Day Surgery: Making it Happen
Key issues in the implementation and development of Day Surgery services.
Castoro Carlo
Consultant Surgeon
Corrospondence:
Istituto Oncologico Veneto (IOV-IRCCS), Dept. of Surgery Oncology,
University of Padova School of Medicine, 64 - 35128, Padova, Italy
Member of the General Assembly of the International Association for Ambulatory Surger.
Tel.: 0039 049 8218842; E-mail: carlo.castoro@unipd.it

To cite this article:
Castoro Carlo, Day Surgery: Making it happen, Key issues in the implemetation and development of Day Surgery
services, Day Surg J India, 2008, 4:21-25.

Introduction

Day Surgery, rather than inpatient surgery, is increasingly being considered the norm for all patients undergoing elective surgery.

The treatment of appropriate non-emergency cases by day surgery can be advantageous not only for the patients and their families but also for health care providers and the communities they serve – more patients can be treated more effectively and more efficiently.

Despite these widely accepted considerations, there are considerable variations in the rates of day surgery across Europe and worldwide.

The development of high quality day surgery services in European countries is now considered an health care priority for the Governments. For this reason a joint initiative of the International Association of Ambulatory Surgery and of the European Observatory on Health Systems and Policies led to the publication of the Policy Brief Day Surgery: Making it Happen. This policy brief is intended for policy-makers and health care professionals exploring how day surgery can respond both to the needs of hospital administrators and to the surgical care needs of specific patients and to help those who wish to expand the provision of day surgery. It identifies the major prerequisites for a successful expansion of day surgery and will be of particular value to health professionals and policy makers where day surgery is still in its infancy.
This policy brief can be of particular value also for non European Countries and most of the content can be useful for developing Countries facing challenging health care problems.

In this short paper we will summarize the content of the policy brief Day Surgery:Making it Happen with a prospective view to the specific needs of developing countries.
State of the Art

Results of a recent survey conducted in 19 countries showed an extremely wide variation in the percentage of day cases among countries (Toftgaard and Parmentier 2006).

The range varies between less than 10% (Poland) and over 80% (United States and Canada). A closer look at these figures also reveals large variations between procedures in the various countries, ranging from 0% to over 90%.
This variation can also be seen within countries, between hospitals in the same country and between departments and specialists in the same hospital. There are a number of reasons for this diversity including the following: regulations and incentives in different countries, financial reimbursement of day surgery, resistance to change and individual practices of surgeons and anaesthetists. The latter is often a factor in variations within the same country.

Day surgery covers a wide spectrum of procedures in all surgical specialities, from operations under local anaesthesia to major ones under general anaesthesia.
Improvements in surgical and anaesthetics techniques have brought about an ever-widening range of procedures which are suitable for day surgery; a good example is nowadays the expansion of laparoscopic and minimally invasive surgery.

Nevertheless some basic principles are to be applied when considering a procedure appropriate for day surgery:
- reduced surgical trauma.
- abdominal and thoracic cavities should only be opened with minimally invasive techniques.
- postoperative pain should be manageable with oral analgesia.
- no significant risk of blood loss.
- no rigid time limits exist but length of procedure should be restricted to less than two hours.

Day surgery is increasingly being considered the first choice for all elective surgical operations but it is necessary to a have a system in place for selecting patients carefully, taking into account surgical, medical and social criteria. Which patient is then suitable for day surgery ? We should perform the right surgical operation in the right patient. A fundamental pragmatic question to consider is whether the management or outcome would be improved by pre- or postoperative hospitalization. If not, the patient should undergo treatment on a day basis. Criteria of choice must be adapted to the single patient in a particular local setting. Social criteria for instance may vary widely in different situations; home circumstances and easy access to a telephone or transportation in case of emergency are important elements.

Day surgery outcomes

The rational of day surgery is that it is as safe, if not safer, and of the same quality as inpatient surgery for the same procedure.

There is evidence in the published literature that the incidence of major morbidity directly associated to day surgery is extremely low, less than 1%, and deaths related to day surgery are extremely rare.

Minor complications such as pain, nausea, drowsiness or fatigue are, however, quite frequent and must be carefully prevented and managed.

Several studies reported high levels of patient satisfaction with day surgery.

Economic outcomes

The financial benefits of day surgery over inpatient surgery are now well established; hospital costs are from 25% to 68% lower than inpatient surgery for the same procedures.
It is , however, important to recognize that substantial sums of money are only saved when cases are transferred from the inpatient unit to the day unit and inpatient beds are closed or released for more complex and emergency cases. This fact could be of great value for countries where surgical facilities are inadequate to meet patients needs.
Concern has been raised about day surgery transferring extra costs to patients and caregivers. The reduced risk of cancellation and earlier return to work associated with day surgery may actually reduce costs for the patient.

Designing the model

The introduction of day surgery should take account of both local needs and existing surgical provision and configuration of facilities.

