Report No: AUS0003281 . Establishing day-surgery units in Sri Lanka’s hospitals: Key issues and options . March 2023 . HNP . . . © 2023 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. 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Establishing day-surgery units in Sri Lanka’s hospitals: Key issues and options Shenglan Tang, Hiang Khoon Tan, Shehan Williams, Truls Østbye, Thyagi Ponnamperuma, Xinyu Zhang, Ruklanthi de Alwis, Dhurga Pulendran, Kinkini Udalamaththa, Xiaohua Ying, Di Dong, Deepika Eranjanie Attygalle, Hideki Higashi March 2023 Acknowledgement This report was prepared by a team from the SingHealth Duke-NUS Global Health Institute (a joint institute between SingHealth and Duke-NUS Medical School, Singapore). The team consisted of Shenglan Tang, Professor, Duke University; Hiang Khoon Tan, Associate Professor and Director, SingHealth Duke-NUS Global Health Institute; Sheham Williams, Professor, University of Kelaniya; Truls Østbye, Professor, Duke University; Thyagi Ponnamperuma, Senior Lecturer, University of Ruhuna; Xinyu Zhang, Research Fellow, Fudan University; Ruklanthi de Alwis, Assistant Professor, Duke-NUS Medical School; Dhurga Pulendran, Sri Lankan consultant; Kinkini Udalamaththa, Research Assistant, University of Ruhuna; and Xiaohua Ying, Professor, Fudan University, with technical inputs from Di Dong, Senior Health Economist, World Bank; Deepika Eranjanie Attygalle, Senior Health Specialist, World Bank; and Hideki Higashi, Senior Health Economist, World Bank. This study was conducted as part of an analytical work of the World Bank “Sri Lanka Pandemic Preparedness Assessment ASA�. The report was reviewed by Mickey Chopra, Lead Health Specialist, World Bank; and Jahanzaib Sohail, Health Economist, World Bank. We would like to express our appreciation for their valuable advice in finalizing this report. We are very grateful for the support and assistance given by the Sri Lanka Ministry of Health, especially Dr. Asela Gunawardena, Director General of Health Services, Dr. Sridharan Sathasivam, Deputy Director General Planning, and all other senior management of the Ministry of Health, the hospital directors and the staff of the selected study hospitals, Sri Lanka College of Surgeons, Sri Lanka College of Anesthesiologists, and Sri Lanka College of Hematologists. We are especially grateful for the directors and administrative staff of the four hospitals in supporting the study design and data collection, especially during the field trips. We also thank all the hospital staff and other interviewees (listed in Appendix III) that took part in the qualitative assessment. Financial support for this work was provided by the Government of Japan through the Policy and Human Resources Development (PHRD) Trust Fund. i Table of Contents ACKNOWLEDGEMENT .......................................................................................................................................... I EXECUTIVE SUMMARY .........................................................................................................................................1 INTRODUCTION .......................................................................................................................................................4 BACKGROUND ..........................................................................................................................................................5 STUDY DESIGN, METHODS AND DATA SOURCES .........................................................................................6 STUDY FINDINGS .....................................................................................................................................................7 SURGERY RELATED HOSPITALIZATIONS .....................................................................................................................7 MAIN CHALLENGES IN PROVISION OF INPATIENT SURGICAL SERVICES .......................................................................9 Current practices of “day surgery� services in Sri Lanka ................................................................................. 11 PERSPECTIVES ON ESTABLISHING DAY SURGERY UNITS IN SRI LANKA FROM KEY STAKEHOLDERS .......................... 12 Directors and senior leadership of the hospitals ................................................................................................ 13 Surgeons, anesthetists and senior nurses ............................................................................................................ 13 Professional associations.................................................................................................................................... 14 Patient groups ..................................................................................................................................................... 15 RECOMMENDATIONS AND OPTIONS FOR ACTION .................................................................................... 16 SUMMARY OF THE KEY FINDINGS ............................................................................................................................. 16 CHOICE OF MODELS FOR IMPLEMENTATION ............................................................................................................. 17 Implementation through a step-by-step approach .............................................................................................. 19 APPENDICES............................................................................................................................................................ 24 APPENDIX I: WORLD BANK’S TOR .......................................................................................................................... 25 APPENDIX II: DETAILED METHODS, DATA SOURCES, MAIN TOOLS AND INSTRUMENTS USED .................................... 29 APPENDIX III: FIELD VISIT PROGRAM AND LIST OF KEY STAKEHOLDERS INTERVIEWED ........................................... 