An Analysis of Safety and Efficacy of Day-care Surgery in Children in a Tertiary Care Hospital in India.

BACKGROUND: Advances in surgery and anesthesia have paved the way for the establishment of day-care surgery (DCS). Observations that children achieve better convalescence in the home environment along with significant economic advantages have led to this paradigm shift in clinical practice. AIMS AND
OBJECTIVES: This study is aimed to evaluate the feasibility of performing various surgical procedures on day-care basis and assess parental satisfaction with DCS in children.
MATERIALS AND METHODS: In this prospective observational study, all children >3 months of age undergoing various elective surgical procedures as day-care cases in our institution were enrolled. Types of operations, complications, including any unplanned admissions and parental satisfaction, were recorded.
RESULTS: Between December 2015 and December 2018, a total of 654 day-care surgeries were performed in our institution by pediatric surgeons. The mean age was 5.5 years with M: F 5.5:1. Thirty different surgical procedures were successfully performed as DCS, the common procedures being inguinal herniotomy (31.5%), and orchidopexy (14.3%). Unplanned admissions were recorded in 2.29% (15/654) patients (scrotal edema-5, postoperative pain-8, and a long recovery from anesthesia-2). No major complications occurred; two minor complications during follow-up were superficial wound infection and drug reaction. Overall parental satisfaction was very high (100%)-preoperative prolonged fasting period and long waiting time in the preoperative room of afternoon shift patients (7.95% and 8.3%) were the reasons for their discontent.
CONCLUSIONS: DCS in children is safe and effective with high parental satisfaction. It can substantially reduce the waiting list for several surgical procedures in children. Copyright:

INTRODUCTION

The concept of organized day-care surgery (DCS) for children was first put forward by Nicoll in 1909.[1] The principle of early ambulation of postoperative patients has gone a step further by discharging them home as soon as the patient recovers from anesthesia or immediate postoperative nursing needs have been met with. This has led to the concept of DCS, which implies that patients come into hospitals for their procedures and go home the same day.

The general observation that children achieve better convalescence in the home environment supports the need for adoption of DCS. It also reduces the financial burden of the family, especially in developing countries, where inpatient beds and resources are scarce. Other benefits of DCS are the decongestion of busy hospital beds, less nosocomial infections, and early recovery at home with the family, therefore, less disruption of personal lives.

Pediatric DCS is practiced widely nowadays in many countries.[23456] However, there is a paucity of data from India about the type of procedures that can be safely performed in children.[78] This study is focused on identifying the type of procedures and the safety and efficacy of pediatric DCS. The results and analysis of this study will help to formulate safety guidelines regarding pediatric DCS in a busy public hospital set up.

MATERIALS AND METHODS

This was a prospective observational study conducted in the department of pediatric surgery, including all cases of planned DCS in children who were considered fit for general anesthesia with an anticipated short duration of the operation. Prematurity, age <3 months, and those requiring prolonged and complicated procedures were excluded from the study.

Preanesthetic check-up and fasting schedule

Preanesthetic check-up (PAC) was done on outpatient department (OPD) basis; clear instructions for fasting were provided to parents. Patients were recommended to fast 6 h for solids and cow milk, 4 h for breast milk, and 2 h for clear fluids which included carbohydrate-rich fluids.

Organization of day-care surgery at our institute

Preoperative preparation

Routine PAC was done on an out-patient basis. The parents were informed about the procedure, including instruction for the preoperative fasting period as per recent fasting guidelines.[9] Parents were asked to bring the child directly to the waiting area of the operating room on the morning of the surgery. On reporting to the hospital, the identity of the patient and parents were established, consent for the procedure taken and preanesthetic fasting was reconfirmed.

Postoperative care and follow-up

Following the operation, all patients were kept in the recovery room under the observation of the trained nurse to monitor the vital signs. Once they were awake and stable, check-up and the modified Alderete scoring[10] was done by the anesthetist, the score of ≥9 was considered adequate for patients to be shifted to postoperative room adjacent to the recovery room in the care of parents. They were given feed and oral analgesics once fully recovered from the anesthesia.

In the postoperative room, they were evaluated by the Pediatric Post Anesthetic Discharge Scoring System (PedPADSS) at an hourly interval for a minimum of 4 h by the nursing staff.[11] A score of >9 was considered fit for discharge to home. Patients were discharged when parents were also comfortable to take care of at home. Discharge instructions included general care, reporting for any warning signs and administration of analgesics.

