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Parent Section: A History of Day Surgery in Australia
High Standards Essential - Clinical Indicators
An International Committee for Ambulatory Surgery was formed in 1993 and held its first meeting during the Second European Congress on Ambulatory Surgery, held in Brussels, March 19-20, 1993. The Committee, of which Australia is a foundation member, made a decision to form the International Association for Ambulatory Surgery and this was ratified at a further meeting of the International Committee in London, September 17-18, 1993.
Quality assurance has been identified as a most important activity of the Committee. The National Day Surgery Committee of Australia made an intensive study of Clinical Indicators for Ambulatory Surgery during 1993 and these are under consideration by the Australian Council on Health Care Standards.
The following paper was prepared for publication in 'Ambulatory Surgery', which is the recently established international journal on ambulatory surgery, and includes comment on suitable Clinical Indicators identified by the National Day Surgery Committee. Several other Clinical Indicators which were considered unsuitable have also been mentioned.
The subject of quality assurance is under consideration by the International Committee as one of the major topics for the first International Congress on Ambulatory Surgery, to be held in Brussels March, 1995.
The concept of Ambulatory (Day) Surgery is now widely established throughout the world and, although it has been developed much more extensively in some nations than in others, it seems that organised, high standard ambulatory surgery is almost nonexistent in some countries. The recently formed International Association for Ambulatory Surgery has, as one of its most important objectives, the task of stimulating the expansion of ambulatory surgery throughout the world.
It is essential that the quality of health care in ambulatory surgery centres should be the same as that provided in traditional overnight bed hospitals. There is, in fact, a body of opinion that the quality of health care may be higher in ambulatory surgery than in overnight stay hospital surgery. An important element in the establishment and expansion of ambulatory surgery is the development of appropriate standards for the assurance of high quality health care in these centres.
The design, structure, equipment and safety standards in ambulatory surgery centres are an essential part of the licensing of these centres, which is a responsibility of appropriate Government authorities (Health Departments) and should be separate from any accreditation system. Some countries have introduced accreditation as a mechanism for the assurance of high quality health care in these centres, although it seems that the present system of accreditation in these countries (e.g. USA, Australia) is excessively time-consuming and expensive, with overemphasis on structure and process rather than quality of outcome.
During 1993 the National Day Surgery Committee of Australia carried out an intensive study of Clinical Indicators for quality assurance in ambulatory surgery centres and it would be ideal if some similar system could be developed for universal application. As a most important principle, any such system of clinical indicators should apply to all ambulatory surgery centres whether they be free standing or within private or public hospitals. The Clinical Indicators identified by the National Day Surgery Committee are as follows, with some brief comments on their implications:
Cancellation on the Day of Surgery
This could be a decision by the patient, for a very good reason, however it may be an indication of failure of the centre to provide appropriate instructions, e.g. medications, failure of the patient to understand the instructions, e.g. language difficulties, or a general lack of motivation and determination by the patient to have the operation.
Cancellation on the day of surgery may also occur when the patient is found to be unfit for anaesthesia following arrival at the centre. This may be due to an unrecognised concurrent medical problem, failure of the patient to carry out appropriate instructions concerning an unrelated condition or the development of an inter-current illness immediately prior to the operation, e.g. upper respiratory tract infection, gastroenteritis.
In summary, there are a number of reasons for the cancellation of an operation on its planned day, and some of these are unavoidable. Nevertheless, both the treating surgeon and management of the ambulatory surgery centre should develop a simple, precise admission system to assist patients and minimise cancellation on the day of operation. In this context, the treating surgeon has an important role in the selection of appropriate patients for ambulatory surgery, regarding both the procedure and the patient's fitness for anaesthesia.
Return to Theatre
This indicator has universal application to both overnight stay surgery as well as ambulatory surgery and would reflect the development of complications related to surgical technique or the failure to detect coexisting, but possibly unrelated pathology which would have an immediate adverse effect on the operation, e.g. a bleeding diathesis. The latter should be detected by the treating surgeon before operation. There will always be the occasional unexpected operative complication, but this should be a rare occurrence and emphasises the importance of acquiring a surgical technique appropriate for ambulatory surgery. Ambulatory surgery requires a high level of surgical practice and skill, and the appropriate training of surgeons cannot be overemphasised.
Unplanned Overnight Admission
It is accepted that a very small number of ambulatory surgery patients will require transfer for overnight(s) stay in hospital and the majority of these will be due to a major surgical or anaesthetic complication requiring further surgery or ongoing post-operative management (intensive care). A significantly increased number of unplanned overnight admissions might be a indicator of inappropriate ambulatory surgery practice. The reasons are multi-factorial and included unsatisfactory selection of patients by the surgeon, (e.g. major operation and/or inexperienced surgeon), delayed recovery from the anaesthetic (the result of a variety of circumstances including high anaesthetic risk patients and/or inexperienced anaesthetist and failure of the centres management (accepting elderly patients with or without physical/medical infirmities and/or unsatisfactory home care back-up).
This indicator applies specifically to ambulatory surgery. For administrative purposes, it can be defined as a period of more than six hours from the time of leaving the operating theatre and may be an indicator of unsuitable choice of procedure, unsuitable anaesthetic and/or inappropriate choice of patient. Since 'street fitness' after many procedures may be reached in as little as one hour or be considerably longer for other procedures, delayed discharge relates to the anticipated recovery time for each patient and procedure. It is essential to ensure a rapid recovery from the anaesthetic so that patient's are fit for discharge in an acceptable period of time from the operation. Any significant number of delayed discharges would seriously affect the through-put of patients in ambulatory surgery centres. The training of anaesthetists to develop appropriate anaesthetic techniques for ambulatory surgery is essential. Three other clinical indicators were also considered but rejected as being impracticable or unsatisfactory for application to ambulatory surgery, and these are as follows:
Infection requiring antibiotics
Notwithstanding that this is a classical indicator which is widely used as an important overnight(s) stay hospital indicator, it was considered that collection of accurate date would be too difficult and time consuming as the patient will be at home and a number of alternative follow-up routes would be necessary - surgeons' rooms, out-patient clinics, casualty departments, general practitioners' rooms. In practice, most surgeons would inform the ambulatory surgery centre if there was an unusually high incidence of unanticipated infected wounds. In summary, it was considered that collection of accurate, reliable data would be onerous and unreliable.
It is highly unlikely that a patient would die in an ambulatory surgery centre. In most instances, postoperative death would occur at a later stage after transfer to a hospital intensive care unit or emergency department. Ambulatory surgery centres would be well aware of such an outcome, however the frequency should be so low as to preclude it as a practical clinical indicator.
Planned overnight admissions
This was considered to be incompatible with the concept of ambulatory surgery and should not be included.
The above mentioned recommended clinical indicators are easy to identify and neither time consuming nor financially onerous. Furthermore, they would appear to be particularly appropriate to assess the quality of service and outcome of ambulatory surgery, having regard to the dominant principle of providing high quality, safe health care to patients.
These clinical indicators have not been introduced into Australia as yet, however they are under consideration by the organisation responsible for accreditation (the Australian Council on Health Care Standards). It is not suggested that this is necessarily a complete or final list and other ambulatory surgery organisations may care to examine and identify appropriate indicators with the ultimate aim of producing an acceptable list of clinical indicators for universal application.
Permission from Butterworth Heinemann to reprint this paper in "This Australian Surgeon" is gratefully acknowledged.