33 APPENDIX IV: ADDITIONAL HOSPITAL STAY AND PROCEDURE DATA ....................................................................... 38 APPENDIX V: SURGERY COST AS REPORTED FROM PRIVATE HOSPITALS IN SRI LANKA 2022 ................................ 43 APPENDIX VI: SURGICAL PROCEDURES THAT ARE RECOMMENDED FOR DAY SURGERY UNITS ................................. 44 ii Executive Summary Sri Lanka has a universal healthcare system that extends free healthcare to all citizens. However, the rapidly ageing population and growing burden of non-communicable diseases (NCDs) challenge the effective and timely provision of public healthcare services. The COVID- 19 pandemic and the 2022 economic crisis in Sri Lanka placed further strain on the health sector. Improving efficiency in healthcare provision has become an urgent health system priority. One recent World Bank-funded study assessed the efficiency of the Sri Lankan healthcare system, especially identifying areas where efficiency gains and cost savings could be made. One of the recommendations that emerged was to explore the use of day surgeries to reduce hospitalization. In response, the World Bank contracted the SingHealth Duke-NUS Global Health Institute to assess the feasibility of establishing day surgery units for selected conditions and services in public hospitals, including tertiary teaching hospitals (TH), provincial general hospitals (PGH), district general hospitals (DGH), and base hospitals (BH). The specific objectives were developed in consultation with the World Bank and the Ministry of Health (MOH):  To map the current situation of the most frequent hospital admissions in the surgical wards (e.g. surgical procedures) which can potentially be shifted to day surgery units  To investigate the feasibility of shifting a selected number of the above procedures and services to day surgery units to reduce hospital admissions for efficiency gains  To develop a set of policy recommendations/options on establishing day surgery units in public hospitals in Sri Lanka The study team collected and analyzed data from four hospitals at different levels (Colombo South Teaching Hospital, Jaffna Teaching Hospital, Nuwara Eliya General Hospital and Kalmunai Base Hospital), and conducted key informant interviews/focus group discussions with stakeholders at the national level and study hospitals, in addition to the review of international literature and practices (especially from China and Singapore). Key findings were:  Day surgery is a global common practice for some non-complicated surgical procedures.  A general openness, interest and acceptance of the concept of day surgery units was shared by various stakeholders in Sri Lanka, including hospital directors/senior administrators, surgeons, anesthetists, nursing officers, and other staff from the four study hospitals, as well as leaders from national health professional associations at the national level. However, certain concerns were raised including lack of adequate health workforce, physical space, and other essential resources, as well as the current absence of clear national policies and guidelines on operation standard of day surgery units from the MOH.  Some de facto day surgery unit are already operational in Sri Lanka, often developed by individual consultants with experience with working in day surgery units overseas.  Patients who had been hospitalized for the surgical procedures in question have mixed feelings about the use of day surgery units. While most appreciated the benefits and 1 convenience, some have concerns and worries, particularly about safety and access to emergency healthcare, when required, discharged.  From the perspective of public hospitals, the main challenges in establishing day surgery units include shortages of surgeons and anesthetists in some hospitals, and insufficient number of nurses in other. Lack of physical space in some places is another challenge.  There was consensus that a day surgery unit policy framework, national guidelines, and administrative support mechanism to overcome institutional barriers and health system challenges should be developed to guide the development/establishment of day surgery practice across the country, as soon as possible. The ideal model is a dedicated surgery care unit with an attached theatre and a dedicated team consisting of essential personnel (i.e. surgeons, anesthetists) and supporting nursing, administrative and minor staff. However, if such resources are limited, then an alternative model is to use routine theatre time in existing surgical wards and existing personnel to start on a planned basis. In either case, the Ministry of Health, together with relevant medical associations may want to form a task force to develop a set of guidelines and protocols, aiming to support the pilot day surgery unit sites and later scale up the implementation. In pilot hospitals, a technical working group including key health professionals may be set up to lead the operation of the pilot studies. Our recommendations fall into two categories: 1) actions related to the patient journey, and 2) overall health system enablers. Patient Journey Pre-op  Establishing a dedicated anesthetic clinic for pre-operation assessment is an essential first step (not all hospitals offering surgical services have this facility at present.)  Where pre-op anesthesia resources are inadequate to support general or regional anesthesia, procedures only require local anesthesia can be prioritized.  