Orthopaedic day case surgery in Nigeria: A single center experience
Malizu EV1, Lasebikan OA2, Omoke NI3
1Rehoboth Specialist hospital, Port Harcourt -Rivers state, Nigeria
2National Orthopaedic Hospital, Enugu- Enugu State
3Department of Surgery, Ebonyi State University/ Federal Teaching Hospital, Abakaliki- Ebonyi State, Nigeria
Dr Isaac Omoke, Department of Surgery, Ebonyi State University/ Federal Teaching Hospital, Abakaliki- Ebonyi State, Nigeria
Background: The concept of day case surgeries is relevant in orthopaedic specialty in developing countries where orthopaedic elective procedures have relatively longer duration of length of surgical waiting time mainly due to lack of in- patient bed space. Objective: To determine the scope, safety and outcome of orthopaedic day case surgeries in a Nigerian setting, and identify potential areas for intervention to improve the practice. Patients and methods: This was a 12 month prospective study of 71 eligible, consenting and consecutive patients who presented in National orthopaedic Hospital Enugu and were carefully selected and prepared for orthopaedic day case surgeries. Results: Within the period of study 53 of 540 elective orthopaedic procedures were done as day case, giving a day case surgery rate of 9.8%. Of the patients enrolled, the male to female ratio was 1.2:1 and the age range was 8 months to 76 years. Eighteen (25.4%) of the patients had their day case procedure cancelled on the day of surgery. The commonest procedure was removal of implant. Conversion rate was 32% and mainly due to operation occurring late. Complication (mainly pain) rate was 30%, and correlated with duration of procedure (p< 0.006). The satisfaction rate among patients was 98%; no re-admission or mortality was observed. Conclusion: In this study, orthopaedic daycase procedures were safe though there was low utilization of day case surgery in scope, complexity and number of procedures. This and the high conversion rate observed
Keywords: Orthopedics, Day case surgery.
Ann Afr Surg. ****; **(*):***
Conflicts of Interest: None
© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Day case surgery is an important part of elective surgery globally. It accounts for over 50% and 60% of elective surgeries in the UK and USA respectively (1). Published reports indicate that day case surgery shortens hospital waiting list, facilitates efficient use of resources and provides high quality, safe and cost-effective surgical care in selected and well-prepared cases (2,3,4,5). It is also acceptable to both patients and health workers (6). The concept of day case surgery could not be more apt in developing countries where demand for elective surgery usually outstrips in-patients’ facilities and long waiting list is often the norm (7). Day case surgery is even more relevant in orthopaedic specialty in developing countries where previous published report indicate that compared to other surgical specialties orthopaedic elective procedures have relatively longer duration of length of surgical waiting time mainly due to lack of in- patient bed space (8)
Safety and patient satisfaction / acceptability are two critical issues in day surgery (6, 9). Safety can be gauged with parameters such as the direct admission, re –admission, and post-operative complication and mortality rates (9). The rates of these parameters and scope of orthopaedic day case vary from and within sub regions (2, 9). A detailed knowledge about the scope, safety and outcome of orthopaedic day case surgery in a setting can facilitate strategies and policy response towards improving the practice. However, there is very limited data on orthopaedic day case surgery in developing countries and the two previous ones were retrospective studies with associated inherent limitations (1,2). This underscores the importance of a prospective data to evaluate orthopaedic day case surgery in our environment. Therefore, this study aimed to determine the scope, safety and outcome of orthopaedic day case surgery in a low resource setting, and identify potential areas for intervention to improve the practice.
Study setting and design
This was a prospective descriptive study carried out among patients for Orthopaedic Day Case Surgery at National Orthopaedic Hospital Enugu, Enugu state, Nigeria from April 2016 to March 2017.
The approval to carry out this study was obtained from the hospital ethical committee (IRB/IIIC No. S/3131850, Protocol No. 132). A written informed consent was obtained from the patients and/or next of kin.
The study included patients of both sexes and all age groups who presented to the hospital within the stipulated study period for Orthopaedic Day Case Surgery; and satisfied the following inclusion criteria.
ASA 1 patients, ASA11 patients with controlled co-morbidities, patients with haemoglobin of at least 10mg/dl and cases with expected duration of surgery less than 120 minutes
Patient livings more than 30km or 1hour drive from the hospital and without relatives in town to stay with / nearby health care facility, ASA III patient, patient without responsible escort, poor domestic circumstance inappropriate for post-operative care, Failure to meet inclusion criteria, patient not willing to be part of the study and patients with uncontrolled co-morbidities.
