Day Surgery – National and International. From the Past to the Future

In February 1981, a working party was formed by the Royal Australasian College of Surgeons, the Faculty of Anaesthetists of the Royal Australasian College of Surgeons (now the Australian and New Zealand College of Anaesthetists), the Australian Association of Surgeons and the Australian Society of Anaesthetists with the inclusion of a group of co-opted members, to prepare the first manual of standards for day surgery. This manual, “Day Surgery; Report and Recommendations”, was published in September 1981 and revised in 1987 and 1997. An expanded revision was completed in July 2004.

In 1987, recognising the potential for future expansion of day surgery, the working party was formalised as a committee and in 1988 changed its name to the National Day Surgery Committee. It was during this same period that an accreditation process was established by the Australian Council on Hospital Standards (now the Australian Council on Healthcare Standards).Clinical Indicators, specifically applicable to day surgery were prepared in 1994 and have been successfully introduced for quality assessment of day surgery practice.

By 1996, the Committee was soundly established as the most informed body on day surgery in Australia. Its activities in all aspects of day surgery practice were expanding; especially the preparation of standards, and its membership had increased to include co-opted representatives from all organisations involved in the provision of procedural services within the health care system. The estimated ultimate potential for day surgery had increased from 50% to 75% (possibly more) of all operations/procedures. Having regard to these increased activities and responsibilities, together with its enhanced authority, the committee changed its name to the Australian Day Surgery Council in October 1996 and continues as such today.

The first modern, purpose designed and constructed free standing day surgery centre was built in Dandenong, Victoria in 1982 and the first free standing centre on the campus of a public hospital, Campbelltown, NSW in 1984. By 1993 there were 83 such centres; however their numbers have increased rapidly over the past decade – today there are 248 freestanding day surgery centres in Australia and they continue to be built.

Since the publication of “Day Surgery; Report and Recommendations” 1981, the Australian Day Surgery Council has reiterated its stance of equal support for hospital based day surgery units and free standing centres however the development of hospital based units has lagged behind. It is acknowledged that a considerable volume of day surgery is practiced in hospitals, approximately 50% of all operations/procedures. About one third of private hospitals have day surgery units however I am unaware of any data indicating the number of public hospitals that have dedicated day surgery units. Anecdotally, it seems that most day surgery patients in public hospitals are located in ward beds or, at most, in a day surgery ward. This apparent failure of the public hospital system to fully utilise all the patient and cost efficiencies and benefits of day surgery should be addressed as a matter of urgency.

The International Association for Ambulatory Surgery was formed in 1995 and Australia (Australian Day Surgery Council) is a foundation member. Initially located in Brussels, the Central Office was transferred to London (Royal College of Surgeons building) in 2004. The official journal of the Association is “Ambulatory Surgery”. Currently it has 15 full members, five Associate members (including the Australian Day Surgery Nurses Association) and numerous individual members.

An important initiative of the Association was the preparation of International Definitions of Ambulatory Surgery, which have been translated into 10 languages. Criteria of standards for various aspects of day surgery practice have also been written and this process will continue. The Association considers these initiatives very important to facilitate the comparison of day surgery practice from one country to another and to assist in the development of this high quality, cost effective procedural service in those countries where it has not been introduced.

The Association holds second yearly International Congresses on Ambulatory Surgery. So far, there have been five Congresses – Brussels, London, Venice, Geneva and Boston; they have all been very successful. The next four Congresses are to be held in Seville (2005), Amsterdam (2007), Brisbane (2009) and Aarhus (2011).

The Australian Day Surgery Nurses Association was formed in 1995 and is totally focused on the advancement of the highest quality, safe nursing practice in day surgery centres/units. It has over 700 members and conducts regular conferences and education sessions for nurses throughout the country. It publishes a journal, three times a year, called “Day Surgery Australia”; it has also produced “Best Practice Guidelines” and they are a credit to them. The ADSNA is a member of the Australian Day Surgery Council and the International Association for Ambulatory Surgery.

So much for the past and the present – what about the future? Day Surgery has not yet reached its full potential in Australia – or anywhere else for that matter. Currently, approximately 50% of all operations/procedures are carried out as day surgery although considerable variation from hospital to hospital and surgeon to surgeon still remains! Unquestionably, freestanding day surgery centres are the most patient and cost efficient facilities and it is from these centres that the absolute costs of day surgery practice can be collated. Certainly, the most inefficient model is to have day surgery patients spread throughout hospitals occupying acute beds – so called “day surgery wards” are not much better. In both models, patients are utilising expensive acute beds, equipment and services and this is more so in the public than the private hospital system. The ideal would be to integrate dedicated free functioning day surgery units within hospitals such that they operate the same as a freestanding centre. An obvious and even better model would be to build the freestanding centres on the campus of hospitals.

