Outpatient operations. I. The surgeon's view

Effect of a surgical day unit on waiting lists

The effect of a surgical day unit (SDU) on the waiting lists of a busy district general hospital is reported over a 4-year period. During this time, 18 (15%) of the general surgical beds were closed for financial reasons. A real saving rather than an apparent one is reported due to the work expansion in the SDU.

[Laser cordectomy without hospitalization. Is it a safe intervention?]

OBJECTIVE

To evaluate the safety of the CO2 Laser Cordectomy in the treatment of glottic carcinoma as a day-case procedure.

MATERIAL AND METHODS

Retrospective study of a cohort of 30 patients with glottic carcinoma treated with CO2 Laser Cordectomy at our institution between 1999-2001 as a day-case procedure.

RESULTS

There were no major complications and no patients required re-intubation. 90% of the patients were discharged the same day of the procedure. There were three unplanned admissions to the hospital but none of them were, in our opinion, the direct result of Cordectomy. These patients were discharged the next day. 100% of the patients answered that they would repeat the experience.

CONCLUSIONS

CO2 Laser Cordectomy of the glottic carcinoma can be safely performed as an outpatient procedure if patients are selected according to specific day-case criteria.

[Ambulatory anesthesia practice in a University Hospital Center: what is done; what could be done. Ambulatory Anesthesia Study Group]

OBJECTIVES

To estimate the number and type of patients, who could be managed on a day-care basis in a University Hospital. Cases of ambulatory anaesthesia (AA) which could be managed in optimal conditions and current AA practice. To assess patients' opinion on inpatient or outpatient practices.

STUDY DESIGN

Prospective survey over 8 weeks in 21 medical units potentially concerned by ambulatory practice.

PATIENTS

Series of 1,396 patients undergoing an operation included in a previously established list of outpatient procedures.

METHOD

A questionnaire was completed for each patient, from preoperative anaesthesia consultation until discharge. Thereafter patients were contacted after home discharge by telephone or mail.

RESULTS

In the group of the 1,396 selected patients, 301 (22%) were contra-indicated for AA. In optimal conditions AA was indicated in 20% of all patients treated in these units. At the time of the survey there were 285 outpatients (26% of potential AA, 5% of all patients). Complications were uncommon. Ninety-eight percent of them would choose day surgery again. Among the 810 inpatients, 279 responded: 53% would prefer to be an ambulatory patient.

CONCLUSION

At the time of this survey only one fourth of the possible oupatients for AA had in fact been treated on a day-case basis. Its development requires an improvement of the structures, team organisation and patients' information.

Early discharge after operation

To assess the feasibility and advantages of short-stay surgery in India, a policy of early discharge was adopted for 386 patients undergoing various major and minor operations. The mean postoperative and total hospital stays of patients admitted for minor surgery were 1.9 and 3.7 days respectively; the corresponding figures for age- and sex-matched historical controls were 7.4 and 11.3 days. The mean postoperative and total stays of patients who had undergone major surgery were 4.1 and 8.0 days respectively; the corresponding control values were 8.9 and 12.5 days. The use of absorbable subcuticular skin sutures helped to shorten postoperative hospital stay and avoided an extra follow-up visit. The overall complication rate in the study group was 9.6 per cent and in historical controls 13.4 per cent (P > 0.05). A total of 2357 hospital bed-days were saved during the study and 95.6 per cent of patients approved of short-stay surgery.

Postoperative analgesia for day-case herniorrhaphy patients. A comparison of cryoanalgesia, paravertebral blockade and oral analgesia

Patients were admitted as day-cases for inguinal herniorrhaphy under epidural anaesthesia and chlormethiazole sedation. The patients were given oral analgesia, and in addition, some were given either a paravertebral block with a dextran/bupivacaine mixture or cryoanalgesia of the ilio-inguinal nerve for postoperative pain relief. These anaesthetic and analgesic techniques are discussed in relation to day-case herniorrhaphy.

Operations for hernia and varicose veins in a day-bed unit

Over eight years (1970-8) 1055 patients underwent operations for hernia or "major" varicose veins in a day-bed unit. Here, 608 were discharged home on the day of operation, 262 were transferred to a convalescent hospital for 48 hours, and 161 were retained in the acute ward as part of a controlled trial. Special emphasis was placed on selection and preadmission screening. Failure of planning was uncommon in that only 2.5% were detained in hospital and 1% had to be readmitted. About one-quarter of the patients had complications but these were generally trivial and were satisfactorily treated by the community nursing sisters or general practitioners, or both. Analysis of the total operations for hernia or varicose veins in the unit over the past 19 years shows that, whereas formerly all patients with these conditions were admitted to the main surgical ward, nowadays almost all are managed either by day care or in a five-day ward.

Consumer acceptability of day care after operations for hernia or varicose veins

The opinions of patients and of caring persons (usually relatives) were sought in this trial of different methods of providing care for 360 patients after operations for hernia or varicose veins. Analysis of patients' opinions suggested that day care was the most acceptable of the three types of care examined. The reactions of caring persons did not reveal any major criticisms or disadvantages.

