ANZ J. Surg.

2004;

74

: 754–759

ORIGINAL ARTICLE

ORIGINAL ARTICLE

A 23-HOUR CARE CENTRE MODEL FOR THE MANAGEMENT OF SURGICAL PATIENTS

R

ICHARD

R

YAN

, J

UDITH

D

AVOREN

, H

ELEN

G

RANT

AND

L

EIGH

D

ELBRIDGE

Division of Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia

Background:

Much of the emphasis on gaining efficiencies in surgical care have, to date, focused on increasing day only (DO)facilities and increasing the utilization of day of surgery admissions (DOSA) for longer stay cases. However, for the majority of casesrequiring surgery, both elective and acute, the episode of care can generally be delivered within an envelope of 23 h during whichtime patients require only pain relief and monitoring in a supervised setting until fit for discharge. The aim of the present study was toevaluate a pilot of a 23-h care centre at a principal referral hospital.

Methods:

A 23-h care centre was established at a principal referral hospital in January 2003 in association with an existing DOand DOSA facility. All patients, both emergency and elective as well as surgical and medical, who fitted the following criteria wereadmitted as ‘23-h patients’ to the centre: absolute expectation of discharge within 24 h; preadmission screening by a nurse screener(if elective); agreed clinical guidelines in place; agreement to protocol-based, nurse-initiated discharge. Outcomes were evaluatedafter 3 months. Existing admission criteria for DO and DOSA patients were maintained.

Results:

Over 3 months, 1601 patients utilized the 23-h care centre as follows: 593 DO patients, 410 DOSA patients and 598 23-hpatients. Transfers from the emergency department constituted 47% of all 23-h patients. Utilization varied with the departments ofhand surgery, ear, nose and throat/head and neck surgery, and gastrointestinal surgery all managing more than 55% of their operativeworkload as 23-h patients (excluding DO and DOSA patients). Excluding inappropriate admissions, overall discharge compliance was83%. Three departments achieved the compliance benchmark of 90% of admitted patients discharged within 23 h. Only 1% of patientsdischarged required referral back to the emergency department, with a further 2% being reviewed by their general practitioner.

Conclusion:

The 23-h care centre model, incorporating DO, DOSA and 23-h patients, offers a workable system of healthcaredelivery for patients who do not require a prolonged stay in hospital including, potentially, the majority of surgical patients.

Key words: 23-hour, day-only surgery, efficiency, short stay.

Abbreviations

: DO, day only; DOSA, day of surgery admissions, MPADSS, modified post anaesthetic discharge scoringsystem.

INTRODUCTION

In the face of rising healthcare costs in Australia, the search foreffective means to reduce a patient’s length of stay while main-taining high quality care has continued. There has been a progres-sive move towards increased efficiency in the management ofpatients requiring admission to hospital for most surgical pro-cedures. This trend has also been driven by the demand for ser-vices and the requirement to decrease cancellation rates becauseof a lack of beds.

Much of the emphasis on gaining efficiencies in surgical carehas, to date, focused on improving access to day only (DO) facil-ities, as well as increasing the numbers of patients admitted to aday of surgery admissions (DOSA) facility for longer stay surgi-cal procedures. The progressive increase in the utilization of DOsurgery, either as a stand-alone facility or incorporated into a hos-pital operating room facility has had a dramatic impact uponlength of stay and efficiency of surgical management. However,stand-alone DO facilities have limitations, particularly in relation

to scheduling of surgical cases late in the afternoon. Likewise,although increasing use of DOSA has resulted in reduced lengthof stay, a focus on DOSA alone does not address issues relatedto early discharge. Conceptually the majority of cases requiringsurgery, both elective and acute, require an envelope of less than24 h for the delivery of care, during which time patients requireonly pain relief and monitoring in a supervised setting until fit fordischarge. As such the 23-h concept is differentiated from the DOconcept, which focuses on achieving discharge same day in orderto avoid an overnight stay. Such care does not require a standardhospital ward and bed, but can be provided by a combination ofwalk-in admission facility, trolleys for postoperative recovery,recliner chairs and a discharge waiting area.

A review of the previous 12 months data from Royal NorthShore Hospital, Sydney, Australia showed that 68% of all elec-tive surgical cases had a length of stay of 1–2 days with a further7% having a length of stay of 3 days. Just as relevant was thefinding that 47% of emergency surgical admissions required lessthan 2 days in hospital. Thus, by driving increased efficiencies inrelation to earlier discharge (by providing guaranteed admissionto a 23-h care centre) there was the potential for up to 75% ofelective and 50% of emergency admissions to be cared for in a23-h care centre without the need for admission to a standard hos-pital ward bed.

