A Take on Day Hospitals as in 2014

Internationally nearly 70-80%% of cases are done in day hospitals, in South Africa only 10% – 15%.

The big hospital groups bought out most of the day hospitals and closed them down, thereby forcing patients to visit their more expensive hospitals.

Services offered at day hospitals are billed at a lower and more cost-effective rate than an acute facility’s surgical beds & the day bed tariff of an acute-bed hospital for cases that are explicitly admitted as “day cases”.

Day hospital set-up

A day-hospital functions exactly like a fully-fledged hospital with the necessary equipment and facilities but services limited to ‘day cases’ only.

Patients are admitted and discharged on the same day. Most specialties will be able to do a multitude of procedures at a day hospital, even dentists.

  • cost-savings through sharing of services
  • these specialists have quick access to easily operate their day cases at our facility
  • the patients are close to an acute bed hospital for pre-op or post-op doctor visits, in case of complications, access to services like comprehensive radiology, laboratory, physiotherapy
  • limited need for consulting rooms (full-time and sessional rooms are available for doctors)
    In the US up to 80% of all operative/surgical procedures are now carried out in day surgical centres and the NHS in the UK is predicting a utilization in day hospitals of up to 75%. In South Africa, a day hospital is also not a novel idea. Some facilities started out as a day hospital and then eventually expanded to a network of full acute bed hospitals. Of these existing day hospitals were bought by the major hospital groups and doctors lured to operate patients in more advanced and expensive units. Some surgical procedures can actually be performed in a doctor’s consulting room, but the capital layout (procedural or diagnostic equipment, extra staff, general and resuscitation equipment) & medico-legal risks have discouraged this from happening.
  • A day hospital provides the balanced option between in-rooms and acute bed hospitals. Most schemes are paying for an acute bed facility whereas the procedure could easily have been performed in a day hospital. The current world-wide socio-economic crisis on top of high healthcare inflation, is forcing those paying for healthcare to take a closer look at the causes, cost-drivers and possible measures to manage their financial risks.
  • The Council of Medical Schemes regularly report on the major cost-drivers and the private hospitals feature prominently on the list. Years ago, Bankmed Medical Scheme changed their benefit design and many conditions are preferred to be treated in the out-of-hospital environment. Any hospital admission or procedure in major theatre would require special motivations. Some schemes and administrators are actually more solutions-driven and would continue to provide certain benefits but then in a more cost-effective environment. Also interesting to note from the above article was that of the top 10 conditions ranked by the hospital admissions of Discovery Health patients, the following were procedures commonly done in day hospitals:
  • lens procedures (eye operations performed under local anaesthetics)
  • digestive systems with scopes (gastroscopies and colonoscopies)
  • tonsil and adenoid procedures

The need for acute bed hospitals will only increase – and increase more than the provision of new acute beds. This highlights the need to shift some of the day-facility case mix patients out of the hospital environment into the day hospital environment. Based on this logic, acute bed hospitals and day hospital beds should not be seen as competition to each other. A busy acute bed hospital should welcome a nearby day hospital.

Cost-effectiveness of a Day Hospital

A day hospital’s infrastructure and maintenance allow it to offer a far more affordable product offering:

  • As a fully equipped kitchen and kitchen staff are not required.
  • Only dedicated theatres are built, no expensive laminar flow theatres.
  • No expensive ICU and high care units are built and maintained; this also dramatically reduces the equipment costs and HR costs (in ICU 1 sister oversees 1 patient).
  • A limited availability of theatre stock, prosthesis, pharmaceuticals and consumables are required – and much less variety of each brand (much easier to standardize a smaller variety of brands).
  • No expensive evening or after-hour HR time.
  • Procedures must be chosen which require short theatre time and/or require little post-operative care or management. The list of such procedures per speciality is detailed in Addendum 1
  • Even if the procedures are short and not too complex, the patient’s health, co-morbidities and medical history must also be taken into consideration. Day Hospitals are not replacing the need for acute bed hospitals. The case mix, especially major surgery, trauma, patients with unstable conditions or co-morbidities, as well as surgery requiring overnight stay and monitoring can only be served in an acute bed hospital. If a patient requiring admission for a day-procedure has co-morbidities and would be a risk-admission in a day-facility, the case would rather be admitted to an acute hospital. The privately insured market is actively growing without the same amount of private beds added. There will be a greater demand for the case mix requiring acute bed hospitals – these patients will just replace the case mix of those who can be treated effectively in day hospitals.
  • Pure day cases – Procedures requiring the use of a full operating theatre environment for which general or appropriate local anaesthetic care is provided.
  • Minor surgery – local anaesthetic, outpatient procedures, where care can be provided in a suitable alternative environment, potentially in Primary Care.
  • Endoscopy – which is best undertaken in a dedicated Endoscopy suite. Procedures which can easily be performed in day hospitals like:
  • cataract surgery & eye lid surgery
  • gastroscopies and colonoscopies
  • cystoscopies
  • arthroscopies
  • bunion procedures
  • hernia repairs
  • varicose veins stripping
  • excision of skin lesions, excision of ganglion
  • breast biopsies
  • manipulations under general anaesthetic

According to several studies internationally, day hospitals provide the following benefits:

  1. Organizational efficiency
  2. More cost effective than treatment in acute bed facilities.
  3. Treatment as day beds in acute bed facilities
  4. Patient convenience & satisfaction &
  5. Recuperation in familiar environment
  6. Quality of care
  7. Less cross infections & Less stress
  8. Reported improved hospital outcomes
  9. Less demand for post-op sedation and analgesics
  10. Comfort of recovering at home

The DHA has developed its own day hospital reference framework with categories of patients and clinical guidelines to enable day hospitals to choose the right patients for the appropriate surgery.

By Bibi Goss-Ross

Director, DHASA | COO, Advanced Health Group.

(Originally published in 2014)