Following discharge, an OPD visit was scheduled within 1 week. During the first postoperative visit, the child was examined and the parents interviewed regarding the postoperative course at home, any complication, and their overall attitude toward the experience of DCS. They were given a questionnaire to record their responses.

RESULTS

A total of 654 day-care procedures in children were recorded between December 2015 and December 2018. During the same period, a total of 5268 operations were performed in the institution by pediatric surgeons. The age ranged from 3 months to 16 years, mean age being 5.5 years [Figure 1]. The maximum number of patients in this series was between 2 and 6 years of age (n = 457). The male-to-female ratio was 5.5:1. The total number of unplanned admissions and complications are shown in Table 1. No major complications were noted. Four minor complications recorded during follow-up included wound infection in three patients and drug reaction in one patient. Overall parental satisfaction was 100%; however, point of discontent included long waiting time before surgery (n = 54 [8.3%]) and prolonged fasting period (n = 52 [7.95%]) shown in Table 2. Other minor numbers of parental complaints are shown in Table 2.

Figure 1

Age distribution

Table 1

Unplanned admissions and complications

Admitted (n=15, 2.29%)				Discharged (n=639, 97.7%)
Reasonfor admission	Edema (5)	Pain (8)	Long recovery time (2)
Procedures (%)	Inguinal hernia (0.76%)	Urethral dilatation (0.61%)	Anal dilatation (0.61%)	Bilateral orchidopexy (0.3%)

Table 2

Parental satisfaction with day-care surgery

Parental questionnaire	Satisfied, n (%)	Not satisfied, n (%)
Waiting time before surgery	600 (91.7)	54 (8.3)
Fasting period	602 (92.0)	52 (7.9)
Pain control	649 (99.2)	5 (0.8)
Nursing care	650 (99.3)	4 (0.6)
Nausea/vomiting	651 (99.5)	3 (0.4)
Overall satisfaction (%)	654 (100)

Thirty different surgical procedures were performed as DCS, out of which inguinal herniotomy (n = 206 [31.5%]), orchidopexy (n = 94 [14.3%]), urethral dilatation (n = 72 [11%]), and circumcision (n = 41 [6.3%]) constituted most of the cases [Table 3].

Table 3

List of procedures performed as day-care surgery

Procedures	n (%)
Anal dilatation	12 (1.8)
Anoplasty	25 (3.82)
Biopsy	13 (1.98)
Umbilical granuloma cauterization	3 (0.45)
Circumcision	41 (6.3)
Cystoscopy	20 (3)
Cystoscopic ureterocele incision	11 (1.6)
Esophageal dilatation	34 (5.1)
Urethral dilatation	72 (11)
Meatal calibration	4 (0.61)
Examination under anesthesia	4 (0.61)
Excision of cysts, sinuses and swellings	31 (4.7)
Tongue tie release	3 (0.45)
Incision and drainage of abscess	11 (1.6)
Laparoscopic inguinal hernia repair	10 (1.53)
Marsupilization	2 (0.30)
Rectal polypectomy	4 (0.61)
Rectal biopsy	21 (3.2)
Foreign body removal	2 (0.30)
Umbilical hernia repair	11 (1.6)
Stomal biopsy	2 (0.30)
Inguinal herniotomy	206 (31.5)
Orchidopexy	94 (14.3)

The average duration of surgery was about 30 min [range 5 min to 1 h, Table 4]. There was no significant difference between the modified Alderete score and the PedPADSS score between admitted and discharged patients. The mean postoperative hospital stay for the same day discharged patients was 5.25 h; those who stayed overnight were discharged on the next day [mean hospital stay 26.85 h, Table 4].

Table 4

Average duration of Surgery, hospital stay and postanaesthesia score

	Unplanned admitted patients	Discharged patients
Average duration of surgery (min)	28.57	27.51
Average total stay in hospital (h)	32.85	9.01
Average postoperative stay (hours)	26.85	5.25
Average modified Alderette score (m)
15 m	9.42	9.78
30 m	9.71	9.98
>30 m	9.71	9.99
Average PedPADSS score (h)
1	13.14	13.82
2	13.1	13.9
3	13.28	13.96
4	13.14	13.97
>4	13.2	13.9

PedPADSS: Paediatric postanaesthetic discharge scoring system

DISCUSSION

Long waiting period for elective surgeries in children is a major problem faced by busy public hospitals in India due to the shortage of hospital beds and operating time. A large number of such cases can be effectively handled by the concept of DCS with optimal utilization of the available resources.[1213]

In India, with 20% of the world's disease burden and just 6% of the world's hospital beds, there is a need for establishing and developing a safe DCS program to ease waiting list pressures.

