Focus

All in A Day's Work

The arrival of the day care concept has made lengthy hospitalisation passé. Sonal Shukla looks at its benefits and feasibility.

With the availability of better anaesthetic drugs, improved understanding of the healing process and better surgical skills, the concept of day care surgery (DCS) has gained prominence. The Day Surgery Operational Guide, issued by the UK Department of Health, defines day care as admission of selected patients to hospital for a planned surgical procedure, discharge on the same day, requiring full operating theatre facility.

Increased overheads and a shortage of beds led to resurgence of DCS. Studies worldwide have shown that DCS delivers the same high-quality care as given to inpatients. Although a well received and established concept worldwide, DCS is still nascent in India.

According to Dr Naresh Row, Founder and Honorary Secretary, The Indian Association of Day Surgery, and Editor, Day Surgery Journal of India, the concept of DCS is not new to Indian hospitals, but the understanding and utilisation is not optimum. In the global context, according to standards/recommendation of international bodies, day care includes major surgeries which earlier required hospitalisation.

"Most major DCS in India are performed in the specialities of ophthalmology and ENT, which is a good beginning. In other surgical specialities, most centres perform a few major cases, but the bulk is minor procedures. They are not utilising the concept of DCS to its maximum. Most hospitals in India will have a list/ward for day surgery, but the exact number of true day surgeries or minor/OPD procedures have to be compiled, for a clearer picture," opines Dr Row.

Options Galore

A Day Care Unit (DCU) can be hospital-integrated, hospital-separated (but accessible to the hospital), and satellite ambulatory unit which works under the same administration, freestanding unit (which is totally independent) and office-based. Today, in India, freestanding centres are mostly centres run by individual doctors, whereas hospitals have in-built wards for day care. According to industry experts, although hospital-integrated is the most common design, freestanding centres too are gaining popularity.

The layout of Day Care Centre by The Indian Association of Day Surgery

Hospital Integrated

This design is a part of a hospital set-up and utilises the same OT facilities and staff and may use the same ward as other patients. This design incurs less infrastructural cost, with indoor admission back-up, if required. However, admission and discharge remain as time consuming and cumbersome.

Infrastructure

While setting up an ideal day care centre, care has to be taken to allow the bare minimum requirements. "Variations are encouraged depending upon the speciality, city of practice, type of patients that would be catered as well as the resources available," opines Dr MM Begani, Founder President, The Indian Association of Day Surgery and consultant surgeon at Bombay Hospital, Mumbai. Separate process flows for different procedures including precautions, preparation and post-op care are recommended by Dr Ashok Chordiya, Medical Director, Fortis Hospital, Mohali for the customisation of day care surgery unit concept for a hospital. Dr Sanjeev Singh, Senior Medical Administrator, AIMS, Kochi, says, "The DCS unit needs to be ideally standalone for seamless functioning. It can be co-located in the existing hospital set-up but linked with outpatient unit. The design should suit the workflow of the healthcare organisation." Separate reception, waiting area, changing area, preparation room, phlebotomy, theatres, ICU, step down, pre anaesthetic check area, preparation area, a surgical theatre, recovery area and post-op care beds are some infrastructural requirements of a day care centre in the hospital set-up. Separate staffing from seven am to seven pm is required with adequate orientation and training in handling almost all surgical procedures and prompt ICU care. According to Dr Begani, most established centres abroad are managed by specially-trained anaesthetists and nursing staff. Staffing and training requirements for a day care unit are quite similar to what is required in a running hospital. Patient education is an important aspect of a DCS unit and extra efforts should be made to educate patients and their families.

Most Popular Hospital Design

"Surgical procedures posted for Day Care Unit should be over in less than an hour" - Dr George Chandy Director, CMC, Vellore

Fortis Hospital based in Mohali has both hospital-integrated and hospital-separated DCS. The facilities are accessible in the main hospital and are also available in a small set-up in the Fortis City Centre, a polyclinic run by the hospital in Chandigarh.
"DCS programme of the hospital cannot be labelled major, simply because it is a tertiary care heart institute, which now also has an equally ambitious multi-speciality programme," explains Dr Ashok Chordiya, Medical Director, Fortis Hospital.

