Day of surgery admission for the elective surgical in-patient: successful implementation of the Elective Surgery Programme

Impact of a same day admission project in reducing the preoperative bed occupancy demand in a pediatric inpatient hospital

Background

A same day admission approach was established for pediatric patients undergoing elective surgery owing to an increase in demand for bed availability and the need for medical, logistical, psychological, and fiscal improvements. This study aimed to assess the effectiveness of the same day admission approach for reducing demand for preoperative bed occupancy in pediatric inpatient units.

Method

Data on elective surgery patients considered for same day admission were prospectively collected in an Excel spreadsheet.

Results

Same day admission patients numbered 269 (25.87%; n = 1040), 461 (41.7%; n = 1104), 382 (38.67%; n = 998), and 560 (44.20%; n = 1267) in 2018, 2019, 2020, and 2021, respectively. Over the 4-year period between 2018 and 2021, pediatric orthopedic surgeries accounted for the majority of same day admissions (29.72%; n = 497), followed by ear, nose, and throat (21.30%; n = 356), general (16.99%; n = 284), plastic (14.53%; n = 243); urology (9.87%; n = 165); optometry and ophthalmology (3.77%; n = 63); neuro (2.51%; n = 42), and dental (1.31%; n = 22) surgeries. The total number of days of saved preoperative beds over the 4-year period was 1672 days (an average of 418 hospital days per year).

Conclusions

This study showed that same day admission approach should be implemented in pediatrics institutions to reduce hospital bed demand. The implementation of this initiative is widely variable between specialties due to interlinked medical, operational, and logistical factors.

Level of Evidence

III.

•

Same day admission is a model to reduce the average length of hospital stay for surgical patients and to reduce costs.

•

The study is confirming the feasibility of applying the same day admissions' project in the pediatric population.

•

This study compares the applicability of the same day admission’s project across pediatrics’ surgical subspecialties.

•

This study proves the possibility of applying same day admission's project in the local region.

Evidence-based perioperative pain management protocol for day case surgery in a resource limited setting: Systematic review

Background

Worldwide, there is an increasing trend of performing more complex operations in a day care setting, usually driven by economic considerations. Provision of appropriate pain relief is still inadequate in this setting. Poor pain control and adverse effects of opioids provided for pain control are common reasons for readmission, with human and economic consequences. The aim of this review was to develop evidence-based protocol for pain management of day surgery in a resource limited setting.

Method

After formulating the key questions, scope, and eligibility criteria for the articles to be included, advanced search strategy of electronic sources from data bases and websites was conducted. Screening of literatures was conducted with proper appraisal checklist. This review was reported in accordance with preferred reporting items for systematic reviews and meta-analysis (PRISMA) 2020 statement.

Results

A total of 333 articles were identified from data bases and websites using an electronic search. 45 articles were removed for duplication and 87 studies were excluded after reviewing titles and abstracts. At the screening stage, 73 articles were retrieved and evaluated for eligibility. Finally, 40 studies met the eligibility criteria and were included in this systematic review.

Conclusion

Day surgery encourages patients to mobilize soon after surgery and empowers them to manage their own pain. Thus, preoperative patient education and high-quality perioperative pain management are paramount. With increasing healthcare demands for more day-case procedures, multi-modal analgesic techniques in the perioperative period with good extension of analgesia into the postoperative discharge period are essential.

•

Nearly one-third of patients experience moderate-to-severe pain after day surgery.

•

Standardized pain evaluation, protocols, and multi-modal analgesia are keys to effective pain control.

•

Patient education and preparation will improve patient compliance of analgesia.

•

Alternatives to opioids should be promoted in day surgery.

•

Local anesthetic techniques facilitate early and safe discharge of patients after day surgery.

National clinical programmes in the Republic of Ireland: a qualitative study of acute hospitals

Background

The national clinical programmes (NCPs) were established in 2010 to achieve three objectives, namely: improve quality, access and cost effectiveness. Limited research exists on their implementation in the Republic of Ireland (ROI). This qualitative study identified key stakeholders' perceptions on (a) implementation thus far, and (b) conditions perceived necessary for implementation in acute hospitals.