In the developed countries 50%–70% of pediatric surgical cases are now performed as DCS;[61415] however, such an adaptation is currently lacking in the developing countries where resource scarcity is evident. Various reports from developed countries have shown the safety and efficacy of DCS in children;[16] however, there is a scarcity of data from India.[7] Since we have been practicing DCS in children, we decided to undertake this study to look into the results in terms of its safety and efficacy; and to formulate safety guidelines, including further propagation for DCS in children. We followed the current day surgery guidelines for children laid by the Anesthetists of Great Britain and Ireland, British Association of Day Surgery.[17] To reduce the potential for complications, we included only those patients who were electively planned for DCS and were considered fit for general anesthesia with the duration of the surgery not exceeding 1 h. However, others have included even longer duration surgeries as daycare.[7] Prior explanation to the parents regarding the day-care procedure is invaluable as they play a pivotal role in the management of their children; taking them into confidence with clear discharge instructions enables sending children home under the care of the parents. Our average duration of surgery was approximately 30 min which is similar to other reported series.[67] The frequency of unplanned admissions ranges from 0.1% to 9.6% in the worldwide data, which is comparable to our series (2.3%).[681618] The common causes of unplanned admissions are postoperative nausea, vomiting, and pain, which is similar to our observations.[61819] Pain was the most common cause of un-planned admission in our patients followed by edema and prolonged recovery from anesthesia. Perhaps closer attention to pain control management could reduce such incidents. There was no mortality in our study. Superficial wound infection and drug reaction were the two minor complications recorded in the follow-up period; however, none required admission. One of the best outcomes of this study was high parental satisfaction and their active involvement in the care of their children. Contrary to the earlier belief that people with a low educational background in developing countries will be a hurdle to DCS and will hamper the DCS program, our parents complied with the needs and provided excellent care to their children. This resulted in the reduction of burden on nursing and other health care personnel. It was observed that the psychological trauma of hospitalization was minimized by having the children's postoperative care managed in the home environment similar to the report of Olumide et al.[20]

Different models of DCS are as follows: Self-contained unit on hospital site, hospital integrated facility (this study), freestanding self-contained unit, or in a physician's office-based unit.[21]

In this study, overall parental satisfaction for DCS was 100% similar to the observation of another study performed in India,[22] but 8.3% of parents were discontented regarding the waiting time before surgery and 7.9% were unhappy due to long fasting period in those children, in whom surgery was performed in the afternoon shift. This was due to the fact that we do not have a dedicated day-care unit. This could be avoided by a dedicated DCS unit and scheduling the patients appropriately, especially operating on them preferably in the forenoon or the afternoon patients can be admitted later in the day. Overall parental satisfaction in our study was far higher than the other reports.[2123] DCS calls for team-work and there should be adequate and trained hospital staff, including surgeons, anesthetists, nursing staff, technicians, and clerical staff for a successful day-care program. DCS reduces the chance of the nosocomial infections in children which was evident from the low infection rate observed in our series.[2425]

Our DCS cases were 12.4% of total surgeries performed in our hospital during the same period which is much less when compared to other countries where day-care surgeries constitute approximately 70% of total surgery.[6] Our numbers were low as we restricted our data only to pediatric surgery and not included other specialties such as ophthalmology, otolaryngology and orthopedics. The spectrum of procedures that can be performed as day care is likely to widen with experience and availability of more data showing its safety and efficacy. Hence, a longer duration of the study including several specialties and procedures needs to be undertaken to validate the extended role of DCS in children.

CONCLUSIONS

Our results validate that DCS in children are safe, efficacious and has high parental satisfaction. A large proportion of pediatric surgical cases can be managed by DCS reducing the burden on hospital beds and is economical. The establishment of a dedicated day-care unit should be considered within existing models to reduce the waiting time for several operations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.