In January 2003, a pilot 23-h care centre was established atRoyal North Shore Hospital, a principal referral hospital. Thisinvolved incorporating an existing DO and DOSA facility within

R. Ryan

BN, MNL;

J. Davoren

BHA, MCom;

H. Grant

BA, MN;

L. Delbridge

MD, FRACS.

Correspondence: Professor Leigh Delbridge, Division of Surgery, RoyalNorth Shore Hospital, St Leonards, NSW 2065, Australia.Email: leighd@med.usyd.edu.au

Accepted for publication 31 January 2004.

23-HOUR SURGICAL CARE 755

a new facility accepting, in addition, 23-h patients. All patients,both emergency and elective as well as surgical and medical, whofitted the following criteria were admitted as 23-h patients to thecentre: absolute expectation of discharge within 24 h; preadmis-sion screening by a nurse screener (for elective patients); agreedclinical guidelines in place; agreement to protocol-based, nurse-initiated discharge. Outcomes were evaluated after 3 months.Existing admission criteria for DO and DOSA patients weremaintained.

The present paper describes the evolution, structure andprocess and outcomes of the pilot 23-h care centre.

MATERIALS AND METHODS

Physical facility

A 23-h care centre was established colocated with an existingDO and DOSA surgical facility. This required simply additionalprovision of the following physical facilities: a larger walk-inadmission facility, extra trolleys for postoperative recovery,recliner chairs for later stages of recovery, and an enlarged dis-charge waiting area.

Admission criteria

The following criteria determined eligibility for admission to thecentre: absolute expectation of discharge less than 24 h; pre-admission screening by a nurse screener (for elective patients);agreed clinical guidelines in place; agreement to protocol-based,nurse-initiated discharge. Existing admission criteria for DO andDOSA patients were maintained.

Clinical guideline development

Clinical guidelines were developed for each admission type,encompassing both elective and emergency admissions, as wellas surgical and medical disorders. Each guideline provided forprotocol-based, nurse-initiated, discharge subject to fulfillingagreed criteria. Each clinical guideline was department and pro-cedure specific (not surgeon specific) with each member of therelevant department having to agree to the guidelines. Admis-sions without agreed guidelines were not generally accepted intothe centre. An example of a clinical guideline for hemithyroidec-tomy is shown in Fig. 1.

Patient flows

For elective patients, once the hospital accepted a request foradmission form, it was screened by the nurse screener (in thepreadmission clinic) to determine the patient’s suitability for the23-h care centre. If the request for admission form was not for asurgical patient, then the RNS clinical bed manager would deter-mine the patient’s suitability for the 23-h care centre or an inpa-tient ward bed. The nurse screener would review the patient’shealth questionnaire to determine their preadmission require-ments. If a preadmission clinic appointment was required then thenurse screener coordinated this process in liaison with adminis-trative staff. For emergency patients, a request for admission wasmade by direct contact between the emergency department andthe clinical bed manager. Patients suitable for admission into the23-h care centre include DO patients, screened DOSA admissionsand 23-h patients. These 23-h patients had to have a clinical

guideline in place for their procedure and have an absolute expec-tation that they would be discharged within 23-h postoperatively.

Suitable elective patients attended the preadmission clinic forreview of all preoperative requirements. On the day of surgery,patients had a nursing assessment and preoperative checklistcompleted by a member of the nursing staff. Patients waited inthe preoperative waiting area until called for surgery, at whichtime they changed into a hospital gown, ready for escort to oper-ating rooms. The purpose of keeping the patients in the waitingarea for as long as possible was to keep them in their own clothesand allow them independence until the time of their procedure.Following completion of the procedure, patients were transferredto stage 1 recovery (located within the operating room complex),until such time as their clinical condition was assessed as stable.At this point, they were brought back to the 23-h care centre forstage 2 recovery. Once a DO patient was considered to have stablehaemodynamic observations and be neurologically alert and orien-tated, they were assisted to change into their own clothes and thenprogress to the recliner chairs in the stage 3 recovery/dischargelounge area. Patients continued to be observed until discharged.Those DOSA patients who presented to hospital for procedureswhich required a postoperative length of stay beyond 23- h, weretransferred from stage 1 recovery to a suitable inpatient ward areafor the remainder of their hospitalization.

