CARE MEDICINE SURGERY
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.
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
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
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
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.
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.
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
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.
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
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
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)