A pilot survey of the hospital operation record book indicated that in 2012 and 2013 an average of 647 elective orthopaedic procedures were done (population size) and 15% of these procedures were day cases. Based on the population size and average percentage of daycase surgery in the pilot survey, a sample size of 68 was calculated from the formulae: Sample size= n / [1+n / population] where n = [Z2 X P X (1 – P) / D2] (10).
Patients underwent clinical assessment and laboratory investigations, haemoglobin, urinalysis and others if needed, then selected for day case surgery. A proforma was opened for all eligible patients. Data entered included: age, sex, highest educational level attained by patient/caregiver, domiciliary address, estimated distance from hospital, mobile phone number, ASA grade, mode of anaesthesia, procedure performed, status of surgeon, status of anaesthetist, duration of surgery, time of commencement and time of end of surgery, tourniquet time (if used), access to hospital and family doctor, type of discharge analgesics, complication(s) and its duration, satisfaction of day case surgery among patient/guardian along with reasons for satisfaction or dissatisfaction. Additional data were entered into the proforma for those that were converted (direct admission) and reasons for conversion, cases that were re-admitted and reasons for readmission, and for cases cancelled along with the reasons for cancellation. Conversion (direct admission) rate otherwise called unplanned overnight admission refers to that proportion of patients initially planned for daycase procedures who subsequently got admitted immediately after operation for any reason (6,9). Re –admission rate refers to that proportion of day cases that were operated and discharged home as planned but got admitted back within 30days for complication developed back at home (6, 9)
The patients were given a detailed explanation of the objective of the study and consent obtained from each of them afterwards. Further explanation that patient should present in the morning of surgery with a responsible adult and will go back home after surgery was done. Patients were instructed to commence fasting 12midnight the preceding night before surgery using the preoperative guideline of 2hours for clear fluid, 4hours for breast milk and 6hours for formular milk and solids. Patients were asked to report at the theatre on the morning of surgery. At arrival in the morning and after fulfilling all administrative procedures; they were prepared for surgery by the nurse at the ward. Prophylatic antibiotic (Ceftriaxone 1gm and Metronidazole 500mg) was administered intravenously to all the patients at induction of anaesthesia. Patient was observed in the theatre recovery room after surgery and then moved to the ward. Patient was discharged home accompanied; after being assessed by the first author in conjunction with a senior member of the operating unit; along with satisfying the following discharge criteria: alert and oriented in time and place, stable vital signs, pain controlled by oral analgesic, nausea or emesis controlled, able to walk without dizziness, regional anaesthesia appropriately resolved, prescription given, patient accepts readiness for discharge and a responsible adult present to accompany patient home. Post-operative pain as a complication was measured at the point of discharge from the hospital using numeric rating scale (NRS) 0-10 where zero represented no pain and 10 the severest pain intensity.
Patients were followed up through phone calls at least once a day after discharge till next clinic appointment. The patient/caregiver was also given the contact number of the first author.s Patients were followed up for at least four weeks and at each clinic visit, they were clinically assessed by one of the authors in conjunction with managing unit.
The data was analyzed using statistical package for social science (SPSS) version 20 (SPSS Chicago IL, USA) for graphs, bar charts, pie charts and frequency tables and cross tabulation. Continuous and categorical variables were summarized using Mean, Frequency, Standard deviation and percentages. Mean comparison of continuous variables was done using student’s t test while associations between categorical variables were done using chi square, and a p-value of < 0.05 was considered significant.
This study enrolled 71 consecutive eligible consenting patients for orthopaedic day case surgery. The male to female ratio was 1.2:1 and the age range was 8 months to 76 years. The estimated distance from the patients’ home to the hospital ranged from 5 to 30Km with a mean of 16Km ± 7.536.
Of the 71 patients, 18 (25.4%) had their day case procedure cancelled on the day of surgery whereas 53 patients underwent surgery as planned. In the period of the study there were 540 elective procedures and 53 of them were done as day case, given a day case surgery rate of 9.8%.
