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Dr Lindsay Roberts, FRCS FRACS. Chairman, Australian Day Surgery Council, 1990 – 2000


Day Surgery Centres In Australia Planning And Design

Lindsay Roberts FRACS
March 2005
Day Surgery Article
Publication Status: 3b
Review Status: SR
Copyright: Copyright of this article is vested in the author. Permissions for reprints or republications must be obtained in writing from the copyright holder. This article has been republished here with permission from the copyright holder.(This article was scanned from "The Australian Surgeon". If there is any discrepancy between this scanned reproduction and the original the original takes precedence.)

Introduction

A successful day (ambulatory) surgery centre/unit must have two fundamental criteria -

  • It must provide operative services of high standards of quality and safety.
  • It must be both patient and cost efficient such that it is financially sustainable.

Day surgery can be provided in freestanding centres or in units within hospitals - there is no preferred model. Freestanding centres are the most patient and cost efficient, and the true costs of providing day surgery services can be collated from data provided by these centres.

The most efficient hospital based day surgery services are provided by dedicated units which are functionally separate from the inpatient sections of the hospital. Ideally, they should have their own operating theatres however this is uncommon and in most hospitals day surgery operations are carried out in the general theatres. The least efficient model is locating day surgery patients throughout the hospital occupying high cost, inpatient beds which should be retained for long stay patients - so called 'day patient wards' are little better.

The majority of day surgery centres are multidisciplinary i.e. they provide services for a wide range of operations in the various surgical specialties. Some centres are unidisciplinary and provide services of only one specialty e.g. ophthalmology, plastic, endoscopy. These centres can be smaller while remaining financially viable. They have the advantage of concentrating very expensive high technology equipment in the one unit, the continuous use of which not only improves the overall cost efficiency but also lowers the individual cost to patients.

The planning and design of a day surgery centre is very important for the achievement of a successful, high standard surgical service to patients and to ensure its overall viability. There is no best model and the necessity for design flexibility, having regard to size, site and range of services is emphasised.

Day surgery/procedure services in rural and remote areas are as essential as those in cities. Generally, these centres will be smaller, multidisciplinary, lower patient volume and built to an appropriate design model. The supplementary services of extended (overnight) recovery and limited care accommodation (medi-motel) are particularly important in these areas (vide infra). Planning

Planning includes the initial professional and logistic decisions which are essential to ensure that a day surgery centre will be financially viable and capable of providing acceptable standards of procedural services to patients. Amongst the most important aspects to be considered for a freestanding centre are the following:

  • Planning/design team.
    At the beginning of the project a planning/design team should be formed, including a surgeon, anaesthetist and nurse with experience in the logistics, functional floor plan and operation of day surgery centres. Ideally, an architect with expertise in day surgery centre/hospital design should be appointed.
  • Support of government, local health authorities and health care insurers.
    This entails a licence to construct and operate a health care facility which conforms to all the appropriate government and local health authority regulations. Support of health care insurers by the inclusion of day surgery rebates is very important to ensure the financial viability of a private day surgery centre. Hospital based day surgery units would be covered by the licence and financial structure of the hospital.
  • Support of medical professionals.
    There should be in depth consultation to obtain the support of medical professionals, who would be appointed and accredited to treat patients at the centre.
  • Support of nurses.
    The involvement of nurses from the earliest stages of planning is crucial to the day to day efficiency and overall success of the centre. Every effort should be made to recruit nurses specially trained in day surgery and the best interests of the centre would be served by appointing a nurse manager as co-ordinator of clinical activities.
  • Location of the centre.
    A demographic survey is most important in order to locate the centre in a community which has a large enough population to support it, and is not already serviced by similar health care facilities. An acute bed hospital should be within a reasonable distance (less than one hour drive) of the centre for transfer of patients in cases of emergency.
  • Site of the centre.
    The site must be appropriate to the overall size of the centre and its suitability for construction, accessibility and parking.
  • Size and range of services.
    The size of a day surgery centre is determined by the number of operating rooms and the patient volume. The largest centres could have up to six, or even more operating rooms while the smaller would require two. Unidisciplinary centres e.g. endoscopy, ophthalmology, plastic surgery etc. can be financially viable with one operating room. The widest range of services are provided in multidisciplinary centres and includes most specialties, however unidisciplinary centres have definite advantages. There is no preferred model and both types have been successfully developed.
  • Information technology.
    All sections of the centre should have the most modern information equipment including direct access to external medical services e.g. radiology, pathology etc.
  • Medical education.
    Day surgery centres are destined to play an increasing role in the teaching of clinical skills, both undergraduate and postgraduate. For this purpose, a conference/education room equipped with all modern teaching devices should be included in the large centres/units especially those located in teaching hospitals.
  • Hospital based day surgery units.
    The planning of a hospital based day surgery unit is different due to its location within the hospital. The best model is a dedicated unit structurally and functionally separate from the inpatient section of the hospital. The ideal would be a freestanding centre co-located on the campus of the hospital.
  • Timing.
    Importantly, whether freestanding or hospital based, the planning process should be completed before progressing to the design and construction of the centre/unit.