CMC, Vellore has adopted both hospital-integrated day care surgery and a freestanding unit. Dr George Chandy, Director, CMC says, "The DCU benefits the hospital through minimising patient stays which reduces the waiting time for other patients requiring major surgeries."

"The Day Care Surgery is always safer, financially more viable and operationally optimal" - Dr K Hari Prasad, CEO Apollo Hospital Hyderabad

Kochi-based AIMS also has a hospital-integrated day care unit, where the respective departments do the day care surgeries in specialised OTs. "We have also planned a separate location for day surgery area, which will be linked with the outpatient area. It will have a separate reception, waiting, preparation area, three separate state-of-the-art theatres with attached ICUs and step down," informs Dr Sanjeev Singh, Senior Medical Administrator, AIMS.

"We have planned a separate location for day surgery, which will be linked with the outpatient area" - Dr Sanjeev Singh Senior Medical Administrator AIMS, Kochi

"Our hospital-integrated DCS is limited to coronary angiography or catheterisation cases where the outcome is a normal vessel and the patient wishes to get discharged early for various reasons," explains Dr N Padmanabhan, Medical Superintendent, Frontier Lifeline Hospital, Chennai. In his opinion, DCS is suitable for multi-speciality hospitals and not super-speciality hospitals like Frontier Lifeline.

The day care surgery centre of Apollo Hospital, Hyderabad is also hospital-integrated. Says Dr K Hari Prasad, CEO, Apollo Hospital, Hyderabad, "This system is always safer, financially more viable and operationally optimal.”

Dr LH Hiranandani Hospital has adopted a hospital-integrated design. "DCS should be a department within the hospital that helps to increase the institutional capacity of the hospital, i.e., a hospital with 130 beds may be able to give service like a 150 or 160 bed hospital, as the turnover in DCUs is rapid," says CEO and MD, Dr Sujit Chatterjee.

Hospital Separated

This unit is situated in a separate wing of the hospital, has separate infrastructure, and proves better than the hospital attached design, with a slightly reduced operational cost. However, there is an additional cost of setting up a separate unit with complete duplication of facilities, increasing the overall cost of the centre, which the hospital management may disagree with.

Satellite Ambulatory Unit

This unit normally gets used as a centre for screening and selection of patients for the larger hospital, like a referral centre. According to Dr Row, AIIMS, New Delhi and PGI, Chandigarh, have found it difficult to run these units due to refusal of doctors to take up additional responsibilities. Hiranandani Hospital has one in Thane, which is attended by their Powai hospital doctors. They are fairly new and are able to manage so far; long-term results remain to be seen.

Freestanding Unit

"DCS should be a department within the hospital that helps to increase the institutional capacity of the hospital" - Dr Sujit Chatterjee CEO and MD Dr LH Hiranandani Hospital Mumbai

These are small units of 20 to 25 beds, with two operation theatres. These units, opened in the morning and closed at night, are managed by one or two shifts of staff. This unit typically gives high output and is low on expense, as there are lower overheads. This saving is passed on to the patient, making treatments less expensive. The admission and discharge procedure is simplified and a single window method is used. Patient convenience is the motto of this design: the patient comes to the centre early on the appointed day of surgery, is assessed by the RMO or nursing staff and put through the admission process and pre-operative preparation smoothly, reducing tension for him and his attendant. The staff is trained to 'think' only for day surgery cases, making surgery a pleasure and not an ordeal as it sometimes can be.

The disadvantage of this unit is the limitation of patient selection, which can be addressed over the time. In case of complications, requiring overnight stay, the patient needs to be shifted to a nursing home or hospital, where they can be cared for. This can be overcome with strict patient selection, discharge criteria and reassurance of a back-up in case of complications, from the patient's family physician and referring doctor, as well as creating a team of junior doctors and nurses to at least check on the patient once at night. “This has worked for us over the past six years and reduced our complication rate to 0.23 per cent. It also helps if you can identify hospitals and larger nursing homes for readmission, either around your centre or near the patient's residence," explains Dr Row, who till recently practiced this design through Abhishek Day Care Institute and Medical Research Centre, which is a General Surgical set-up.

