By Rene Bosman
Editor, Specialist Forum
The 2020/21 lockdown due to Covid-19 resulted in thousands of elective surgeries being put on hold, leaving surgeons and hospitals grappling to reduce the backlog. Many elective surgeries are time-sensitive and those not falling under the definition of urgent/emergency surgery, which have been postponed over recent months, by implication have become urgent or qualify as emergency surgery, says Leonie Bredell, relationship manager for the Day Hospital Association of South Africa (DHASA).
Many of these surgeries can be performed in a day hospital setting. With experts warning that with South Africa’s winter just around the corner, the country may experience a third or even a fourth wave of Covid-19, increasing the backlog even more.
This pandemic has only just started. We are going to get a third wave, even a fourth, Prof Tivani Mashamba, diagnostic researcher at the University of Pretoria, told The Guardian newspaper in January. If the country goes into lockdown again, it means many patients who require elective procedures have now been waiting for more than 12 months to undergo procedures.
Are day hospitals the solution?
In the United States, Europe and Australia, surgeons were encouraged to make use of day hospitals to address backlogs. International trends have shown:
- An increase in the number of surgeons working in day hospitals
- Momentum in disciplines such as orthopaedics, gynaecology and urology moving more procedures to day hospital environments
- A wider variety of procedures per discipline, performed in day hospitals
- Medical funders moving away from traditional hospital networks, revoking co-payments for patients choosing non-designated service provider hospitals and co-payments linked to certain procedures.
During lockdown, day hospitals did experience an uptake in interest from surgeons. Day hospitals were able to assist surgeons looking for alternative settings to perform surgical cases for patients that could not be deferred. This was especially prevalent in geographical areas hard hit by the pandemic, with acute hospital resources caring and battling Covid-19 on the frontlines. Urgent and emergency day surgery procedures still went ahead at around 10% of normal daily capacity.
Why is the South African day hospital industry lagging?
The main reason, says Bredell, is because many surgeons and patients are unfamiliar with this so-called ‘new generation’ of day hospitals. Furthermore, surgeons erroneously believe that day hospital facilities are not sufficiently equipped or staffed, have no available capacity and that quality and risk management protocols are lacking. In 2019, DHASA embarked on a project that debunked these misconceptions for the members they represent.
Benefits of day hospitals
Lower risk of infection
One of the many benefits of day hospitals is that the risk of infection is much lower compared to acute hospitals. According to Bredell the risk of contracting Covid-19 is negligible in day hospitals because the environment in which they operate is more controllable. For example, because of the small size and the lay-out of the day hospitals, the quicker patient turnaround times due to the short-stay and the fact that no long-term ill patients are admitted, infection control is more manageable.
More cost-effective
Bibi Goss–Ross, COO and executive director at Advanced Health Ltd, writes that in general, a hospital account consists of the following tariff structures:
- Hospital
- Theatre
- Consumables
- Equipment.
If you compare a day ward fee in a day hospital with a larger acute hospital, the day hospital fee is lower. Theatre fees are billed per minute in theatre – once again, day hospitals are the cheaper option when compared to larger acute hospitals.
Day hospitals, by nature surgically orientated, only offer theatre facilities and ward accommodation and are streamlined, and do not have to make provision for highly specialised units and other medical services found in larger acute hospitals like trauma, intensive care, maternity units etc. making it easier to offer cost effective rates to medical aids and patients
Ten years ago, the difference in pricing between acute- and day hospitals were significantly greater. Growth in the day hospital industry over recent years has resulted in acute hospitals lowering their price on day procedures to remain competitive in the healthcare market.
The question remains – if day hospitals close their doors what would happen to overall hospital costs in the industry?
Without a doubt this will increase again, which is exactly why the day hospital industry feels strongly that patients and funders have to support the day hospital concept and doctors should without a doubt secure theatre slots in both acute and day hospital settings. It is vital to the sustainability of the overall healthcare industry that day procedures are performed in the most cost-effective setting with careful consideration of patient suitability to the environment and the risks involved with any surgical procedure.
Day hospitals generate income by performing same day surgical procedures only. Medical schemes can provide data on day hospital procedure outcomes and the cost-effectiveness of these procedures in comparison to the same service in larger acute hospitals.
