Clinical indicators for day surgery

doi:10.1016/S0966-6532(98)00063-8

Ambulatory Surgery

Volume 7, Issue 3, July 1999, Pages 155-157

https://doi.org/10.1016/S0966-6532(98)00063-8 Get rights and content

Abstract

As the number, variety and complexity of day procedures increase it is clearly important to ensure maintenance (and improvement) in the quality of the care given. To do so the Australian Day Surgery Council, assisted by the Australian Council on Healthcare Standards Care Evaluation Program, introduced five generic performance indicators. They were addressed by 240 healthcare organisations in 1997 reflecting the management of over 380 000 patients in day procedure facilities. Aggregate rates for the five indicators in 1997 were: failure to arrive, 1.5%; cancellation of procedure after arrival, 0.9%; unplanned return to operating room, 0.08% and unplanned delayed discharge, 0.56%. The unplanned overnight admission rate was significantly lower in freestanding than in attached facilities and significantly lower rates were noted for private compared with public facilities for all the indicators. Numerous actions were reported by 64% of organisations (as a result of indicator monitoring) including increased patient education, the production of information leaflets, establishment of pre-anaesthetic clinics, alteration of surgical techniques, introduction of drug trials and numerous policy changes.

Introduction

In 1995 Ira Rutkow wrote that ‘ambulatory surgery is one of those rare socio-economic political movements in which all participants have benefited as demonstrated by public interest and demand, surgeon satisfaction, patient participation and most importantly, payer encouragement and mandate’ [1]. However, there is no mention of quality in this statement and as the number, variety and complexity of day procedures increase it is clearly important to ensure the maintenance (and improvement) of the quality of care given. This issue has been addressed by the Australian Day Surgery Council (ADSC) and the Australian Council on Healthcare Standards (ACHS) Care Evaluation Program (CEP) in the development and implementation of a set of performance measures or clinical indicators [2]. They now form part of the larger program of the ACHS CEP and the medical colleges which has seen the introduction of 15 sets of clinical indicators into the Evaluation and Quality Improvement Program (EQuIP), the new accreditation process of the ACHS [3]. This has enabled the establishment of a ‘national’ database reflecting the quality of medical care. It is unique in its provider (medical college) involvement and the wide range of conditions and procedures addressed [4].

Clinical indicators are defined as measures of the management and/or outcome of care whose purpose is to act as flags of possible problems in patient care.

Section snippets

Clinical indicators for day procedures

Five generic indicators have been developed reflecting access and efficiency of booking, appropriateness of patient selection, safety of anaesthesia and surgery and discharge planning. They are:

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Failure of booked patients to arrive
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Cancellation of the procedure after arrival
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Unplanned return to the operating room
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Unplanned overnight admission
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Unplanned delay in discharge greater than 6 h.

The indicators were introduced in 1996 for health care organisations undergoing an accreditation survey in that

Validity of clinical indicator data

The CEP exercises no control over or direction on the methods for data collection used by the participating health care organisations. However, being provider developed the indicators have face validity and content validity in that they measure performance in aspects of care identified by the medical colleges as directly relevant to quality. As the number of contributing organisations increases, variation by any one organisation has less influence on the aggregate rate and therefore the

Responsiveness of the clinical indicators

Kazandjian and co workers in the Maryland program of indicators have commented that the ‘responsiveness’ of an indicator, that is its ability to induce action in facilities monitoring the indicator, is the best index of its value [14]. It was pleasing to note that 64% of the facilities monitoring these indicators took some action after reviewing their results.

The types of action taken related to: patient education, e.g. advice about fasting and cessation of certain drugs; information leaflets,

Conclusion

There has been good facility acceptance of the indicators. The overall standards of care as reflected by the indicators appear to be satisfactory, with free standing facilities in particular performing well. The indicators have proven to be responsive and as a result there is documented improvement in patient management. We can, in time, expect improvement in outcomes to be documented.

