J. of Ambulatory Surgery 12 (2006) 143–145

Review

Day surgery—National and internationalFrom the past to the future

Lindsay Roberts∗

No. 72, Beatrie Street, Balgowlah, NSW 2093, Australia

Received 1 October 2004; accepted 22 February 2005Available online 3 October 2005

In February 1981, a working party was formed by theRoyal Australasian College of Surgeons, the Faculty ofAnaesthetists of the Royal Australasian College of Surgeons(now the Australian and New Zealand College of Anaes-thetists), the Australian Association of Surgeons and the

Australian Day Surgery Council in October 1996 and contin-ues as such today.

The first modern, purpose designed and constructed freestanding day surgery centre was built in Dandenong, Victoriain 1982 and the first free standing centre on the campus of a

ereeasedtand-o be

ec-ncilasedr thend. Itrgeryera-aveicat-day

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Australian Society of Anaesthetists with the inclusion of agroup of co-opted members, to prepare the first manual ofstandards for day surgery. This manual, “Day Surgery; Reportand Recommendations”, was published in September 1981and revised in 1987 and 1997. An expanded revision wascompleted in July 2004.

In 1987, recognising the potential for future expansion ofday surgery, the working party was formalised as a committeeand in 1988 changed its name to the National Day SurgeryCommittee. It was during this same period that an accredi-tation process was established by the Australian Council onHospital Standards (now the Australian Council on Health-care Standards). Clinical Indicators, specifically applicableto day surgery were prepared in 1994 and have been suc-cessfully introduced for quality assessment of day surgerypractice.

By 1996, the Committee was soundly established as themost informed body on day surgery in Australia. Its activ-

public hospital, Campbelltown, NSW in 1984. By 1993 thwere 83 such centres; however their numbers have incrrapidly over the past decade—today there are 248 freesing day surgery centres in Australia and they continue tbuilt.

Since the publication of “Day Surgery; Report and Rommendations” 1981, the Australian Day Surgery Couhas reiterated its stance of equal support for hospital bday surgery units and free standing centres howevedevelopment of hospital based units has lagged behiis acknowledged that a considerable volume of day suis practiced in hospitals, approximately 50% of all options/procedures. About one-third of private hospitals hday surgery units however I am unaware of any data inding the number of public hospitals that have dedicatedsurgery units. Anecdotally, it seems that most day surpatients in public hospitals are located in ward beds omost, in a day surgery ward. This apparent failure of the

ities in all aspects of day surgery practice were expanding;especially the preparation of standards, and its membershiphad increased to include co-opted representatives from allo ser-v matep 5%( gardt r withi to the

lic hospital system to fully utilise all the patient and costefficiencies and benefits of day surgery should be addressedas a matter of urgency.

eryw eryC us-s oyalC ur-n tlyi dingt mer-o

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rganisations involved in the provision of proceduralices within the health care system. The estimated ultiotential for day surgery had increased from 50% to 7possibly more) of all operations/procedures. Having reo these increased activities and responsibilities, togethets enhanced authority, the committee changed its name

∗ Tel.: +61 2 9948 2636; fax: +61 2 9948 0498.E-mail address: lmcgeorge@optusnet.com.au.

966-6532/$ – see front matter © 2005 Elsevier B.V. All rights reserveoi:10.1016/j.ambsur.2005.02.002

The International Association for Ambulatory Surgas formed in 1995 and Australia (Australian Day Surgouncil) is a foundation member. Initially located in Brels, the Central Office was transferred to London (Rollege of Surgeons building) in 2004. The official joal of the Association is “Ambulatory Surgery”. Curren

t has 15 full members, five Associate members (incluhe Australian Day Surgery Nurses Association) and nuus individual members.

144 L. Roberts / J. of Ambulatory Surgery 12 (2006) 143–145

An important initiative of the Association was the prepa-ration of International Definitions of Ambulatory Surgery,which have been translated into 10 languages. Criteria ofstandards for various aspects of day surgery practice havealso been written and this process will continue. The Asso-ciation considers these initiatives very important to facilitatethe comparison of day surgery practice from one country toanother and to assist in the development of this high quality,cost effective procedural service in those countries where ithas not been introduced.

The Association holds second yearly International Con-gresses on Ambulatory Surgery. So far, there have been fiveCongresses—Brussels, London, Venice, Geneva and Boston;they have all been very successful. The next four Congressesare to be held in Seville (2005), Amsterdam (2007), Brisbane(2009) and Aarhus (2011).

The Australian Day Surgery Nurses Association wasformed in 1995 and is totally focused on the advancementof the highest quality, safe nursing practice in day surgerycentres/units. It has over 700 members and conducts regu-lar conferences and education sessions for nurses throughoutthe country. It publishes a journal, three times a year, called“Day Surgery Australia”; it has also produced “Best Prac-tice Guidelines” and they are a credit to them. The ADSNAis a member of the Australian Day Surgery Council and theInternational Association for Ambulatory Surgery.

t thef ntiali tly,a rriedo fromh ins!U e them omt prac-t deli ospi-t rds”a singe his ism Thei days samea odelw us ofh

In1 % ofa ient( gery.U

un-c lianD tod mosti ralia

and will continue to provide their proven expertise for daysurgery to achieve its ultimate potential. This will be anonerous challenge as the further expansion will includethe most major operations capable of being carried out inday surgery compatible with the highest levels of qualityand safety that have already been set and which must beprotected.