Aims

The overall aim of this research was to undertake an in-depth study to explore from the perspectives of key stakeholders, their perceptions on implementation of the national clinical programmes, thus far, in relation to three overarching objectives (to improve quality, access, cost effectiveness) and what are the conditions necessary for their implementation in the Republic of Ireland's acute hospitals.

Methods

Twenty participants were interviewed using face-to-face audio-recorded semi-structured interviews. Transcribed data were coded and analysed, and a number of themes emerged from the dataset relating to the study aims.

Results

Implementation was perceived as being inconsistent. Outcomes were identified as: best practice guidelines, models of care, protocols, pathways; education & training; new services; improved discharges; improved patient outcomes; reduced length of stay; timely access; reduced waiting lists; cost effectiveness and other intangible outcomes. Sixteen conditions, under four themes, were perceived necessary for implementation, namely: Governance - structure, audit & monitoring, senior management support, accountability, and clear objectives and expectations; Communication - visible face-to-face engagement, internal awareness, and external awareness; Leadership - programme level, national level, hospital level, and professional level; Resources - budget, staff, information technology, training, skills, and competency.

Conclusions

This study adds to the existing limited body of knowledge on implementation of the NCPs in the acute hospitals in the ROI while contributing to the wider international literature in this area. The study provides hitherto unreported knowledge on the conditions that are perceived necessary for implementation. Novel in the ROI context is the perceived necessity to condense the number of NCPs, placing greater emphasis on (a) the need to structurally integrate the NCPs across the continuum of care, and (b) the importance of communication through visible face-to-face engagement. This study concludes that significant progress has been made by the NCPs towards meeting the objectives, albeit to varying degrees. There is a strong perception that the NCPs should remain, and that addressing the conditions perceived necessary for implementation in the areas of governance, communications, leadership and resources by both top-down senior health officials and bottom-up front-line hospital staff would significantly enhance the ability of the NCPs to meet objectives and implementation. It provides the ROI health services with valuable information to inform future reform, strategic planning and NCP implementation.

Using Lean Six Sigma to improve rates of day of surgery admission in a national thoracic surgery department

Objective

The aim of this study is to improve rates of day of surgery admission (DOSA) for all suitable elective thoracic surgery patients.

Design

Lean Six Sigma (LSS) methods were used to enable improvements to both the operational process and the organizational working of the department over a period of 19 months.

Setting

A national thoracic surgery department in a large teaching hospital in Ireland.

Participants

Thoracic surgery staff, patients and quality improvement staff at the hospital.

Intervention(s)

LSS methods were employed to identify and remove the non-value-add in the patient’s journey and achieve higher levels of DOSA. A pre-surgery checklist and Thoracic Planning Meeting were introduced to support a multidisciplinary approach to enhanced recovery after surgery (ERAS), reduce rework, improve list efficiency and optimize bed management.

Main Outcome Measure(s)

To achieve DOSA for all suitable elective thoracic surgery patients in line with the National Key Performance Indicator of 75%. A secondary outcome would be to further decrease overall length of stay by 1 day.

Results

Over a 19 month period, DOSA has increased from 10 to 75%. Duplication of preoperative tests reduced from 83 to <2%. Staff and patient surveys show increased satisfaction and improved understanding of ERAS.

Conclusions

Using LSS methods to improve both operational process efficiency and organizational clinical processes led to the successful achievement of increasing rates of DOSA in line with national targets.

Hospitalization before surgery and subsequent risk of infective complications after radical cystectomy: A population-based analysis

INTRODUCTION

The length of stay prior to surgery increases the risk of postoperative infections (PIs) in several surgical settings, such as cardiac, orthopedic, and general surgery. However, data for urological oncology procedures are limited. We examined PI rates after radical cystectomy (RC) according to the length of stay prior to RC (LOSPRC).