Day care after operations for hernia or varicose veins: a controlled trial

Alternative systems of care after operations for varicose veins or hernia were compared in a total of 360 selected patients, of whom 121 were allocated to be managed in an acute ward for 48 h, 122 in a convalescent hospital for 48 h and 117 to be discharged directly home to the care of the district nursing sister and general practitioner. There were no deaths or major complications. Anaesthetic or surgical problems caused 5 patients (3 convalescent and 2 day care) to be retained in hospital on the day of operation. Minor complications were recorded in approximately one-third of the patients. The majority of these were effectively dealt with by the district nursing sister and only one-third of the complications needed the attention of the general practitioner. Two of the ward patients and 1 of the convalescent patients required readmission to hospital (1 per cent in all). No significant difference was demonstrated in the medical outcome between the three groups after operation. Day care was the most economical of the three systems of care. Inquiry into the patients' opinions elicited the highest proportion of favourable responses in the day care group.

Day care and short stay surgery for hernia

The duration of postoperative stay has been falling in recent years as more conditions are considered suitable for outpatient care. The introduction of short stay surgery not only relieves hospital waiting lists but also represents an economic advantage and has certain social benefits for the patient. The treatment of more patients as day cases reallocates the workload, putting increased responsibility on to outpatient clinics and general practitioner and community services. It also demands careful consideration of in-hospital operative and anaesthetic techniques to speed recovery and minimize complications.

Ambulatory inguinal hernia repair compared with short-stay surgery

Two groups of patients operated on for inguinal hernia, one outpatient group and one inpatient group, are compared with respect to subjective distress and immediate postoperative complications. The groups were chosen at random and matched for sex and age. A large number of those who received treatment as outpatients suffered marked distress during the first postoperative days. Some form of intermediary or light nursing should be tried out for the outpatients so that if necessary they can stay the night after operation at the hospital. The number of postoperative complications was equal in the two groups. With suitable patient selection and with a small number of reserve places in a light-care ward, the majority of inguinal hernia operations can be performed on outpatients, resulting in a considerable economic saving and shorter waiting time.

Outpatient surgery in a developing country

233 outpatient operations were performed under general anaesthesia on Nigerian patients whose selection was not influenced by adverse social circumstances. The complication-rate was similar to that found in comparable series from the United Kingdom. The incidence of wound infection was related to the age and social circumstances of the patient and was not affected by the type of hospital in which the operation was performed.

The scope and safety of short-stay surgery in the treatment of groin herniae and varicose veins. A report on 705 cases

Between 1948 and 1968 the number of surgical patients treated in England and Wales increased by 38·6 per cent. In 1968, 267, 300 more surgical patients were admitted to hospital than in 1948. During the same period of time the increase in the number of beds was less than 1 per cent.

Faced with a steadily growing demand to treat patients suffering from cancer and other serious diseases it is difficult to find the beds and the operating time to treat patients with hernia and varicosa veins. Even so the operating performed on patients suffering from these two complaints amount to nearly one-third of all the operatons performed annually. There are 231 other operations in general surgery.

As a result the average time patients with ruptures and variocse veins languish on hospital waiting lists is up to 2 years, and ofter for longer than that.

At the present time in England and Wales the average time a patient stays in hospital after a herniorrhaphy or an operation for varicose veins is 10·5 days. This is an expensive waste of beds; 75 per cent of all patients can safely be sent home 48 hours after both these types of operatun. The number of patients who develop an acute postoperative comlication and cannote go home is only 5·4 per cent and the number who need readmission for a delayed complication is less than 1 per cent.

Being discharged home 48 hours after having their hernia reparied or thier varicose veins operated on is popular both with the great majority of patients and also with their relatives. Moreover it is accepted by the general practitioners concerned. Proceeding in this way the time such patients have to wait for their operation is reduced to an average of 3–6 months.

It is important to realize, however, that short-stay surgery will increase the total number of operations performed each year. They are additional operations and, as such, need extra theartre time and extra theatre staff, otherwise they cancnote be done.

The present series of 705 cases could note have been operated on if an additional theartre and staff had not been provided.

Postoperative care: in hospital or at home? A feasibility study

This study was carried out, first, to determine the feasibility of postoperative home care for three elective operations and, second, to explore the feasibility of introducing postoperative home care as a more economical alternative for the following surgical procedures: herniorrhaphy, vaginal hysterectomy, and vein stripping. Clinical, environmental, operative, and socioeconomic criteria were applied to 487 outpatients of which 44 pairs were selected and matched by age, sex, diagnosis, environmental, and socioeconomic characteristics. Each member of a pair was randomly assigned to either hospital care or home care. The place of postoperative care was disclosed only after the operation. After three to five hours in the recovery room, the hospital care patient was transferred to the general surgical wards and the home care patient was transferred by ambulance to his home. There were two minor complications in the home care group and three in the hospital care group. The duration of convalescence was significantly shorter for home care patients with post–hernia repair and with hysterectomy. Economic analysis showed that from the hospital viewpoint, the average cost for both herniorrhaphy and hysterectomy home care patients is one–fourth of the average cost of hospital care. The home care alternative also provides for other savings which are described in the study.