The Current Status of Day Care Surgery

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WIG

: CURRENT STATUS OF DAY CARE SURGERY459

Indian J. Anaesth. 2005

; 49 (6) : 459 - 466

M.D.,F.A.M.S.Department of Anaesthesia and Intensive CarePostgraduate Institute of Medical Education and Research,Chandigarh-160 012, India.

Correspond to :

Prof. Jyotsna Wig,H.No. 8-H/5, PGI CampusSector-12, Chandigarh – 160 012.E-mail : jdwsjni@hotmail.com

(Accepted for publication on 21 - 05 - 2005)

THE CURRENT STATUS OF DAY CARE SURGERY..... A REVIEW

Prof. Jyotsna WigSUMMARY

Outpatient surgery and anaesthesia which started as a money saving modality has picked up momentum even in India in the last onedecade due to innovations in surgical techniques and advances in anaesthesia. The positive feedback from the patients and their relationshave enhanced the popularity of outpatient surgery. On the basis of a number of studies and the current practice in India, it can berecommended that a number of operative procedures on carefully selected patients of all age groups can be conducted on day care basiseven in public hospital setting. However, patient safety should never be compromised in the name of ‘Fast tracking’ and cost containment. Rational use of a combination of anaesthetic drugs would ensure smooth intraoperative period and postoperative recovery.Top priorities for successful outpatient surgery are the four ‘A’s : Alertness, Ambulation, Analgesia and Alimentation. We have aresponsibility to be aware of postoperative problems that occur at home after discharge. These can delay a patient’s return to full functionand leave a poor impression of ambulatory surgery.

Keywords : Day care surgery, Anaesthesia.

Introduction

The earliest reference for day care surgery ismentioned as early as beginning of the 19

th

Century byJames Nicoll a Glassgow surgeon who performed almost9000 outpatient operations on children in 1903

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and later in1912 when Ralphwaters from Iowa, USA described“The Down Town Anaesthesia Clinic”, where he gaveanaesthesia for minor outpatient surgery.

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However, over the next two decades, it lost its momentum. In 1960, thefirst hospital based ambulatory unit was developed. Theformal development of ambulatory anaesthesia occurredwith the establishment of the ‘Society for AmbulatoryAnaesthesia’ (SAMBA) in 1984

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and with the evolutionof postgraduate subspeciality training programme. Thepotential for day care surgery has increased over the lastfew years.Success of day care surgery can be attributed toadvances in surgical technologies and in the field of anaesthesiology. Advances in surgical technologies thatmade outpatient surgery and minimally invasive surgerypossible include various endoscopic procedures i.e.laparoscopy, arthroscopy, laser and shock wave lithotripsy,laparoscopic cholecystectomy, vaginal hysterectomy,thyroidectomy, shoulder, knee and ankle repair.Apart from cost containment, other benefits of outpatients surgery are : decompression of busy hospital beds,less nosocomial infections and early recovery in homeenvironment with the family. Thus, there is less disruptionof personal lives.However, in a country like ours, with problems of financial constraints, insufficient grants for health care,lack of adequate money for improvisation of theatresand recovery rooms, and social factors, we are not able tocash on all the advantages of day care surgery in our hospitals.

Cost containment

In USA a saving of 15-30% and in UK a saving of 40% in the cost has been reported with the day care surgery.The expenditure incurred by the civic authorities in Indiaon a patient occupying a bed is around Rs.800-900/- per day.

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This does not take into account the drugs, medicationand the material used for surgery. The estimated expenditurein Postgraduate Institute of Medical Education and Research,Chandigarh is Rs. 1000/- per bed per day.

Setting for outpatient surgery

The designs of a prototypical ambulatory surgicalunit could be : hospital integrated, hospital separated (butaccessible to the hospital), satellite ambulatory unit (whichworks under the same administration), free standing unit(which is totally independent) and office based. The majorityof outpatient surgeries are still being performed in a hospitalsetting, either in integrated or separated units. Although15-20% of all outpatient operations are being done as officebased surgeries in the USA

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, however, because of largelyunregulated setting, serious questions are being asked aboutthe safety of office-based surgeries. The decision as towhere should the surgery be performed depends upon the

REVIEW ARTICLE

INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2005460

levels of ambulatory surgery. The levels of ambulatorysurgery is classified as follows :a)Minor ambulatory surgery (under local anaesthesia )b)Major ambulatory surgery (under G.A., centralneuroaxial block with or without I.V. sedation).c)In-patient ambulatory surgery.Because of the topographical variations, and theabsence of strict laws and the quality control, outpatientsurgery in India is performed in chemists shops, privateclinics, nursing homes, primary health centers, civil hospitals,peripheral medical colleges as well as tertiary care centers.Extra surveillance is required while screening patients for outpatient surgery.

Modalities of pre-anaesthetic assessment are :

1.Pre-anaesthesia clinics2.Health questionnaire3.Telephonic interviews

Pre-anaesthesia clinics

: These clinics are useful toget the necessary consultations and laboratory tests doneand cut down the unnecessary delays and cancellations.

Health questionnaires

: Standardised questionnairesare completed in surgeon’s office or with primary carephysician. The data is subsequently reviewed by theanaesthesia staff prior to administration of anaesthesia.

Telephonic interviews

: This is not feasible at themoment in our country.

Setup in postgraduate institute of medical educationand research, chandigarh (fig. 1).

investigations / consultations as and when applicable.Necessary preoperative instructions / premedication isadvised. The patient is instructed to come on the morningof surgery and depending upon the anaesthetictechnique / surgical procedure, the patient is observed inthe recovery room postoperatively. We do not have theconcept of office based surgeries unlike USA where15-20% of all outpatient procedures are office based.

