“Going home the same day” – Is day care neurosurgery a measure of surgical skill and technical advancement?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.198168
Source of Support: None, Conflict of Interest: None
“Mid pleasures and palaces though we may roam
Be it ever so humble, there's no place like Home”
John Howard Payne
A perfectly executed surgical endeavor is a matter of pure delight. The joy and benefits of it extend to the surgical team, the patient, his/her kith and kin, and to the surgical community at large. The positive outcome measures include a faster recovery from the disease, shorter hospital stay, affordable costs of medical care, and above all, a satisfied patient and surgical team. It also leaves room for the exciting possibility of “going home the same day.” We were fascinated by the brilliant review by Turel et al., which explores the evolution of day care neurosurgery and its contemporary status.
The article inspired us further to evaluate two fundamental questions:
Ambulatory surgery: Skill or fashion?
Ambulatory surgery continues to grow both in the complexity of procedures and in the number of cases performed. Advancements in anesthesia and less invasive surgery, patient demands, scarcity of inpatient beds, cost constraints, peer pressure, prospects of an early recovery, and less nosocomial infection, etc., have all been the key propulsive forces in its development. Not to forget is the cost containment benefit, wherein ambulatory surgery is estimated to have brought about cost savings to the tune of 30–40% in the US and UK. Thus, insurance providers and state-sponsored health systems, as in the west, benefit immensely from ambulatory surgery.,, Large billboards of hospitals, advertising “going home the same day” after surgery, evoke significant attention among lay people and the procedure is considered fashionable.
A surgical procedure is technically defined as an incision, excision, manipulation, or suturing of tissue that penetrates the skin and typically requires the use of an operating room and use of regional or general anesthesia or sedation, or a combination of these.
A Glasgow surgeon, James Nicoll, who performed almost 9000 outpatient operations on children in 1903 is credited to have sowed the seeds for ambulatory surgery, and in 1912, Ralphwaters from Iowa reported the “The Down Town Anaesthesia Clinic,” where anesthesia was given for minor outpatient surgery., The International Association for Ambulatory Surgery, a multidisciplinary international forum, was formed in 1995, and publishes the journal 'Ambulatory Surgery,' which reviews multispecialty day care surgery practices. The International Association of Ambulatory Surgery defines day-care surgery as “an operation or procedure where the patient is discharged on the same working day.” In the current era, in developed nations, approximately 70–75% of elective surgical procedures are day care procedures. Approximately 50% of ambulatory surgeries worldwide are done in dedicated outpatient surgery units.,
Where neurosurgery stands? Top 25
Though traditionally considered a speciality of complex and long duration procedures, some neurosurgical operations make it to the top 25 most common ambulatory surgery procedures  [Table 1]. Lumbar discectomy and peripheral nerve decompression/carpal tunnel release have pitched the cause for ambulatory neurosurgery even before other specialities such as laparoscopy made it big in ambulatory surgery.
Day-care stereotactic biopsy has been the earliest day-care cranial neurosurgical procedure reported to have been done as early as 1996 in Toronto. Bernstein's earliest series of day-care craniotomy for gliomas in 2001 has inspired many such works, and this practice gained momentum worldwide. The advent of awake craniotomy has added a further thrust to ambulatory cranial intrinsic brain tumor surgery.,,
Postoperative hospital stay: Norms and guidelines
There is a paucity of norms and guidelines on the optimum duration of postoperative hospital stay. The duration of postoperative stay is often considered as a surrogate marker of surgical skill. Common sense suggests that a better performed operation would automatically result in an earlier discharge from hospital. Thus, the “pressure to discharge early” has been catching up even in superspecialities with extended surgical procedures, such as neurosurgery and cardiac surgery.
In day-care surgery, readmission rates have been used as a measure of “failed ambulatory surgery.” Reasons for readmission could range from the innocuous (e.g., operative site pain) to the life threatening (e.g., operative bed hematoma). Postoperative patients usually remain admitted in hospital for hemodynamic and neurological monitoring, parenteral medications (antibiotics, anticonvulsants), easy access to professional care, and corrective surgical action in the event of an operative site bleed or cerebral edema. “Do patients feel safer if admitted overnight after surgery?,” is a matter of debate. Thus, if a mechanism for prompt access to medical care and readmission exists, the spectrum of day-care procedures could expand further.
Most high-volume neurosurgical centres have their own protocols on the duration of postoperative stay and discharge from hospital care. Often, surgeons and patients' care givers prefer to let the postsurgical patient have a short duration of postoperative in-hospital stay for easy access to medical care. A level of confidence both from the anesthesia-surgeon team and the patient caregiver team is an essential prerequisite for “going home the same day.” Back up plans such as a robust mechanism for readmission and home-based support systems are also cornerstones for the success of ambulatory surgery.,
Early discharge: Measure of skill or other incentives?
A predictable and short postoperative hospital stay is undoubtedly an indicator of an uneventful “surgical process” which includes the anesthesia, the surgical operation, and the postoperative care. On the other hand, many patients prefer the detached privacy of a hospital room away from unwanted visitors and thereby insist on a short period of postoperative hospital stay despite their suitability for a same day discharge. Thus, the optimum duration of postoperative hospital stay varies at different centres and is heavily influenced by protocols, tradition, and social milieu., Thus, discharge after surgery could be confounded by several factors beyond surgical and anesthesia skills. The patient's proximity to hospital services after discharge and availability of a responsible caretaker adult also influence “ambulatory surgery fitness” criteria. The suitability for same day discharge should always be assessed at the “point of discharge” although eligibility criteria based on the medical, surgical, and social factors could be predetermined.
In a government or insurance-sponsored health care system, the same day discharge saves costs. In a system where the patients fund their own treatment, a longer hospital stay earns revenue for the hospital. An undue influence of these “incentives” could influence the suitability of ambulatory surgery beyond patient, disease, skill and procedure-specific factors. The fashion to fit into an ambulatory surgery protocol could create the unhealthy trend of a “pressure to discharge” the same day. An unhappy patient “going home the same day” is bound to come back sooner or later. At times, “out of sight” after ambulatory surgery may imply readmission to another centre rather than “all's well.” In such a scenario, even “readmission rates” could be deceptive to gauge the success of an ambulatory surgery program. Hence, the emphasis on a robust follow up mechanism that eliminates these biases is crucial. A national accreditation and audit system to review day-care surgery practices and guidelines is also the need of the hour.,
The cornerstones for success of a day-care neurosurgical programme include day-care enthusiast surgeons, a robust ambulatory surgery hospital system, and motivated patients. However, suitability for day-care neurosurgery is influenced not just by the fitness of patients, or by procedure-specific, or skill-related factors. In the current era, both proponents and opponents of day-care neurosurgery exist in equal measure. As the last word on ambulatory neurosurgery is yet to be stated, perhaps day-care brain aneurysm clipping and selective amygdalohippocampectomy may not really be that far away.
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Conflicts of interest
There are no conflicts of interest.