Abstract

Background: Day of surgery admission, rather than inpatient surgery, is increasingly being considered the norm for all patients undergoing elective surgery, rather than simply an alternative form of treatment for a few. However, it is also important to recognize that the model of provision should be geared to the patient’s needs, since not all patients can be treated on a day-surgery basis. It is necessary to have a system in place for selecting patients carefully, considering surgical, medical (comorbidity) and social criteria. Objective: This study aims to identify the factors affecting implementation of day of surgery admission in hospital. Subjects and Methods: A descriptive cross-sectional design was used to achieve the aim of the study. The population included all the healthcare workers who involved in day of surgery admission process including surgeons, anesthetists, nurses, and administrative staffs in King Abdullah Medical City (KAMC). The researcher made a questionnaire for data collection which included five variables that affect the implementation of day of surgery admission procedures. Data was collected from the participants by using online survey questionnaires. Results: The result shows that all the factors have high mean score which indicate the participants positively agree the statements and when proving the hypothesis, the result appear that there's a solid relationship exist between consider factors and implementation of day of surgery admission. Finally, it was found that some dependent variables have positive correlation with others. Conclusion and Recommendations: it was concluded that the proper implementation of day of surgery admission with the organizational management support can contribute to reduce the waiting time of the patient, cancelation of procedures and all healthcare team will be satisfied. This study recommends the health care leaders to develop a strategic plan to implement day of surgery admission process However, further studies are needed to conduct by including patient’s opinions and as multicenter comparative study to find the effectiveness of day of surgery admission process.

1. Introduction

Day of surgery admission (DOSA) is now a high quality, safe and cost-effective approach to surgical health care, enjoying a high rate of patient satisfaction. It is fast becoming the norm for nearly all elective surgery; in countries such as the United States and Canada, it accounts for nearly 90% of all surgery performed but remains much less common in many other countries ¹.

A wide variety of procedures are performed as day of surgery admission including, but not limited to, ear, nose and throat surgery, gynecological and orthopedic procedures, and gastrointestinal and plastic surgery. Patients undergoing day surgery admission in Australia may attend day surgery centers, either stand-alone or associated with a hospital, a ward in a hospital dedicated to day surgery cases, or a smaller specialized center such as an endoscopy clinic. All these institutions can provide high standards of care. ².

Day of surgery admission, rather than inpatient surgery, is increasingly being considered the norm for all patients undergoing elective surgery, rather than simply an alternative form of treatment for a few. However, it is also important to recognize that the model of provision should be geared to the patient’s needs, since not all patients can be treated on a day-surgery basis. It is necessary to have a system in place for selecting patients carefully, considering surgical, medical (comorbidity) and social criteria. Traditionally, all surgical patients are hospitalized at least one day prior to surgery for being clerked, investigated, and evaluated by the anesthesiologist ³.

Now, the preoperative anesthetic assessment is performed in an outpatient visit and usually when the patient that is admitted to the hospital is waiting for a surgical procedure. Only a few cases require specific preoperative arrangements for surgery that recommend an admission the day before the intervention. However, there still are admissions the day before to avoid cancellations due to the lack of ward beds or to avoid delays in going to the theatre for earlier procedures ⁴.

A policy of day of surgery admission (DOSA) is emerging. Because of worldwide financial constraints, changes in practice are increasingly necessary to facilitate cost effectiveness and efficiency in modern elective surgical practice. One of these changes is the reduction of unnecessary admission of elective inpatients to hospital the night before planned surgical procedures ⁵. If successfully implemented, a policy of DOSA has potential advantages to both the institution and the patient. These include improved cost efficiency, reduced surgery cancellation rates, patient friendly admission policies and a potential reduction in rates of hospital-acquired infection ⁶.

Day of surgery admission requires a multidisciplinary approach. For a successful outcome, it requires active participation by all healthcare teams – managers, nurses, surgeons, anesthetists, and general practitioners. There is a need for a flexible approach, with regular re-evaluation of practice to provide a level of care that reflects individual patient needs. However, there is limited evidence on the most appropriate staffing models for the different types of day-surgery units ⁷.

Since the 1970s, there has been a dramatic increase in the number of procedures that are carried out as day of surgery admission, so much so that across developed countries it is estimated that day surgery now accounts for between 50 and 80% of all surgical procedures ⁸.

One of the most visible organizational changes is a shorter hospital stay, especially for elective surgery, which includes increased use of day of surgery admission, improved discharge planning and post-acute care at home, less invasive surgical techniques, and improved anesthetic drugs ⁹.