Design

The design of a day surgery centre is critically important for both its functional and financial success. By its very nature, day surgery is a rapid turn over operative/procedural service and the standards of quality and safety must be the same as those provided in acute bed hospitals.

Paramount in its design is a patient flow path that ensures maximum efficiency from admission to pre-op area to operating rooms to recovery and finally discharge, and the flow path should be uni directional.

There is no 'best model' and the dimensions of the individual areas and rooms will vary depending on the overall size of the centre and the types of operations/procedures that are carried out. Most day surgery centres are multidisciplinary i.e. they provide operative facilities for a variety of specialties and, in general, the dimensions would be larger to accommodate all the high technology equipment and increased volume of patients. Unidisciplinary day surgery centres e.g. ophthalmology, plastic surgery, endoscopy etc. are generally smaller and are designed specifically for the range of operations/procedures within that specialty.

A model design of a larger freestanding day surgery centre is presented (see illustration) and various important design features, which are essential to ensure an efficient, high standard centre with unimpeded patient flow path, will be emphasized. This model also includes two extensions of the standard 'same day' day surgery centre, namely extended (overnight) recovery and post discharge limited care accommodation (medi motel). With the addition of more major operations, as day surgery continues to expand towards its ultimate potential of 75-80% of all operations/procedures, these two supplementary services will become increasingly important. Note: The model design is not drawn to scale.

Model Day Surgery Center

Before proceeding to design features of the day surgery centre, it is important to consider its site. Ideally, the centre should be built on its own site as a freestanding facility - it is unquestionable that freestanding centres are the most capital and cost efficient model, as well as being the most patient efficient. This would allow it to be designed as a single level building which is much less costly than a multiple level building. There needs to be ample parking space at both the admission and discharge areas, which should be separate, with a covered designated ambulance bay for the emergency transfer of patients to an acute bed hospital. Efficient, easy access to the centre by service vehicles must also be provided. There is an advantage in a gently sloping site which would allow a lower ground section to be built under the operating rooms/csd/recovery areas of the centre. Not only can the auxiliary (electricity) power unit, medical gas cylinders, air compressor and laundry storage be located in this section but it can also provide extensive general storage space, which is so essential in day surgery centres, and facilitate delivery and waste disposal services. A small service lift can connect the two areas which is a very efficient design feature. However, many day surgery centres are located in multiple level buildings and these must similarly provide ample car parking areas, emergency patient transfer services including lifts large enough to take patient trolleys, together with the other support services mentioned above.

Admission Area

The size of the admission area will vary according to the planned patient volume. There should be a spacious waiting room with comfortable seating, divided into sections by small partitions, pot plants etc. to provide some privacy. The interior décor should be carefully designed to minimise anxiety, with special consideration for children in those centres providing paediatric services.

The admission desk must be adequate to accommodate all the essential modern electronic office equipment with a connected staff room for the storage of office equipment, patient records, staff amenities etc. The large majority of centres would require two or three admission staff.

The nurse manager's office is adjacent to the admissions office and both of these open into a wide (1.5metre) passage way which connects the admission area to the discharge area. This facilitates the movement of staff and patient's relatives from the waiting room to the discharge lounge. A pre-operation examination room could be located adjacent to the manager's office with access from the passage way. Note: In the model design this room is located further along the passage.

