Ambulatory Urology and Urogynaecology. Группа авторов
more space is required to house pre‐ and post‐operative patients in separate areas and at certain times of the day, there will be unused space. The ‘non‐racetrack’ model conversely does mix patients, economising on space, but possibly at the detriment of quality.
Following this, members of the board team need to consider space for reception, patient's changing rooms, toilets, consulting rooms, staff common rooms and catering facilities. Medical gas supply must be incorporated into the design. Hardware such as trolleys, operating tables, beds, blood fridges, and emergency trolleys must be thought out. Operating theatres must be designed and anaesthetic equipment taken into account.
Following the design, a business plan should be constructed, including the capital costs, income, and expenditure over the next five years. This will need to be presented to investors or local funding panels
Economics of Ambulatory Surgery
The economic benefits of ambulatory surgery are a major drive for uptake. A number of studies have demonstrated the cost‐effectiveness of various procedures when performed in the outpatient versus inpatient setting (Hollingsworth 2012). In 1990, the UK's Audit Commission suggested that if all health authorities in England and Wales performed day surgery consistently for 20 common procedures, an additional 186 000 patients could be treated each year without increased costs. This led to the England's Department of Health recommendation that 75% of all elective surgery be undertaken as day‐case procedures (Alan Milburn NHS plan 2002). The UK Department of Health's reference costs for 2013–2014 calculated that the average day‐case cost was £698 compared to £3375 for elective inpatient cases (reference costs 2013–2014).
These economic benefits stem from shorter hospital stays, with reduced waiting lists and higher patient turnover; fixed scheduling with reduced cancellations; staff reductions with lower overnight capacity; reduced operating times and lower costs associated with post‐operative care (Aboutarabi 2014). Furthermore, patients benefit from reduced disruption from normal routine and quicker recovery back to work.
Various strategies have been proposed to economise even further within ambulatory surgery. Nerve blocks for reduction of pain, fast‐tracking, and modifying the type and amount of anaesthesia have all been investigated in detail. Future innovations in terms of surgical technology and technique, anaesthesia and post‐operative monitoring including the use of telemedicine will likely further the scope and economic efficiency of ambulatory surgery.
Complication Rates
Transfer to an acute care facility or hospitalisation after discharge is often used as a marker of the complication rate for day‐care surgery. Outpatient gynaecological and urogynaecology procedures have been successfully performed with very few patients (1.6%) requiring inpatient treatment within 72 hours (Kannan 2008). Similar results have been replicated in numerous studies of urology patients.
A multicentre quality improvement project performed in the USA found that 12% of patients undergoing other ambulatory surgery required hospital transfer and 10% required hospitalisation or an emergency room attendance within 48 hours of discharge from the day‐care unit (Davis 2019).
Conclusion
Redistributing surgical procedures from the inpatient setting to ambulatory centres can be done without impacting quality. Ambulatory surgery confers substantial advantage and will continue to increase in popularity, in line with economic pressures. Re‐evaluation and improvement are central to its success and units should routinely audit their cases and outcomes, along with the incorporation of novel techniques and innovations.
Further Reading
1 Aboutorabi, A., Ghiasipour, M., Rezapour, A. et al. (2014 Spring). A cost‐minimization analysis of day‐care versus in‐patient surgery for five most common general surgical procedures. Journal of Health Policy and Sustainable Health. 1 (2): 33–36.
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12 Davis, K.K., Mahishi, V., Singal, R. et al. (2019). Quality Improvement in Ambulatory Surgery Centers: A Major National Effort Aimed at Reducing Infections and Other Surgical Complications. J Clin Med Res. 11 (1): 7–14.
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