Prospective day surgery patients should be provided clear information about their procedure, including the risks and benefits, recovery expectations, and follow-up care. Operation day  In order to minimize admission related delays, direct admission arrangements should be put in place in the hospitals where the day surgery units will be piloted;  Consider protocol-led discharge for selected low risk procedures (e.g. surgery performed under local anesthesia). This may relieve the workload on the surgical team who may be in operating theatre or clinic. It may also simplify the discharge process. Post-op follow-up  Establish a hotline for post-surgical emergencies (e.g. painrelief, post-op rehabilitation)  coordinate with other healthcare partners to ensure continuity of care for the patients. System enablers Organization and Governance 2  Establish a Day Surgery Management/ technical working group with representation from anesthetists, surgeons, and nurses in each hospital to operationalize workflow and provide clinical governance.  Set up a robust quality assurance program including clinical audit to ensure that patients receive the highest quality of care.  Elective surgical workflow should be separated from emergency surgical workflow if possible. Mixing of these two undermines the overall efficiency. Staff  Development of a comprehensive training and capacity plan, e.g. providing good in- service training for Medical Officers in anesthesia. Engagement of provincial, district, and primary care staff for seamless transition of care after discharge.  Consider re-allocation/re-deployment of surgeons, anesthetics, and senior nurses to where the day surgery units are required, by offering financial or other incentives.  Consider theatre staff shifts that can achieve greater efficiency of theatre use. Facilities  Non-casualty surgical ward beds are often underutilized on non-casualty days. These beds may be better used for post-op observations for day surgeries.  Where there is inadequate space or theatre facilities, establishment of day surgery units in close satellite base hospitals (BH) or district hospitals (DH) may be considered. This may apply to large teaching hospitals with extreme competition for theatre time.  “Double decking� of emergency patients is sometimes necessary in casualty wards, given limited bed resource and exigencies of care. However, such practices should be discouraged as they often lead to sub-optimal care and potential safety problems. Patient needs and choices  Consider a flexible approach depending on social, financial, educational and cultural background: pre-op preparation may be challenging for some patients, while for others finding transportation to and from hospital in the mornings or late evenings after discharge may be difficult. We propose an integrated approach to the establishment of day surgery units. We also suggest a list of prioritized surgical procedures that can be first undertaken in the pilot day surgery units, in consultation with local surgeons (Appendix VI). To implement the above-suggested models of care, the hospitals may initially face challenges in the organization and management. A consensus building process is essential to ensure that all stakeholders are aligned. Some existing human resource policies may lack flexibility in compensating health workers for over-time work, or in re-allocation/deployment of surgeons or/anesthetists to work outside their primary duty hospitals. The Ministry of Health, together with other relevant government agencies, may want to re-visit and reconsider these policies. Appropriate incentives should be developed to ensure effective health staff recruitment and retention to serve the day surgery units in these hospitals. 3 Introduction Sri Lanka has a universal healthcare system that extends free healthcare to all citizens. Health has been a national priority, and Sri Lanka health system is one of the most effective health systems in terms of equity and efficiency among the low- and middle-income countries (LMICs). Public health services function under the purview of the Ministry of Health (MOH). Both curative and preventive health services are managed by the government at the central and provincial levels. Preventive care services are delivered through 354 medical officer of health areas, while curative services are through a system of outpatient services in hospitals and primary care institutions to tertiary care institutions and specialized hospitals. The private health sector is also an increasingly important service provider in Sri Lanka in the recent decades, as it has provided about 50% of outpatient services and 5% of inpatient services. The rapidly ageing population and the growing burden of non-communicable diseases (NCDs) have already led to increased demands for health and long-term care services that require investments from both government and households. The recent global COVID-19 pandemic and the economic crisis experienced in Sri Lanka in 2022, have placed the health sector in a very challenging position. Improving economic efficiency in healthcare provision has become an urgent priority. One recent study, funded by the World Bank, was undertaken to assess potential efficiency gains in the Sri Lankan healthcare system, especially, to examine the sources of inefficiency in the provision of health services, and identify areas where efficiency gains could be made to finance the growing demands for NCD care. The study identified several sources of inefficiency including: (i) mild or chronic medical conditions, e.g. cataract, hernia, upper GI endoscopy, chronic wounds, etc. which can be treated at day-surgery units, if such services available. (ii) lack of a proper back referral system, which promotes transfer of patients from higher level care institutions to a lower-level once specialist care is completed, and (iii) non-optimal NCD management. These findings have led the government to consider how to identify opportunities to deliver these types of health care in more efficient and cost-effective modes. The concept of establishing ambulatory or day surgery unit* in Sri Lanka’s hospitals has been suggested as one intervention that can achieve the efficiency gain in health service delivery. Against this background, the World Bank has contracted the SingHealth Duke-NUS Global Health Institute (SDGHI) to undertake a study aimed to examine the feasibility of establishing day surgery units for certain services in hospitals of Sri Lanka. The overall objective of the study was to assess the feasibility of setting up day surgery units for certain services at tertiary teaching hospitals (TH), * We use the term ambulatory or day surgery unit in this report, rather than day care unit used in the World Bank’s TOR, as the term day care unit can refer to community facilities that provides rehab services to elderly or patients who require nursing care in the day but not necessarily any surgical procedure. Ambulatory or day surgery unit/center is a more appropriate term for the scope of this study. 