Acknowledgements

The ACHS gratefully acknowledges the financial support of the Commonwealth Department of Health and Family Services and the cooperation of the Australian Day Surgery Council working party in the development of the indicators. Gratitude is also expressed to the 240 individual Healthcare organisations contributing data to the ACHS Care Evaluation Program.

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The monitoring of quality parameters in day-case surgery has been a useful tool in our clinical and quality management. Globally, the unplanned transfer and cancellations have been within the quality standards and many of the indicators analysed have improved.
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Citation Excerpt :
In recent literature, even today, far fewer studies are made into the quality and efficiency of the services rather than those concerning clinical aspects of day surgery. In this sector there is almost a complete absence of large scale report trials, and the only systematic initiative is that set up in 1996 by the Australian Council on Health Care Standards (ACHCS) on D.S. the results of which are now being published.6,7 In 1996, five defect signals were introduced for day surgery accreditation.
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  Data collection of complication
- •
  Data collection for infections
- •
  Quality rating questionnaire
- •
  Follow up
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  Information leaflet for day surgery
- •
  Meetings with nursing staff.
The study was carried out by comparing data from the period 2003–2006. The activity of general surgery includes: general, breast, plastic and vascular. From 2003 to 2006 day surgery activity increased considerably, partly due to good organization and partly because it has been favourably received by the population.
During the period 2003–2006, 1835 operations were carried out in day surgery. The percentage of operations in D. S. compared to the total activity of Surgery Division I, demonstrates a gradual increase from 18.7 to 32%. In the last few years, some changes have been introduced in day surgery:
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From research to clinical practice an interdisciplinary project of day surgery anaesthesiological course: From preoperative evaluation to patient discharge
2008, International Journal of Surgery
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Some parameters have been collected systematically only from 2006. Comparing data collected by the Australian Council of Health Care Standards (ACHCS) in order to measure quality and efficiency of the service delivered by Day Surgery we can safely state that our organisation model and the quality of our performance are in line with international standards for what concerns intraoperative and discharge phases, whereas there is room for improvement in the preoperative phase, confirming that day surgery is a practice with a small incidence of major complications but with a high incidence of organisational defects.10 Day Surgery is an important organisational model which has established itself more and more not only for cost containment (although important for a Health Service lacking resource) but also because it enables to deliver a high quality standard of care fulfilling social and cultural needs of nowadays.
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Day surgery: Where do our efforts need to be focused?: Results of a review and simulation on administrative data
2004, Ambulatory Surgery
Citation Excerpt :
Indeed, several factors could reduce the implementation of day surgery in practice. It has been recognised that organisational factors play a crucial role in facilitating or limiting day surgery [10,11]. Other variables have been also identified in which patients’ clinical conditions [12], anaesthetist and surgeon skill [13–15], patients’ preferences [3,16], quality of care outside the hospital [17] and, obviously, the specific type of procedure involved [17].
Study objective: First, to appraise the utilisation of day surgery in an advanced Italian region. Second, to identify which surgical procedures, among those rarely performed in day surgery, can be effectively performed without ordinary hospitalisation. Design: Retrospective analysis of hospital discharge records related to all the 683,615 surgical interventions performed in Lombardy in 1998. Review of the last 10 years literature supporting or undermining the practicability of day surgery for the 262 procedures that, although performed at least once in day surgery, overall rarely performed in such a way. Main results: While as many as 1189 procedures out of 2140 (56%) were performed at least once in day surgery, the overall percentage of surgical interventions performed in this regimen was only 15.6%. The review of the literature yielded 41 procedures regarded as effectively performable in day surgery. We calculated that an absolute increment of day surgery of 20% in only these procedures would produce an increment of 5% in the overall prevalence of day surgery. Conclusion: Health policies aimed at reducing the length of hospitalisation after surgery can be effective even by focusing on a tiny set of procedures. Analysis of administrative data could provide useful steering hints for policy makers.
