Day Surgery Unit, TQEH

The Day Surgery Unit is located at The Queen Elizabeth Hospital. It provides same-day surgical procedures for patients who do not require an overnight hospital stay. This article explores the early history of the Day Surgery Unit from 1992-2007.

Beginnings

The Day Surgery Unit opened on 10th November 1992. It was situated on the sixth floor of the Maternity Building, using the existing maternity theatres and labour wards. These were redesigned and renovated, resulting in the redevelopment of a very attractive, self-contained area.

The unit was geographically located BUT functionally separate from the main hospital – autonomous in management and function.  Co-located within the unit were clerical admission and discharge, waiting areas, operating theatres, procedural areas, post-anaesthesia recovery, stage 2 recovery (armchair) area, pre-anaesthetic clinic and offices.  Departments needed to support the Day Surgery Unit were:

• Medical Records,
• Central Sterilising Department,
• Pharmacy, and
• Stores (by an imprest system).

Initially, the unit was open from 0700 to 1630 hours, Monday to Friday.  This time was increased gradually from 0700 to 1830 hours.

The Unit was staffed with:

• Consultant Anaesthetist (who was Medical Director),
• Clinical Nurse Manager,
• Registered Nurses (with experience in the operating theatre, anaesthetic and post-anaesthetic nursing),
• Nurse Attendant (with CSSD training), and
• Dedicated clerical staff.

At the time of opening, the Day Surgery Unit was the only free-standing unit in South Australia.  One other Day Surgery existed in Ashford Private Hospital. However, it included only the post-anaesthesia area, as the general theatre suite was used for surgery.

Philosophy

The philosophy of the Day Surgery Unit was to provide high-quality, focused care in a safe environment, where patients were admitted, recovered, and discharged on the same day.

Advantages to the hospital were also numerous: It reduced the number of acute care beds required, enabled better control of admissions, and resulted in cost savings by allowing for facility reorganization. Surgeons could plan and utilize their time more efficiently, and there was the potential for more flexible work arrangements and higher employee morale. Staff and facilities were not required during the hours that attract penalty rates of pay (ie evening/night, weekends and public holidays). Moreover, day surgery allowed treatment of large numbers of patients at a lower cost than inpatient treatment for the same conditions.

Advantages to the patient included:

1. Early post-operative ambulation was important for respiratory and cardiovascular functioning, reducing the risk of thrombo-embolism;
2. Provision of a high level of safety, including a lower incidence of hospital-acquired infection compared with the inpatient rate;
3. Reduced psychological stress;
4. It was promoted as simple, controllable and convenient with a faster return to daily routine, involving less disruption to the family, less working time and wage loss and the ability to assume greater self responsibility for health needs;
5. Day surgery could reduce the complications that may occur if the patient has a long wait for elective surgery; and
6. Cost savings for the patient could be substantial, compared with the costs for the same surgery performed on an inpatient basis – time, travel and sometimes accommodation were needed for relatives visiting inpatients.

Ophthalmology

When the Day Surgery Unit opened, the primary surgical specialty of the unit was ophthalmology. Within a period of six weeks, the unit had successfully completed more than 230 surgical procedures.

During the initial stages of its opening, Dr Richard Mills, Head of Ophthalmology, managed to perform up to 12 procedures each day. This figure was twice the number that was previously achievable in the same time frame.

In February 1993, the surgical unit commissioned its second operating theatre, expanding its capacity to accommodate more procedures. By the end of the same year, the unit had successfully completed 1000 surgical procedures across various selected specialties, thereby reducing waiting lists.

Surgical Procedures

• Ophthalmology – cataract extraction and insertion intra-ocular lens, other ophthalmic procedures;
• Gynaecology – laparoscopy (sterilisation), curettage/hysteroscopy – diagnostic and therapeutic, laser surgery, urodynamics;
• General Surgery – minor procedures (vasectomy, carpal tunnel etc), hernia repair;
• Colo-rectal Surgery – colonoscopy, haemorrhoidectomy and other surgical procedures, anal manometry, rectal bleeding clinic;
• Gastro-enterology – upper GI endoscopy, colonoscopy;
• Orthopaedics – arthroscopy knee, ACL Reconstruction (required overnight stay);
• Plastic Surgery;
• Urology – flexible cystoscopy;
• Vascular – varicose vein surgery;
• ENT – day stay tonsillectomy, laser palatoplasty, minor ear surgery;
• Dental – extractions requiring general anaesthesia; and
• Haematology – bone marrow aspiration.

By 2007, the Day Surgery Unit performed over 4,800 procedures annually (50 weeks), averaging 380 procedures a month (Monday to Friday 0700 to 1830 hours). The unit closed for two weeks over the Christmas period.

