Day Surgery: Contemporary Approaches to Nursing Care - Brossura

Brossura

ISBN 10: 0470319844 ISBN 13: 9780470319840

Casa editrice: John Wiley & Sons Inc, 2009

Riassunto

The evolution of day surgery has heralded a new era of medical, anaesthetic and nursing knowledge, skills and practice. Day Surgery: Contemporary Approaches to Nursing Care explores the familiar concepts within nursing, such as evidence-based practice, patient-centred communication, management, practice development and models of care, and uses these theoretical constructs to provide a comprehensive overview of contemporary services and nursing approaches within day surgery. This book is written with the intention of providing nurses working in day surgery with a comprehensive applied text that can be used as a reference when caring for patients.

Day Surgery: Contemporary Approaches to Nursing Care:

• Provides a comprehensive overview of nursing approaches in day surgery
• Utilises models of care
• Includes evidence based practice
• Provides practical advice on management of day surgery services including setting up and implementing nurse led services in the area.

Su questo libro

Informazioni sull?autore

Fiona Timmins is an Associate Professor at the School of Nursing and Midwifery, Trinity College Dublin, Ireland. Her research interests include professional nursing issues, nurse education, spirituality and reflection. Catherine McCabe is the author of Day Surgery: Contemporary Approaches to Nursing Care published by Wiley.

Day Surgery: Contemporary Approaches to Nursing Care:

• Provides a comprehensive overview of nursing approaches in day surgery
• Utilises models of care
• Includes evidence based practice
• Provides practical advice on management of day surgery services including setting up and implementing nurse led services in the area.

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Day Surgery

Contemporary Approaches to Nursing CareBy Fiona Timmins Catherine McCabe

John Wiley & Sons

Copyright © 2009 Fiona Timmins and Catherine McCabe
All right reserved.
ISBN: 978-0-470-31984-0

Chapter One

Introduction to Day Surgery

Phillipa Ryan Withero

Historical background

The evolution of day surgery has heralded a new era of medical, anaesthetic and nursing knowledge, skills and practice. Surgical techniques and technological advances coupled with developments in anaesthetic approaches have contributed positively and significantly not only to the initial but ongoing developments within the field of day surgery, which today accounts for 50-80% of all surgical procedures. The international drive to increase day surgery rates is grounded in the well articulated benefits including: reduced demand for overnight or weekend staff, hence reduced costs; more rapid throughput of patients; reduction in the number of patients on waiting lists and reduction in the number of patients who fail to attend for surgery. Potential problems associated with surgery (post-operative nausea, vomiting or pain), responsibility for which may fall within a self-care remit or entail an increased burden on community services, require attention to ensure that day surgery services appropriately address these requirements. The political, economic and policy-driven demands for greater bed utilisation, value for money and cost containment measures have influenced the expansion and development of day surgery throughout its history.

The growth of day surgery, albeit a substantial one, is not a new concept. In the early stages of nursing, its founder, Florence Nightingale, noted that patients should not stay a day longer than is absolutely necessary in all hospitals and in particular children's hospitals (Nightingale 1914). In recognising the significant value a shorter hospital stay has for the patient, her opinion was not based upon economic or political perspectives, but on reducing the possibility of patients contracting further illness or diseases as a result of hospitalisation.

One of the earliest references to day surgery is that of the now landmark publication by Dr Nicoll in the British Medical Journal in 1909. Nicoll outlined his ten-year surgical experience of performing 8988 day surgery procedures at a Glasgow outpatients clinic for sick children. Over half of the children were less than three years old. The procedures included treatment of cleft palate, hare lip, hernias, talipes and mastoid diseases. Nicoll disapproved of hospitalisation and was adamant that children should return to their nursing mothers as early as possible. Even at this early stage of day surgery, he drew attention to the necessity for suitable home conditions in addition to General Practitioner (GP) support, a feature that was reiterated in 1955 by Farquharson.

In 1916 Ralph Waters wrote about his establishment of a free-standing anaesthesia clinic in Iowa, providing day surgery for dental and minor surgery cases. The revolution had begun. Hospital-based ambulatory units were developed in 1959 by Webb and Horace in Vancouver, in 1962 by Cohen and Dillon in Los Angeles and in 1970 by Levy and Coakley in Washington. The first successful free-standing ambulatory facility was established in 1969 by Ford and Reed in Arizona (Epstein 2005).

The day surgery revolution within the United Kingdom (UK) was slower to progress since first being mooted by Nicoll in 1909. It was not until over 50 years later, in 1960, that the first stand-alone day surgery unit within a hospital in the UK was developed at Hammersmith (Calnan and Martin 1971). In response to the evolution of day surgery, the Royal College of Surgeons in England published Guidelines for Day Surgery in 1985, based upon a working party report which stated that day surgery was the best possible option for 50% of all patients undergoing surgical procedures electively. At the time of the report the national average for day surgery was as low as 15%, despite Palumbo et al. (1952) outlining the possibility of greater bed utilisation owing to a shorter length of stay.

