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

Background

Highly organised day surgery, whereby patients "walk in to receive a surgical service and walk out on the same day" from a specially designed and constructed Day Surgery Facility, has been in existence overseas, especially in the U.S.A., for the past fifteen years yet Australia lags far behind in the development of this efficient and economic service, (See "Origins of Day Surgery" in this Journal.)

It is estimated that over forty per cent of' all operations in the U.S.A. are now carried out in day surgery facilities and with the ever increasing costs of overnight hospital beds day surgery is expected to expand even further. In Australia there are only a handful of free standing day surgery facilities but it is anticipated that their numbers will rapidly increase.

The first step to establish appropriate high standards for such facilities was taken in 1981 when, following an initiative by the Australian Association of Surgeons, a Working Party on Day Surgery was formed by representatives of the Royal Australasian College of Surgeons, the Faculty of Anaesthetists of the Royal Australasian College of Surgeons, the Australian Association of Surgeons and the Australasian Society of Anaesthetists with input from all other organisations and Associations having an interest in day surgery, "The Report and Recommendations on Day Surgery" was published in September 1981, and forwarded to the Federal and all State Governments and their Ministers for Health but regrettably these Governments seemed unable to grasp the potential of day surgery and little, if anything, occurred until 1985/86.

In recent years Hospital costs have exploded and the public hospital system, especially in New South Wales and Victoria, has collapsed under inept bureaucracy and administration together with inadequate funding. This has probably been the main stimulus for a recent upsurge of interest in day surgery facilities and in New South Wales two new, highly sophisticated free standing facilities have opened in the past six months.

The decision by the Federal Government to introduce a "Day Only Rebate" into the Basic Table of Hospital Insurance is tacit, though belated, recognition of the economic benefits of day surgery.

Recognising not only the great potential of day surgery services but also the upsurge of interest, a Day Surgery Facility Professional Standards Advisory Committee was formed in New South Wales at a meeting on 10th December, 1985, and like its National predecessor, the Committee is made up of representatives of the same four Colleges and Associations with the addition of representatives of the New South Wales Medical Services Committee and the nursing profession.

In April 1986, the original Working Party was reconvened to revise the first "Report and Recommendations on Day Surgery" and the revised Report is now available. An important decision was made at this meeting to form a National Day Surgery Facility Standards Committee which replaces the original Working Party.

The Day Surgery Facility Professional Standards Advisory Committee, which is recognised by the National Day Surgery Facility Standards Committee, has drawn up standards for the accreditation of day surgery facilities in New South Wales and published them in a Manual for the Accreditation of Day Surgery Facilities.

The New South Wales Minister for Health has been informed of' the formation and activities of the Committee, the publication of the Manual for Accreditation of Day Surgery Facilities and the commencement of surveys, on a voluntary basis, of day surgery facilities. The New South Wales based Committee has called on the Minister to give his full support to this initiative of surgeons and anaesthetists in the field of day surgery which has so many advantages to offer, especially to patients as well as to the medical profession, Government and Health authorities.

Standards of Day Surgery Facilities

Day surgery services can be provided in public and private hospitals or in free standing facilities designed and constructed specifically for that purpose.

Free-standing day surgery facilities best demonstrate the simplicity, efficiency and economy of day surgery. Some public and private hospitals have developed day surgery units but their patients are generally integrated into the overall administration of the hospital, thereby losing the advantages of this form of service. Day surgery facilities in public or private hospitals should be developed and administered separately from the remainder of the hospitals services if the efficiency and economy is to be achieved.

The advantages of day surgery are as follows:

• for the patient - planned and guaranteed admission on the day, a planned time of discharge, known fixed cost, minimum disruption to home life, usually faster return to work and a reduced chance of cross-infection. Families can assist in the latter stages of recovery and by sharing in the care of the patient at home, recovery is speedy and costs are reduced. Children are particularly advantaged by day surgery as their parents can remain with them virtually throughout the day;
• for the surgeon - day surgery eliminates excessive "red tape", improves productivity and provides planned operating time with a high degree of versatility in the number of cases treated;
• for the anaesthetist - there is elimination of "red tape", greater efficiency, a planned case load and a purpose built facility enabling easy access to newly arrived patients for pre-anaesthetic assessment;
• for the staff - there is the predictability of office working hours with no overnight or weekend duties and this is particularly attractive to nursing staff with the added advantage of flexible rostering;
• for hospitals - the removal of surgery cases from overnight bed allows maximum availability for the treatment of acute and major surgery thereby significantly assisting in the reduction of waiting lists
• for Governments - there are economic benefits due to the lower costs per patient service and the avoidance of high cost overnight, weekend and public holiday services with generic economy due to the simplicity and efficiency of day surgery services
• for health insurance - the lower cost per patient / service compared to overnight admission in private or public hospitals.

As a basic concept it is important to recognise day surgery facilities as distinct from Day Medical Centres, where non-operative medical services are provided on a "walk in and walk out" basis. A third which must also he recognised as a separate entity, is minor operating procedural complexes which are extensions of private practitioners' consulting rooms, whether general practitioners or specialists. Neither of these latter two "Day Only" services require the highly sophisticated and expensive operating theatre complexes which are the dominant feature of day surgery facilities. The standards, both of the operating theatres and the surgeons and anaesthetists, demanded in day surgery facilities must be no less than those which are found in public or private hospitals.

The Report and Recommendations on Day Surgery has stated that a list of defined conditions suitable for day surgery is not recommended. The selection of patients is a professional decision and will vary depending on the surgeons experience, the fitness for general anaesthesia, assessment of the patient's response, the standard of the day surgery facility and the patient's support at home after discharge.

It is essential that impatient beds be available if a patient requires admission to hospital because of an unpredictable complication e.g.. more extensive surgery, prolonged nausea and vomiting, respiratory complication or anaesthetic problems. An appropriate arrangement with a private or public hospital is required at day surgery facilities seeking accreditation.

The registration, accreditation and control of day surgery facilities is important to establish and maintain the highest standards of patient care and facility services. The National Day Surgery Facility Standards Committee has expressed the view that there should be a three-tiered committee structure:

1. A National Day Surgery Facility Standards Committee to establish and provide approval of standards in day surgery facilities, to communicate policy to State level and to liaise with other medical, paramedical, nursing, administrative, government and insurance bodies.
2. A Professional Committee responsible for accrediting, regulating and registering individual facilities.
   N.B. The composition and functions of this Committee have yet to be defined, however because of the urgency for action in New South Wales where new day surgery facilities are evolving rapidly, it was recommended that: "Without prejudice to the outcome of the proposed discussions with the Australian Council on Hospital Standards, the Working Party recommends that as an interim measure the New South Wales Day Surgery Facilities Professional Standards Advisory Committee be given the imprimatur to act in the matter of accreditation of day surgery facilities in New South Wales".
3. A Medical Executive Committee in each day surgery facility to advise and assist the governing body of each day surgery facility in the maintenance of standards of patient care and facility services, to be responsible for and advise the governing body on the delineation of privileges of the medical staff and to monitor performances at each day surgery facility.

The Report and Recommendations on Day Surgery (1981), as revised at the meeting on 19th April, 1986, and which sets out standards for day surgery and day surgery facilities, will be available in the near future.

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