Twenty-three-hour patients were managed in a similar fashionto DO patients. The main exception was that all these patients hadto have a clinical guideline, which outlined the specific care theyneed to receive in the postoperative period and allowed nurse-initiated discharge without medical review. The stage 3 recovery/discharge lounge area was also utilized once the patient had beenassessed by the nursing staff as ready for discharge.

All patients were given a follow-up phone call on the day fol-lowing discharge to see if they had any specific questions and tocheck on their recovery. This was an excellent tool for assessingif some patients have had delayed responses to any medications,as well as providing a personal touch for the patients in relation totheir stay in hospital.

RESULTS

Throughout the pilot project, 1601 patients utilized the 23-h carecentre, comprising 593 DO, 598 23-h and 410 DOSA patients.Table 1 outlines the activity levels for the top 10 departments thatutilized the 23-h care centre throughout the 3 months, and thepercentage distribution of their patients for the respective threecategories charted. The results illustrate that the departments ofhand surgery; ear, nose and throat/head and neck, and gastrointes-tinal surgery managed greater than 50% of their patients as 23-hpatients (excluding DO and DOSA).

Throughout the introduction of the 23-h care centre, it wasimperative to ensure that DO and DOSA patient numbers did notreduce as a result of the introduction of a 23-h centre. Throughoutthe pilot project only 27 DO patients required admission over-night. For all these patients, clinical necessity was the reason forthe extended length of stay.

Elective admissions comprised 53% of admissions, with 47%of 23-h patients coming from the emergency department. Themajority of emergency patients underwent surgery in the after-noon or evening, and it was this group that was particularlyadvantaged in having access to such a facility. The ability of thecentre to manage fluctuating workloads within short time periodsand assist with relieving the pressure on the emergency depart-

756 RYAN

ET AL

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. 1.

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23-HOUR SURGICAL CARE 757

ment is crucial to its function and long-term viability. The 23-hconcept must always be open every day, all day in order tomanage the large numbers of patients who present to hospital atshort notice for either surgical intervention or medical care.

Although primarily a surgical facility, the 23-h care centre alsoaccepted emergency medical patients provided they fulfilled theagreed admission criteria. A total of 22 23-h patients (4%) and117 DO patients (20%) with a medical diagnosis were admitted tothe centre during the study period. The most common medicaldiagnosis in that group was renal colic.

Activity varied throughout the week. Wednesday has proven tobe the highest activity level for both 23-h patients (mean = 10) aswell as for total patient activity (mean = 29). On weekends thevolume of patients does diminish, however, the acceptance ofemergency admissions requires the centre to be open on week-ends. Overall the nursing ratio for the centre was 1:6, however,no specific ratio was used as is done in ward areas, where theratio would be between 1:4 and 1:6 depending upon the acuity ofpatients and staffing levels, because the turnover is much higher.It was considered more beneficial to allocate each staff memberto specific areas within the centre.

In relation to the 90% discharge benchmark, 136 patientsstayed longer than 23-h postoperative. While only three depart-ments achieved the discharge compliance benchmark, there werea further seven departments whose percentage of discharge com-pliance was above the mean of 77%. Of those, in fact there were61 patients whose discharge occurred between 0 and 4 h after thedesignated 23-h benchmark. These 61 patients represented 10%of all 23-h patients. Of the 136 patients with a postoperative staygreater than 23 h, there were 35 inappropriate admissions to the23-h care centre. These were patients whose procedure was notone of the nominated procedures (i.e., no clinical guideline inplace and historical data suggested their length of stay to begreater than 3 days, hence they were not targeted throughout thetrial). An example is an infected hand from a dog bite, as theygenerally require several days of i.v. antibiotics. Excluding theseinappropriate admissions increases the overall discharge compli-ance rate to 83%. The inappropriate admissions resulted from alack of awareness among after hours nurse managers regardingthe admission policy of the 23-h care centre and the pressure forbeds within the hospital at various times.

All patients received a follow-up phone call the day followingdischarge to determine if any adverse outcomes had occurred as

well as to maintain the human side of the service. Only 1% ofpatients required referral back to the emergency department witha further 2% returning to their general practitioner. 5% had nocontact details, certainly a concern. A little surprising was that27% did not return phone messages left, but were presumablywell. During the pilot, patients were given information on follow-up phone calls when they received the information brochure.They were then called twice postoperatively during the followinglate afternoon early evening period.

To ascertain the significance of the changes from a patient per-spective, the nursing staff at the follow-up phone calls conducteda telephone survey. The telephone survey provided an opportu-nity to review all components of the hospital admission from apatient’s perspective.