In 1989 the British Association of Day Surgery was established with a multidisciplinary membership, recognising the necessity for quality in the delivery of day surgery and the potential benefits, not only for patients but for the health service. Key drivers for day surgery within the UK were a number of pivotal reports published over a short period of time, which brought into intense focus the proliferation of day surgery units and facilities within the National Health Service (NHS). The first of these, the Bevan Report (1989), was undertaken by the NHS Management Executive Value for Money Unit. Support for day surgery expansion was indicated, given the significant impact it would have on waiting lists and financial costs. In 1990 the Audit Commission, an external auditor for the NHS, published A Short Cut to Better Services. This report is now recognised as one of the major catalysts for the development and advancement of day surgery within the UK. It examined the expansion of day surgery within England and Wales, concluding that the rate of expansion was slower than anticipated; it also identified significant variances in day surgery between health authorities. A consequence of the report was the introduction of what became known as the 'basket' of 20 common procedures - still in use today - that could be performed as day surgery cases. The rationale for the introduction of this 'basket' of procedures was to develop uniformity and limit the variance in day surgery procedures across the health service, with a view to improving cost-effectiveness by increasing the number of patients that could be treated as day cases. The Audit Commission also reported on possible barriers to the growth of day surgery, such as lack of facilities, poor management structures and a preference for traditional approaches, and suggested methods to overcome them.

Building on the Audit Commission report, in 1991 the Value for Money Unit published Day Surgery: Making it Happen. This report focused on the design, practice and management of day units, outlined recommendations on staffing, training and quality, and highlighted the financial rewards for the NHS. Also in 1991 the Audit Commission reported on day surgery from the patient's perspective: their investigation found that 80% of patients preferred day case surgery, with 83% recommending this approach to a friend. This report reinforced awareness of acceptance of day surgery by patients, thus justifying the continued expansion of this approach to surgery.

One of the motivating factors for the expansion of day surgery was clearly the resultant financial rewards for the NHS, although significant funding for the establishment of day surgery facilities would first be required. In recognition of the financial implications, a regional task force to oversee investment was established in the early 1990s. The task force produced a toolkit for managers and clinicians as an aid for the establishment and review of day surgery facilities, and set a target of 50% for all elective surgery as day case procedures. Despite significant investment, the report of the task force in 1993 revealed that few proposals had been implemented, with considerable variation in progress towards meeting the 50% target across the NHS, and raised the target to 75%. Not surprisingly, in 2001 the Audit Commission confirmed that no service was achieving 75%, with a number of units not being utilised to maximum capacity. Consequently, 31 million was invested from the Funding treasury Capital Modernisation in order to achieve the target of 75%. In conjunction with the launch of the Day Surgery Strategy in 2002, the Day Surgery Operational Guide was published in order to support the drive towards achieving the target of 75% and the Department of Health's commitment to this strategy was evidenced by the inclusion of day surgery for inpatient stays as one of the NHS Modernisation Agency's '10 High Impact Changes'.

By 2003 the Healthcare Commission was created and given the authority to take over responsibilities from other commissions, including the Audit Commission. In a review of the acute hospital day surgery portfolio in 2005, the Healthcare Commission reported that variability in the organisation of day surgery continued to exist. Determining the overall achievement of the 75% target proved difficult as a result of this variability. The report concluded that support for increased capacity and measures to improve the level of uptake of day surgery should be continued.

Approaches to day surgery development vary within the developed world. The Republic of Ireland (ROI), for example, although in close proximity to the UK, presents a very different picture in terms of progression and innovation: the motivation towards an increase in day surgery rates in ROI was much slower and less well defined. The reasons for this are multifaceted and include complex factors related to gross under-funding of the health system in addition to organisation, management and structure of the health system itself. In 1980 day surgery rates were as low as 2%, which is not surprising given that the number of day surgery beds recorded for that period was just 26 (DOHC 2002). In the period between 1980 and 2000, this figure increased to 562, with a subsequent increase in overall activity from 2% to 38%. The low level of day surgery rates in Ireland in the 1980s was indicative of significant under-funding of services during this period. The 1990s saw a period of reform in which the Irish healthcare system was struggling to compensate for the investment deficit of the 1980s. The most significant increase in day surgery rates occurred during the decade 1990-99, when figures rose from 20% of total activity to 38% (DOHC 2002). Much of the early developments and achievements can be attributed to the health strategy of 1994, 'Shaping a Healthier Future' (DOHC 1994).

One of the earliest references promoting the advancement of day surgery in ROI was made by the Report of the Commission on Health Funding (1989), which highlighted the cost-effectiveness of increased bed utilisation in the context of the lengthy waiting lists which were a feature of healthcare at this period. Concluding that an improvement in the utilisation of hospital beds as a result of day surgery would positively impact on waiting lists, the report recommended the development and implementation of a 'casemix' funding approach, which would lead to a rapid move towards the provision of surgery on an outpatient or day ward basis. This recommendation was a major catalyst in the development of day surgery in Ireland: funding was awarded on the basis of increased bed utilisation and activity and the National Casemix programme was instituted in 1991 (DOHC 2004). A national review of the casmix programme in 2004, 12 years following its institution, concluded that 95% of all acute inpatient and day-case hospital admissions were participating in the national casemix programme, with 20% of the activity related funding for the hospitals being casemix dependent (DOHC 2004).

