Abstract
Hospital care has been subject to important changes during the last century. In stead of treating patients with various diseases with bed rest, medical care has shifted from in hospital to an ambulatory or outpatient setting as much as possible. Admission time after surgery shortened and day surgery became popular.
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The central theme of this thesis was to assess the developments of day surgery in the Netherlands in the past two centuries and to address several relevant clinical issues. Data on clinical and day care admissions were provided by Prismant, Utrecht. First, developments from 1984-1995 were assessed and a future scenario was formulated. Second, further developments from 1996-2004 were studied and the realisation of the previous future scenario was evaluated. Meanwhile, some aspects of day surgery in daily clinical practice were studied. The present quality of day surgery, expressed in safety, efficacy and patient satisfaction was assessed during one year in a general surgery department of a district training hospital. Feasibility of day surgery in morbidly obese patients who underwent laparoscopic gastric banding was studied and compared to a group who was admitted for overnight stay. The application of thrombosis prophylaxis in day surgery among Dutch surgeons and gynaecologists was assessed with an overview of current literature and guidelines on this topic. Finally, postoperative resumption of daily physical activity after laparoscopic cholecystectomy was measured in unselected patients. Day surgery showed a steady increase in the Netherlands during the past two decades until 49% of all surgical admissions in 2004. The largest growth was to be found among elderly patients. Based on data from 1995, where huge differences between hospitals existed and the fact that the current change in the financial health care system might entail a more rewarding situation for day care, a further increase in day surgery can be expected. The measurement of quality of day surgery in a Dutch training hospital showed an absence of serious complications due to early discharge, unplanned admission and readmission rates of 3.6% and 0.7%, respectively, and 86% of patients who would choose day surgery again. Laparoscopic gastric banding appeared to be safe and feasible as a one day procedure, and was cheaper than overnight stay. Day care patients, however, experienced more postoperative pain and half of them would have preferred overnight stay. The need for thromboprophylaxis in surgical day care patients, in contrast to clinically admitted patients, remained unclear. Current guidelines were based on expert opinion and mostly advocated an individual approach. In the Netherlands, most surgeons (57%) prescribed prophylaxis to all day care patients, while most gynaecologists (81%) never used prophylaxis. After day case laparoscopic cholecystectomy, resumption of daily physical activity to the preoperative level took more than a week in most patients. Encouragement by means of an accelerometer did not shorten this period significantly. In conclusion, day surgery in the Netherlands has increased during the last decades and probably will continue to do so in the near future. This development entails new challenges in perioperative medical care and management.
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