Day Surgery/Victoria Hospital DSU Audit

Presenter: Dr. E. M. Regis Jr. MDHouse Officer Dept. Of Gen Surgery/ Ortho

12/03/14

Outline

Overview VH DSU History Number of cases per trimester from Oct 2012 – Dec

2013 Assessment of the finances Summary

Definition –

surgical procedures that are performed which do not require an overnight hospital stay.

<23hr hospital stay

Selection of patients

Patients referred from; outpatient clinics, A&E departments or primary care.

Recent advances in surgical and anaesthetic techniques, as well as the publication of successful outcomes in patients with multiple comorbidities, have changed the emphasis in day surgery patient selection.

It is now accepted that the majority of patients are appropriate for day surgery unless there is a valid reason why an overnight stay would be to their benefit.

It is recommended that a multidisciplinary approach, with agreedprotocols for patient assessment including inclusion and exclusion criteria for day surgery, should be agreed locally with the anaesthetic department.

Patient assessment for day surgery falls into three main categories:

1)Social Factors

2)Medical Factors

3)Surgical Factors

Social Factors

(a) The patient must understand the planned procedure and postoperative care and consent to day surgery.

(b) Following most procedures under general anaesthesia, a responsible adult should escort the patient home and provide support for the first 24 hrs.

(c) The patient’s domestic circumstances should be appropriate for postoperative care.

(d) The patient must live a reasonable distance from the centre.

(e) The patient must have access to transportation & telephone.

Medical Factors

(a) Fitness for a procedure should relate to the patient’s health as determined at pre-operative assessment and not limited by arbitrary limits such as ASA status, age or BMI.

(b) Patients with stable chronic disease such as diabetes, asthma or epilepsy are often better managed as day cases because of minimal disruption to their daily routine.

(c) Obesity per say is not a contraindication to day surgery as even morbidly obese patients can be safely managed in expert hands, with appropriate resources.

In addition, obese patients benefit from the short-duration anaesthetic techniques and early mobilization associated with day surgery.

Surgical Factors

(a) The procedure should not carry a significant risk of serious complications requiring immediate medical attention (hemorrhage, cardiovascular instability)

(b) Postoperative symptoms must be controllable by the use of a combination of oral medication and local anaesthetic techniques.

(c) The procedure should not prohibit the patient from resuming oral intake within a few hours.

(d) Patients should usually be able to mobilize before discharge although full mobilization is not always essential. (e.g. certain orthopedic cases)

History

Day Surgery Unit (DSU) opened on October 15th, 2012.

First case was the following day, October 16th, 2012.

DSU is staffed with 2 nurses, and houses 3 patient beds.

DSU is opened Monday – Friday. (8am-4pm)

Oct 15th – Dec 20th 2012

Intermediate 18Minor 40Cancel 4Total 62

Intermediate cases for this trimester range from hernia repair, leep biopsy, OGD.

Minor cases comprise mostly biopsies, exploration, removal of plates and screws, extraction of external fixation.

Oct 15th – Dec 20th 2012

January – March 2013

Intermediate 34Minor 26Cancel 1Total 61

Majority of intermediate cases were hernia repairs, insertion of hemodialysis catheters, leep biopsy and scopes.

The minor cases for this trimester were I&Ds, change of tracheostomy, insertion of chemoport, excision and biospy.

January – March 2013

April – June 2013

Intermediate 58Minor 39Cancel 5Total 102

Majority of intermediate cases were OGDs (>1/2 cases due to teaching by foreign professional), hemodialysis catheter insertion, colonoscopies.

Minor cases ranged from circumscion, tendon release, FB removal, excision and biopsies.

April – June 2013

July – September 2013

Intermediate 37Minor 32Cancel 4Total 73

Intermediate cases for this trimester included hernia repairs, increase in the number of upper and lower GI scopes due to new team member (Ms. A. Charles), AV fistula, ORIF.

Minor cases included FB removal, tendon release and usual excision and biopsies.

July - September 2013

October – December 2013

Intermediate 69Minor 59Cancel 12Total 140

Intermediate cases included OGD, hernia repair, cystoscopy, LEEP, laparoscopy.

Minors ranged from closed reduction, wound exploration, wound closure, excision and biopsy, suprapubic catheterization.

October - December 2013

Jan 2013 – Dec 2013

Departmental Users Of DSU (2013)

Assessment Of The Finances

Processing Fee $10 Bed $ 75 Intermediate $500 Minor $250

We estimate that before the advent of DSU, any minor case, patient(s) would be admitted for at least 2 days, and intermediate 3 days.

So DSU essentially reduces days spent in hospital, hence increases bed availability on wards.

Potentially there is an increase/assured revenue as patient(s) pay in advance

2013

Intermediate Cases: 198 x $585 = $115,830

Minor Cases: 156 x $335 = $52,260

Total Revenue Estimated $168,090

Forecast of “estimated bed days” saved

Minor 1 day

Intermediate 2 days

In 2013….

Minor Cases 156 x 1 = 156 bed days saved

Intermediate 198 x 2 = 396 bed days saved

Total = 552

Bed occupancy of DSU

Work days per trimester x Available beds 1st Tri (Jan-March) …. 59 x 3 = 177 2nd Tri (April-June) …. 62 x 3 = 186 3rd Tri (July-Sept.) ….. 62 x 3 = 186 4th Tri ( Oct.-Dec.) …. 59 x 3 = 177

% of bed occupancy

(Patients/ Bed Occupancy) x 100%

4th trimester (2012) 40.3%1st trimester (2013) 33.9%2nd trimester (2013) 52.2%3rd trimester (2013) 37.1%4th trimester (2013) 72.3%

Summary

2013, a total of 354 cases were done with an estimated 552 bed days saved.

2013, a total bed occupancy of DSU was estimated to be 726.

Total revenue estimated to have been generated from DSU in 2013 was $168,090

From opening DSU, percentage bed occupancy increased from 40% in 1st tri to 72% at the end of 2013.

Acknowledgements

Special thanks to Dr. A. Charles who assigned me this VH DSU research project and now by extension presenting it.

Also thanks to VH DSU staff, especially Nurse B. who provided me with numerical data and photos for this presentation.

Last, to my colleagues who provided support in whatever way possible.

References

1) Royal College of Nursing

2) Day Case and Short Case Surgery, The British Association of Day Surgery, The Association of Anesthetists of Great Britain & Ireland, May 2011

3) www.google.com/images