In order to achieve this further expansion of day surgeryit will be essential to introduce the concept of extended(overnight) recovery in day surgery centres/units and post-discharge convalescent limited care accommodation facili-ties (medi motels). Both concepts are important for moremajor operations however limited care accommodation facil-ities have the added advantage of allowing socially stressedpatients e.g. elderly, solitary, disabled, etc. and those fromrural and remote areas, who would otherwise require admis-sion to acute bed hospitals, to be treated in day surgeryfollowed by a couple of days convalescence before return-ing home. An added advantage is the cost of limited careaccommodation which is approximately half that of acutehospital beds. The Australian Day Surgery Council haspublished standards for these concepts however the healthinsurance industry has failed to provide a facility rebate foreither!

Office based surgery in purpose built units, which areextensions of medical practitioners consulting rooms, is noty althi orem car-r ncilh red-i thats Thea incen-t eatedi

days on—e Theb ol-o d ind le tom cernt olu-t its int tionw cuteb ationb

s toa rgeryi l ser-v ingc tageso cia-t ship

So much for the past and the present—what abouuture? Day Surgery has not yet reached its full poten Australia or anywhere else for that matter. Currenpproximately 50% of all operations/procedures are caut as day surgery although considerable variationospital to hospital and surgeon to surgeon still remanquestionably, freestanding day surgery centres arost patient and cost efficient facilities and it is fr

hese centres that the absolute costs of day surgeryice can be collated. Certainly, the most inefficient mos to have day surgery patients spread throughout hals occupying acute beds—so-called “day surgery ware not much better. In both models, patients are utilixpensive acute beds, equipment and services and tore so in the public than the private hospital system.

deal would be to integrate dedicated free functioningurgery units within hospitals such that they operate thes a freestanding centre. An obvious and even better mould be to build the freestanding centres on the campospitals.

So what is the ultimate potential for day surgery?999, Twersky and Showan predicted that by 2005, 82ll surgery in the USA would be carried out as outpatday) surgery and 24% of this would be office-based surnbelievable—yes, but they are heading that way!The Australian Day Surgery Council is a unique co

il totally dedicated to day surgery, just as the Austraay Surgery Nurses Association is totally dedicateday surgery nursing. They are unsurpassed as the

nformed bodies on all aspects of day surgery in Aust

et established in Australia largely due to the failure of hensurers to provide a facility rebate. A large number of m

inor operations/procedures, possibly 20–25% could beied out in such units and the Australian Day Surgery Couas published comprehensive “Guidelines for the Acc

tation of Office Based Surgery Facilities” to ensuretandards of quality and safety are not compromised.bsence of an office based surgery rebate is a major dis

ive and as such, many of these patients are currently trn day surgery centres/units at much greater cost.

An important generally acknowledged sequela ofurgery has been its influence on medical educatispecially the teaching of undergraduate clinical skills.ig majority of patients with surgical conditions and pathgy so essential for teaching clinical skills are now treateay surgery and for all practical purposes are not availabedical students. This is a cause of frustration and con

o clinical tutors (surgeons) and students alike. One sion is the development of large day surgery centres/uneaching hospitals to which the majority of clinical educaould be transferred while retaining some teaching in aed wards. This matter is deserving of urgent considery medical schools.

In the international forum, the greatest challenge issist the introduction and expansion of ambulatory su

nto those countries where this high standard proceduraice, provided in centres/units of low capital and ongoosts, has not yet been introduced or is in its earliest sf development. To achieve this, the International Asso

ion for Ambulatory Surgery needs to expand its member

L. Roberts / J. of Ambulatory Surgery 12 (2006) 143–145 145

to include such countries. The International Congresses onAmbulatory Surgery are important forums for the propaga-tion of knowledge, experience and expertise in this mostvaluable procedural service.

In summary:

• Day surgery in Australia and many other countries is estab-lished as an indispensable procedural service within thenation’s health care system.

• It has not yet reached its ultimate potential and the intro-duction of extended (overnight) recovery; limited careaccommodation facilities (medi motels) and office basedsurgery units should be vigorously supported.

• There is now an imperative for the Commonwealth Depart-ment of Health and Ageing to formalise the recategori-sation of procedural services and for health insurers tointroduce facility rebates for these concepts.

• The Australian Day Surgery Council is unsurpassed as themost informed body on all aspects of day surgery in Aus-tralia and will continue with its activities and in its advisoryrole to achieve these goals.

• There is sound logic in and great potential for developingdedicated day surgery centres/units in teaching hospitals tobecome the focus of teaching clinical skills in the medicaleducation curriculum.

• The challenge for the International Association for Ambu-latory Surgery is to promote and stimulate the developmentof day surgery in those countries where this valuable proce-dural service has not yet been introduced or is in its earlieststages.1

Lindsay Roberts was Chairman of the Australian DaySurgery Council from 1990 to 2000 and President of the Inter-national Association for Ambulatory Surgery from 2001 to2003.

Acknowledgement

Permission to reproduce this Review, which was initiallypublished in Day Surgery Australia, November 2004, is grate-fully acknowledged.

1 In the above text “day” and “ambulatory” are synonyms.