According to Dr Chatterjee, standalone day care centres must have a method of evacuation to a centre that can render care in any complication. If during surgery, the operation has to be expanded, then the infrastructure should be designed to tackle it and the patient should not have to move from one operation theatre to another. The travel time from the standalone centre to a full-fledged well-equipped hospital should not be more than 30 minutes, and helicopter medical evacuation should be considered.

The Approach

If utilised properly, almost 60 per cent of cases can be dealt with in the day surgery ward, leaving hospital beds free for emergency and cases requiring hospital stay. This can create a reputation that this particular hospital does not hospitalise patients overnight, unnecessarily. In this way, the hospital caters for patient convenience, creating separate staff for better care of day surgery cases, specially trained doctors who will rotate in the DCU.

"Initial investment of approximately Rs 1 crore to Rs 1.25 crore per centre, (including operational costs for the first eight months), excluding land cost, may be high, but with proper management, high output operation theatre will increase the turnover, making it possible to reduce the margin of profit, and make day surgery affordable," opines Dr Row. The investment for a day care centre depends on the extent of expansion and customisation. In an existing hospital, no major investments are required as the existing facility, equipment and staff can be utilised.

Patient Selection

Right patient selection is the key to successful day care surgery. The benefit of DCS far outweighs the risk involved, provided proper selection of case and preparation in reducing post-op complications is done. Dr Hari Prasad feels selection is not simply a matter of choosing patients with conditions that may be treated on a day care basis, but also involves excluding those patients who are unsuitable for medical and social reasons. "DCU in our hospital has achieved an excellent record, with a very low incidence of complications, because of careful patient selection, and adequate back-up facilities to meet any emergency," he opines.

Expected duration of surgery is also an important determinant of patient selection. Federation of Ambulatory Surgery Associations (FASA) concludes that incidence of complications is related to the duration of surgery and anaesthesia. More than the chronological age, the physiological age, surgical and anaesthetic techniques, and quality care at home determine the outcome of DCS.

As Dr RD Bapat, Chairman, Haffkine Bio-pharmaceutical Corporation and former Head, Department of General Surgery and Gastroenterology Surgical services at KEM Hospital, Mumbai, puts it, DCS is not a shortcut surgery, but instead is a natural progression of routine safe surgery, to be practiced after having gained a certain degree of expertise. "It should not only meet the necessary pre-operative, intra-operative and post-operative pre-requisites that are a must for a routine surgery, but also the infrastructure required of the operation theatre," explains Dr Bapat. It is also important to weigh the risk benefit ratio prior to recruiting patients.

Selection of Surgeries

Expert opinion suggests that hospitals that have indoor facilities can cover a greater variety of cases than freestanding centres. Roughly about 250 routine cases can be performed as day care. The majority of procedures performed fall into the following categories: eye surgery, including cataracts, eye muscle surgery and removal of foreign bodies; gynaecological procedures including dilation and curettage (D&C), laparoscopies and biopsies; ear/nose/throat surgery such as removal of tonsils and adenoids; bone surgery such as biopsies, bone grafts and arthroscopic surgery; general surgery such as breast and biopsies, hernia repair, haemorrhoid operations and laparoscopic cholecystectomies; and cosmetic surgery such as scar revision, skin grafts and facial surgery. "This list is ever increasing and rapidly changing. The criteria are only limited by concerns about patient safety. For example, patient fall, infection or haemorrhage for which the hospital should be equipped with the latest technology," believes

Dr Chordiya. Most surgeries previously excluded from the list are now included in this category, such as coronary angiography, especially radial artery interventions, advanced laparoscopic surgeries in different specialities, Intra-ocular lens implants, arthroscopic treatments, and many procedures in oncology, nephrology and gastroenterology.

Many doctors have started performing minimally invasive surgical procedures using endoscopes requiring very small incisions, so that the risks involved in conventional major surgery can be avoided. Secondly, surgeries which require very less intervention and can be done under the effect of newer anaesthesia drugs are selected. This also allows patients to recover consciousness very quickly, so that they can go home soon after the surgery is over. Modern painkillers are more powerful; patients have much less pain after the operation and can successfully relieve the pain themselves by taking medications at home. In AIMS, the surgeries are selected on the basis of clinical judgement of the operating surgeons and the hospital policy. "Surgical procedures posted for day care unit should be over in less than an hour. Hence, procedures with minimal postoperative complications are selected for day care unit," explains Dr Chandy.