In reviewing the comments from patients to the telephonequestions, the emphasis of all their comments were positivereflections on the excellent nursing care received and the friendlynature of the staff. Other issues identified by patients were thelimited space around the trolleys, and a delay in waiting for dis-charge medications. There were several patients who were con-cerned about the long delay waiting for surgery, an issue alsoreflected in the data obtained on preoperative waiting times.

A potential advantage of the introduction of the 23-h carecentre was a reduction in the number of cancelled operating roomcases because of a lack of postoperative ward beds. A total offour cases were cancelled during the study period compared tofive cases during the corresponding period 12 months prior.Although reduced, this difference was not statistically significant.

Specific cost-savings in dollar terms were difficult to quantifyfor such a pilot project within the overall budget of the division ofsurgery. The opening of the 23-h unit, however, allowed for the‘consolidation’ of surgical beds throughout the hospital equiva-lent to a 25 bed ward. The only costs related to the opening of thecentre were the purchase of patient trolleys and a new callsystem. A number of targeted procedures achieved a significantdecrease in average length of stay throughout the entire hospital(not just the 23-h centre) during the pilot e.g., appendicectomyreduced from 3.14 to 2.36 days; thyroid procedures from 2.40 to1.86 days; cystourethroscopy from 2.47 to 1.68 days; other elbowor forearm procedures from 2.47 to 1.68 days; cardiac pacemakerimplantation from 1.17 to 1.00 days; cardiac catheterization from1.59 to 1.09 days.

No specific patient-related outcome data were collected as partof the pilot project, other than what would have been collected aspart of the hospital’s overall quality assurance program. Duringthe period of the pilot project no specific adverse incidents relatedto the activity of the 23-h centre were reported to the division ofsurgery.

DISCUSSION

Increased efficiencies in the management of surgical patientsin association with the introduction of DO and DOSA units arewell recognized. The principle that the majority of patientsrequiring surgical care can be managed within a 23-h envelopehas increased opportunities for further efficiencies by adding anew category of ‘23-h patients’ to existing DO/DOSA facilities.

The fundamental principles underpinning a 23-h care centreare: the majority of patients undergoing elective or emergencyprocedures (surgical and medical) require only pain relief andmonitoring in a supervised setting until fit for discharge and donot need a formal hospital ward bed; the majority of surgical and

Table 1.

Top 10 departments by 23 h use

Department No. patients Total 23-h DO DOSA

Hand surgery 174 71 4 249Gastrointestinal surgery 107 38 53 198ENT/head and neck surgery 62 34 13 109Gynaecology 59 63 31 153Cardiothoracic surgery 39 25 22 86Endocrine/oncology surgery 36 2 44 82Orthopaedic surgery 31 58 129 218Urology 23 75 35 133Plastic surgery 14 29 34 77Vascular surgery 12 14 14 40

DO, day only; DOSA, day of surgery admissions; ENT, ear, nose andthroat.

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some medical patients can be managed completely within theconfines of one single unit; a clinical guideline driven approachcan drive patient care; nurse-initiated discharge with no need forroutine medical review prior to discharge for patients who fulfilthe clinical guidelines allows timely discharge; such facilities canprovide for both elective and emergency admissions requiringovernight care.

While there is support for the introduction of either a surgical

1

or medical

2,3

short stay ward or observation unit, there is littlepublished information about combining the two specialtiestogether. These studies reported a shorter length of stay, lowerrates of in-hospital complications and lower rates of readmissionfor patients from short stay units, compared to patients admittedto the general ward areas.

A pure surgical ward has the potential to have fluctuatingoccupancy levels because of operating room availability andtherefore not be a cost-effective model of care. Establishing a unitthat manages surgical and medical admissions addresses thisissue. A 23-h care centre has the potential to generate significantcost savings and efficiencies for an organization, with decreasedlength of stay, streamlined admission and discharge process and amore efficient use of staffing and hospital facilities.

The introduction of observation units within emergencydepartments is a trend that has evolved in recent years. In generalthese units have been aligned to their respective emergencydepartment and managed by the emergency physicians. Theestablishment of such units has assisted in reducing the numberof patients who have required a ward bed. Patients have beenadmitted to the observation unit if it is anticipated that the dis-charge will occur within 48 h. Organizations who have estab-lished such systems have utilized a 90% discharge compliance tomeasure the success of their respective units. Similarly, a 90%discharge compliance benchmark was established for the 23-hcare centre to allow for direct comparisons with other hospitalunits.