The three top procedures performed as day case were removal of implants (plates and screws), biopsy and manipulation under anaesthesia as shown in Table 1. Majority (84.6%) of the day case surgeries were only therapeutic procedures whereas 5(9.6%) and 3 (5.8%) of cases were only diagnostic and therapeutic/diagnostics procedures respectively. All patients in this study were ASA Grade 1 status. Spinal, general and local anaesthesia was the mode of anaesthesia given to 24 (45%), 22 (42%) and 7(13%) of the patients respectively. Majority 47(89%) of the patients were anaesthetized by Nurse Anaesthetists whereas 6 (11%) of patients were anaesthetized by Consultant anaesthetist. Senior Registrar performed 42 (79%) of this procedure whereas Consultant Orthopaedic surgeons performed the rest 11 (21%), of the procedures.
Twelve (22.6%) of the patients had access to family doctor to care for them at home whereas the rest (77.4%) do not have family doctors. Sixteen (30.2%) of the patients have private cars to access the hospital should there be an emergency whereas majority 69.8% of the patients depend on public transport to access the hospital.
Seventeen patients were admitted as an in-patient after surgery given a conversion rate of 32%. Social reasons, operation occurring too late ( operation after normal working hours of 4pm when priority and attention of theater workforce is focused on emergency cases) was the reason in 16 (94.1%) of these patients that were converted to in patients hospital admission where as extensive surgical procedure was the reason in one (5.9%) of those that were converted.
Sixteen (30%) of patients who had day case procedure had complication. Complications reported in this study were surgical related complication; pain and hematoma. Of the 16 patients that had complications, 15 and 1 of them had pain and hematoma respectively. Hematoma was observed in a patient following excision biopsy of a popliteal mass without a wound drain.None of the patients had wound infection. There was no association between the complication and the rank of anaesthetist as shown in Table 2. The rate of complication was higher in procedures done by Senior Registrar compared to the ones done by the Consultants but this difference was not statistically significant (p =0.330) as shown in Table 2. The complication rate correlated (p < 0.006) with mean duration of surgery as shown in Table 3. There was no case of re-admission into the ward for complications developed back home, and no mortality was observed among the patients.
Patients were given different types post op analgesics: Non steriodal anti-inflammatory drugs (NSAID), Opiods, NSAID + Opiods, NSAID + Paracetamol and Opiods+ Paracetamol were given to 20, 1, 8, 6 and 18 of them respectively. There was no significant association (p =0.272) between the incidence of post-operative pain and the type discharge analgesics. There was immediate post-operative pain in 93.8 % of the patients; the first day post-operative period the incidence of pain reduced to 31.3% and afterward complete resolution of pain in all the patients.
The three top reasons for the cancellation of day case procedure during the period of this study were: failure to arrive to hospital, time constraint on the part of surgeon and lack of theatre space as shown in Table 4. Day case surgery was highly recommended by 52 of the patients giving a satisfaction rate of 98%.
The age distribution of eligible patients enrolled in this was similar to the finding reported by Ajibade et al in another orthopaedic hospital setting in Northern Nigeria (2). The wide age range in this study and the previous ones indicate availability of standard anaesthesia facilities with qualified and experienced anaesthetist to handle different age categories for day case procedures in a low resource setting such as ours (2,11).
Majority of procedures in this study was carried out under spinal anaesthesia (45%), this was quite different from general and local anaesthesia for majority of the procedures in the series reported by Ajibade et al and Adewole et respectively (2,12). In this study, spinal anaesthesia was mostly used because implant removal, the commonest of procedure observed, were carried out mostly on the lower limb. Spinal anaesthesia is a preferred option because the residual analgesia from block also reduces post-operative pain (4).
Therapeutic procedures constituted 84.6% of all procedures; with removal of implant (59.6%) the commonest specific procedure performed in this study is at variance to biopsy as the commonest procedure reported by Ajibade et. al (2). The reason for this variation is not evident.