According to Bredell, DHASA believes the day hospital industry is part of the solution to reduce the cost of private healthcare. By encouraging industry engagement, collaboration, and active relationships, they have managed to provide patients with access to day procedures at a lower cost, while at the same time safeguarding funder reserves.
Patient benefits
Patient benefits include minimum disruption to daily life as procedures are done on the same day, requiring no overnight stay. Studies show that recovery times are faster in for example home environments. As mentioned already, the risk of infection is reduced and tariffs are charged according to medical scale of benefits.
Surgeon benefits
Surgeons are assisted by well-trained and experienced nursing staff, who do not work shifts or rotate. This means that doctors always work with teams that they are familiar with. Management teams are flexible and willing to negotiate on treatment co-payments and provide support and assistance with pre-authorisations.
What surgeries can be performed at day hospitals?
Short-stay elective procedures that do not require critical care can also be performed at these modern, state-of-the-art facilities, says Bredell. Case selection is extremely important and relies on the clinical expertise and judgement of surgeons, in consultation with anaesthetists, as well as the patient, says Bredell.
A number of surgical procedures across various disciplines ranging from orthopaedic to plastic surgery can be performed currently in day hospitals. In fact, international research shows that more than 70% of surgical procedures can be performed in a day hospital setting. Goss-Ross adds that continuous medical and technological advances will create the opportunity for more complex procedures to be performed in day hospitals.
| General procedures/surgeries | Approved breast procedures | Ophthalmology | Orthopaedic procedures | Cosmetic procedures | Urological procedures | Ear, nose, and throat | Gynaecological procedures | Gastrointestinal procedures |
|---|---|---|---|---|---|---|---|---|
| Skin biopsies | Mastectomy for gynaecomastia | Cataract surgery | Achilles tendon release | Blepharoplasty | Cystoscopy and ureteral dilation | Cochlear implant | Cerclage of uterine cervix | Anorectal procedures |
| Incision and drainage of abscess and/or cyst | Lumpectomy (fibroadenoma) | Corneal surgery and transplants | Arthroscopy, arthrotomy and arthrodesis | Breast augmentation | Male genital procedures such as circumcision | Middle ear procedures such as tympanoplasty | Dilation and curettage | Scopes such as oesophagoscopy, gastroscopy, colonoscopy |
| Simple superficial lymphadenectomy | Intra-ocular injections | Ganglionectomy | Face lift | Removal of ureteral stones | Tonsillectomy and/or adenoidectomy | Endometrial ablation | ||
| Debridement and removal of lesions (depending on site and size) as well as superficial wound care | Other eye procedures such as removal of foreign body and conjunctival surgery | Tendon and/or ligament repair, muscle debridement, fascia procedure | Labiaplasty | Renal calcultus removal and stent insertion | Repair nasal turbinates, septum, ear fistula | Hysteroscope | ||
| General surgical procedures include Laparoscopic appendicectomy | Laser surgery | Minor joint arthroplasty | Liposuction | Scope and pyelogram | Scopes (nasal endoscopy, laryngoscopy | Laparoscopic gynaecological procedures | ||
| Umbilical hernia repair | Treatment of glaucoma | Release of trigger finger and repair of bunion or toe deformity | Scar excision, revision surgery or removal of lesions | Simple procedures for nose bleeding and sinus procedures | Sterilisation | |||
| Other general surgical procedures include anal dilation, excision lipoma, haemorrhoidectomy, inguinal hernia repair | Treatment of simple closed fractures or dislocations, removal of pins, plates, k-wires (subject to individual case review) | Other procedures such as mastopexy, nose reconstruction or rhinoplasty |
Conclusions
Day hospitals offer benefits to patients, surgeons making use of the facilities and healthcare funders, reducing private healthcare costs. Patient and surgeon education about the benefits of day hospitals is lacking. Ross-Goss, however, believes that the day hospital in South Africa will follow international trends, which saw an increase in the utilisation of these state-of-the-art facilities. International studies show that more than 70% of surgeries can be performed in a day hospital setting. Medical technological advances will create the opportunity for more complex procedures to be performed in these settings in future.