Limitations

Statistics show that almost 60 per cent of all surgeries done in India can be performed as DCS. This is in contrast to just 11 per cent cases being treated currently. "Reluctant surgeons do not want to devote time in convincing the patient. Unwillingness of the surgeons to accept that this is the way the world has gone and we cannot lag behind is one of the reasons," points out Dr Row. The lack of awareness, lack of understanding of the advantages of DCS like low infection rates, shorter stay in the hospital, lower hospital bills and quick recovery as well as an inclination for admission for the procedures due to uncertainty of patient care at home, are other important reasons.

Patients discharged immediately after surgical procedures have increased possibility of getting infections due to unclean surroundings, poor home conditions for example, lack of availability of beds, water, hygiene, etc. Indian patients also lack education and general awareness about healthy living and clean environment to avoid post-operative infections /complications. "The solution could be to establish halfway homes, a facility with infrastructure and the advantage of nurses and doctors on call which will serve discharged patients after surgeries in the DCU," opines Dr Chandy.

Benefits

This concept bears potential as it increases the institutional capacity of the hospital, and also helps reduce the Average Length Of Stay (ALOS) to less than five, which is the international norm. "Nosocomial infection is minimised, hospital occupancy is increased, the overall vibrancy also increases," believes Dr Chatterjee. "For our patients, it means less time away from home, less time off from work, and less disruption of their schedule. We have increased our bed turnover rates so that we can focus on the higher acute levels of surgery," says Dr Hari Prasad.

AIMS has reaped the benefits of day care in terms of reduction in waiting list, reduction in healthcare associated infections, faster turnover of patients, better bed turnover rate, less ALOS and better patient satisfaction index. "It is extremely comfortable for the patients and bystanders, since they need not wait for bureaucratic clerical hassles. It is cost-effective to the hospital with shorter stay for patients and less chance for hospital-acquired infections," adds Dr Singh. In CMC, the concept reduced the waiting time in the main operating theatre due to the posting of smaller cases to DCU. Establishing a DCU paved the way to admit patients with more serious complications requiring surgical intervention. This has become very popular among patients and doctors. Procedures done in DCU have reduced costs for the patients and hospital.

The Future

Experts feel that the approach should be to raise awareness that day care allows comfortable recuperation at home. "Patients find DCS less stressful, as short recovery times allow anxious patients to be comforted soon after surgery by their relatives and they don't need to be isolated in a hospital room," says Dr Hari Prasad.

It is safe to presume that every other person in his or her lifetime will have to undergo some surgical procedure, however minor it may be. With our population it means half a billion procedures that can be easily handled in day surgery units, feels Dr Row.

Considering the growing importance of this concept, some big hospitals are gearing up to embrace its business potential. AIMS is soon starting a separate facility co-located with the outpatient unit and has finished construction of 150 rooms in five floors as guest house (post treatment stay) for day care patients. CMC, Vellore is also planning the expansion of this service by increasing the number of day care units. It has done a detailed survey prior to starting the day care unit among the likely users (surgeons) to judge the usefulness. Cost benefit analysis was also conducted.

Dr Row plans to set up 25 standardised multi-speciality, state-of-the-art centres, in all the major cities of India, with ISO certification. They will be 'freestanding' or 'standalone' units of 3,500-4,000 sq.ft., of 25 beds, two fully-equipped operation theatres and consulting rooms. Everything will be outsourced including the diagnostic facilities. Administration will be provided by qualified professionals. Staff will be trained in the concept. "Centres will be set up in phases; site selection and population study will be undertaken to create a high standard multi-speciality centre, which will provide affordable, high quality surgery. Projections have shown feasibility of these centres, which are profitable from the fifth year onwards when the centre gets fully operational. We are looking for financers and interested groups," informs Dr Row. Charitable organisations could run centres on a no-profit-no-loss basis. It would be ideal for slum rehabilitation programmes and to provide urban facilities to rural areas. As Dr Chordiya puts it, today, no Government or private/corporate hospital can afford to be wasteful or has unlimited resources; finding and following best practices makes practical sense.

sonal.shukla@expressindia.com