4 provincial general hospitals (PGH), district general hospitals (DGH) and base hospitals (BH) to reduce hospitalization and improve efficiency. The specific objectives of this study were developed in consultation with the World Bank and the Ministry of Health, Sri Lanka, and were as follows.  To map the current situation of the most frequent hospital admissions in the surgical wards (e.g. surgical procedures) which can potentially be shifted to day surgery units  To investigate the feasibility of shifting a selected number of the above procedures and services to day surgery units so as to reduce hospital admissions and inpatient services for efficiency gain;  To develop a set of policy recommendations/options on establishing day surgery units for day surgeries, including pilot studies, in Sri Lanka Background Prior to study start, the Duke-NUS team undertook a review of the ‘day surgery concept’: guidelines, literature and policy documents on the topics, as well as discussions with international experts, with a special reference to China and Singapore. This background information was used to guide the study design and the development of the interview guides and the data collection instruments. With developments in surgical techniques, anesthesia, nursing and technology, “day surgery�, where patients are sent home the same day for several common procedures previously done in hospital and requiring overnight stays. has become increasingly common in recent decades, especially after the founding of the International Association for Ambulatory Surgery (IAAS) in 1995. IAAS defines Ambulatory Surgery as “an operation/procedure, excluding an office or outpatient operation/procedure, where the patient is discharged on the same working day�. Similarly, the British Association of Day Surgery (BADS), states: “the patient is admitted and discharged on the same day, with day surgery as the intended management�, and the China Ambulatory Surgery Alliance (CASA): “a patient completes admission, surgery and discharge within one working day and does not include outpatient surgery in a clinic or hospital�. Different types of ambulatory surgery units exist globally, roughly classifying into five types: A. Self-contained ambulatory surgery units that are free-standing (common in the US). A challenge here is that when these units are far from the nearest Emergency Department, from medical and paramedical staff such as physiotherapists and laboratory services as well as intensive care and radiology are remote from the unit; B. Office-based surgery, while popular in several countries, there are concerns about patient safety and regulation of these facilities; C. Self-contained ambulatory surgery units integrated with a hospital (common in Europe). Here, support services are available and it is easy for patients to visit the unit on the same day as their outpatient clinic visit for preoperative assessment. While seen by 5 many as ideal, as there is no loss of staff time due to travelling, it is still recommended that ambulatory surgery works best when it is provided in a self-contained unit that is functionally and structurally separate from inpatient wards and operating theaters, with its own reception, consulting rooms, ward, theaters and recovery area, together with administrative facilities; D. Self-contained ambulatory wards using dedicated theatres in a main theatre complex; E. Self-contained ambulatory wards with no dedicated operating theatres (all patients together on the theatre lists). The latter is not recommended by IAAS as ambulatory surgery usually gets lower priority than that for the more serious, hospitalized patients, but may negatively affects the quality of service for the ambulatory patients. Key guiding principles have been developed for the establishment of such units by IAAS and other organizations, as outlined below. Each unit should have a Clinical Lead or Director who has a specific interest in ambulatory surgery. A consultant anesthetist or surgeon with management experience is ideally suited to such a post. A senior nurse, spending most his / her time in the unit should provide day-to-day administration of the unit in liaison with the Director. A multidisciplinary operational group should oversee the day to day running operation of the unit. This can include staff from anesthesia, surgery, hospital nursing, community nursing, general practice, pharmacy, management, finance, audit, and ancillary care. A fundamental principle should be that surgery undertaken as ambulatory surgery must ensure patient safety and quality of care. Therefore, only certain procedures, and only for relatively low risk patients, should they be performed. Procedures that can potentially be performed without overnight stays, as recommended by IAAS. Patients presenting with acute conditions requiring urgent surgery can be efficiently and effectively treated in an ambulatory fashion via a semi-elective pathway. After initial assessment, many patients can be discharged home and return for surgery at an appropriate time, either on a day-case list or as a scheduled patient on an operating list, whereas others can be immediately transferred to the day surgery service. Ambulatory surgery is also suitable for children, even those with complex comorbidities, can have safe day