It was initially considered that the introduction of the 23-h carecentre might have lead to a decrease in the clinical expertise ofnursing staff as speciality skills are overtaken by the need forgeneralist skills. From our pilot project however, we have foundthat the 23-h care centre provides an opportunity for the explora-tion of a new speciality and culture within nursing. There hasbeen a flow on effect throughout other wards within the hospital,who are now receiving less outlier patients and predominantlyhigher acuity patients related to their speciality. This provides adifferent challenge for effective patient management.

A key factor in the successful implementation has been the useof clinical guidelines with nurse-initiated discharge practices.Clinical guidelines incorporate the managed care concept of uti-lizing collaborative and multidisciplinary health care delivery inthe pursuit of total patient care. The procedure specific clinicalguidelines, is a structured double-sided document that allocatespatient care into 6-hourly time periods. These time periods allowfor the documentation of care by all members of the health careteam with the nursing staff coordinating the patient managementand monitoring outcomes. It allows for variances to be high-lighted as early as possible so review and possible interventioncan occur, thereby not unnecessarily increasing length of stay.The strength of the concept is it’s ability to address and outlinethe essential components of care in a coordinated manner

4

while

providing cost-effective and accessible care to patients

5

in a time-orientated manner.

Nurse-initiated discharge provides a unique opportunityfor effective patient management provided by nursing staff,while maintaining a multidisciplinary team orientated approach.Current practice throughout Australia is very limited in nurse-initiated discharge. Incorporated within the nurse-initiateddischarge system is the modified post anaesthetic dischargescoring system (MPADSS). The MPADSS system provides anassessment tool for nursing staff to see where the patient ispostanaesthetic

6

as it has five components reflecting: vitalsigns; ambulation; nausea/vomiting; pain; surgical bleeding.The combination of procedure specific and anaesthetic relateddischarge criteria allows clinicians to make decisions regardingpatients readiness for discharge based upon a structured reliableguide.

While the inability to achieve the benchmarked 90% dischargewithin 23 h postoperative across the entire service was dis-appointing, the significance of the results obtained must beacknowledged. The introduction of the 23-h concept has been asignificant cultural shift for the organization and there have beenseveral factors throughout the pilot project that have impacted onthe ability of the 23-h care centre to operate to its full potential.These factors included the inability of medical staff to completedischarge medications and summaries at the time of procedure,thereby creating the need for medical review of patients by defaultfor the completion of paperwork. There was also reluctance bysome nursing staff to discharge the patients, based solely on thedocumented discharge criteria because it was such a significantcultural shift for them to have the autonomy and authority to do so.

In evaluating all the data obtained from the pilot project,the introduction of the 23-h care centre has been a success forthe organization and patients. Positive feedback from patientsand reductions in length of stay for particular procedures hasenabled the streamlining of patients admission and reductions inepisode length of stay. The 243 23-h patients that have beenadmitted directly from the emergency department is indicative ofthe centre’s ability to assist in reducing pressure within the emer-gency department by providing access to beds for patients whoare requiring an overnight hospital admission. The link estab-lished with the day surgery centre has assisted in enhancing oper-ating room utilization, which in turn assists in managing andreducing more effectively waiting lists.

The results from the pilot study have also brought about somepractice changes. The fact that 5% of patients had no contactdetails was certainly a concern and specific attention is now paidwhen the admission referral is lodged to ensure that all patientinformation is completed and a phone number is correct. Withrespect to the 27% that did not return phone messages, they arenow provided with a specific 2 h time frame in which they arecalled, and will receive a second phone call 24 h later if still notcontacted.

In summary, the 23-h care centre has created and defined aninnovative model of care, which can be adapted for other organi-zations. Future challenges will be to extend the concept to themanagement of all surgical patients. The 23-h envelope of timerepresents a concept wherein perioperative management for allsurgical patients could be provided, starting from admission dayof surgery. In future, the majority of patient will be able to be

23-HOUR SURGICAL CARE 759

discharged home directly from the 23-h centre, either same day orwithin 23 h after overnight care, without the need for a hospitalward bed. A significant number of patients would be able to bedischarged directly to a rehabilitation centre, also avoiding occu-pying an acute hospital bed. The remaining patients (now aminority) requiring long-term care could then be ‘discharged’ toan acute hospital ward bed. Thus the 23-h care centre, in associa-tion with operating and procedure rooms, may in future becomethe central focus of surgical activity with traditional hospital wardblocks relegated to an annex for a minority of patients.

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