Experience With Day Stay Surgery By Douglas Cohen, John Keneally, Alan Black, Sandra Gaffney, and Andra Johnson

Sydney, Aus t ra l ia

�9 Potential advantages of day stay surgery are cost saving, improved utilization of staff and hospital facilities, and reduction of stress for the paediatric patient and his family. The successful program requires careful case selection, full operating and anesthetic facilities and good follow-up. Day stay surgery was initiated at Royal Alexandra Hospital for Children in 1974. Experience is reviewed in relation to the total number and nature of surgical admis- sions and the daily utilisation of the facility. Utiliza- t ion has markedly increased in the past 2 yr. Current practice is reviewed with regard to initial assess- ment, preparation for surgery and overall manage- ment during the day admission. Parental attitudes towards day stay surgery were evaluated indicating both the advantages and the problems encountered. These related mainly to insufficient information, transport difficulties and afternoon operations. Recommendations for improving the day stay service are discussed with special reference to: (1) communication with the parents as to adequate pre-operative explanation, revision of the day stay information pamphlet and improved distribution, and clear postoperative instructions, (2) the timing of operations, and (3) transport and parking facilities.

INDEX WORDS: Day surgery; outpatient surgery; ambulatory surgery.

T HERE IS NOTHING new in the concept of pediatric 1 day surgery. Seventy years ago,

Nicoll I reported a series of almost 9000 outpa- tient procedures performed over a 20-yr period in Glasgow.

In more recent times, the pioneers of day stay surgery for children in the United Kingdom have been Rex Lawrie 2 of Guy's Hospital, London, and John Atwell 3 of Southampton.

In North America, day care surgical programs have been actively utilized for many years, notably in the Children's Hospitals in Vancouver 4 and Toronto 5 and an increasing number of ambulatory surgery programs have been progressively introduced in the United States.

It is worth recording that Hipsley, 6 in his "Early History of the Royal Alexandra Hospital for Children, Sydney--1880 to 1905" comments that "'minor operations such as removal of tonsils and adenoids were carried out in this department (outpatients). Children who had had their tonsils removed were sent home soon after the opera-

Journal of Pediatric Surgery, Vol. 15, No. 1 (February), 1980

tion; and it is not surprising that an occasional fatality occurred due to postoperative hemor- rhage."

Day stay surgery should not be regarded as being synonymous with outpatient surgery. Facilities and standards of care in the day stay surgical unit must be comparable to those provided for inpatients. With this important provisio, many investigations and minor surgical procedures can satisfactorily be performed on a day only basis without the need for overnight admission.

There are a number of advantages in brief hospitalization for uncomplicated medical and surgical cases. In the United Kingdom, single day hospitalization has found widespread appli- cation to relieve the chronic shortage of hospital beds. 7'8 This is also an important consideration in the United States T M and in Australia where Vance ~2 has described a day stay transfusion center for the treatment of children with thalas- semia major in Melbourne.

Such studies consistently report on the economic advantages, minimal complications and high patient acceptability of single day hospitalization. Other major advantages are the reduction in psychological stress due to the shorter period of hospitalization and the absence of overnight stay, reduced loss of school time, diminished travel cost for parents and less social disruption for the child and the family.

THE ESSENTIAL FEATURES OF A DAY STAY SURGERY PROGRAM

Obviously, day stay surgery is only suitable for non-major procedures. In addition, the

From the Department of Surgery and the Department of Anesthesia, Royal Alexandra Hospital for Children, Sydney, Australia.

Presented before the XXV1 Annual International Congress of the British Association of Paediatrie Surgeons, Marseilles, France, July 17-20, 1979.

Address reprint requests to Dr. D. H. Cohen, Head, Department of Surgery, Royal Alexandra Hospital for Children, Bridge Road, Camperdown, N.S.W. 2050, Sydney, Australia.

�9 1980 by Grune & Stratton, Inc.

21

22 COHEN ET AL.

surgeon needs to assess how adequately the mother will cope with the situation, especially after returning home postoperatively. One must be certain that the parents fully comprehend the responsibility that will be incurred, particularly the requirement for preoperative fasting. Low intellectual level or difficulty in comprehension may make day stay surgery inadvisable. Geographic considerations also should be taken into account although, if private transport is available, this will extend the distance from which patients can conveniently be accepted. The following general criteris must be met: '3 (1) There must be nothing within reason that can go wrong afterwards; (2) No special postoperative supervision should be needed beyond the moth- er's loving care; (3) No special drugs should be required; and (4) No restraints should be neces- sary other than those imposed by the child's own initiative.

Preparation for Day Stay Surgery

The surgeon is responsible for informing the parents and the child, when appropriate, about the procedure and what is required of them. The parents are given a date for surgery and advised about the time of admission, the approximate time of operation and the necessity for preopera- tive fasting. An explanatory pamphlet on day stay surgery is available.