surgery if pre-operative assessment is robust and care is individualized and delivered by experienced staff in appropriate facilities. Many elderly patients can also be safely operated on in the day surgery environment. Study design, methods and data sources The study adopted a mixed-method approach, including collection and analysis of routine medical record data from 4 selected hospitals, and key informant interviews/focus group discussions with key stakeholders at the national level and study hospitals. The detailed description on methods used for the study can be found in Appendix II. Below is a short summary of how the study was carried out. 6 In consultation with the Ministry of Health, Sri Lanka, under the auspices of the World Bank team, the Duke-NUS chose four hospitals for the study: Colombo South Teaching Hospital, Jaffna Teaching Hospital (also a provincial general hospital), Nuwara Eliya General Hospital, and Kalmunai Base Hospital. These four hospitals represent different levels of public hospitals in operation across different areas of Sri Lanka. The study team first developed the data collection tools/instruments for medical record data collection from the hospitals. Colombo South Teaching Hospital was used to test the tools/instruments before finalization. Then the instruments were administered to the four hospitals. The local consultants visited these hospitals to work with the hospital staff to ensure that the data provided by the hospitals were accurate and of high quality. The main sources of quantitative data were: Hospital Electronic Medical Record keeping, Theater Registration Book, and the Ward Admission Book. Once the collection of the quantitative data on surgical procedures was completed, the preliminary analysis of the data was conducted to generate preliminary findings upon which the questions for the key informant interviews and focus group discussions with key stakeholders were developed. The whole team members spent one week (from Nov 13-19) to undertake the interviews and focus group discussions at the national level and the four study hospitals, discussing the key issues and options on establishing the day surgery units with selected key stakeholders. The program for the field visits and the list of meetings with the key stakeholders are attached as Appendix III. After the field visits, a debriefing meeting with the World Bank was held. Study findings This part of the report presents the information collected related to the hospital admissions in the four study hospitals, with a focus on surgical procedures, and then discusses main factors associated with the surgical procedures related hospitalizations. It also examines the current practices of day surgery services that have always existed in these hospitals, such as eye surgery and hematology related treatment, and its key challenges. It ends with a discussion on perspectives on establishing day surgery units from key stakeholders, and about potential efficient gains. Surgery related hospitalizations Table 1 shows the data for the ten most common surgical procedures of the inpatients hospitalized at general surgery wards of the four study hospitals and their average duration of stay for the surgical procedures. I & D of abscess was the top one cited cause for the surgical ward admission, accounting for 29.57% of all admissions with the average duration of say being 2.64 days. Inguinal hernia repair, appendectomy, sebaceous cyst excision and SF ligation are the other four causes, respectively accounting for 12.15%, 12.13%, 9.94% and 8.68% of admissions. Their 7 average durations of stay were 3.43 days, 2.94 days, 3.21 days, and 2.96 days, respectively. The other top causes of the surgical related hospitalizations were excision of breast lump, para umbilical hernia, foreign body removal, perineal abscess and excision of breast abscess. Those inpatients stayed at least two days in the hospitals, except the inpatient for the procedures of foreign body removal. Table 1. Common surgical procedures and average duration of stay in all four hospitals Procedure ICD Code Total Mean duration Percentage (%) of stay (days) I&D of abscess L02 1151 2.64 29.57 Inguinal Hernia Repair K40 473 3.43 12.15 Appendectomy K35 472 2.94 12.13 Sebaceous cyst excision L72.1 387 3.21 9.94 SF Ligation I83 338 2.06 8.68 Excision of breast lump N63 272 3.02 6.99 Para umbilical hernia K42 242 3.61 6.22 Foreign body removal L92.3 222 0.97 5.70 Perineal abscess K61 187 2.9 4.80 Excision of breast abscess N61 148 2.5 3.80 Source: Electronic Medical Record Keeping system (Jan-Jun, 2019) The distribution of the top ten surgical procedures from each of the four study hospitals are more or less similar. However, wound toilet (i.e. the cleaning and dressing of wounds) was reported as one of the common procedures in Jaffna hospital and thyroidectomy in Kamunai and Nuwara Eliya. The detailed analysis on each of those 4 hospitals are given in Appendix IV. Based on the data from the surgical operation theaters of the four hospitals, minor surgical procedures accounted for more than half of the operations (52%) in 2019, as shown in Figure 1. In the teaching hospitals in Jaffna and Colombo South the proportion was slightly lower than that in other two hospitals, as the higher level the hospitals are, the more complicated cases they need to handle. 