Philosophically, the Hospital should value the rights of all patients and individuals believing they should receive an optimal standard of health care and treatment with utmost dignity and respect.
A key objective for all is to continually look for ways to improve the experience and care of patients. The aim of the ambulatory care service would be to provide patient focused care in a minimal number of visits and within the shortest possible time.
Ambulatory Care can be defined as a system by which care is provided to a patient in a non-hospital admission context in a convenient and comfortable environment for outpatient surgery patients who will be in and out of the hospital in the same day.
Why Day Care Surgery?
Today hospital is just like any other industry. Present concept for the hospital is of visualization as a Business Centre, whereby each unit has to be Self Sustaining and thus Viable. While the sources of funding are limited the high and constantly escalating costs of treatment and delivery of care is a big stumbling block for all concerned. The unit must keep in purview the Up-gradation requirements, whereby the surplus is to be generated, which needs to be ploughed back, since the medical technology is constantly changing, with upgrades coming up with newer, faster equipment with better imagery/ utility et al.
Even the institution with the vision and philosophy of ‘Not for Profit Model’ need to look at the concepts of viability, with sources of funding getting meager and meager. Thus the focus shifts to the concept of Minimum Cost - Maximum Output, i.e., effective and efficient utilization of resources.
The number of beds any organization shall host is equally important – since this is directly related to the overheads incurred. The Mantra is for Optimization of beds – since the more the beds the more the overheads incurred to sustain the services.
The general trends of an increase in the number of admissions and a decrease in the number of occupied bed days has persisted and at the same time there is continuing a greater increase in the number of outpatient attendances, thus the emphasis has shifted in physical design and service delivery terms, from in-patient beds to ambulatory care facilities. These trends have important implications for health planners and hospital/healthcare facility designers.
It has often been recommended that about 30% of total work should come from Ambulatory care settings in any hospital.
Advances in medical technology have enabled the use of day only procedures and have moved the emphasis from admission for patient management to safe and effective ambulatory management.
ALOS (average length of stay) a cleaver indicator for health of a hospital averages to about 3.6 internationally, while in our settings it hovers around 7-8 (Indian perspective). Thus the emphasis for ambulatory care and its promotion cannot be greater emphasized.
While today’s Customer is a vigilant one. He has choices and has information available at the press of the key. He expects Value For Money. It is equally imperative to match up and meet the Expectations of the clients. The service delivery has not only to be of acceptable quality but consistent in delivery too.
The community, the medical profession and the funders of health care have accepted this trend. Ambulatory care is seen to emphasize that the purpose of treatment is:
- To return the patient to the community as soon as possible,
- Avoid separation of patients from their families (particularly important in treating paediatric patients),
- Reducing capital requirements and
- Hopefully reducing recurrent costs.
Ambulatory Care has been practiced almost as long as formal medicine has been available to the community. It is practiced in hospitals, both public and private, and from non-hospital premises. When provided by a hospital it has been regarded almost as an adjunct to, rather than an integral part of, its operations.
To conceptualize thus, the concept of Day Surgery in which the majority of medical and nursing care required by an individual patient is provided without recourse to prolonged in-patient care thus should be based on the medical, social and financial influences being brought to bear on the delivery of health care.
Thus the emphasis is on the delivery of Patient Focused Care. The primary requirements for ensuring delivery of such high quality care in a consistent manner is outlines by a need for rapid but safe turn over times in the ambulatory setting, thus necessitate extensive use of modern monitoring techniques and information technology.
The set up would entail requirement of a dedicated set-up having exclusive: -
- Reception,
- Admission, billing,
- Day care beds and
- OT with Modern Equipment
To further reduce chances of errors and for standardization standardized medical record format is the recommended need of the hour, with pre-designed formats of required forms/requisition/history sheets etc.
A simplified and prompt admission procedure, minimal “fixed” investigations, streamlined billing and discharge form the mainstay of such units, requiring the set up of a separate reception/accounts unit.
Same day surgeries include prompt admission and simplified discharge procedures, obvious cost effectiveness, translating into lower medical expense for the patient, and less time spent separated from family and home.
A look at the advantages from patient perspective: -
The patient gains
- By getting high quality care.
- With lower medical expense.
- Quicker return to Own environment.
(Such early return of patient to family and community reduces capital requirements and hopefully reducing recurrent costs)
Advantages from the Institutional purview
The hospital gains by way of
- Increased revenue generation by effectively reducing costs and generating more income
- High patient capacity and faster turnover. To increase bed utilization and patient turnover.
- By increased utilization of OT
- By reducing overhead expenses by reducing bed stay
- Increasing hospital yield
- Provides accessible surgical care.
- Reduction in the cost of surgery to the patient
- Reduced overhead cost
The hospital gains by way of increased revenue generation, reduction in overheads and expenses by reducing bed stay, without the need for dedicated staff strength/investigatory support – thus effectively reducing costs and generating more income. This directly increases the bed utilization and patient turnover with increased utilization of OT thus contributing to increase in hospital yield by higher patient capacity and turnover
On the Flip Side
- This set-up requires specially trained personnel to handle unique needs, ideally requires dedicated OT/Day stay unit etc.
- Although the patient returns to home same day, the responsibility for post-operative recovery still lies with hospital but control over situation is lost.
- Special emphasis is on our Indian Perspective – where Education/Awareness levels and hygiene standards of general public are insufficient to allow adherence to recommendations/advice.
- Faulty Case Selection – There has been recommendations on Case selections criteria, by The Indian Association of Day Surgery, for Day Surgery cases in general, but its wide spread implementation is required. They need to be debated and refined, specialty wise, so as to increase the safety margin of the selected case.
FONDAPARINUX REDUCES THROMBOEMBOLISM IN ELDERLY MEDICAL PATIENTS
Fondaparinux,a selective factor Xa inhibitor, is effective and safe for preventing venous thromboembolism in acutely ill, medical inpatients at moderate risk. In a double blind, randomised, placebo controlled trial, cohen and colleagues allocated more than 800 bedridden medical patients aged 60 or older to either 2.5 mg fondaparinux or placebo given subcutaneously daily for 6-14 days. Drug treatment reduced patients’ relative risk of venous thromboembolism by 47% at no increased risk of major bleeds.
BMJ, 2006; 332 : 335. |
|
