Source: Front page of "Liberation Daily" on February 28
"Liberation Daily" Reporter: Yangzi Huang

Just before the Lunar New Year, the 65-year-old Mr. Zhang was discharged from Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine on the second day after receiving laparoscopic cholecystectomy under general anesthesia. He felt so incredible that the stomach ache that had been bared for so long time, could be solved through such a minor surgery within one day of hospitalization?" The doctor told me that this is a ‘day surgery’. The examinations which can be carried out only after admission to the hospital previously can now be done well in advance before waiting for the notice of surgery at home.

The "living" bed could facilitate the no longer "difficult" surgery. Since September in 2005, Renji took the lead in the pilot implementation for the mode of “day surgery” in Department of Urology. In 2008 Renji opened the first independent day ward in Shanghai, so that the practice within more than ten years has proved the feasibility of day surgery in our country. However, since the introduction of day surgery into China in the 1990s, it has not been widely promoted yet, and people's awareness and acceptance are still low. At the beginning of this year, at the National Conference on Medical Management Work, the State Health Planning Commission explicitly listed "Broaden the pilot implementation of day surgery in tertiary hospitals" as one of its key work. Would day surgery enter the fast lane? Whether there are still "acclimatized" problems to be solved during the promotion?

Why is day surgery?

Day surgery is not a new mode of surgery, but a new management model. That is, the length of stay will be shortened to within 24 hours for the patients, while the longest hospital stay does not exceed 48 hours for those special conditions that need to be delayed, excluding outpatient surgery. At present, China Day Surgery Alliance recommends a total of 56 surgical procedures, and is planning to select the second batch this year. But for specific exploration, the hospitals can choose to expand the diseases according to the actual situation. Director of Department of Medical Affairs from Renji Hospital, Jidong Zhang, introduced that Renji hospital had carried out day surgery for318 kinds of diseases in 2017, and tend to more three or four levels of operations and give incentives, "such as popliteal cyst excision, inguinal hernia repair surgery and other low-level surgeries, we hope to sink those tobe completed in the second-class hospitals".

In 2015, the Lancet Council commented on day surgery at “Global Surgery 2030”: "It is a key way to achieve universal access to safe and adequate surgical treatment." Taking the data of Renji Hospital in 2016 for day surgery as an example, the day wards which occupy about 6.22% of the total operating beds of the hospital win a total operation volume of 30855, accounting for 40.1% of the total operation volume of the hospital. The efficiency of utilization of medical resources is significantly improved. For patients, the day surgery brings convenience and concessions. Such as the laparoscopic cholecystectomy received by Zhang, in 2016 the number of people that have been admitted to Renji for this surgery ranked the top among the tertiary hospitals in the city. The average cost of discharged patients was 17.7% lower than that in other tertiary hospitals and the average cost of medicines was reduced by 33.5%. The average length of stay was reduced 35.6%.

Jidong Zhang said frankly that in the traditional management model, more than 70% of beds or even sources of departments are dominated by chiefs and major doctors in tertiary hospitals. "In the face of difficult cases, young doctors only have the opportunity of observing and learning, not to mention to admit their own patients." Nowadays, day surgery gives them a stage to develop. As long as they have the qualifications and pass the examination, they have the opportunity to open their own operation and the surgical skills can be improved in the short term." In our hospital, the day surgery beds are open for all the qualified doctors. According to the first-come first-serve principle, the date of surgery can be booked in accordance with the wishes of the patients and surgeons."

What is the problem of domestic promotion?

At present, from the international experience, day surgery is the trend of the times. In Europe and the United States, the ratio is as high as 80%. How is the development in our country?

Last year, some information was disclosed during the 12th International Day Surgery Conference: Up to the end of 2016, there were over 2,000 medical institutions operating day surgery in our country, in which 396 institutions have day surgery centers. The ratio of day surgery has been increased from 5% in 2015 to 11%.

Dayang Wen, vice chairman of China Day Surgery Alliance and deputy director of the Municipal Health Planning Commission, pointed out that although day surgery has entered an accelerated period, it still has a long way to follow the United States and Europe. China still needs a more sound and complete guideline. The setup structure, surgical procedures, management processes, evaluation system and other multi-dimensional issues need to have a unified standard at the national level for day surgery. The guidance document is still in urgent need of development."

Anesthesia is another important factor in the sound development of day surgery. Weifeng Yu, Director of Department of Anesthesia at Renji Hospital, proposed whether the day surgery center that involved various kinds of operations should be managed by the Department of Anesthesia. "From the screening assessment of preoperative patients, the adjustment for basic diseases, talk and communication with family members to the short, flat, fast, less choice of intraoperative anesthetic drugs, adding postoperative analgesia and treatment of nausea and vomiting, wound bleeding and other complications. All these things need a professional anesthesiologist to participate." He introduced that their department has set up sub-professional team of day surgery anesthesia, "For long-term effective operation, day surgery operating room and ward should consider the importance of anesthesia doctors. Otherwise discharged within a short period of time can only be on paper. "

Admittedly, the bottleneck of day surgery development is not only from the hospital itself, but patients with poor motivation also obstructed its promotion. In Shanghai, day surgery was better supported by Medicare Clearing. Although the pre-operative medical checkups are reimbursed by the outpatient medical insurance system, there is a small gap between the proportions of self-pay for day surgery and hospitalization. However, in other provinces and municipalities, perhaps it is not so lucky." In some provinces and cities in our country, medical insurance coverage only covers the cost of hospitalization. In fact, the out-patient examination costs and operating costs can be included in the total package settlement. But during the day surgery, the overall reimbursement ratio has decreased. "Daxiang Wen introduced, "At present, Zhejiang, Jiangsu and other provinces and municipalities have successively introduced adjustment policies to adapt to day surgery."

Linkage to first or second-class hospitals as well as social medical institutions

As Jidong Zhang said, "At present, although many tertiary hospitals carry out day surgery, the diseases and surgical procedures are still limited to one or two simple surgeries, which are inconsistent with their dedication to solving the most critical and complex diseases." Therefore In the future, with the improvement of the service level of the second-class hospitals, some day-time surgical procedures may further sink to the second-class hospitals after the standardization. Meanwhile, the community health service center should also play an important role in carrying out the nursing rehabilitation and follow-upmanagement.

It can be said that the "short and fast" medical treatment process during day surgery increased the patients' concerns to some extent. Even if the anesthetic drugs and recovery technology have been matured, there are still patients disliking it. "Traditionally, prevention and treatment of postoperative complications are mostly done in the hospital. After day surgery, community health service center with certain nursing capacity has become the best place to rehab." Daxiang Wen introduced, Renji Hospital has actively collaborated with three surrounding communities to track patient recovery through community-linked follow-up management.

Of course, day surgery, as a new service model, is not only promoted in public hospitals. Medical institutions outside the system are also actively trying. As the leader of Doctor Group for the day surgery mode, Dr. Qiang Zhang’s Group conducted the first day surgery for iliac artery stent in our country and the first day surgery for varicose veins of the lower extremities combined with groin hernia. He introduced that "Day surgery can account for more than 90% of the total amount of our surgery. Day surgery is usually for a single disease, is easier to establish standardized and orderly standards. It can benefit for multi-point practitioners to maximize their fragmentation time." "We hope that the development of day surgery is gradual," Daxiang Wen said, “In the end it will certainly become a regular service model for the benefit of the majority of patients.”