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.
2 Aldrete, J.A. (1995 Feb). The post‐anesthesia recovery score revisited. J Clin Anesth. 7 (1): 89–91.
3 Ansell, G.L. and Montgomery, J.E. (2004 Jan). Outcome of ASA III patients undergoing day case surgery. Br J Anaesth. 92 (1): 71–74.
4 Apfel, C.C., Läärä, E., Koivuranta, M. et al. (1999 Sep). A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross‐validations between two centers. Anesthesiology. 91 (3): 693–700.
5 Armstrong, K.A., Semple, J.L., and Coyte, P.C. (2014 Sep 22). Replacing ambulatory surgical follow‐up visits with mobile app home monitoring: modeling cost‐effective scenarios. J Med Internet Res. 16 (9): e213.
6 Atkins, M., White, J., and Ahmed, K. (2002). Day surgery and body mass index: results of a national survey. Anaesthesia. 57 (2): 169–182.
7 Barron, K.I., Savageau, J.A., Young, S.B. et al. (2006). Prediction of successful voiding immediately after outpatient mid‐urethral sling. Int Urogynecol J Pelvic Floor Dysfunct. 17 (6): 570–575. https://doi.org/10.1007/s00192‐005‐0064‐8.
8 Chan, M.T.V., Cheng, B.C.P., Lee, T.M.C. et al. (2013 Jan). BIS‐guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 25 (1): 33.
9 Choi, S., Mahon, P., and Awad, I.T. (2012). Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review [published correction appears in Can J Anaesth. 2017 Dec 18]. Can J Anaesth. 59 (7): 681–703.
10 Chung, F., Chan, V.W., and Ong, D. (1995 Sep). A post‐anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth. 7 (6): 500–506.
11 Chung, F., Mezei, G., and Tong, D. (1999 Apr 1). Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Can J Anaesth. 46 (4): 309.
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.
13 Dexter, F., Bayman, E.O., and Epstein, R.H. (2010 Feb 1). Statistical modeling of average and variability of time to extubation for meta‐analysis comparing desflurane to sevoflurane. Anesth Analg. 110 (2): 570–580.
14 Duncan, P.G., Cohen, M.M., Tweed, W.A. et al. (1992 May 1). The Canadian four‐centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth. 39 (5): 440.
15 Duncan, P.G., Shandro, J., Bachand, R., and Ainsworth, L. (2001 Aug). A pilot study of recovery room bypass (“fast‐track protocol”) in a community hospital. Can J Anaesth. 48 (7): 630–636.
16 Elvir‐Lazo, O.L. and White, P.F. (2010). Postoperative pain management after ambulatory surgery: role of multimodal analgesia. Anesthesiol Clin. 28 (2): 217–224.
17 Fong, R. and Sweitzer, B.J. (2014 Dec 1). Preoperative optimization of patients undergoing ambulatory surgery. Curr Anesthesiol Rep. 4 (4): 303–315.
18 Hollingsworth, J.M., Saigal, C.S., Lai, J.C. et al. (2012). Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery. J Urol. 188 (4): 1274–1278.
19 Hwa, K. and Wren, S.M. (2013 Sep). Telehealth follow‐up in lieu of postoperative clinic visit for ambulatory surgery: results of a pilot program. JAMA Surg. 148 (9): 823–827.
20 Jin, F., Norris, A., Chung, F., and Ganeshram, T. (1998 Aug). Should adult patients drink fluids before discharge from ambulatory surgery? Anesth Analg. 87 (2): 306–311.
21 Joshi, G.P., Ahmad, S., Riad, W. et al. (2013 Nov). Selection of obese patients undergoing ambulatory surgery: a systematic review of the literature. Anesth Analg. 117 (5): 1082–1091.
22 Kamming, D., Chung, F., Williams, D. et al. (2004 Jun). Pain management in ambulatory surgery. J Perianesthesia Nurs Off J Am Soc PeriAnesthesia Nurses. 19 (3):