In a number of governmental reports, which strengthened efforts to progress day surgery by reinforcing the benefits of this approach, a common theme was the absence of clearly defined national targets for day surgery rates in Ireland. The impetus for improvement in day surgery rates appeared to rely on the motivation to procure additional funding through the casemix programme, based upon day surgery performance activity rates. The 1994 health strategy, 'Shaping a Healthier Future', outlined the significant increase in day surgery rates, from 15% in 1987 to 25% in 1993, and indicated the expected rise in this trend for the years ahead. Specific, quantifiable targets for improvement in day surgery rates were not, and are still not clearly articulated, with performance assessment based solely upon the impact on hospital waiting lists.

Healthcare waiting lists endured as a constant feature within the Irish healthcare system. In 1998 the report of the review group on the waiting list initiative recommended a continued move towards day case work (DOHC 1998) and proposed a close examination for the provision of standalone day surgery units on acute hospital sites in order to address the number of patients on waiting lists between 1999 and 2001.

Acknowledged within the report was the necessity, as a matter of urgency, to review and address the capacity of acute hospitals. The contentious issue of hospital capacity is one that was mirrored by the value for money audit of the Irish healthcare system by Deloitte and Touche (DOHC 2001a). The audit, commissioned by the Department of Health, concluded that although day surgery rates were improving, overall capacity of the acute hospitals was adversely affecting bed utilisation in addressing the significant waiting list. Utilisation of day surgery beds for inpatient care was a becoming a common feature as a direct result of capacity issues within the acute hospital sector. The publication of the health strategy Quality and Fairness (DOHC 2001b) sought to address these issues. This report focused on equitable access to service and set as one of its targets an increase in proportion the number of one-day procedures. Although it did not quantify this increase in terms of a national target, it did recommend the establishment of a National Treatment Purchase Fund, whereby patients on the public waiting list could avail themselves of treatment purchased by the state from private hospitals. Since its establishment in April 2002, the NTPF has facilitated 120,000 cases/people (www.ntpf.ie accessed September 2008). The impact on the public service has been to relieve the capacity crisis by reducing the number of day-case beds being inappropriately used as inpatient beds, so reducting the number of patients on hospital waiting lists. The organisational and structural components of the health system also required attention in order to drive these changes.

The Health Service Reform Programme (DOHC 2003) outlined the structural changes that were necessary in order achieve positive improvement in healthcare delivery in Ireland. These included rationalisation and reorganisation of the existing health service agencies to reduce fragmentation, and the establishment of a Health Service Executive on the basis of three core divisions: a National Hospitals Office; a Primary Community and Continuing Care Directorate; and a National Shared Services Centre. The National Hospitals Office is now charged with the responsibility for the management of the acute hospitals sector.

As a result of these reports, strategies and reforms, the number of day-case procedures in Ireland has continued to rise annually, from 357,676 cases in 2001 to 448,676 cases in 2003 (DOHC 2005). The importance of governmental policy in supporting the development of day-case approaches to surgery should not be underestimated. Advances in anaesthesia, surgical technique and nursing care in day surgery require significant financial, managerial and organisational support, not only at a high level within an organisation but also at governmental policy level, in order to establish a coordinated and committed approach. Although the rate of development of day surgery care may vary between countries and within national health care provision, what is important is the obvious benefit not only for providers but also for patients.

Overview of services

Day surgery services are constantly evolving and are delivered in a variety of ways in a variety of units. In order to gain the insight required to interpret them in detail, it is pertinent to examine specifics such as how and where services are delivered and levels of patient satisfaction achieved; definitions, terminology, structure, organisation and delivery of day care also require exploration.

Traditionally day surgery is defined as the same-day admission and discharge for a planned surgical procedure whereby the patient has made a complete recovery from their procedure. The patient may undergo a pre-assessment procedure whereby their suitability for day surgery will be assessed. The term 'ambulatory surgery' is used interchangeably to describe the same process. There are a variety of ways to provide ambulatory/ day surgery services, each with its advantages and disadvantages.

(Continues...)

Excerpted from Day Surgeryby Fiona Timmins Catherine McCabe Copyright © 2009 by Fiona Timmins and Catherine McCabe. Excerpted by permission.
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Dettagli dell'edizione

• Editore: John Wiley & Sons Inc
• Data di pubblicazione: 2009
• Lingua: Inglese
• ISBN 10: 0470319844
• ISBN 13: 9780470319840
• Rilegatura: Copertina flessibile
• Numero edizione: 1
• Numero di pagine: 179
• Redattore: Timmins Fiona, Mccabe Catherine
• Contatto del produttore: WROX; https://www.wiley.com/en-us; ; 111 River Street; Hoboken; NJ; 7030; U.S.A.
• Persona responsabile: non disponibile