Private and hospital patients are booked on the same operating list as convenient.

Preoperatively, the child must be examined for any sign of illness, particularly respiratory tract infections, infected skin lesions, or other infectious diseases such as measles. Many parents and some physicians are not aware that elective surgery is inadvisable for 6 wk after an attack of measles.

Admission Procedure

The children and their parents arrive early in the morning of the day of admission and are accommodated either in a special day stay ward or in the private section of the hospital according to the wishes of the parents and the surgeon. The day stay ward is staffed by a sister and a nurse each day from 7:30 a.m. to 6:30 p.m., 5 days a week. Continuity of trained staff is maintained in the ward. It has been found that this mini- mizes administrative problems related to the

rapid patient turnover and the staff become familiar with the special requirements of the ward.

The patients are admitted by a resident medi- cal officer and assessed by an anesthetist prior to surgery. No routine preoperative tests are ordered other than those considered appropriate by the surgeon.

A play room is attached to the ward to encour- age a free and relaxed atmosphere. The children are not restricted to bed until they are placed on the trolley for transfer to the operating theatre. Parents accompany their child to the operating theatre reception area. Postoperatively, all patients pass through the main recovery room where they are rejoined by their parents.

It is a routine requirement that all patients are observed for a minimum period of 4 hr following anesthesia. The resident medical officer nor- mally makes a decision regarding discharge but if there are any postoperat ive problems, discharge is delayed and the patient is reviewed by the anesthetist or surgeon as appropriate.

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Fig. 1. M i n o r surg ica l p r o c e d u r e s u n d e r t a k e n on a day s t a y bas is a t t h e Roya l A l e x a n d r a Hosp i ta l fo r Ch i ld ren , 1974-1978 inclusive.

DAY STAY SURGERY 23

Overnight admission is occasionally required either for medical reasons or, in some instances, on parental request.

Utilization of Day Stay Facilities Minor surgical procedures have been under-

taken on a day stay basis since 1974 (Fig. 1). The marked increase since 1976 corresponds to the introduction of day stay surgery on a 5 day a week basis. Over 700 patients per year are now admitted to the day stay ward. This represents approximately 14% of the total annual surgical admissions to the hospital.

Daily utilization of the ward appears to be relatively well distributed with an average of approximately 160 patients per year on each day of the week (Fig. 2). It has been found that the seven-bed day stay ward is only just adequate for current requirements.

Types of Operation Performed Individual surgeons vary in their opinions as

to the type of operation that can safely be

Table 1. Day Stay Surgical Procedures--R.A,H.C. January-June. 1978

"Glue ears" 114

Circumcision 95 Inguinal hernia 73

Excision of skin lesions 46

Cystoscopy 41

Microinspection of ears 36

Probing of tear duct 24

Cure of hydrocele 20

Orchidopexy 19

Eyes--examination under G.A. 18

Dental procedures 15

Urethral dilatation 12

Repair umbilical hernia 12

Division of tongue tie 10

Miscellaneous 103

Total 638

performed on a day stay basis. Day stay proce- dures commonly performed at the hospital are shown in Table 1. It has also been noted that there appears to be individual preferences among surgeons, some using the day stay facility much more than others. Two points are worthy of comment. Bronchoscopy, esophagoscopy, and

Fig. 2. Daily utilization of the day stay ward. January-November. 1978.

~ILV UTILIZATION OF FAITHFULL WARD DAY STAY FAOILITIES

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24 COHEN ET AL.

tonsillectomy are not accepted to day stay surgery as overnight observation is considered mandatory in all such cases. Circumcision and orchidopexy require careful individual consider- ation. All circumcisions require some postopera- tive analgesia which may need to be repeated at home. Orchidopexy is also more likely to require post-operative analgesia than most other day stay surgery.

Anesthetic Considerations

The anesthetic should be as short as possible and all anesthetic agents and medication should be chosen so as to reduce the post-operative recovery time.

Whether or not to premedicate these children is still debated. However, most anesthetists at the Royal Alexandra Hospital for Children prefer to do so, usually using pethidine and atro- pine or atropine alone in younger infants, avoid- ing other agents which are likely to make the child more drowsy postoperatively. In general, there is the tendency to avoid intubation although the child will be intubated if he is very young or if there is any difficulty in maintaining an airway with a mask. However, many centers employ endotracheal intubation freely. ~4"~5

Follow-Up

This should be adequate to ensure early recog- nition and management of any complication that may occur. Our patients are referred to the consulting rooms or regular outpatient clinic of the surgeon involved. In the United Kingdom, the practice has been to utilize hospital clinics ~3 or pediatric home nurses working in collabora- tion with the local general practitioner. ~6

We have not found any increase in postopera- tive complications. The wound infection rate of 1.8% for patients undergoing day stay surgery is very comparable with our overall clean wound infection rate at the hospital. These findings are comparable with other similar studies. ~4'~6

RECOMMENDATIONS FOR IMPROVING THE DAY STAY SERVICE

A number of studies have been undertaken to evaluate the effectiveness of day stay surgery at the Royal Alexandra Hospital for Children. Forty-nine parents of children being admitted for day stay surgery were interviewed and a

sample of 28 subsequently contacted to ascertain whether they had experienced any problem after returning home. In a further prospective study, 81 patients were evaluated with regard to post- operative pain and the requirement for analgesia following day stay surgery.