Pre-operation Area

In the pre-operation area, the entrance of which is close to the waiting room, patients change from personal clothes into operating room garb. The size of this area will vary with the number of operating rooms and patient volume. Within this area there are the following:

  • A series of changing cubicles. Patients are provided with carry bags for their clothes, which remain with them until discharge.
  • Toilets with hand basins, at least one of which is modified for wheel-chair/disabled patients. Separate male and female toilets are advisable.
  • An area for surgical trolleys - two for each operating room, partitioned by curtains for privacy. This is an important feature as most centres have a mix of male and female patients. In some centres there are ambulant patients who walk to the operating room and there should be a separate area/room with comfortable chairs for these patients. Again, some partitioning is advisable.
  • Storage space. It is essential to provide adequate storage space in the pre-operation area, not only for operating room garb and carry bags for clothing, but also general storage for trolley sheets, pillows and pillow cases, towels, toiletries etc.
  • Doorways leading from the pre-operation area to the operating room corridor and back into this area from the first stage recovery section should be wide (minimum 1.5metres) to allow easy manipulation of trolleys. Note: Wide corridors (minimum 2metres) are important design features to facilitate the free and easy manipulation of trolleys throughout the centre.

In small day surgery centres with restricted space the pre-operative and discharge areas can be combined, requiring separate male and female change rooms with security lockers for clothing. This is not a preferred model as pre-operative and post-operative patients must change in the same room.

Operating Suite Area

Fundamentally, the operating room complex of a day surgery centre is no different in design or function from that of an acute bed hospital.

The number and size of the operating rooms in a day surgery centre will vary. Experience has shown that a multidisciplinary centre requires a minimum of two operating rooms to be financially viable, however unidisciplinary centres with one operating room e.g. ophthalmology, plastic/cosmetic, gynaecology, endoscopy can also be viable. The model design, as illustrated, has four operating rooms, with hand scrub areas nearby. The minimum recommended size of an operating room is 42 square metres, however for some specialties e.g. plastic surgery, endoscopy, this can be reduced to 30 square metres. In the future, larger theatres may be required for robotic surgery. Anaesthetic induction areas (12 square metres) at the entrance of each operating room are optional and not considered essential.

In the model design, the operating room (Number 1) adjacent to the pre-operation area would be of the smaller size and appropriate for operations under local or minor regional block anaesthesia. The majority of these patients can walk to and from the operating room without entering the major operating area, and proceed directly to the second stage recovery-discharge lounge.

The foyer of the major operating room area should be spacious to facilitate the unobstructed movement of patient trolleys. It is recommended that there should be three trained nurses for each operating room.

In larger centres with higher volumes of major operations, especially those requiring major regional block anaesthesia, it is advisable to provide one or two anaesthetic induction rooms - minimum 12 square metres. These induction rooms can also provide storage space.

Note: The provision of adequate storage space in all areas of a day surgery centre cannot be over emphasized. In the model design there are two induction/storage rooms, one on each side of the foyer.

Centrally located between the operating rooms is a service area approximately 30 square metres which includes the following:

  • Patient (trolley) holding bay with curtains
  • Nurses station
  • Disposal/clean-up room for instruments and consumables
  • Storage space with fixed and mobile (steel mesh) shelving for packs of sterilised instruments, linen, consumables etc.

Note: An access corridor two metres wide, at the rear of and connected to each operating room and the service area, leading to the central sterilising department, is a very practical and efficient design feature (this is not shown in the model).

Staff Change Rooms and Lounge

Separate male and female staff change rooms must be provided containing hanging space, lockers, shower/toilet and adequate storage space. The size will vary according to the planned staff numbers and they open into the access corridor to the operating room foyer. Adjacent to these is a staff lounge close to the foyer. In the model design these three rooms are located along one side of the centre and have a separate entrance from outside.

Conference and Education Room

In large day surgery centres, especially those which may be used for medical education, there should be a staff conference/education room which is large enough to accommodate the modern communication and teaching equipment. This room can be strategically located towards the front of the centre adjacent to the staff change rooms and admission area, with access from both.