8 33% Minor Intermediate 52% Major 15% Figure 1. Types of surgeries conducted in all hospitals Main challenges in provision of inpatient surgical services Public hospitals in Sri Lanka provide around 95% of inpatient care free of charge at the point of service delivery. While such a policy and practice has put the health system as one of the most equitable ones among developing countries, a majority of patients, especially those who require tertiary/teaching hospital admissions for major surgeries, have to wait several weeks to get admitted for the surgical procedures. This long waiting time is due to the overcrowding of surgical wards in tertiary/teaching hospitals, and inadequate financial, human and other physical resources to admit more patients. The hospitals at different levels have faced different challenges in shortening the waiting list for surgical procedures, as we have confirmed in our interviews with various key stakeholders in the health sector. Shifting minor surgeries to day units may free up more theater time for major surgeries, thus, reducing the waiting list. In this section we discuss a few key challenges in the organization and provision of surgical services in the study hospitals. Lack of / inadequate health workforce in Sri Lanka is one of the major challenges in the provision of healthcare in general, and the surgical services in particular. Based on the information we collected, Colombo South Teaching Hospital, Jaffna Teaching Hospital, Nuwara Eliya District General Hospital and Kalmunai North Base Hospital have 24, 10, 2 and 1 general surgeons, respectively. The numbers of anesthesiologists in these four study hospitals are even less adequate (5, 7, 2 and 1 respectively). Our interviews with key stakeholders during the field visits indicate that the public hospitals at the different levels have got different problems in recruiting and retaining specific types of health professionals. In the teaching/tertiary hospitals, such as Colombo South and Jaffna, there is a serious shortage of nurses and minor staff. In Colombo South Teaching Hospital, there are over 300 vacancies for nurses that need to be filled at the moment. A similar situation has also be found in Jaffna, albeit less serious. The cost of living in Columbo and other large cities is expensive, while the renumeration for the nurses is low. This is one of the main reasons why many nurses want to work in district general hospitals or base hospitals, especially in their hometowns, as we found out. In Nuwara-Eliya District General Hospital and Kalmunal Base Hospital, the 9 biggest challenge related to health workforce is lack of anesthesia personnel, both consultants and trained medical officers in anesthesia. As mentioned above, only one consultant anesthesiologist is working in Kalmunal Base Hospital, while in Nuwara-Eliya there are only 2 responsible for the four operational theaters. Lack of consultant surgeons in the district general hospitals/base hospitals also appear to be an issue. Nuwara-Eliya has got six theaters, but only four are functioning, as we observed in our field visit, largely due to lack of anesthetists. Inadequate physical infrastructure in teaching/tertiary hospitals is another major barrier to offering a higher number and more efficient surgical procedures to the patients (Table 2). The most frequently mentioned issue in the interviews with the hospital directors and the surgeons working in these hospitals is lack of space/theater time. The surgical and medical wards are always the busiest among the inpatient wards, with a high bed occupancy rate of more than 85%, almost always spilling over and exceeding capacity on casualty days. In other wards, bed occupancy rates are often low, with an average bed occupancy of around 65%. Investment in developing physical infrastructure is very limited, although Columbo South Teaching Hospital will be opening a new emergency/theatre complex soon. However, it should also be pointed out that except the theaters used for emergency medicine/casualty wards, the routine theater operating time is between 8am to 4pm during the weekdays and 8am to 12 noon on Saturdays. There is a potential to better utilize these theaters during afterwork hours and weekends. Table 2. Current surgery-related challenges at hospitals in Sri Lanka Hospital type Challenge area Specific challenges Teaching hospital Manpower  Serious shortage of nurses and minor/junior staff  Difficulties in staff recruitment and retention. Infrastructure  Inadequate number of surgical theatres to meet surgical demand.  Shortage of physical space  No budget even for essential surgical equipment. Patient flow  Large number of surgeries and shortage of operating theatre time. As a consequence, elective cases that typically would have been discharged on the same day, are scheduled for operation in emergency theatres and stay in hospital longer to wait for emergency theatres to become available.  Elective and emergency cases in the casualty ward often overwhelms the limited bed capacity and result in ‘floor 10 patients’, compromising patient care experience. Non-teaching Manpower  Shortage of surgeons and anaesthesia hospital (district personnel, including consultants and hospitals and base trained medical officers. hospitals) Pre and post-  Patients might prefer to rest a day or two operation in the hospital before departure from hospital. Transportation  Patients unable to arrive and depart hospital in time due to lack of early morning and late evening public transportation. All hospitals Operational  Limited working hours in routine hours operating theatres (i.e only operational between 8am-4pm on weekdays and 8am- 12pm on Saturdays). Guidelines  No Ministry of Health guidelines for the establishment and operation of day surgery units. Health System  Suboptimal communication between primary care / home care and hospitals, and between provincial and district levels Current practices of “day surgery� services in Sri Lanka Traditionally, all the surgical procedures require patients to be admitted to hospital for a couple of days, as they have to go through a series of sequential steps, at least including pre- surgical preparation, surgical operation, and monitoring/recovery after the surgical operation, before they can be safely discharged from hospital. However, the hospitals in developed countries have already started to use day surgery from the early 20th century. An increasing number of low- and middle-income countries have followed such a practice in recent decades. Based on the interviews with several hospital