Clinical indicators to evaluate quality in ambulatory surgery
2004, Cirugia Espanola
El estudio muestra la gestión de calidad que se lleva a cabo en una unidad de cirugía ambulatoria multidisciplinaria mediante la monitorización de determinados indicadores.
Mediante el análisis de las bases de datos de la unidad de cirugía ambulatoria y los datos proporcionados por la administración del hospital, se han estudiado 9 indicadores: a) ingresos inmediatos; b) ingresos tardíos; c) relación de intervenciones suspendidas o canceladas; d) morbilidad mayor; e) morbilidad menor; f) infección de herida; g) estado del enfermo a las 24 h de la intervención; h) grado de satisfacción, e i) índices de sustitución. Las bases de datos con más de 8.000 pacientes se han creado con el programa Stat View 5.0.1. Se ha llevado a cabo un estudio estadístico descriptivo.
a) Ingresos inmediatos: 2,2%; b) ingresos tardíos: 0,55%; c) intervenciones suspendidas o canceladas: 1,9%/1,6%; d) morbilidad mayor: 0,025%; e) morbilidad menor: 11,3%; f) infección de herida: 1,3%; g) estado del enfermo a las 24 h: excelente o bueno en el 98,6%; h) grado de satisfacción: 84,4%, e i) índice de sustitución global del hospital en 2003: 16,3%. El análisis de estos indicadores a lo largo del tiempo permite observar una mejora de los porcentajes de ingresos no deseados, un incremento de las intervenciones suspendidas, una estabilización de la morbilidad, una mejora del estado del enfermo y del grado de satisfacción, y un lento incremento de los índices de sustitución.
La validez de los indicadores empleados está en función de su capacidad para inducir modificaciones tendentes a su corrección. Los indicadores con mayor utilidad para la monitorización son: cancelación de procedimientos; acontecimientos adversos; ingresos no deseados, y grado de satisfacción de los pacientes.
This study describes quality assessment in a multidisciplinary day surgery unit through the use of clinical indicators.
The unit’s databases and the hospital’s general database, made available by the hospital’s administration, were used to study 9 different indicators: a) hospital admissions; b) hospital readmissions; c) the ratio between suspended procedures/ canceled procedures; d) major complications; e) minor complications; f) wound infection; g) patient comfort 24 hours after the procedure; h) patient satisfaction, and i) substitution indexes. The databases of the day surgery unit, with more than 8.000 patients, were constructed using the Stat View 5.0.1 program. A descriptive statistical analysis was performed.
a) Hospital admissions: 2.2%; b) hospital readmissions: 0.55%. c) ratio between suspended procedures/ canceled procedures: 1.9%/1.6%; d) major complications: 0.025%; e) minor complications: 11.3%; f) wound infection: 1.3%; g) patient comfort 24 hours after the procedure: excellent or good in 98.6%; h) patient satisfaction: 84.4%, and i) substitution index in 2003: 16.3%. Analysis of these indicators over time allowed us to observe improvement in the percentage of unexpected hospital admissions, an increase in the number of canceled procedures, a stable rate of complications, improvement in patient comfort and satisfaction, and a small increase in substitution indexes.
The validity of clinical indicators used in ambulatory surgery depends on their ability to induce changes to improve the quality of care provided. The most useful indicators to monitor day surgery units are cancellation of booked procedures, the incidence of adverse events, unexpected hospital admissions, and patient satisfaction.

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Clinical indicators for day surgery

Abstract

Introduction

Section snippets

Clinical indicators for day procedures

Validity of clinical indicator data

Responsiveness of the clinical indicators

Conclusion

Acknowledgements

J. Clin. Anaesth.

International comparison of ambulatory surgery: status in the United States

Chirurg

Healthcare performance measurement systems and the ACHS care evaluation program

J. Qual. Clin. Pract.

A national clinical database: issues of reliability and validity

Aust. Health Rev.

Hospital admissions from the surgical day care centre of Vancouver general hospital 1977–1987

Can. J. Anaesth. 37

Postoperative hospital admission from a day surgery unit: a seven year retrospective survey

Anaesth. Intens. Care