Day surgery is usually carried out in one of four organizational models:
- Hospital-integrated facility – dedicated day-surgery beds in an inpatient facility, sharing operating theatres, recovery facilities, and medical and nursing personnel with the inpatient department.
- Self-contained unit on hospital site – operating theatres and ward dedicated to day-case surgery and functionally separate from the inpatient areas of the hospital. Nurses and administrative personnel are dedicated to the day unit. Many surgical specialties working in the
same unit share facilities and non-medical personnel.
- Free-standing self-contained unit – identical to self-contained units but not on a hospital site. They may be more cost-effective than self-contained units on hospital sites. Free-standing units have the potential to provide day surgery near to where the patient lives.
- Physician’s office-based unit – small, self-contained surgical annexes in surgeon’s consulting rooms.

Expansion of day surgery can take place in existing hospitals using various permutations of inpatient or day wards with inpatient or dedicated operating theatres (hospital-integrated facilities). However, these facilities, based on configurations created for traditional surgery, often present physical barriers to the establishment of integrated pathways, and the separation of staff and functions can make it difficult to develop the necessary cohesion and teamwork among staff, making them less than ideal in terms of cost-effectiveness and quality of care. The ideal day surgery service on a hospital site is provided by a self-contained day unit (self-contained unit on hospital site) which is functionally and structurally separate from the inpatient unit.

Multidisciplinary approach
Human resources

It is the leadership and management as well as staff members, and not the physical structure or the quality of the equipment, that determines the success of a day-surgery service. Success requires the implementation of policies that extend all the advantages of day surgery to the patient, the health care professional and the community at large.

Day surgery units tend to achieve maximum efficiency and effectiveness when management and staff are specific to that service.

Day surgery requires a multidisciplinary approach. For a successful outcome it requires active participation by all players – managers, nurses, surgeons, anaesthetists and general practitioners. There is a need for a flexible approach, with regular re-evaluation of practice to provide a level of care that reflects individual patient needs. However, there is limited evidence on the most appropriate staffing models for the different types of day-surgery units.
Staffing models must be adapted to the local situation.

Improved job satisfaction and enhanced staff competency through investment in training an development leads to better staff retention, flexibility of the workforce, better informed and educated patients and carers because staff are motivated and familiar with the entire patient experience.

Patient information

Patient information provision is crucial, not only to ensure the success of the procedure, but also for patient safety.
An informed patient is able to better adjust to surgery and minimize the risks in the postoperative period. Information should be given to the patient in a structured manner. The use of both oral and written information is essential.


Day Surgery: developing countries’ perspective

Developing countries worldwide are facing many different challenges and health care priorities.

However, a common aspect is shortage of everything apart from patients.

In virtually everything developing countries there are limited facilities, medical equipment, human resources, drugs and financial resources. Medical facilities both at the primary and secondary level are often inadequate for the large populations they are intended to serve. Training of health care professional is often not optimal and there are tremendous workloads.

Health care policy in developing countries does not reflect the real surgical needs of the populations. This is particularly true for children surgical conditions. Surgery should be considered an essential component of basic health care for example in relation to the management of congenital pathologic conditions and traumatic injuries. At other time surgery can be preventive as in the case of elective hernia repair.

A lack of political commitment by governments and international agencies may be the single most important reason why surgical care has not progressed in developing countries.

Irrespective to the availability of resources, political commitment is the principal prerequisite for ensuring essential health services for the disadvantaged in these countries. (Bickler SW and Rode H, 2002).

Surgical care should be an essential component of child and adult health programmes in developing countries.

The development of day surgery services adapted to the particular needs of these countries could provide a significant improvement of health care services and a better use of available resources. There is sufficient evidence in the literature that day surgery is feasible and well accepted by patients in developing countries. However, the provision of day care services as of inpatient surgery must be adapted to the different needs of the populations of urban and rural areas.

MAKING IT HAPPEN
Overcoming barriers – fear and resistance to change
Day surgery is an innovative approach to surgical health care and, as in all innovative situations, there may be initial resistance to change (Jarrett and Staniszewski 2006). In France, the publication of a major study by the National Insurance Company (CNAM) on the experience with day surgery in that country was important in changing the prevailing opinion, showing as it did that the advantages obtained elsewhere were equally relevant in France (Toftgaard and Parmentier 2006). There may also be legal and regulatory barriers to be overcome. For example, until the end of the 1990s, day surgery was prohibited in public hospitals in Germany.

The barriers to expansion of day surgery include the following:
• Regulatory – national regulations and legislation may preclude a shift to day surgery.
• Economic – reimbursement may be more advantageous for hospitals or surgeons if patients are hospitalized for 24 hours or more, or patients may be obliged to pay a percentage of the total fee for day surgery, as opposed to full coverage by health plans for regular hospitalization.
• Educational – lack of educational programmes for undergraduate and postgraduate medical students may reduce awareness of the benefits of day surgery.
• Facility design – available health facilities may not be configured in ways that facilitate the development of day surgery, in terms of both their internal configuration (ensuring ease of patient flows) and their external configuration (ease of access by patients).
• Local, home and community support – lack of adequate community services may preclude some patients from obtaining day surgery.
• Information – prospective patients and their referring physicians may not be fully aware of the opportunity to have day surgery.
• Organizational – weak multidisciplinary teamwork.