Day of surgery admission is now established practice with rates still increasing around the world and has greatly evolved since the early days of the specialty. Now due to advances in anesthesia and surgical techniques, day of surgery admission is the standard pathway of care for many complex patients and procedures traditionally treated through inpatient pathways. Day of surgery admission represents high-quality patient care with excellent patient satisfaction. Shorter hospital stays and early mobilization reduce rates of hospital-acquired infection and venous thromboembolism. Patients overwhelmingly endorse day surgery, with smaller waiting times, less risk of cancellation, lower rates of infection, and the preference of their own surroundings to convalesce ¹.

While day of surgery admission is an innovative area in the health care system. We do not have much research dealing with these areas. This research will be very valuable because it is the first one that provides a detailed description including cancellation of surgery, waiting time, patient satisfaction and health care team opinions, which may be affecting implementation of day of surgery admission in the health care system of Saudi Arabia.

The aim of the research will be to identify the factors affecting implementation of day of surgery admission in hospital. This aim is achieved through the following objectives:

1. To identify the factors affecting implementation of day of surgery admission.

2. To assess the health care team’s perception on day of surgery admission.

3. To identify the infrastructure limitations on day of surgery admission.

1. There is a significant relationship between pre-operative waiting time and day of surgery admission.

2. There is a significant relationship between cancelation of procedures and day of surgery admission.

3. There is a significant relationship between health care team responses and day of surgery admission.

4. There is a significant relationship between infrastructure limitation and day of surgery admission.

2. Subjects and Methods

The design of this study was a descriptive cross-sectional design. The population included permanent healthcare staff who is responsible for day of surgery admission. It included surgeons, anesthetists, nurses, and administrative staff at KAMC, makkah, Saudi Arabia.

The surgeons, anesthetists, nurses, and administrative staff involved in day of surgery admission also included in the data collections. The minimum sample size by total number of health care team was 66 assuming a minimum response rate of 50% and a confidence interval of +/-5%.

The sample number in each category as follow:

The researcher made the data collection tool, which included the most suitable variable to measure the factors affecting implementation of day of surgery admission procedures. The survey tool consist of two sections as follows Section A represents demographic details of the patient’s admitted on day of surgery. Section B included the questionnaires related to factors Affect implementation of day of Surgery Admission. These parts included questions representing independent variables such as waiting time in pre-operative area, cancelation of procedures, health care team responses, infrastructure limitation in day of surgery admission and dependent variable as Implementation of day of surgery admission. The health care worker was answered the questionnaire by using Likert scale, which included as Excellent, very good, good poor and failure and some answers as strongly agree, agree, neutral, disagree and strongly disagree. Each questions answer was scored from 1-5. The questionnaire survey was distributed electronically to the study sample by online.

The questionnaire was pre-tested for validity to a small sample (5-20 people) several times to ensure that wording, format, length, and sequencing were appropriate based on expert opinion (e.g., medical professionals, and researcher experts). The reliability test done by using Cronbach's Alpha method and make sure the instrument is reliable to measure the objectives of the study. It was 0.602, 0.543, 0.947, and 0.619 for waiting time in pre-operative area, cancelation of procedures, health care team responses and Infrastructure limitation scale respectively.

IRB approval is obtained from KAMC Research Center 21-773, dated 01/04/2021. After obtaining official approval from the IRB. The researcher was committed to all ethical considerations required to conduct research. For ethical consideration, research objective and information component describing research data were included in the study to determine their interaction. Participants were not identified in the study. In this way the researcher was kept anonymous and confidential by the participants.

The study will be beginning with demographic data of the patient and data related today of surgery admission and it was taken from the HIS system to generalize results. The investigator was collected data from the participants by using online questionnaire. Part of the invitation was included in the study to understand the purpose of the study for participants and to find their cooperation. A data sheet was provided before beginning to answer the questions, which included a description of the study purposes. The selection of the sample was using by simple random sampling method. The survey tool consist of two sections as follows. Section A represents demographic details of the patient’s admitted on day of surgery. The data will be collected from HIS and the respondents. Section B included the questionnaires related to factors Affect implementation of day of Surgery Admission. These parts included questions representing independent variables such as waiting time in pre-operative area, cancelation of procedures, health care team responses, infrastructure limitation in day of surgery admission and dependent variable as Implementation of day of surgery admission. All this data also collected from both the HIS system and the healthcare staff by using questionnaires.

Data were analyzed through SPSS package version 25. The categorical variables were expressed as number and percentage while continuous variables were expressed as mean, and standard deviation. Chi square (x2) was used to test the statistical relationship between the individual variables. Pearson correlation coefficient utilized to test association between continuous variables. P value was considered statistically significant at ≤0.05 and 0.01.

3. Results

Figure 1 shows A total number of 96 participants enrolled in this study representing the surgeon 17.7%. anesthetists 13.5%, Nurse 47.9% and administrative staff 20.9%.

