Reports

This report deals with the identification of national and facility-specific barriers for the development ambulatory surgery in Hungary. For clarity this report will include the use of the terms ambulatory surgery and day surgery interchangeably. The International Association for Ambulatory Surgery (IAAS) has standardised on using the term ambulatory surgery but many countries including Hungary use the term day surgery. Clinical colleagues from HAAS have asked that the term day surgery is used where possible hence this term will be used where appropriate.

A questionnaire was developed to assess national barriers to the development of day surgery. Local barriers were assessed by the use of a further questionnaire that assessed the facilities and organisational structure for day surgery in the 8 hospitals taking part in the programme. This questionnaire was backed by representatives of IAAS and HAAS performing hospital visits – the results of those visits are part of a separate report. However, local barriers identified during these interviews with clinical and management staff are included in this report where appropriate.

An over view of findings and recommendations included

• suggestion to update the Hungarian definition of day surgery to bring in line with international definition by removing inclusion of overnight stay.
• in the short term hospitals should look at what is feasible within their current facilities in developing day surgery – international team emphasised that hospitals should not wait for new facilities
• in the medium term the design and provision of suitable facilities is to be encouraged
• importance of training for staff involved in day surgery in free-standing day surgery units to ensure patient safety
• importance of formal transfer agreements form free standing units to hospitals when patients cannot be discharged
• importance of each Unit having an Operational Policy – examples were provided
• importance of each hospital having a multidisciplinary day surgery management team to promote the adoption of day surgery
• importance of preoperative assessment as part of the successful day surgery pathway

This report is part of the programme of support to the Ministry of Human Capacities in the preparation of a strategic framework for Ambulatory Surgery. This document contains the reports provided to each individual hospital and the questionnaires returned to the expert team prior to the visits. The panel of experts found many common themes across all hospitals visited. Common themes covered were

• need to change the Hungarian definition of day surgery to remove overnight stay
• Preoperative Assessment – the need for hospital to develop these services to ensure patients are suitable and informed
• Patient information – the need for hospitals to develop patient information leaflets 
• Selection criteria – hospitals need to develop clear criteria for accepting patients for day surgery
• Preoperative testing – evidence of routine use of preoperative tests that are not required for the safe management of the patient
• Day Surgery Task Force or User Group – recommendation that hospitals set up multidisciplinary teams to develop day surgery
• Facilities – recommendation to start now within hospitals and not wait for new day surgery facilities to be built

This report contains the outcome of the IAAS and HAAS Expert Panel review of the Hungarian basket of day surgery procedures. This report is based on the translation of the original document. To facilitate the review and gap analysis the procedures were categorised by specialty and entered onto an Excel spreadsheet for ease of review. This data was then compared by the International Team against procedures performed in their countries. The Excel spreadsheet is included with this report as we believe this will aid translation, provision of coding and future reviews. The main publication reviewed as part of this process was the British Association of Day Surgery Directory of Procedures which was first published in 2006 and is now on its 6th Edition. This was aided by the evidence of day surgery activity for each procedure provided by the companion publication the BADS National dataset. To demonstrate the feasibility of each new procedure suggested we have, where possible, included how the best 25% of UK hospitals are performing from the BADS dataset. There are some procedures that the expert group felt should be removed from the basket either because they were felt to be medical procedures rather than day surgery or that they were no longer appropriate surgical procedures. These are highlighted for consideration. The expert group felt that the Hungarian basket of procedures should be renamed perhaps as the Hungarian Directory of Day Surgery Procedures. This should be reviewed regularly so that new procedures can be added, and obsolete procedures removed. We suggest that the Ministry could work with HAAS on future reviews.

This report contains the outcome of the IAAS and HAAS Expert Panel review of Day Surgery Clinical Quality Indicators for use at hospital and national level.

The capacity to evaluate and report on quality is a critical building block for improvement of health care delivery and patient outcomes both at the day surgery unit and the national level. Clinical indicator results provide valuable information in assessing the performance of health services. Clinical indicators, and especially outcome measures are important to help ensure a safe, effective, and efficient service in day surgery.

The IAAS has been a keen supporter in the development of clinical quality indicators having completed the Day Surgery Data Project which was supported through a grant for the European Commission. [1] Whilst the outcomes from this project have underpinned the creation of this report, we have taken this opportunity to review the international evidence on the use of indicators in day surgery.

Following guidance from the data project and from WHO/OECD publication on improving healthcare quality[2] we have provided indicators for both hospital and national level and grouped to cover the following themes

• Structural
• Process
• Outcomes

Local Hospital Level indicators

Structural

Number of beds or trolley spaces dedicated to day surgery

• % of day surgery beds/trolleys of total surgical bed spaces.
• These provide a measure of move to provision of quality day surgery facilities that can be tracked over time.

Specialties involved in day surgery

• Number of day surgery cases by specialty
• Day case rate as a percentage of total elective surgical cases by specialty

These provide a measure of how each specialty is performing that again can be tracked over time.

Process Indicators

• Existence of an agreed protocol for pre-assessment which has been reviewed in the last two years by a multidisciplinary team. 
• Evidence that supports that quality preoperative assessment has been planned.
• The % of procedures carried out as day cases with written information which should include common complications and the expected period of incapacity. 
• % of patients who have received a preoperative assessment before admission for day surgery 
• All patients should undergo preoperative assessment.
• % cancelled on day of surgery due to pre-existing medical condition
• % cancelled on day of surgery due to acute medical condition 
• % patients failing to attend or cancelling within two days of surgery
• % cancelled on day of surgery by hospital for non-medical reasons
• % unplanned overnight admission or transfer to inpatient facility
• Number of unplanned returns to operating room on same day as initial procedure

• % unplanned re-admission to hospital or acute care facility within 7 days
• % of day surgery admissions who experienced wrong site, wrong side, wrong patient, wrong procedure, or wrong implant
• % followed up phone call within 7 days
• % of patients overall satisfied with service 
• % patients achieving pain score of ‘mild’ or ‘none’ after discharge. 
• % patients with verbal pain score of ‘severe’ in the first 48 hours. 
• % patients satisfied with pain management at home.
• % of surgical wound infection 

• Number of dedicated day surgery units and design
  • Self-contained day surgery unit – free-standing
  • Self-contained day surgery unit – integrated with main hospital
  • Self-contained day ward – using dedicated theatres in main theatre complex
  • Self-contained day ward – patients incorporated on in-patient theatre lists
• Number of theatres in unit
• Number of bed spaces in unit

In absence of if dedicated day surgery unit.

• Number of theatres sessions dedicated to day surgery
• Number of bed spaces dedicated to day surgery

• % of elective surgery performed as day surgery for the overall list of elective basket procedures and each elective basket procedure 
• % unplanned overnight admission  
• % unplanned returns to the operating room within 24 hours 
• % of day surgery admissions who experienced wrong site, wrong side, wrong patient, wrong procedure, or wrong implant 

• % unplanned re-admission to a hospital within 7 days
• Case fatality ratio within 30 days for patients undergoing any of elective basket procedure  
• Expenditure on day surgery care as absolute value and % of total health expenditure
• % patients overall satisfied with day surgery