also, suffice.
Care should be taken to see that the provision of the recovery area is not far from the operation theatre complex, as to facilitate periodic check on the patient’s recovery by the anaesthetist and the operation team of doctors.
Toilet : An important consideration, often overlooked in the planning of a hospital in our country. Remember, passing of urine is an important criterion for the discharge of the patient. It should be as close to the recovery area as possible. A fully conscious patient will be able to walk to a toilet rather than use a bedpan, but to negotiate steps, or corridors to reach one, will be asking too much.
Pantry : Facilities for the provision of refreshments should be kept in mind. Increases your points in a patient friendly set up.
Consulting rooms : More professional if you could discuss pre and post operative instructions in the seclusion of your consulting rooms, also gives a feeling of security to your recovering patient.
Duty Room : Or a work station would be very handy for your staff that would be doing the paper work for the discharge of the patient, explaining any questions and giving instructions.

Other requirements
Autoclaving and storage facilities of surgical equipment, sterilizer, washing and drying area.
Parking space for the visitors, availability of lifts in your building, easy access to public transport.
Separate entrance to your centre, if it is housed as part of an institution or hospital, would definitely increase the convenience to the patient, allowing him to be separate from the hustle and bustle of indoor patients. Thus giving a feeling of ‘in and out’ of surgery.
Provision for admitting the patient overnight, if the need arises, should be explained to the patient in advance, so that he is prepared for such an eventuality.
Post operative follow up by a visit or a phone call from your team should be included as part of the surgical care, to reassure the patient and check on complications. This procedure should be repeated in the morning after or the patient can be called over.
Involvement of the patient’s family physician or the referring doctor considerably eases the strain on your schedule. He should be taught to look for complication and report to you on the progress of the patient.

Discussion
Most of the points have been discussed in the above narration, some points of added advantage and disadvantages are:
Medical Insurance : Medical insurance companies still have some reservation in reimbursing case done on Day Care basis today, but, with better understanding of this modality of treatment, future of Day Care surgery looks promising. Around 1970, the first free standing ambulatory centre, the Dudley Street Ambulatory Surgical Centre, Providence, Rhode Island, USA, had to be closed, “though a well-planned and operated, this small unit encountered difficulty in procuring reimbursement for the service not provided in a hospital”.4
Institute / hospital : the resources of a hospital is at your disposal, making it less taxing on the management and back up facilities. Admission and discharge become cumbersome, as the patient has to confer with the requirements of indoor patients, thus possibility of undue delay. Rotating staff, not tuned to day care management.
Free standing unit : ease of convenience offered to the patient, thus speeding up the whole process. But, taxing on your resources and facilities. You may find days when your OT is idle. You have to consider and make provision for admitting the patient, if the need arises.
Day Care Inns / Hotel : for the convenience of the patients coming from long distances and who do not want to travel back on the same day, there is a ‘Hotel’, attached or near, to the centre, which can be utilised for spending the night and coming for follow up the next morning, before leaving for home. Thus, saving a trip for follow up, as well as, still making use of the day care facility.
Management : Seniority should not dictate staffing: knowledge, experience, and interest in ambulatory care should.5 Most of the established centres abroad, are managed by anaesthetists and Nursing staff, who are trained in day care management, they know the importance of scheduling the OT list, looking for and managing the post-operative complications; discharging the patient with complete instructions. Follow up of patients can also be managed by the nursing and paramedical staff, who can be trained, specially for this purpose, and have been found to be of a great boon in the already established centres abroad.
Thus, leaving the surgeon relatively free to concentrate on his work.

In conclusion
You have to tailor your requirement as per your speciality and needs.
Within the established guidelines, one can easily fit and practice day care, if you are not prone to taking shortcuts and improvisation.
Day care surgery is a fast growing and accepted norm of providing care to your patients.
Emphasis is on meticulous care and following of instructions. This is only possible if you are clear in your understanding of the concept of Day Care.
“ We exist because of the patient; therefore, the patient needs come first.
The health cares system is changing and so must we to contain cost and still provide quality patient care.
The ambulatory care programme now revolves around the inpatient programme. In time, the inpatient programme will revolve around the ambulatory care programme.”
- Dr. James P Richardson

References
1. Ford F, Reed W: The Surgicenter-innovation in the delivery and cost of medical care. Ariz Med 1969; 26 : 801.
2. James E. Davis: Development of Ambulatory Surgical Unit. Major ambulatory Surgery 1986; 57-72.
3. Marlene J. Berkoff, Pangrajio JR.: Planning and Designing Ambulatory Surgical Facility. Major Ambulatory Surgery 1986, 73-88.
4. Hill CL: Ambulatory surgical facility. RI Med J 1975; 58-313.
5. Mitchell RT: Managing and staffing The major Ambulatory Surgery Unit. Major Ambulatory Surgery 1986; 89-101.

( *Consultant Surgeon, Abhishek Day Care Institute and Medical research Centre; **Honorary Consultant Surgeon, Bombay Hospital Institute of Medical Sciences; ***Assistant Hon. Surg., Bombay Hospital Institute of Medical Sciences, Mumbai)



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