Figure 2 Indicates that Total professional experiences included 33.3% 6 to 10 years and 28.2% include 11 to 15 years remaining 14.6% 1 to 5 years, 13.5% more than 20 years and 10.4% have 16 to 20 years’ experience respectively.

Figure 3 reveals that the patients for demographic characteristics of the patient who are admitted for DOSA. Total 100 patients admitted for DOSA during data collection period, and it included 50 males and 50 females respectively. Most of the patient was age more than 40-50 years (28) and 23 patients have more than 60 years. Most of the patient from inside Makkah (73) and remaining was from outside Makkah (27). Most of the patient admitted for DOSA was for major surgery (83) and remaining was minor surgeries (17). Surgical oncology was performed more (59) then bariatric (17) surgeries.

Table 1 illustrates the frequency distribution of each statement of the dimension of waiting time in pre-operative area scale, the results reached are the following: The greater means of this dimension were (3.60) for item (Time taken to complete registration process in admission office is acceptable), but the lowest mean value were (2.80) for item (Waiting time from pre-operative area to operation room is more than 2 hours). The p value indicates all the statement have association with implementation of day of surgery admission.

Table 2 shows that the greater means of this dimension were (3.88) for item (Patients medical condition is the most reason for cancellation of day of surgery admission procedure), but the lowest mean value were (3.21) for item (Operating rooms availability is the most reason for cancellation of day of surgery admission procedure). P value indicate all the statements in cancelation of procedures have association with implementation of day of surgery admission. So, it is factor that influence implementation of day of surgery admission in KAMC.

Table 3 illustrates that the health care team responses shows that the greater means of this dimension were (4.01) for item (Day of surgery admission program helping to reduce the length of stay.), but the lowest mean value were (3.37) for item (The day of surgery admission program is promising a complete pre-operative preparation). P value indicate all the statements in health care team responses have association with implementation of day of surgery admission. So, it is factor that influence implementation of day of surgery admission in KAMC.

Table 4 indicate that the greater means of this dimension were (4.20) for item (Good infrastructure helping to manage patient flows for day of surgery admission), but the lowest mean value were (3.48) for item (Infrastructure for day of surgery admission procedures different as compared to normal inpatient procedures. (Such as operation theatres, staff level, separate OR beds)). P value indicate all the statements in infrastructure limitation have association with implementation of day of surgery admission. So, it is factor that influence implementation of day of surgery admission in KAMC.

Table 5 shows a significant correlation between some of the study variables at 0.01 and 0.05 level.

Table 6 shows that the greater means score (3.90) of this study variables was infrastructure limitation, and it is the most influencing independent variables on implementation of day of surgery admission in King Abdullah medical city. The second mean score was health care team responses (3.71) and this result indicating that it also influencing factor in implementation of day of surgery admission in KAMC. Remaining two variables cancelation of procedures (3.43) and waiting time in pre-operative area (3.19) also showing influence on implementation of day of surgery admission in KAMC.

4. Discussion

The aim of the study is to identify the factors affecting implementation of day of surgery admission in KAMC. Day of surgery admission is now established practice with rates still increasing around the world and has greatly evolved since the early days of the specialty. Day of surgery admission represents high-quality patient care with excellent patient satisfaction. Shorter hospital stays and early mobilization reduce rates of hospital-acquired infection and venous thromboembolism ¹. Day of surgery admission process has a lot of challenges that may affect the successful implementation and compliance to it.

The result of the study regarding the variable waiting time in preoperative area indicate that most of the response agree that the time taken to complete registration process in admission office is acceptable and the time taken in recovery area after requesting a bed for admission is acceptable. In the next variables cancellation of procedures, the most of the participant’s responses agree the following statements patients’ medical condition is the most reason for cancellation of day of surgery admission procedure and unavailability of bed in preoperative area is the most reason for cancellation of day of surgery admission procedure. These results are consistent with the previous studies that increased number of cancellations due to the patient being medically unfit in hospitals ^{10, 11, 12}. Published studies from public hospitals, mainly in Europe, report similarly high rates of cancellations on the day of surgery due to lack off beds in preoperative area ^{13, 14, 15, 16}. Another study revealed that the commonest reason for cancellation, as reported in the literature, is bed unavailability in preoperative area ¹⁷.