Sterilising and preparation area - csd

This area is located close to the operating rooms and provides the same services as in an acute bed hospital. The overall efficiency of a day surgery centre is very dependent on the 'turn around time' between operations and the efficiency of the sterilization/preparation area is crucial in reducing the time between operations. In the model design this area is located in the corner between the operating rooms and the recovery area. It should include the following with an appropriate flow path:

  • Reception of used instrument trolleys
  • Washing and drying facilities
  • Sorting and packing benches
  • Cooling and storing benches/shelves.

Note: Endoscopy rooms should have adjacent areas with facilities for cleaning scopes, specialised sterilising machines and hanging racks.

An alternative system is the off-site preparation, packaging and sterilisation of instruments which are then delivered to the day surgery centres. This requires large storage rooms/areas within the centres and is very costly.

First Stage Recovery

From the operating rooms, patients are transferred to the first stage recovery area, the services, facilities and equipment of which are the same as the recovery area in an acute bed hospital. In the model design this area is located along the (other) side of the centre, opposite to the staff change rooms and lounge, thus maintaining the uni directional patient flow path. The size of the recovery area will vary according to the number of operating rooms and patient numbers, with a minimum of four trolley spaces (each space 9 square metres) for every operating room, separated by curtain partitions. There should be a minimum 2.5 metre central area between opposite spaces to facilitate the movement and manipulation of trolleys. There should be a clean utility/storage room (12 square metres) and a dirty utility/disposal room (12 square metres) in the first stage recovery area.

A nurses station should be strategically located in the recovery area with clear visibility to all patients and provided with adequate work desk, storage shelves, cupboards and a strong locked cupboard for drugs. Appropriate staffing is very important. For unconscious patients it is recommended that the nurse/patient ratio should be one to one. For conscious, stable patients, the ration should be one nurse for every three to five patients, depending on patient numbers. The recovery area should have a fully equipped emergency cardio-pulmonary resuscitation trolley.

Second Stage Recovery - Discharge Area

The second stage recovery - discharge area, is located at the front of the centre on the opposite side to the admission area, and there is a connecting passage way between the two which allows the office staff easy access to patients for final discharge instructions. The exit from the discharge area should be separate from the admission entrance. The covered ambulance bay for transfer of patients to hospital in cases of emergency should be close to and easily accessible from the recovery areas.

When patients are ready for transfer to the discharge area, the majority will change into their own clothes before leaving the first stage recovery. In large centres and those treating ambulatory patients, a series of change rooms should be provided and these would be located between the first and second stage recovery areas. Toilets should also be located in the change room area.

The discharge lounge (minimum 56 square metres) must have large comfortable chairs with adequate space between them for small tables. There should be a minimum of three chairs for each operating room with low level partitions to separate male and female patients. Centres which have a high volume of more rapid turn over patients with shorter first stage recovery e.g. endoscopy, cystoscopy, ophthalmology, plastic surgery, will require larger discharge lounges with more chairs to avoid over crowding. Centres which treat paediatric patients should provide a separate section in the discharge area designed specifically for the recovery of children.

It is recommended that there should be a minimum of one nurse for every five patients in the discharge area. Note: One of the most common design faults in day surgery centres is an inadequately sized discharge area which results in over crowding and decreased overall efficiency.

Extended Recovery

Day surgery continues to expand by the inclusion of patients having more major operations who were previously admitted to hospitals as inpatients. In order to maintain high standards of treatment, the recovery period of these patients should be extended over night before discharge the following morning, and it would be the larger multidisciplinary centres that could be expected to provide this service.

Extended recovery patients could remain in the first stage recovery area or be transferred to adjacent designated extended recovery rooms. In the model design there are five extended recovery rooms located between the first and second stage recover areas, and the nurses station is nearby. A dedicated day surgery ward has particular advantages for extended (overnight) recovery patients and same day patients whose discharge is prolonged. This ward could be adjacent and connected to a freestanding centre or located in a hospital close to the operating suite. All the fixed and mobile resuscitation/recovery equipment and services of high dependency beds must be provided. Standards for Extended Recovery In Day Surgery Units (prepared by the Australian Day Surgery Council) are listed in Appendix A.

