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Edmund M. Regis Jr.
Edmund M. Regis Jr.

In 2013, Victoria Hospital's Day Surgery Unit (DSU) performed 354 cases, saving an estimated 552 bed days and generating $168,090 in revenue. The DSU, opened in October 2012, saw increasing utilization over the year from 40% bed occupancy in the first trimester to 72% in the final trimester of 2013. The presentation evaluated the DSU's history, case volumes, financial assessment, and concluded the unit was providing benefits in terms of reduced hospital stays and increased revenue for the hospital.

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Day Surgery/Victoria Hospital DSU Audit Presenter: Dr. E. M. Regis Jr. MD House 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 bene t.鍖
It is recommended that a multidisciplinary approach, with agreed protocols 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 rst 24 hrs.鍖
(c) The patients 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 patients 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 bene t from the short-duration鍖 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)
theatre users presentation
Oct 15th Dec 20th 2012 Intermediate 18 Minor 40 Cancel 4 Total 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 34 Minor 26 Cancel 1 Total 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 58 Minor 39 Cancel 5 Total 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 37 Minor 32 Cancel 4 Total 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 69 Minor 59 Cancel 12 Total 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%
theatre users presentation
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

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theatre users presentation

  • 1. Day Surgery/Victoria Hospital DSU Audit Presenter: Dr. E. M. Regis Jr. MD House Officer Dept. Of Gen Surgery/ Ortho 12/03/14
  • 2. Outline Overview VH DSU History Number of cases per trimester from Oct 2012 Dec 2013 Assessment of the finances Summary
  • 3. Definition surgical procedures that are performed which do not require an overnight hospital stay. <23hr hospital stay
  • 4. 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 bene t.鍖
  • 5. It is recommended that a multidisciplinary approach, with agreed protocols 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
  • 6. 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 rst 24 hrs.鍖
  • 7. (c) The patients 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.
  • 8. Medical Factors (a) Fitness for a procedure should relate to the patients 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.
  • 9. (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 bene t from the short-duration鍖 anaesthetic techniques and early mobilization associated with day surgery.
  • 10. 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.
  • 11. (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)
  • 12. 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)
  • 14. Oct 15th Dec 20th 2012 Intermediate 18 Minor 40 Cancel 4 Total 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.
  • 15. Oct 15th Dec 20th 2012
  • 16. January March 2013 Intermediate 34 Minor 26 Cancel 1 Total 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.
  • 18. April June 2013 Intermediate 58 Minor 39 Cancel 5 Total 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.
  • 19. April June 2013
  • 20. July September 2013 Intermediate 37 Minor 32 Cancel 4 Total 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.
  • 22. October December 2013 Intermediate 69 Minor 59 Cancel 12 Total 140 Intermediate cases included OGD, hernia repair, cystoscopy, LEEP, laparoscopy. Minors ranged from closed reduction, wound exploration, wound closure, excision and biopsy, suprapubic catheterization.
  • 24. Jan 2013 Dec 2013
  • 25. Departmental Users Of DSU (2013)
  • 26. Assessment Of The Finances Processing Fee $10 Bed $ 75 Intermediate $500 Minor $250
  • 27. 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
  • 28. 2013 Intermediate Cases: 198 x $585 = $115,830 Minor Cases: 156 x $335 = $52,260 Total Revenue Estimated $168,090
  • 29. 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
  • 30. 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
  • 31. % 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%
  • 33. 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.
  • 34. 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.
  • 35. 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

Editor's Notes

  • #4: Day surgery define deferently depends on the countryus differs from europe. Money is the key
  • #5: . If inpatient surgery is being considered it is important to question whether any strategies could be employed to enable the patient to be treated as a day case. Full-term infants over 1 month are usually appropriate to undergo day surgery. A higher age limit is advisable for ex-premature infants (60 weeks post-conceptional age). The signi鍖cant risk posed by postoperative apnoea must be considered and infants with recent apnoea episodes, cardiac or respiratory disease, family history of sudden infant death syndrome and adverse social circumstances should be considered for overnight admission and close monitoring. Day surgery units should not perform surgery on children unless they have suitable staff and facilities.
  • #9: TheASA physical status classification systemis a system for assessing the fitness of cases beforesurgery. In 1963 theAmerican Society of Anesthesiologists(ASA) adopted the five-category physical status classification system; a sixth category was later added. These are: Healthy person. Mildsystemic disease. Severe systemicdisease. Severe systemic disease that is a constant threat tolife. Amoribundperson who is not expected to survive without theoperation. A declaredbrain-deadperson whoseorgansare being removed fordonorpurposes.
  • #10: The incidence of complications during the operation or in the early recovery phase increases with increasing BMI. However, these problems would still occur with inpatient care and have usually resolved or been successfully treated by the time a day case patient would be discharged
  • #26: Gen Surgery 287 O&amp;G 15 Ortho 34 Ent 15 Nephro 14 Optham 1