In the third variable healthcare team responses most of the participants agree the following statements you have a positive feeling about the day of surgery admission program. day of surgery admission program have benefits to your health care organization, day of surgery admission program helping to reduce the length of stay and day of surgery admission program have an impact on reducing surgical infection rate. Some of the studies concluding the same result that the day of surgery admission have shorter length of stay, early mobilization, reduce rates of hospital-acquired infection and venous thromboembolism ¹. Another study supporting this finding that day of surgery admission offers many advantages to traditional inpatient services like a faster throughput of patients and a fixed time for surgery and savings in hospital costs ¹⁸

The fourth variable infrastructure limitation most of the participants agree the following statements as dedicated infrastructure for day of surgery admission will helps to improve the process, good infrastructure helping to manage patient flows for day of surgery admission and lack of infrastructure will lead to cancellation of day of surgery admission procedures. The supportive study regarding infrastructure limitation relatively little in primary research one study concluding that there should be hospital-integrated facility for dedicated day of surgery admission facility, sharing operating theatres, recovery facilities, and medical and nursing personnel with the inpatient department. ^{19, 20}.

Finally, the last variable implementation of day of surgery admission. Most of the participants agree the following statements are the employee working in day of surgery admission area is performing their job well and Patients abide by the instructions given to them before surgery. One of the studies supporting that day of surgery admission is a now a high-quality, safe, and cost-effective approach to surgical health care, enjoying a high rate of patient satisfaction. It is fast becoming the norm for nearly all elective surgery; in countries such as the United States and Canada, it accounts for nearly 90% of all surgery performed ²¹.

When proving the hypothesis, the result shows that the day of surgery admission have a significant relationship with all variables such as waiting time in pre-operative area, cancelation of procedures, health care team responses and infrastructure limitation and hence it is supported that all these factors that influence implementation of day of surgery admission in king Abdullah medical city. It was supported by A study that implementation of day of surgery admission have some relationship with pre-operative waiting time and cancelation of procedures ²². Regarding the health care team responses on implementation of day of surgery admission some study concluded that not only patients, but all medical personal benefit from a complete preoperative evaluation of these complicated patients and this creates harmony during the entire hospitalization ²³. Another study also concluded that based on nurses' perceptions in day of surgery admission, continuity of care was relatively well realized ^{24, 25}. Regarding the infrastructure limitation with implementation of day of surgery admission There are no studies that have investigated the infrastructure limitation with implementation of day of surgery admission.

The current study also examined the correlation between the variables and the result shows that there is a positive correlation exist between the study variables including waiting time in pre-operative area, cancelation of procedures, health care team responses and infrastructure limitation with implementation of day of surgery admission. Some of the studies reported the same result which shows that pre-operative waiting time, cancelation of procedures and health care team responses have a positive relation with implementation of day of surgery admission ^{11, 22, 26}.

5. Conclusion and Recommendations

The result regarding each statement of the study variable waiting time in preoperative area, most of the response agree that the time taken to complete registration process in admission office and the time taken in recovery area after requesting a bed for admission are acceptable. In the next variables cancellation of procedures, the most of the participant’s responses agree the following statements patients’ medical condition and unavailability of bed in preoperative area are the most reason for cancellation of day of surgery admission procedure.

Regarding the infrastructure limitation, most of the participants agree the following statements as dedicated infrastructure for day of surgery admission will helps to improve the process, good infrastructure helping to manage patient flows for day of surgery admission and lack of infrastructure will lead to cancellation of day of surgery admission procedures. Finally, the implementation of day of surgery admission most of the participants agree the following statements are the employee working in day of surgery admission area is performing their job well and patients abide by the instructions given to them before surgery. The result show that the day of surgery admission have a significant relationship with all variables such as waiting time in pre-operative area, cancelation of procedures, health care team responses and infrastructure limitation and hence it is supported that all these factors that influence implementation of day of surgery admission in king Abdullah medical city.

6. Implications and Recommendations

These findings will help hospital leaders make some changes on day of surgery admission. The result of the study showing the factors that affect the implementation of day of surgery admission will help the leaders to prepare future improvement plans. The result showed that the day of surgery admission have a significant relationship with all variables such as waiting time in pre-operative area, cancelation of procedures, health care team responses and infrastructure limitation and hence it is supported that all these factors that influence implementation of day of surgery admission in king Abdullah medical city. Finally, the current study also examined the correlation between the variables and the result shows that there is a positive correlation exist between the study variables including waiting time in pre-operative area, cancelation of procedures, health care team responses and infrastructure limitation with implementation of day of surgery admission. This study findings recommending to the health care leaders to develop a strategic plan to implement day of surgery admission process

7. Limitations of the Study

The present study has some limitations. Firstly, it discusses the factors affecting implementation of day of surgery in a specialist hospital from the healthcare staff perspectives, it needs to be involved the patients concerns also therefore the findings and recommendations might not be generalizable and applicable in institutions with significantly different operational policies and serving a population with different characteristics. Another limitation is that the data collections conducted on online platform and if possible, using participant interactions may find additional ideas and suggestions for improving the implementation of day of surgery admission process in hospital settings.

References