National Demonstration Hospitals Programme

In 1995/1996, the Professor of Surgery, Professor Guy Maddern, organised a working party to meet over the Christmas break and prepare a submission for The Queen Elizabeth Hospital and Day Surgery in particular, to apply to be part of the National Demonstration Hospitals Programme.

Fifty-five public hospitals in all Australian States and Territories participated in the first two phases of National Demonstration Hospitals Program (NDHP). The program was established in 1994 as part of a commitment by the then Department of Health and Family Services to reduce waiting times and improve health outcomes for patients.  The program uses a collaborative approach to assist public hospitals to improve service delivery and patient care outcomes. Key results from Phases 1 and 2 of the NDHP have confirmed that identification of industry best practice, collaboration, knowledge sharing and innovation are key elements required to achieve positive health care reforms.

Australian Health Review Vol 23 No 4 2000 – Amanda Alexander (pge 198-204)

The Queen Elizabeth Hospital Day Surgery Unit successfully joined this programme as a lead hospital. It established networking and collaborative relationships with eastern states hospitals, especially St George and Coffs Harbour hospitals. As part of the programme, there were many visits from other collaborative hospital clinical staff to The Queen Elizabeth Hospital Day Surgery Unit.

The NDHP was allocated funds from the 1993-94 Commonwealth Budget to address clinically inappropriate waiting times for elective surgery. $11 million was allocated to NDHP-1 and $7.5 million to NDHP-2.

Australian Health Review Vol 23 No 4 2000 – Amanda Alexander (pge 200)

The funding that the Day Surgery Unit was allocated from the programme assisted in purchasing extra equipment and replacement equipment as needed.

Day Surgery Unit Personal (1992-2007)

Director: Dr Ashim Sen MB, BS (Cal), DA, (RCP&S), FFA(RCS), FANZCA. A graduate of Calcutta University, India 1964. Anaesthetic training in London. DA (Lond) from the Royal College of Physicians and Surgeons in 1968 and FFARCS (England) in 1971. 1971 –73 Dr Sen was a senior register and staff specialist in England and then Australia. Appointed as Staff Specialist at The Queen Elizabeth Hospital in February 1974 and Director of Day Surgery in July 1992. Elected as a Fellow of the Australian College of Anaesthesia (FFARACS) in 1977 – now known as FANZCA.

Clinical Nurse Consultant (Manager): Robyn Johnston OAM, FCNA. A graduate of The Queen Elizabeth Hospital in 1975, and completed a Certificate in Operating Room Nursing in 1979. Between 1982 and 1987, she held various senior nursing positions in the Operating Theatres Suites at Hutt Street Private and Wakefield Memorial Hospitals. In 1987-1989, she was appointed Lecturer in Nursing at Flinders University. In December 1991, she was appointed The Queen Elizabeth Hospital Nurse Educator, Operating Room Nursing Course and Clinical Nurse Consultant of Day Surgery Unit, October 1992. Postgraduate studies: Diploma in Applied Science (Nursing) and a Bachelor of Nursing at Flinders University. She is also a Fellow of the College of Nursing Australia. During her tenure, Robyn was a founding member of the Day Surgery Nurses Association, a member of the SAHC Day Surgery Working Party and a committee member of the SA Perioperative Nurses Association. Presentations include: Moderator at AORN International Conference 1984 Adelaide, Inaugural Nursing Practice Conference at the Royal Adelaide Hospital 1995 ‘ Perioperative Nursing – a Day Surgery Focus’, 11th World Congress of Anaesthesiologists, Sydney, 1996 ‘Economics and Quality in Ambulatory Anaesthesia – Pushing the Limits: Facility’, Managed Surgical Care Conference at The Queen Elizabeth Hospital 1999, ‘Day Surgery – Is it cost-effective?’, Third National Surgical Nursing Conference 2001 Adelaide ‘Proud to be a perioperative Nurse’, Presentations at SA Perioperative Nurses Conferences, 5th Day Surgery Conference March 2002, Managed Surgical Care: An Australian Best Practice Model.