These studies confirm that parents were over- whelmingly in favor of day stay surgery. How- ever, several parents noted some problems and special reference was made to the following points: (1) Insufficient explanation regarding the nature of the operation and indications for it; (2) Instructions about fasting were not always understood; (3) Parents were not always told of the likely time of operation nor of the possibility of staying overnight; (4) Several parents felt that postoperative instructions were inadequate and were unsure about the level of activity allowed on return home. (5) Several parents noted signif- icant problems with transport to and from hospi- tal.

As a result of these investigations, a number of steps have been taken to improve the day stay surgical service.

Appropriate alterations have been made to the pamphlet supplied to parents. It already gives adequate information about the procedure to be followed on the day of surgery, the need for preoperative fasting and other routine details but it has amplified such points as the need to stay four hours after operation, the possibility of overnight stay should any complications occur and a suggestion to the parents to bring some- thing to occupy themselves during the day. Many of our parents are migrants. As a number of these have a poor command of English, consideration is being given to making the day stay pamphlet available in other appropriate languages. Since it is apparent that many parents are apprehensive about postoperative management, emphasis has been placed on the requirement for postoperative instructions both verbal and written. The parents are also given the name of a specific person, usually the surgi- cal registrar on duty, who they can call should problems occur on returning home. We are also looking at the feasibility of a routine phone call to each parent by the surgical registrar during the evening after the child has returned home to ascertain whether they need any advice or reas- surance.

DAY STAY SURGERY 25

CONCLUSIONS

It is again emphasized that day stay surgery is not synonymous with outpat ient surgery. Wi th the availabil i ty of a day stay ward, this facility can be offered with the same level of safety as t radi t ional inpat ient surgery for suitable cases and any problems can be ant icipated and over-

come. Increasing concern about the rapid escalation

of the cost of hospitalization has s t imulated the need to reevaluate the current delivery of hospi- tal services. In 1978, the estimated daily bed cost

at the Royal Alexandra Hospital for Children

was $168. Apar t from any economic advantages, our

studies conf i rm the f indings of others z't4,~6 regard ing m i n i m a l compl ica t ions and high pat ient and parent acceptabil i ty of single day hospitalization.

Other major advantages are the reduction in psychologic stress due to the shorter period of hospitalization and the absence of overnight stay, diminished travel cost for parents and less social disruption for the child and the family.

REFERENCES

1. Nicoll JH: The surgery of infancy. Br Med J 2:753, 1909

2. Lawrie R: Why keep them in? Nursing Times 67:79, 1971

3. Atwell JD: Changing patterns in paediatric surgical care. Aria. RCS E 60:375, 1978

4. Davenport HT, Shah CP, Robinson GC: Day surgery for children. CMA J 105:498, 1971

5. Steward D J: Experience with an outpatients anaesthe- sia service for children. Anaesth Analg 52:877, 1973

6. Hipsley PL: History Of The Royal Alexandra Hospital For Children--1880 to 1908. Sydney, Angus & Robertson, 1952 p 99

7. Ruckley CV, Maclean M, Smith AN, et al. Team approach to early discharge and outpatient surgery. Lancet 1:177, 1971

8. Simpson JEP: Day care surgery. Br J Hosp Med: 511, 1976

9. Hawthorne DD: Hospital-based unit improves utiliza- tion. Hospital49:62, 1975

10. Kernaghan SG: Peripheral issues cloud basic ques- tions in day surgery. Hospital 49:58, 1975

11. Cloud DT, Reed WA, Ford JL, et al. The surgicenter. J Pediatr Surg 7:206, 1972

12. Vance JC: Day transfusion centre for patients with thalassaemia major. Lancet 1:967, 1975

13. Lawrie R: Operating on children as day cases. Lancet 2:1289, 1964

14. Shah CP, Robinson GC, Davenport HT: Day care surgery for children. Medical Care 10:437, 1972

15. Jones SEF, Smith BAC: Presented at Meeting of BAPS, Marseilles, France, July 17-20, 1979

16. Atwell JD: Paediatric day stay surgery in Southamp- ton. Nursing Times 71:841, 1975