The scope of procedures in this study was similar to those reported by similar studies in other Nigerian hospitals in Kano and Lagos, though additionally Kirschner wire fixation and open reduction and internal fixation of forearm fractures with plate and screws were done as day case procedures respectively (2,12). In Kenya, Mulimba et al reported a wider scope and complexity of orthopaedic procedures done as day case; this included open reduction and internal fixation of fractures, sequestrectomies, and amputations, arthroscopies of the knee, tendon and nerve repairs (12).In the United Kingdom complex surgeries like anterior cruciate ligament reconstructions, arthroscopic menisectomy done as day case were reported by Older et al and Khan et al respectively (13,14). Procedures such as subacromial decompression and tendon transfer, tarsal coalition excision have been reported as day case procedures respectively (2,15) . The limited development of minimally invasive orthopaedic surgery, unavailability of dedicated day case units and lack of provision of community services by community physicians and nurses in Nigeria perhaps explains the wide gap in scope of procedures in this setting and in other countries (2,16).
The period of this study that coincided with the peak of economic recession in Nigeria is a plausible explanation for the rate of day case surgery that is below the average rate observed from the pilot survey. However,the day case surgery rate in this study was higher than 3.48% reported by Ajibade et al (2) . This level of utilization falls short of the reported rates in other surgery specialties like urology (61.6%), plastic surgery (37.2%) reported in Nigeria and the reason is not evident (14,17).
The conversion rate in this study was higher than 3.3%, 1.07%, 1.4% and 0.01% reported by Ajibade et al Cardosa et al Margorsky et al and Mulimba et al respectively (2, 18, 19,11). The very high conversion rate in this study was mainly due to social reason of operation occurring too late whereas in these previous reports, conversions were due to surgical and anaesthetic reasons (18,19,11). In this study, only one patient had surgical reason, extensive operation, for conversion. If late operations were eliminated, then a conversion rate of (1/53) 1.9% (resulting from extensive surgical procedure) is within the range of 2-3% recommended by Royal College of Surgeons (19). This implies the safety of the practice in our setting and calls for measures aimed at reducing the incidence of late operations among patients for day case procedures.
In this study, the mean estimated distance was 16km from the hospital and only 30% of patients had private car access to the hospital bearing in mind the relative lack of good and efficient public transport system in our setting. This is an important factor for high conversion rate; as most patients cannot get back home when operations are done late; considering the security situation in our setting and therefore admitted overnight. It is therefore important that patients are operated at the beginning of the morning list and every effort made to ensure that day cases are dealt with before mid-day to ensure early, safe discharge. This also calls for a dedicated day- case unit so that day case patients will not compete with in-patients for theatre space.
The complication rate in this study was higher than 2.7% and 2.37% by Ajibade et al (2) and Cardosa et al respectively in similar studies (18). Pain as the commonest complication was also similar to the findings reported by Cardosa et al and Mulimba et al respectively but at variance with wound infection as commonest complication reported by Ajibade et al (18, 11, 2) There was no significant correlation between complications rates with mode of anaesthesia, rank of surgeon, rank of anaesthetist, duration of tourniquet, education level of patient/caregiver and type of discharge analgesics, and this is similar to the findings reported by Cardosa et al (18) . There was significant correlation between duration of surgery and complication rate in this study but the reason is not evident. The resolution of pain in all the patients after day one post operation indicate adequacy of our discharge analgesics and compliance of patients with intake of analgesics and ability of patient/caregiver to comply with instructions for preparation for surgery and post-operative care as previously reported by Abdurrahman (21). That none of the patients had post-operative wound infection also indicate adequacy of prophylactic antibiotics and patient/ care giver compliance with the instructions.
In this study, there was no readmission and mortality; a similar finding reported by Adewole et al (12). This indicates proper patient selection and the safety of orthopaedic day case practice in our setting. The cancellation rate in this study was higher than 15.6% and 11.06% reported by Ramyil et al and Kolawole et al respectively (5,22) . In this study, the main reason for cancellation, failure to arrive to the hospital due to financial difficulty was similar to the findings by Ramyil et al but at variance with surgical related factor of time constraint reported by Kolawole et al (5, 22). An organized health insurance scheme with wide coverage may help cover the financial bills of patients. The surgeon related factor for cancellation could be mitigated by making realistic theatre list. A dedicated day case unit by eliminating day case and in-patient competition for theatre space and surgeons time could have prevented more than a third of the cancellations as shown in Table 5. In this study, that over ninety percent will recommend day case surgery to other people is an indication of its acceptability in our environment
In this study, orthopaedic day case procedures were safe though there was low utilization of day case surgery in scope, complexity and number of procedures. This and the high cancellation and conversion rates observed call for provision of a dedicated daycase unit and measures to facilitate timeliness of the procedures.
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