So what is the ultimate potential for day surgery? In 1999, Twersky and Showan predicted that by 2005, 82% of all surgery in the USA would be carried out as outpatient (day) surgery and 24% of this would be office-based surgery. Unbelievable – yes, but they are heading that way!

The Australian Day Surgery Council is a unique council totally dedicated to day surgery, just as the Australian Day Surgery Nurses Association is totally dedicated to day surgery nursing. They are unsurpassed as the most informed bodies on all aspects of day surgery in Australia and will continue to provide their proven expertise for day surgery to achieve its ultimate potential. This will be an onerous challenge as the further expansion will include the most major operations capable of being carried out in day surgery compatible with the highest levels of quality and safety that have already been set and which must be protected.

In order to achieve this further expansion of day surgery it will be essential to introduce the concept of extended (overnight) recovery in day surgery centres/units and post-discharge convalescent limited care accommodation facilities (medi motels). Both concepts are important for more major operations however limited care accommodation facilities have the added advantage of allowing socially stressed patients eg elderly, solitary, disabled etc and those from rural and remote areas, who would otherwise require admission to acute bed hospitals, to be treated in day surgery followed by a couple of days convalescence before returning home. An added advantage is the cost of limited care accommodation which is approximately half that of acute hospital beds. The Australian Day Surgery Council has published standards for these concepts however the health insurance industry has failed to provide a facility rebate for either!

Office based surgery in purpose built units, which are extensions of medical practitioners consulting rooms, is not yet established in Australia largely due to the failure of health insurers to provide a facility rebate. A large number of more minor operations/procedures, possibly 20-25% could be carried out in such units and the Australian Day Surgery Council has published comprehensive “Guidelines for the Accreditation of Office Based Surgery Facilities” to ensure that standards of quality and safety are not compromised. The absence of an office based surgery rebate is a major disincentive and as such, many of these patients are currently treated in day surgery centres/units at much greater cost.

An important generally acknowledged sequela of day surgery has been its influence on medical education – especially the teaching of undergraduate clinical skills. The big majority of patients with surgical conditions and pathology so essential for teaching clinical skills are now treated in day surgery and for all practical purposes are not available to medical students. This is a cause of frustration and concern to clinical tutors (surgeons) and students alike. One solution is the development of large day surgery centres/units in teaching hospitals to which the majority of clinical education would be transferred while retaining some teaching in acute bed wards. This matter is deserving of urgent consideration by medical schools.

In the international forum, the greatest challenge is to assist the introduction and expansion of ambulatory surgery into those countries where this high standard procedural service, provided in centres/units of low capital and ongoing costs, has not yet been introduced or is in its earliest stages of development. To achieve this, the International Association for Ambulatory Surgery needs to expand its membership to include such countries. The International Congresses on Ambulatory Surgery are important forums for the propagation of knowledge, experience and expertise in this most valuable procedural service.

In Summary:

• Day Surgery in Australia and many other countries is established as an indispensable procedural service within the nation’s health care system.
• It has not yet reached its ultimate potential and the introduction of extended (overnight) recovery; limited care accommodation facilities (medi motels) and office based surgery units should be vigorously supported.
• There is now an imperative for the Commonwealth Department of Health and Ageing to formalise the recategorisation of procedural services and for health insurers to introduce facility rebates for these concepts.
• The Australian Day Surgery Council is unsurpassed as the most informed body on all aspects of day surgery in Australia and will continue with its activities and in its advisory role to achieve these goals.
• There is sound logic in and great potential for developing dedicated day surgery centres/units in teaching hospitals to become the focus of teaching clinical skills in the medical education curriculum.
• The challenge for the International Association for Ambulatory Surgery is to promote and stimulate the development of day surgery in those countries where this valuable procedural service has not yet been introduced or is in its earliest stages.

Lindsay Roberts was Chairman of the Australian Day Surgery Council from 1990 to 2000 and President of the International Association for Ambulatory Surgery from 2001 to 2003.

NOTE: In the above text “day” and “ambulatory” are synonyms.