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Day Surgery - The Future
The concept of day surgery as a high quality, safe procedural service is now well established in Australia and there has been rapid expansion in the past five years. Day surgery services are provided in hospital based units, private and public, as well as in free-standing centres. Some hospitals have constructed separate free functioning day surgery units. However in many hospitals this ideal situation does not exist and day surgery patients are mixed with overnight stay patients. The cost advantage of day surgery is best achieved in free-standing centres or totally free-functioning units within acute bed hospitals. The number of free-standing day surgery/procedure centres has almost doubled since 1993. As indicated in Table 1, there were 83 free-standing day surgery/procedure centres registered with the Commonwealth Government in January 1993 and this increased to 139 by January 1996. The greatest number of these centres are of multidisciplinary type, but there has been a notable increase in the number of day eye surgery centres. In Australia at the present time approximately 40% of operations are carried out as . day surgery, although it is generally accepted that 60 % , and possibly more, of surgical operations can be treated this way. In 1992, the Australian Day Surgery Council identified 18 commonly performed operations which, at that time, were mostly carried out as overnight(s) stay surgery in acute bed hospitals. There has been an increase in the proportion of day surgery for these procedures from 1993 to 1996, as indicted in Table 2 (this data applies to private insured patients and was provided by Medibank Private). Nevertheless, the levels of day surgery for some of these procedures is unacceptably low. It is frequently stated by surgeons that many patients having intermediate type operations have not sufficiently recovered or are not comfortable enough to be discharged on the same day as the operation. These patients require an extended period of recovery involving overnight stay e.g., many laproscopic abdominal operations, anorectal operations, cataract/lens replacement operations and tonsils. The Australian Day Surgery Council, at a meeting on 12 October 1996, unanimously supported the concept of extended recovery for day surgery and this will include overnight stay. Very importantly, it will be necessary to provide specifically constructed/modified recovery units for such patients and these can be attached to freestanding centres or hospital based units. These extended recovery units would be of "hotel type" and not the typical highly sophisticated and serviced acute hospital bed accommodation. In view of this important decision, Council considered it was essential to define all facets of day surgery, and at a subsequent meeting on 28 February 1997, the following definitions applying to day surgery were identified.
OFFICE-BASED PROCEDURES A number of minor operations/ procedures carried out under local anaesthetic, minor oral sedation or without anaesthetic, are suitable to be carried out as office-based procedures. Until the present time, there has been a major disincentive for medical practitioners to carry out office-based surgery as there is no health insurance facility rebate for these procedures with the costs of providing this service carried by either the patient or the medical practitioner. The recent more acute awareness of anti-infection standards necessitating the use of autoclaves, together with the steady increase in overall costs, has increased this disincentive. Legislation in the Australian Capital Territory (The Skin Penetration Procedures Act 1994) came into force in mid 1995. This Act provides for minimal anti-infection standards and applies to any procedure or operation where the skin is penetrated. In summary, under the Act it will be compulsory to have a certificate of accreditation where these office-based procedures / operations are carried out, and the Act applies to medical practitioners (general and specialist), dentists and other practitioners, such as acupuncturists and tattooists. It is understood that other States are considering the introduction of legislation and accreditation processes for office-based surgery similar to that which has been introduced into the ACT. As a result of these influences, it is now imperative that an office-based facility rebate be introduced into the Medicare Schedule of Rebates. It would be inappropriate for such a rebate to be paid by private health insurance funds, as they now only cover about one third of the population. Furthermore, private health insurance funds may only pay facility rebates for services provided at hospitals or registered freestanding day surgery centres. EXTENDED RECOVERY UNITS FOR DAY SURGERY Many patients having intermediate type operations are not being treated in day surgery at the present time because they are considered to be insufficiently recovered to be discharged on the day of operation. Some elderly patients, with inadequate social back-up, may also be unsuitable for discharge on the day of surgery. Such patients require an extended period of recovery and this would involve overnight stay. The standard recovery rooms of operating complexes, be they freestanding centres or hospital-based day surgery units, do not provide accommodation for an extended period of recovery. Specifically designed and constructed / modified extended recovery units with hotel type facilities are required for these patients. At existing free-standing day surgery centres these would mostly be additions to the existing structures as most centres do not have enough space to construct them within the centre. New freestanding centres could design and construct the extended recovery unit as an integral part of the day surgery centre. It would be much easier in hospitals to relocate and modify existing sections of the hospital as day surgery recovery units. It is emphasised that these extended recovery units should be of hotel type and do not require the sophisticated and expensive acute hospital wards / rooms, with inbuilt resuscitation and related equipment. The capital and running costs of these units would therefore be considerably less than acute bed hospital accommodation. Patients in these units would be supervised by appropriately trained nurses. A further option is the development of unsupervised hotel/hostel accommodation for day surgery/procedure patients, with or without on call professional health care. In respect of these day surgery options, the paramount principle is reiterated, that the choice of procedure and the operation venue must remain the responsibility of the surgeon and/or anaesthetist. EDUCATION There has been very little formal education of medical practitioners up to the present time on the subject of day surgery, neither undergraduate nor postgraduate, and this needs to be addressed. Specific anaesthetic and surgical techniques are necessary if patients are to make a rapid recovery from operations so that they are fit for discharge either on the same day, or the following day for extended recovery patients. It is suggested that a segment on day surgery practice be introduced into the final year undergraduate medical course. Free-standing day surgery centres, with their high daily number of patients, have a wealth of clinical material which, at the present time, is not utilised in either undergraduate or postgraduate teaching. Secondment of undergraduate medical students and resident medical officers in their early postgraduate years to selected day surgery centres deserves serious consideration. The inclusion of day surgery in postgraduate specialist courses for surgeons and anaesthetists should also be considered. On the basis of the above comments, the following recommendations are made:
Introduction of the above mentioned recommendations would provide a major stimulus for the expansion of day surgery to achieve its potential of 60%, if not more, of all surgical operations/procedures, and eliminate the serious disincentive that currently exists for office-based operations/procedures. Acknowledgement The author gratefully acknowledges the Commonwealth Department of Health and Community Services and Medibank Private for providing the data in Tables 1 and 2. TABLE 1
TABLE 2
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