directors and (eye) surgeons in Sri Lanka, it was clear that many eye surgical procedures, such as cataract, have been undertaken in the eye wards/theaters, admitted and discharged in the same day, although these study hospitals have not yet officially established the day eye-surgery units. Table 3 presents the volume of cataract and other eye surgeries undertaken in the four study hospitals. Cataract accounted for about 60% of eye surgical operations in those hospitals. The post-op review for the cataract surgery are usually undertaken in the eye wards themselves. As we understand, however, there is still lack of an official consensus that it should be done as a day procedure and the practice does differ, depending on individual consultants and the units. There are units that still prefer overnight stay. 11 Table 3. Eye surgeries conducted in all four hospitals (2022)* Procedure Percentage Cataract 59.08 Other day procedures 39.24 Other eye surgeries that cannot be done 1.68 as day procedures Total 100.00 *Data obtained from the electronic medical record keeping system in each hospital from January to June 2022. In some non-surgical specialties there is also potential to reduce hospital stay by promoting the concept of day procedures. Hematology is one such specialty and in our meeting with the hematologists we learnt that some hospitals in Sri Lanka have started to operate surgery services in dedicated units for hematological procedures and chemo-therapy, as such needs are emerging. These measures will certainly reduce overcrowding in medical wards, where these patients would otherwise be admitted for procedures with consequent overnight stays and delays in discharge. As discussed above, an increasing number of the hospitals in Sri Lanka have started to apply a version of “day surgery� services in order to make the service provision more efficient and friendly to the patients. Some surgeons regularly admit patients the same morning to their wards for surgery and discharge them the same day. Notably, some of these ‘elective’ patients were admitted into the ‘emergency’ ward and had their surgeries performed in operating theatres designated for emergency surgeries. The patients were then discharged on the same day. However, exigencies of true emergency surgeries sometimes led to unavailability of emergency operating theatre for these ‘elective cases’, which in turn resulted in these patients staying in the hospital longer than they would normally require for their surgical conditions. One observation is that surgeons and anesthetists in these study hospitals who had the experiences of overseas training have in fact worked in the day surgery units before. This has obviously facilitated the introduction of day surgery concept and practice in these hospitals. However, it is our understanding from the meetings with the various stakeholders that the Ministry of Health has not yet developed any guidelines in the establishment of day surgery units. In other words, the practice has not yet been institutionalized from the point view of health system development. Perspectives on establishing day surgery units in Sri Lanka from key stakeholders To assess the feasibility of establishing day surgery units in the public hospitals at different levels of Sri Lanka, it is critically important to understand the perspectives on this potential policy initiative from the key stakeholders who need to be engaged in its development and operation, 12 should it be put in the hospitals in the near future. Hence, we have undertaken, as indicated in the section of approaches and methods, a series of interviews and focus group discussions. Directors and senior leadership of the hospitals The interviews with the hospital directors and other senior leaders of the study hospitals clearly indicate that most would be keen to support the establishment of day surgery units in their hospitals, as they apparently understand potential benefits the units could bring to the hospitals and the patients alike. However, many of them have pointed out several challenges the hospitals would have to tackle in advancing this initiative. The hospitals at the different levels are facing different challenges, if the day surgery units are to be set up. In the teaching hospitals, like Colombo South and Jaffna, the health workforce, especially the lack of nursing and minor/junior staff might be one of the biggest challenges, as the health system is facing difficulties in staff recruitment and retention. Insufficient elective theatre time (due to lack of facilities or staff) leads to shunting of non-emergency cases for admission into casualty ward so that they can be operated in emergency operating theatres. This practice impacts the accessibility of operating theatre for time-sensitive emergency surgery. Prolonged in-patient stays for these elective procedures happens if the emergency operating theatre are occupied with bona fide emergency surgeries. The convergence of elective and emergency cases into the casualty ward often overwhelms the limited bed capacity and resulting in ‘floor patients’. This can compromise care and raises patient safety concerns. In Colombo South, the building of new operating theatre complex may provide an opportunity to re-design processes to separate elective and emergency workload. In the district and base hospitals, the directors are concerned about the lack of adequate number of surgeons and anesthetists who often are reluctant to work in the remote and rural areas. All the leaders of these hospitals are not worried too much about medical supplies and equipment, if the day surgery unit is to be established in their hospitals, as they think that these challenges can be handled with some re-allocation of resources and very modest investment. Nevertheless, most of the directors and other hospital leaders believed that the establishment of day surgery units are a right direction that the Sri Lanka’s health system should pursue, as