General Staffing: The Nursing staff were all Registered Nurses with specialty areas of expertise in Intensive Care, Recovery, Operating Room and Anaesthetics. Clinical skills need by Day Surgery Unit Nurses:

• Good Communication Skill
• Counselling Skills
• Adaptability
• Creativity
• Problem Solving Ability
• Educational Skills
• Patient Assessment Skills
• Understanding of Surgical Procedures and Outcomes
• Knowledge of:
  • Scrub and Circulating Nurse Duties
  • Aseptic Technique
  • Post-Anaesthesia Criteria
  • Anaesthetic Drugs and Techniques
  • Equipment and New Technology

General Patient Information

After attendance at the Outpatient Department or doctors’ private rooms and determination of suitability for Day Surgery, patients were booked by the Operating Surgeon for the appropriate operating list.
Information needed at booking included:

1. Patient name and address
2. Patient date of birth and sex
3. Patient UR Number (if known)
4. Diagnosis and Surgical Procedure
   During the appointment, the surgeon obtained the patient’s operative consent and provided them with an information booklet. The Day Surgery Unit forwarded the consent to the Outpatient Department and the Surgeons’ rooms and scheduled the patient for the next available operating list.

Urgent procedures were undertaken as soon as possible. Except for the Plastics and Ophthalmic Surgery lists, the Day Surgery Unit maintained the operating lists and booked patients from the Day Surgery Unit waiting list.

Patients referred directly from GP Rooms for the Rectal Bleeding Clinic were seen by a Consultant Colo-rectal surgeon within two weeks.

All patients who required a general/sedation-type anaesthetic attended a pre-anaesthetic clinic, where possible. A Registered Nurse and Anaesthetist clinically assessed the patient and checked their home resources during the clinic. These clinics were held every afternoon, and patients were typically booked one week before surgery. Patients who underwent general or sedation-type anaesthesia were required to have an escort home and a responsible adult to stay with them on the first night following the surgery. Occasionally, patients with insufficient home/social resources required the support of a GP or Hospital at Home services.

The Day Surgery Unit was available to both Public and Private Patients. Private patients were charged a fee for bed only – no theatre fee.

Patient admission times were made for approximately one hour before the Surgical Procedure. A follow-up appointment was made before discharge from the unit, as appropriate. A set of detailed discharge instructions were given to the patient before leaving. The nursing staff called the patient the next day to check on post-operative progress and answer any questions.

Patient Journey

On arrival at the unit, patients were greeted by clerical staff who completed the necessary paperwork required for admission. The patient was then escorted to a waiting area, and nursing staff conducted a clinical admission and assessment. Relatives were encouraged to leave as the area was not very large. The patient was then asked to change into appropriate hospital attire. Within the waiting area, there was a television which was generously donated by the Woodville Uniting Church.

At the appropriate time, the patient was escorted to the operating theatre by a nursing member of the operating team. The surgical team performed the necessary check procedures, which included verifying the correct patient, identification (UR Number), consent, allergies, and the correct procedure type.

After the surgery, the patient was taken to the post-anaesthesia recovery area, either Stage 1 or Stage 2, where registered nurses kept a close eye on them. The Stage 1 area was for patients who had undergone general, neuroleptic, or sedation anaesthesia, and they stayed there for 45 minutes or until they were clinically stable. The Stage 2 area had 20 reclining chairs, where patients were provided with food and fluids before being discharged. They were encouraged to wear their own clothing as soon as possible to help them return to normal. The volunteer group ‘Friends of The Queen Elizabeth Hospital’ assisted the nursing staff in this area by providing refreshments and talking to patients as needed.

When clinically suitable for discharge, the escorting person was contacted to come to the Day Surgery Unit to collect the patient. For certain procedures, it was mandatory for the patient to be accompanied home and have a caregiver present for 24 hours.

Patient Discharge

The nursing staff of the Day Surgery Unit carried out extensive research over ten months using Modified Discharge Criteria developed by Rebecca Twersky, MD, a pioneering anaesthetist in day anaesthesia. This led to implementing these criteria, allowing patients to be discharged as early as one hour after leaving the operating theatre. The research was presented to the Consultant Anaesthetists and Surgeons, and it enabled nurse-initiated discharge, thereby enhancing the unit’s efficiency.

Moreover, the unit collaborated with other departments at The Queen Elizabeth Hospital, such as the Convalescent Ward, which provided overnight care/admission for post-surgery patients, and the Hospital at Home, which visited patients in their homes on an as-needed basis. These initiatives expanded the unit’s scope, extending patient selection criteria, which further helped to reduce waiting lists for some surgical procedures, including those performed in Day Surgery.

Future of Day Surgery

Although this article focuses on the period between 1992 and 2007, it should be noted that The Queen Elizabeth Hospital Day Surgery Unit continued to progress and adapt to the changing surgical, medical, and technological advancements. The number of day surgeries performed at the unit continued to increase. Looking ahead to 2024, a new era for The Queen Elizabeth Hospital is set to begin with the opening of a new Clinical Services Building that will include a dedicated day surgery suite.

Written by Robyn Johnston, CALHN Health Museum Volunteer and former Day Surgery Unit Clinical Nurse Consultant