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Parent Section: A History of Day Surgery in Australia
Origins of Day Surgery
Lindsay Roberts, FRCS FRACS
Chairman, Australian Day Surgery Council, 1990 – 2000
President Elect, International Association For Ambulatory Surgery 1999
Extract from media release in Adelaide by Mr. D.G. Maclesih, President, Royal Australasian College of Surgeons, May 1986.
The concept of organising an operating theatre complex dedicated to "walk in walk out" surgery originated in some hospitals in the United States as far back as 1962, though it is true that the practice of day surgery on an ad-hoc basis is as old as surgery itself.
But it was the opening of Surgicenter, a dedicated freestanding facility in East McDowell Street, Phoenix, opposite the Good Samaritan Hospital, in 1971 which has pioneered the modern-day approach. It was the first freestanding clinic in the US to bring together a medical team of surgeons, anaesthetists and nurses specialising in outpatient surgical care.
There are now hundreds of Day Surgery facilities across the United States and the number is expanding rapidly because of competition for patients. Even Surgicenter in Phoenix is now surrounded by 16 Day Surgery competitors.
In an article "Development of an Independent Outpatient Surgical Centre" (Outpatient Anaesthesia, Summer 1976, Vol 14, No 2 ) Reed and Ford, the doctors who developed Surgicenter, explained what inspired them:
"In recent years, countless appeals and recommendations have been made to physicians concerning the need to reduce the cost of medical care. Calls for innovation have come . . . also from leading spokesmen for the medical profession ...
Prominent among the recommendations that have been made have been proposals to perform minor surgery on an outpatient basis, eliminating the need for hospitalisation and its attendant costs (and with findings that) a safe and efficient facility, for the performance of general anaesthesia and minor surgical procedures need not be affiliated either administratively or geographically with a hospital."
Earlier, in the mid 1960s, studies had shown a difference of $40 between inpatient and outpatient charges for a diagnostic dilatation and curettage ($131 vs. $91). By 1970 the difference had grown to $75 ($170 v. $95). Major reason for the outpatient saving was the absence of charges for "room and board" other costs, such as in the main operating and recovery rooms were comparable.
In Phoenix in 1969 the inpatient charges for diagnostic D & C were averaging $265 whereas outpatient charges were about $150. Outpatient Facilities were little used.
Ford and Reed reasoned that a special purpose facility designed from the outset to serve the particular needs of ambulatory patients and their surgeons could make day surgery more appealing to both and achieve savings additional to those accomplished by eliminating room and board.
Thus was born Surgicenter, with all the equipment and personnel necessary for high quality Care but without the extra expenses of' cafeteria, laundry, 24-hour emergency coverage, 24-hour laboratory service and the other characteristics that add to the overheads of the conventional hospital.
It has six operating rooms, an admitting area for adults, a separate large recovery room for adults and another combined admitting and recovery room for seven children, a reception or waiting room, and two dressing rooms for patients. Women doctors and nurses have their own dressing rooms, as do the male doctors, and they share a large lounge. Surgicenter is seeing about 600 patients a month and 85% of procedures are done under general anaesthesia.
Surgicenter saw nearly 3,000 cases in its first year and was used by more than 200 qualified surgeons. It was estimated that patients and/or their insurance carer saved about $130 per case on the basis that at least 90% of patients would otherwise have been hospitalised.
On the assumption that at least 75% of these patients would have been hospitalised for two days, it was calculated that day surgery on Surgicenter's first 3,000 patients saved 4,500 hospital days.
One report recorded:
"This saved the community the cost of constructing 10 to 15 new hospital beds, at $50,000 per bed this amounts to a figure of from $500,000 to $750,000"
"In addition, the patients themselves were saved considerable time and inconvenience, and most went back to work sooner than they would have otherwise done, families of patients save time by making fewer trips to the hospital. And the surgeons themselves saved time by eliminating extra hospital calls."
Of the first 3,000 cases at Phoenixes Surgicenter, 10 required admission to hospital for surgical reasons (none as an emergency). There were no deaths. The commonest complications were nausea and vomiting, sore throat and headaches.
Surgicenter has now done more than 80,000 operations without a fatality. The list of operations includes the following:
Hospitals will continue to admit patients who require major surgery or who are poor risks. But almost any operation which does not require major intervention into the abdomen, chest and skull can be considered for day surgery.
While the type of surgery will generally be the controlling factor the physical status of the patient is most important. Patients with serious heart disease, severe diabetes or marked anaemia are not candidates for day surgery. Nor is the person with severe respiratory problems who may need special care for several hours afterward. Day surgery is also contraindicated in patients worried about having a "walk in - walk out" surgery; they are likely to by psychologically unsuited for a short stay and should therefore be admitted to hospital.