Education – training issues

Day surgery is expected to continue to grow in many countries; existing services are expanding, and new services are beginning to develop in eastern Europe and in many low-income countries. This creates a need for enhanced training of undergraduate medical students and residents, linked to continuing professional development for existing staff, from all of the professional backgrounds involved in the provision of day surgery.

Undergraduate teaching in a day-surgery facility is, however, sometimes difficult and costly. There is a need to ensure consistency in the learning experience, demanding new educational approaches that take account of the fact that, unlike a traditional surgical facility, patients are only on site for a short time.

Day surgery makes demands on the different skills of each professional involved, and each professional needs to keep abreast of the advances being made in surgery, anaesthesia and nursing. Appropriate continuing professional development programmes are essential to maintaining safe day surgery. Continuing medical education and professional societies are well established in many countries and provide opportunities for the experienced day-surgery professional to remain up to date. Events should be multidisciplinary to facilitate communication within teams.

Aligning incentives

In spite of its many benefits, day surgery cannot and will not develop in isolation. A change in behavior requires encouragement. Therefore, incentives are needed on all levels to overcome the barriers to its growth and development. Incentives may be aimed at hospitals, managers, professionals or patients. Examples include:
• financial incentives – a change in reimbursement schedules can promote day surgery;
• educational – continuing medical education and continuing professional developments provide opportunities for staff members, helping to create champions for change;
• quality incentives – improvements in safety and quality will bring preferential referrals and thus more income and greater financial rewards.


THE FUTURE OF SURGICAL SERVICES

The considerable diversity in the utilization of day surgery, both within and among countries, indicates that day surgery is likely to expand further, even assuming no change in technology.

Yet science is changing. Further developments in day-surgery processes, patient selection, pre- and postoperative procedures and pain relief as well as progress in minimally invasive clinical and anaesthetic techniques are likely to reduce surgery time and increase the number and type of procedures suitable for day surgery.

In recent years a move from day surgery to office-based surgery for some procedures has been observed. Office-based surgery is carried out in self-contained surgical annexes in medical practitioners’ premises. From the patient’s viewpoint, office units are smaller and thus can be more personal and closer to where they live, compared with dedicated facilities in hospitals.

Problems in office-based surgery can arise where there is a weak system of regulation or accreditation. Where this occurs, there may be pressure to reduce costs, leading to poor facilities, inadequate patient monitoring, absence of a specialist anaesthetist, and surgeons undertaking procedures for which they are not fully trained.
10 KEY RECOMMENDATIONS IN MAKING DAY SURGERY HAPPEN

1. Consider day surgery, rather than inpatient surgery, the norm for all elective procedures
2. Separate flows of day-surgery patients from inpatients
3. Design day-surgery facilities according to local needs, structurally separate from inpatient facilities whenever possible
4. Provide day-surgery units with independent management structures and dedicated nursing staff
5. Take advantage of motivated surgeons and anaesthetists to lead the change
6. Achieve economies by ensuring that expansion of day surgery facilities is accompanied by reductions in inpatient capacity
7. Invest in educational programmes for hospital and community staff
8. Remove regulatory and economic barriers
9. Align incentives
10. Monitor and provide feedback on results (including patients’ views)

Conclusion

Day surgery will be an integral component of health care in the future.

An understanding of the scope of day surgery is of critical importance for health policy makers An expansion of day surgery will have profound implications for the design of health facilities and the composition of the health care workforce.

The expansion of day surgery entails a change in mindset. Often, changes in national policies and regulations will be necessary, such as the removal of incentives that promote unnecessary hospital stays or obsolete professionals demarcations. Once these changes have been put in place, it will often be necessary to reorganize and/or redesignate existing structures, extend the roles of health professionals and other staff, explore ways of achieving better integration with primary care services to ensure optimal pre- and postoperative care, and develop appropriate financial and non-financial incentives.

Political commitment by governments and international agencies may be the single most important step in the development of a policy for the provision of appropriate surgical services for the disadvantaged in developing countries.
References

1) Castoro C, Bertinato L, Baccaglini U, Drace C A, McKee M (2007). Policy brief. Day Surgery: Making it Happen. Copenhagen: WHO Regional Office for Europe, on behalf of European Observatory on Health Systems and Policies.

2) Toftgaard C and Parmentier G (2006). International terminology in ambulatory surgery and its worldwide practice. In: Lemos P, Jarrett PEM, Philip B (eds). Day surgery – development and practice. London: International Association for Ambulatory Surgery: 35–60.

3) Bickler S W, Rode H. Surgical services for children in developing countries. Bulletin of The World Health Organization 2002; 80: 829-835.

4) Jarrett PEM and Staniszewski A (2006). The development of ambulatory surgery and future challenges. In: Lemos P, Jarrett PEM, Philip B (eds). Day surgery – development and practice. London: International Association for Ambulatory Surgery: 89–124.