Day Care Surgery Tirth Patel Third - Final Year, GMERS Medical College, Ahmedabad November, 2016
Introduction The notion of day care surgery goes back to the days of Dr James Nicoll, a surgeon and founder of modern ambulatory surgery, who published his landmark article on the surgery of infancy in 1909 1. He described a 10-year surgical experience at the outpatient clinic in the Glasgow Hospital for Sick Children in which 8988 patients were treated as outpatients after operation. In 1960, the first hospital based ambulatory unit was developed. The formal development of ambulatory anaesthesia occurred with the establishment of the Society for Ambulatory Anaesthesia (SAMBA) in 1984 2. Over last two decades, many different countries have experienced a spectacular change from inpatient to day-surgery. Currently day care surgery is the norm rather than the exception. Success of day care surgery can be attributed to advances in surgical technologies and in the field of anaesthesiology. Advances in surgical technologies that made outpatient surgery and minimally invasive surgery possible include various endoscopic procedures i.e. laparoscopy, arthroscopy, laser and shock wave lithotripsy, laparoscopic cholecystectomy etc. Currently day care surgery is the norm rather than the exception.
What is? is discharge within 23 hours (USA); surgery done without night stay (UK); patient recovers from surgery and fit to return home within a day i.e. 24 hrs (India). has been defined by the Royal College of Surgeons as when the surgical day case patient is admitted for investigation or operation on a planned non-resident basis and who nonetheless requires facilities for recovery. This definition excludes upper and lower GI endoscopies, outpatient procedures such as flexible cystoscopy, and minor superficial surgery under local anaesthetic, none of which require full day care facilities for recovery. It is important to mention that day care surgery is different from outpatient surgery. Requires pre-op assessment Post-op nursing is must and patient is observed for some hours and if it is uneventful patient is discharged. Out-patient surgery No pre-op assessment needed. No post-op nursing or observation is needed in this. is an upcoming field in surgical practice. It is a unique method where in general practitioner, nurse at day care ward and theatre, surgeon, anaesthetist work in hand so that hospital stay and cost is reduced. Patient comes in hospital early morning for surgery and leaves the hospital on same day evening.
Common Day Surgeries Basic Requirements In house anaesthesiologist, recovery room, experienced surgeon, theatre and recovery room/ward nurse, all essential surgical set-up including monitor and ventilator. Alertness, Ambulation, Analgesia & Alimentation Basis for day care of surgery.
Assessment done prior to surgery Pre-anesthetic clinic Systemic evaluation (ASA Grading) Surgeon & Physician Health Questionnaire Routine investigation Telephonic interviews Patient selection, Patient information, Patient acceptance are important parts for day care surgery.
1. Patient selection American Society for Anaesthesiologist (ASA) category I and II patient can be taken for surgery. A key to the successful day care surgery, is not simply a matter of choosing patients with conditions that may be treated on a day care basis, but also involves shifting out those patients who are unsuitable for medical and social reasons. Exclusion criteria is as below: Table 2: Exclusion Criteria for day care surgery patient I. Medical a) Unfit ASA IV, ASA III b) Obese : Body mass index > 35 c) Nature of pathology: Large scrotal hernias, major intra-thoracic, intra-abdominal or intracranial surgery d) Procedures requiring more than one hour e) Surgery expected to have major fluid or blood loss. f) Pregnancy II. III. Patient a) Concept of day care surgery unacceptable to the patient. b) Psychologically unstable c) If patient lives far away from the hospital d) Infants Social : No competent relative or friend to a) Accompany or drive patient home after operation b) Look after him or her at home for the next 24-48 hrs
2. Patient Information Comprehensive and well-presented information using lay terminologies for patients and their relatives is essential for the success of day surgery. Day Care patients, unlike in-patients, do not have ready access preoperatively and postoperatively to health care professionals to answer their questions and deal with their queries. As suggested by Baskerville et al 3, the information given to patients should at-least commence a. Brief description of the condition for which they are being treated b. Procedure being undertaken. c. Instructions regarding what patients must do before coming to the unit. d. The postoperative analgesic regimen, what they should do at home, and what is expected in the days following their operation. e. Make them aware about common complications after surgery are post-op nausea & vomiting, post-op pain and how to deal with those. f. Include advice on self-medication and when to seek professional help. g. Patients need advice on when they can return to various activities. 3. Patient acceptability Patient acceptability methods of gauging the acceptability of day care surgery in patients is to look for a number of unsolicited complaints, incidence of readmission after patients have returned home, and postoperative complication rates.
Advantages of Day Care Surgery To Hospitals o Economic savings o More attractive to nursing staff because there is less shift work involved. o More bed available for in patients o Less Nosocomial infections o Productivity of hospital increases To Patients o Pre-booked date and less likely to be cancelled o Easier domestic arrangements o Earlier mobilization o Insurance benefits are same, as there are no changes for day care surgery and regular surgery stay. Insurance policy nowadays are so flexible that it is very helpful to all and there comes no issue of clearance and other things. o Minimal disruption of patient's personal life o Earlier return to normal environment o Reduced risk of cross-infection o Avoidance of disruptive nights in hospital wards o Less loss of time at work o Less psychological disturbances in children
Disadvantages of day care surgery o The need for a responsible person to oversee the day care patient at home for the first 24-48 hours. o The restriction of day case surgery to experienced senior staff; little opportunity for junior staff to practice. o Extra work for the general practitioner in the postoperative period; patients often ring them for advice or treatment. o The cost-effectiveness of the unit is reduced when less complex cases are dealt with on a day basis. Nurses hold an important role in day care surgery
References 1) Nicoll JH, The surgery of infancy, Br Med J 1909; 18: 753 755. 2) Newson CD, Nathanson MH, White PF. Anaesthesia for Day-stay (come and Go) surgery. In : Healy TEJ, Cohen PJ eds. Wylie and Churchill Davidson s : A practice of Anaesthesia. Sixth edition: London: Edward Arnold 1995; 1363-90. 3) Baskerville PA, Heddle RM, Jerret PEM. Preoperative information for the patient. Practitioner 1995; 229: 677-78. 4) SRB - Manual of surgery
About the Author Tirth Patel 3rd Year MBBS Student, GMERS Medical College Ahmedabad PlexusMD Management Intern His topics of interests include medicine, emergency care, healthcare management and surgery. He wishes to specialize in emergency care or diabetology. Connect at: https://www.plexusmd.com/drtirthpatel Email: tirth8795@gmail.com Capsule Reviewed by PlexusMD Editorial Panel
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