MATERIALS AND METHODS

A total of 24,242 patients with bladder cancer treated with RC between 1998 and 2013 were abstracted from the National Inpatients Sample database. We evaluated changes over time in LOSPRC (0 vs. 1 vs. 2 days or more) and tested its effect on PI rates. Multivariable logistic regression analyses were adjusted for the year of surgery, sex, age, ethnicity, comorbidities, hospital location, teaching status, hospital surgical volume, and number of hospital beds.

RESULTS

Overall, 19,401 (80.0%), 3,990 (16.5%), and 851 (3.5%) individuals with LOSPRC of 0, 1. and 2 or more were identified. The proportion of LOSPRC 0 patients increased from 61.4% in 1998 to 91.0% in 2013 (P<0.001), whereas the opposite trend was observed for LOSPRC 1 and 2 or more. In multivariable logistic regression analyses predicting PIs, LOSPRC of 1 (odds ratio: 1.38; 95% CI: 1.25-1.53; P<0.001) and LOSPRC of 2 or more (odds ratio: 2.15; 95% CI: 1.81-2.55; P<0.001) achieved independent predictor status.

CONCLUSIONS

A delay in surgery as short as 1 day significantly increases the risk of PIs after RC. In consequence, same day of admission surgery policies should be further promoted to reduce the risk of PIs.

Higher surgical training opportunities in the general hospital setting; getting the balance right

BACKGROUND

The general hospital can play an important role in training of higher surgical trainees (HSTs) in Ireland and abroad. Training opportunities in such a setting have not been closely analysed to date.

AIMS

The aim of this study was to quantify operative exposure for HSTs over a 5-year period in a single institution.

METHODS

Analysis of electronic training logbooks (over a 5-year period, 2007-2012) was performed for general surgery trainees on the higher surgical training programme in Ireland. The most commonly performed adult and paediatric procedures per trainee, per year were analysed.

RESULTS

Standard general surgery operations such as herniae (average 58, range 32-86) and cholecystectomy (average 60, range 49-72) ranked highly in each logbook. The most frequently performed emergency operations were appendicectomy (average 45, range 33-53) and laparotomy for acute abdomen (average 48, range 10-79). Paediatric surgical experience included appendicectomy, circumcision, orchidopexy and hernia/hydrocoele repair. Overall, the procedure most commonly performed in the adult setting was endoscopy, with each trainee recording an average of 116 (range 98-132) oesophagogastroduodenoscopies and 284 (range 227-354) colonoscopies.

CONCLUSIONS

General hospitals continue to play a major role in the training of higher surgical trainees. Analysis of the electronic logbooks over a 5-year period reveals the high volume of procedures available to trainees in a non-specialist centre. Such training opportunities are invaluable in the context of changing work practices and limited resources.

Life after the cancer strategy: analysis of surgical workload in the general hospital setting

BACKGROUND

The National Cancer Strategy heralded a major reorganisation of the delivery of cancer services in Ireland. As a result of this policy, cancer care was centralised to eight centres. The impact of this strategy on hospitals no longer providing cancer services has not been analysed to date.

AIM

The aim of this study was to examine the impact of centralisation of cancer services on surgical workload at Mayo General Hospital.

METHODS

Data pertaining to all surgical procedures performed in 2007 (prior to the introduction of the National Cancer Strategy) and 2011 were obtained using the Hospital Inpatient Enquiry system. Histopathology reports and theatre registers were also analysed to ensure accuracy of the data.

RESULTS

The numbers of elective and emergency surgical admissions during 2007 and 2011 were broadly similar (2,581 vs. 2,662). One hundred and thirty-five oncological procedures (colorectal and breast) were carried out in 2007 compared with 50 (colorectal) in 2011. This represents a 63% reduction in cancer surgery workload following the implementation of the National Cancer Strategy. There was a concomitant increase in surgery performed for benign conditions (laparoscopic cholecystectomy and hernia repair), which coincided with the innovative introduction of 43 ring-fenced surgical in-patient beds in June 2010.

CONCLUSION

This study demonstrates the impact of the centralisation of cancer services on surgical workload in a non-cancer centre. Our results show that there continues to be a role for general hospitals in the provision of elective surgical services. Hospital network arrangements have the potential to facilitate such developments.