Parent Section: A History of Day Surgery in Australia
Dr Lindsay Roberts, FRCS FRACS. Chairman, Australian Day Surgery Council, 1990 – 2000

The campaign for the establishment of day surgery units is gaining momentum.

Hardly a week goes by without some mention in the public media of the need to establish a facility in which patients can receive minor surgery procedures without incurring the costs generated by even an overnight stay in an acute hospital bed.

The final report on day surgery prepared by the joint Working Party of the Royal Australasian College of Surgeons, the Australian Association of Surgeons, the Faculty of Anaesthetists of the Royal Australasian College of Surgeons and The Australian Society of Anaesthetists has now been presented to the Federal Minister for Health and State Minister for Health and all have accepted the recommendation of the report in principle.

The major health funds are also in favour and it would appear to be only a matter of time before a fund benefit rebate is agreed and day surgery units come into being. In the light of all these developments AAS members should not overlook the important, indeed vital role played by the Australian Association of Surgeons to bring matters to their present stage.

Indeed, the AAS was instrumental in both establishing the feasibility of such units and in persuading other interested parties of the need for a system which ensured a high standard of patient care, yet which still allowed costs to be contained.

In May 1980 Lindsay Roberts first presented a paper on day surgery to the NSW Committee of the AAS.

His paper was taken up by Federal Council and after considerable work the joint Working Party was established under the chairmanship of E. Durham Smith.

By now most surgeons are well aware of the advantages of day surgery units.

in summary, day surgery allows the treatment of large number of patients at less cost than in-patient surgical treatment for the same conditions.

As the report states, costs are reduced because staff and facilities are not needed at night at weekends or on public holidays; fewer staff are required for a day surgery centre than for in-patient surgery; acute beds in hospitals are not needlessly taken up.

A survey mentioned in the report suggests that up to 25 per cent of patients who occupy acute hospital beds could be treated in day surgery units.

Hospitals will benefit not only because of economic savings.

Recruiting problems will be eased because hours on duty in a day centre will suit part-time or married people; and fewer short stay patients will allow in-patient facilities to be run more efficiently.

The preparation of records, the examination and preparation of patients for operations and post-operative care, and discharge of short stay patients, also detract staff from the care of patients with major illnesses.

Advantages to patients and their relatives include less anxiety because an overnight stay in hospital is avoided, a quicker return to normal activities including work, and less stress for relatives who will not need to spend time and often money on travel and even accommodation to visit the in-patient.

The report states that the type of facility required for a day surgery already exists in many public and private hospitals and could be available in free standing facilities constructed specifically for this purpose.

But it stresses that the standards of patient care offered at administrative, clinical and technical levels must be as good as those provided in in-patient accommodation. (Recommended surgical standards and procedures are outlined later in this article.)

In order to ensure that standards of care are maintained, the report recommends that day centres be registered with State health authorities and the registration be on the basis of accreditation by an appropriate committee.

It envisages the need for a federal representative committee responsible for establishing standards.

This would be the Australian Council on Hospital Standards or a subcommittee of that body.

Each state or territory should have a licensing authority responsible for regulating, registering and accrediting individual centres.

And each centre should have its own executive committee to manage and monitor performance and ensure the complete observance of standards.

Of course, there are still some procedural matters to be finalised before day surgery centres come into being.

With the backing of government at all levels, the funds and the active support of all those involved in and responsible for patient care in Australia, these can be quickly solved.

There is no doubt that day surgery centres, if established and run along the lines recommended by the joint Working Party, will be successful.

And the money saved can be put to good use in correcting growing deficiencies in Australia's health services.

Surgical Standards and Procedures for day centres listed in Appendix B of the report are as follows;

1. The surgeon must be accredited and the requirement for accreditation is the possession of the diploma of FRACS or its equivalent.
2. It shall be the responsibility of the surgeon and/or his anaesthetist to select those patients suitable for treatment as day surgery patients with maximum regard for safety and the maintenance of the highest professional standards.
   In the event that any patient is considered unfit for discharge following an operation, then the attending medical practitioner shall be responsible for the patient's transfer to an appropriate public or private hospital for further management.
3. It shall be the responsibility of the day surgery centre executive committee to maintain the physical plant and equipment and the appropriate staff to set standards.
4. A list of defined procedures suitable for day surgery is not recommended, but the suitability of the patients selected is the responsibility of the surgeon and/or anaesthetist. Craniotomy, formal laporatomy and thoracotomy would not be acceptable procedures for day surgery centres. The surgical and anaesthetic staff should themselves be subject to delineation of privileges as defined for that particular institution.
5. The final decision about fitness for anaesthesia rests with the anaesthetist who is to administer the anaesthetic.
   Guidelines for the selection of patients include:
   i. An assessment that post-operative pain can be controlled without parentral narcotics after discharge.
   ii. An assessment that the post-operative course is predictable.
   iii. A willingness on the part of the patient to be so treated.
   iv. Provision of transport by a person other than the patient and availability of a suitable person at home to watch the patient.
   v. No language difficulty for the communication of instructions.
   vi. Exclusion of patients who do not satisfy the categories as defined above.
6. The pre-operative preparation by the surgeon would include an explanation of the procedure, the reasons for it and the expected result.
7. Clear mechanisms must be established for the notification of pre-admission arrangements by the day centre. In the case of children a pre-admission visit to the centre may be helpful to reduce anxiety.
8. After admission to the centre, the patient undresses, is supplied with an identity bracelet and gown and shaved if necessary; clothes are stored in the cubicle cupboard. Admission instructions should advise that no responsibility is taken for the care of valuables although a storage area should be provided.
9. After discharge from the recovery ward, a period of observation is required in the day centre ward.
   During this period.
   a. A minimum recovery period of three hours should be allowed from the completion of the last procedure of the day to that patient's discharge if general or major regional anaesthesia have been used. Adequate staff must be available during this time.
   b. Parents should be encouraged to stay and participate in their child's care while the child is in the unit.
   c. If appropriate to the medical condition staff should make available tea or coffee to patients and relatives.
   d. Before discharge the patient should be fully awake and well orientated. There should be minimal nausea or vomiting. The circulation should be stable and there should be no apparent surgical complications.
   e, There must be a post-operative clinical check by the surgeon or anaesthetist. If the nurse in charge has any doubt about the fitness of the patient for discharge, she must contact the surgeon or anaesthetist before the patient is discharged. However, the final responsibility must remain with the anaesthetist or surgeon.
10. At the discharge area:
    a. Clerical staff prepare the necessary discharge documents.
    b. The professional checking the discharge assesses the adequacy of the discharge instructions.
    c. The Charge Nurse checks that the necessary discharge drugs and dressings are supplied.
    d. The staff issue the compulsory warnings about transport, cessation of work and prohibition of alcohol, and issue the written warning instructions for patients recovery from any anaesthesia, general, local or regional block.
    e. The anaesthetist should be available for consultation post-operatively should relevant complications develop; all patients who are discharged should have written instructions telling the name and appropriate medical practitioner and how to contact him if complications develop.

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