Day Surgery Units in Acute Bed Hospitals

Day surgery units should be developed in acute bed hospitals, public and private, to ensure that this high standard, cost efficient procedural service is available to all patients. For units within a hospital, the preferred model is a dedicated unit that is functionally separate from the inpatient sections. The design features are similar to a freestanding centre but appropriately modified for its location within the hospital and having regard to the range of operations and patient volume. In most hospitals, however, this preferred model is seldom achieved and the day surgery unit consists of an admission/pre operation area and a post operation/discharge area, the patients being transferred to the general operating room suite for their operation and first stage recovery.

The ideal model would be freestanding centres on the campus of acute bed hospitals. Such centres would totally separate day patients from inpatients and have all the patient and cost efficiencies of freestanding centres together with the co-location advantages of being very close or even connected to the inpatient building eg. for the rapid transfer of patients in cases of emergency and sharing of some of the hospital support services.

Mobile Surgical Service

An innovation of the day surgery principle has been the design of a mobile operating theatre which is, in fact, a very compact day surgery unit (see illustration). The 'day surgery bus', eg. as constructed in New Zealand, is a large semi trailer which has an admission/change area at the front, an operating room in the centre with all the essential facilities and services - including air conditioning, sterilising equipment, medical gases, a full range of anaesthetic/resuscitation equipment and an auxiliary power unit, and a recovery/discharge area at the rear. In practice, sterilized pre-packed instruments etc. are carried on the bus which is parked at a hospital or other suitable building which provides the main power supply and recover facilities for patients after their operations. Only ambulant patients having minor procedures recover in the bus before discharge.

Mobile Surgical Service floor plan

Limited Care Accommodation

Patients from rural and remote areas and those who are socially stressed eg. elderly, solitary, disabled etc. need several days convalescence before returning home, especially after major operations. Limited care accommodation facilities (medi motels) are designed for such patients who would otherwise be unsuitable for day surgery and would require admission to hospital as inpatients. The bed day costs are much lower for limited care accommodation than for hospital inpatient accommodation - approximately one third.

The model design demonstrates a limited care accommodation facility as an extension of the day surgery centre and this has many advantages, however they can also be constructed as freestanding facilities. Acute bed hospitals could also provide limited care accommodation in addition to their traditional inpatient services. The expansion of day surgery to reach its ultimate potential will be further assisted by the development of this post discharge convalescent service.

Standards for limited care accommodation facilities (prepared by the Australian Day Surgery Council) are listed in Appendix B.

Essential Support Services

In a freestanding day surgery centre the following essential support services must be provided, some of which will require separate strategically located rooms:

  • Air conditioning
  • Auxiliary electricity power unit
  • Storage for medical gases
  • Covered ambulance bay
  • Fire extinguishing equipment
  • Emergency exits
  • Laundry service
  • Delivery and waste disposal service
  • Food and beverage service
  • Security for patients and staff

Appendix A: Standards for Extended Recovery in Day Surgery Centres/Units

  1. Extended Day Surgery/Procedure Recovery Centre/Unit.
    * Definition: Purpose constructed/modified patient accommodation, within a registered day surgery centre or hospital, specifically designed for the extended recovery of day surgery/procedure patients.
  2. Location
    * Extension of the Recovery area of the day surgery centre (facility). Separate rooms may be provided.
  3. General Services
    * All services as per the usual day surgery centre (facility).
    * Patients may be nursed on trolleys or transferred to beds. Call bells available.
  4. Meals
    * Centres(facilities) should meet the needs of the patients.
  5. Medical/Nursing Services
    * Minimum of 2 Registered Nurses present at all times.
    * Nurse/patient ratios will depend on the acuity of the patients, but should not exceed 1:5.
    * The surgeon, the anaesthetist or a designated medical practitioner must be contactable at all times, and able to attend the centre (facility) if needed.
    * All emergency equipment and procedures should be in place as per usual day surgery centre (facility).
    * Clinical protocols should be in place for channeling and selecting patients for this service. Extended recovery may be planned or unplanned. Planned: Patients purpose booked for extended recovery Unplanned: Patients selected for extended recovery as clinically indicated after admission to the day surgery centre/unit.
    * Discharge protocols should be in place, and should include nurse initiated discharge protocol.
    * Special arrangements must be in place for:
    Transferring patients to an acute care facility
    Emergency codes overnight
  6. Security
    * Arrangements must be made to secure the building at night. For example: security firm visiting regularly; duress alarms linked to security firm/police.