Factors relevant for the success of day care surgery

Day care surgery demands the highest standards of professional skills and organization. Although, the operationscould be minor, an anaesthetic is never minor. Listed beloware some of the factors relevant for the success of day caresurgery.a.Patient selectionb.Patient informationc.Preoperative assessment / tests.d.Proper anaesthetic and postanaesthetic caree.Patient acceptabilityf.Audit

a. Patient Selection

This is the key to the successful day care surgery.Selection is not simply a matter of choosing patients withconditions that may be treated on a day care basis, but alsoinvolves shifting out those patients who are unsuitable for medical and social reasons. The current exclusion criteriafor patient selection are shown in Table 1. There are somecontroversial exclusion criteria also (Table 2).

Table - 1 : Exclusion criteria for outpatient surgery.

I.Medical

a.Unfit ASA IV, ASA IIIb.Obese : Body mass index > 35c.Nature of pathology : Large scrotal hernias, major intrathoracic,intraabdominal or intracranial surgeryd.Procedures requiring more than one hour e.Surgery expected to have major fluid or blood loss.

II.Patient

a.Concept of day care surgery unacceptable to the patient.b.Psychologically unstablec.If patient lives far away from the hospitald.Infants <3 months of age and preterm babies.

III.Social : No competent relative or friend to

i)Accompany or drive patient home after operationii)Look after him or her at home for the next 24-48 hrs.

PAC clinic(Investigations)SurgeryRecovery RoomHomeWardO.T. days ISurgical OPD(Investigations)

Fig. 1 :

Outpatient surgical setup at PGIMER, Chandigarh

Patients are referred to the pre-anaesthesiaclinic (run by anaesthesiologists 6 days a week) by thesurgeons after getting the investigations done. A senior anaesthesiologist reviews the patient and advises further

WIG

: CURRENT STATUS OF DAY CARE SURGERY461

Table - 2 : Controversial exclusion criteria.

â

Morbid obesity

â

Significant sleep apnoea

â

Fragile diabetes

â

COPD

â

Severe asthma

â

Significant epilepsy

â

Patients prone to malignant hyperpyrexia

â

Alcohol abuse

Physical status plays an important role in selectingpatients. Majority of patients should be ASA grade I andII. ASA Grade III patients with medical stability for 3months could be acceptable with the consensus of theanaesthesiologist and the surgeon. We at the PGIMER acceptpatients of ASA I and II only.

Table - 3 : Risk factors for PONV.

Patient factors:Young, obese females at the preovulatory stage of menstrual cycle, history of PONV / motionsickness, pregnancy.Surgical Factors:Eye, ENT, suction D&C, Laparoscopy,orchidopexyAnesthetic/Analgesics:Opiates, nitrous oxide, volatile Inhalational agentsAnaesthesiologist:Good or bad

Expected duration of surgery is also an importantdeterminant of patients selection. Federation of AmbulatorySurgery Association (FASA) concludes : that incidence of complications is related to the duration of surgery andanaesthesia. In surgeries lasting for less than 1 hour, thecomplication rate is 1 in 55 patients and in surgeries of 2 hours, it is 1 in 55 surgeries.

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Influence of ages : Extremes of age is no longer adeterrent to out patient surgery. More than the chronologicalage, the physiological age, surgical and anaesthetictechniques, and quality care at home determine the outcomeof day care surgery.In recent years there has been a trend towardsperforming increasing number of surgeries on children aswell. Healthy paediatric patients are well suited for daycare surgery. Special care however should be taken inpreterm infants because of increased risk of apnoea. Spellsof bradycardia and cyanosis in early postoperative periodand sudden death are well known complications in suchinfants. We, at our Institute do not undertake preterm babiesfor day care surgery.

b. Patient Information

Comprehensive and well presented information usinglay terminologies for patients and their relatives is essentialfor the success of day surgery. Day Care patients, unlikein-patients, do not have ready access preoperatively andpostoperatively to health care professionals to answer their questions and deal with their queries. As suggested byBaskerville et al,

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the information given to patients shouldcommence with a brief description of the condition for which they are being treated and the procedure beingundertaken. This is followed by instructions regarding whatpatients must do before coming to the unit, the postoperativeanalgesic regimen, what they should do at home, and whatis expected in the days following their operation. Finally,patients need advice on when they can return to variousactivities. Perhaps the utmost information that must begiven to the patients is related to the problems that mightarise at home following surgery and how to deal with those.This will include advice on self-medication and when toseek professional help.

c. Preoperative Assessment / tests

An asymptomatic low risk patient does not need abattery of screening tests unless the medical history or thephysical examination suggests otherwise. In paediatrics,routine haemoglobin (Hb) evaluation and urine examinationare done. In adults above 40 years, in addition to Hb andurine, ECG is also required. In older patients (patients>50 years, chest X-ray and serum glucose are also advised.The preoperative assessment should be detailed and similar to in-patients.

d. Post anaesthetic care

Several recent innovative facilities for post-anaesthesia care after outpatient surgery have allowedsurgeons to do more complicated surgeries on sicker patients as outpatient procedures and have made outpatientanaesthesia less risky.In an overnight stay unit (23-hour admission unit) :post-surgery patients are observed overnight but dischargedthe next morning, within 23 hours of surgery. This courseovercomes the arbitrary limit to quality for reimbursementas an outpatient procedure.Free standing recovery units / surgical hospitals arenew concepts. These are private entrepreneurial units for those patients who prefer not to go home soon after surgery.More recently, the concept of surgical hospital has replacedthe Free Standing Recovery Units. These surgical hospitalshave beds for postoperative recovery for a few days.Hospital hotels and home health care are other options not

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