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Orthopedic Day-case Surgery in Nigeria: A Single-center Experience

Echezona Valentine Malizu,1 Omolade Ayoola Lasebikan,2 Njoku Isaac Omoke3

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

Correspondence to: Dr Isaac Omoke, E-mail: zicopino@yahoo.com

Received: 26 August 2019; Revised: 31 March 2020; Accepted: 01 May 2020; Available online: 25 May 2020

 

Abstract

Background: The concept of day-case surgeries is relevant in orthopedic specialty in developing countries, where orthopedic elective procedures have relatively longer duration of surgical waiting time, mainly due to lack of inpatient bed space. We aimed to determine the scope, safety and outcome of orthopedic day-case surgeries in a Nigerian setting, and identify potential areas for intervention to improve the practice. Methods: This was a 12-month prospective study of 71 eligible, consenting and consecutive patients who presented at the National Orthopedic Hospital Enugu and were carefully selected and prepared for orthopedic day-case surgeries. Results:  Within the period of study, 53 of 540 elective orthopedic procedures were carried out as day-case, giving a day-case surgery rate of 9.8%. Of the patients enrolled, male to female ratio was 1.2:1 and age range was 8 months to 76 years. Eighteen (25.4%) patients had their day-case procedure cancelled on the day of surgery. The commonest procedure was removal of implant. Conversion rate was 32% 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, orthopedic day-case procedures were safe, though there was low use of day-case surgery in scope, complexity and number of procedures. This and the high conversion rate observed call for a dedicated day-case unit and measures to facilitate timelines of the procedures.

 

Keywords: Orthopedics, Day-case surgery

Ann Afr Surg. 2021; 18(1):52–58

DOI: http://dx.doi.org/10.4314/aas.v18i1.10

Conflicts of Interest: None

Funding: None

© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

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 show 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 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 inpatient facilities and long waiting list is often the norm (7). Day-case surgery is even more relevant in orthopedic specialty in developing countries. Published reports show that compared with other surgical specialties, orthopedic elective procedures have relatively longer duration of length of surgical waiting time mainly due to lack of inpatient 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 postoperative complication and mortality rates (9). The rates of these parameters and scope of orthopedic day-case vary from and within subregions (2,9). Detailed knowledge about the scope, safety and outcome of orthopedic day-case surgery in a setting can facilitate strategies and policy response towards improving the practice. However, data is limited on orthopedic day-case surgery in developing countries; the two previous reports were retrospective studies with associated inherent limitations (1,2). This underscores the importance of prospective data to evaluate orthopedic day-case surgery in our environment. Therefore, this study aimed to determine the scope, safety and outcome of orthopedic day-case surgery in a low-resource setting, and identify potential areas for intervention to improve the practice.

Methods

Study setting and design

This was a prospective descriptive study carried out among patients for orthopedic day-case surgery at the National Orthopaedic Hospital Enugu, Enugu State, Nigeria, from April 2016 to March 2017.

 

Ethical approval

The approval to carry out this study was obtained from the hospital’s ethical committee (IRB/IIIC No. S/3131850, Protocol No. 132). A written informed consent was obtained from the patients and/or next of kin.

 

Study population

The study included patients of both sexes and all age groups who presented to the hospital within the stipulated study period for orthopedic day-case surgery; and satisfied the inclusion criteria.

Inclusion criteria

ASA 1 patients, ASA11 patients with controlled comorbidities, patients with hemoglobin of at least 10 mg/dL, and cases with expected duration of surgery less than 120 minutes.

 

Exclusion criteria

Patient living more than 30 km or 1-hour drive from the hospital and without relatives in town to stay with / nearby health care facility, ASA III patients, patient without responsible escort, poor domestic circumstances inappropriate for postoperative care, failure to meet inclusion criteria, patient not willing to be part of the study, and patients with uncontrolled comorbidities.

 

Sample size

A pilot survey of the hospital operation record book showed that in 2012 and 2013, an average of 647 elective orthopedic procedures were done (population size) and 15% of these procedures were day cases. Based on the population size and average percentage of day-case surgery in the pilot survey, a sample size of 68 was calculated from the formula: Sample size=n/[1+n/ population] where n=[Z2´P´(1–P)/D2] (10).