Appendix B: Standards for Limited Care Accommodation Facilities

1. Definition

Hotel/hostel accommodation for day surgery/procedure patients where professional health care is available on a call basis.

It is the responsibility of the attending medical practitioner to refer appropriate patients to a Limited Care Accommodation Facility.

2. Location

  • Freestanding Facility Connected to a Day Surgery Centre. Separate, stand alone facility to which day surgery patients are regularly transferred, with ground floor access or lift/ramp access.
  • Hospital Located Facility - public or private Separate or connected freestanding facility on the campus of a hospital. Dedicated section of a hospital.

3. General Services

  • Administration Office
  • Store room eg. linen, records etc.
  • Cleaners room/service
  • Linen/laundry service
  • Contract for disposal of contaminated waste and linen. Note: Some or all of the above would not be essential for facilities located within a hospital or attached to a freestanding day surgery centre.

4. Accommodation

Each unit (room) would provide the following:

  • Patient bed (or cot)
  • One extra bed for partner/carer
  • One comfortable lounge chair
  • En-suite with shower, basin and toilet
  • Simple cupboard and drawers
  • Air-conditioning/heating
  • Tea/coffee, toast making equipment
  • Refrigerator
  • Television
  • Telephone
  • Wheelchair accessibility

5. Lounge A comfortable lounge room for patients and relatives/carers, including a suitable separate area for children and parents.

6. Meals/Dining

  • Freestanding facilities - meals would be provided by one of the following: - External catering by private contract - Kitchen within the facility providing room service - Kitchen/dining room within the facility Note: each unit would provide simple food preparation equipment for light meals/snacks with hot and cold beverages.
  • Integrated accommodation within a hospital - Meals would be provided by the hospital catering service. Note: In free-standing facilities a combined lounge/dining area might be provided.

7. Medical/Nursing Services

A limited care accommodation facility must provide the following:

  • An immediately available manager/attendant who may be a nurse or a person trained in cardio-pulmonary resuscitation.
  • An emergency 24 hours call system in each room. The emergency call system would be linked to the hospital or day surgery nurse emergency call system where the limited care accommodation is located within an acute bed hospital or attached to a freestanding day surgery centre with extended recovery services, which includes on-site 24 hour nursing service. The emergency call system would be connected to the office of the on-site manager/attendant, who may be a nurse or a person trained in cardio-pulmonary resuscitation, where the limited accommodation facility is either a separate stand alone facility or is attached to a same day freestanding day surgery centre.
  • An emergency cardio-pulmonary resuscitation trolley with an extra self-inflating bag suitable for artificial ventilation for every 10 rooms.
  • An appropriately equipped medical utility room with hand wash basin and disposal container for sharps and contaminated dressings etc., for the use of medical practitioners and nurses, including infection control guidelines.
  • A telephone in each room and on-site manager/attendant office for contact with the attending surgeon, anaesthetist, general practitioner and ambulance.
  • There must be an arrangement for the transfer of patients to an acute care facility for the on-going treatment of a medical emergency.

8. Medication

Patients medication is the responsibility of the patient or relative/carer.

9. Records

Records to be maintained including details of patient, resident relative/carer, attending medical practitioner, time and date of admission-discharge and details of any patient incidents.

References

1. Roberts LM, Model day surgery complex with extended recovery and medi-motel. The Australian Surgeon 2000; 24,1: 22-23.
Website: www.aams.org.au

2. Roberts LM, An alternative to acute bed hospitals based on the day surgery principle. . The Australian Surgeon 1999; 23,1: 13-19.
Website: www.aams.org.au

3. Mobile Surgical Services, New Zealand Ltd. The Mobile Surgical Unit - Concept to Reality and the Future. Christchurch, New Zealand, 2002. Promotional Brochure.
Contact: Stuart Gowland
Website: mobilesurgical.co.nz

4. Australian Day Surgery Council. Day Surgery in Australia. Revised edition. Melbourne, Australia, 2004. Website: www.surgeons.org/wedo/adsc/adsc_dsia






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