it will make the provision of healthcare more efficient and effective. It might also be beneficial to the patients in terms of reducing their economic and social burdens (although the evidence for the latter is not unambiguous – some patients prefer to rest in the hospital for a day or two before going home to a challenging home environment). Surgeons, anesthetists and senior nurses During the field visits, we organized a series of interviews with the surgeons, anesthetists and senior nurses, asking for their views on the establishment of the day surgery units in their hospitals, in terms of potential benefits and challenges. One interesting finding emanating from the interviews is that almost all the surgeons and anesthetists, have experience with working at the day surgery units when they received the professional training or worked overseas. Hence, they are not only familiar with the concept and 13 practice, but also are very supportive to such an initiative. They think that the Ministry of Health should lead the development of the national guidelines and support a few pilot studies in selected hospitals in the near future. They firmly believe a vast majority of minor surgeries can be easily done in the day surgery units once they are set up with adequate resources and operational guidelines. While most surgeons understand the benefits of day surgery, the lack of operating facilities meant that some surgeons resorted to admitting patients into the ‘emergency/trauma’ wards so that they can gain access to emergency operating theatre resource to perform these minor ‘elective’ surgeries. The nurses’ views on the day surgery units are more complex, as they considered the pros and cons of using the day surgery units for most minor surgeries. They clearly understand the potential benefits brought into the hospitals and the patients, while they are also concerned about several challenges they might face. Whether or not such units could be staffed an adequate number of nurses and minor staff is a big concern. In addition, they are also worried about some patients who might not be able to follow the preparation guidelines given, due to their low educational level. This would interrupt the arrangements and negatively affect the operation of the day surgery units. Streamlining day patients with special admission tags and priority for investigations they felt would strengthen the process. The surgeons, the anesthetists and the nurses emphasized the importance of patient safety in the operation of the day surgery units. Hence, all suggested that only minor surgeries, with relatively low risk of complications, should be chosen during a pilot phase. Appropriate process should be put in place to facilitate urgent consultation if the patient requires urgent medical attention after discharge from the day surgery unit. This would require stronger integration of health services at the provincial and district level to ensure seamless transition of care. (as outlined in the recommendation section). The anesthetists were particularly in favor of developing an emergency hotline that patients could access following discharge after day surgeries. Professional associations We had three separate meetings with the College of Surgeons, the College of Anesthesiologists and College of hematologists to discuss the feasibility of establishing the day surgery units in the public hospitals. The most important message was that all of them are very supportive to such a practice which many of them think is over-due. In fact, the colleague of anesthesiologists has submitted a report to the Ministry of Health in 2018, suggesting that the day surgery units in Sri Lanka should be set up in order to tackle the current challenges in meeting the needs of the patients The leaders from the College of Surgeons clearly indicated the importance of setting up the day surgery units in the public hospitals and urged the Ministry of Health to take a leadership role in developing the national guidelines for day surgery and facilitating the pilot initiatives. They suggested that a limited number of hospitals, particularly the teaching and tertiary hospitals, be chosen to pilot the experiment to assess the feasibility and identify the resources required for the day surgery units to function in an effective and efficient way. 14 The current and former presidents and president-elect of the College of Anesthesiologists are also very supportive to the establishment of day surgery units, as they fully believe this is the right thing to do for the improvement of Sri Lanka’s health system performance, under the context of the economic challenges at the moment. Such a practice can improve efficiency in service provision, increase patient satisfaction, and in hospitals where bed occupancies are very high, it will also increase cost efficiency. They think that some hospitals can use the existing system to set up the day surgery units, while others may develop a new dedicated system to provide such services. While they strongly advocate this initiative, they also voiced some concerns regarding challenges in the implementation of the day surgery units in most of the public hospitals. These challenges include the lack of anesthesiologists, particularly at the district level and remote areas, lack of adequate physical space in many teaching and tertiary hospitals, and urgent needs of training nurses and minor staff required to work for the day surgery units, as well as extra investment in essential equipment for the operation. They also advocate for the setting up of dedicated pre-operation anesthetic clinics in all hospitals with surgical procedures to facilitate the day surgeries. As for the challenges related to shortage of surgeons and anesthetics, a few potential solutions discussed include in-service training given to medical officers, and re- allocation/deployment of these specialists and medical officers trained, provided some adequate incentives offered. Leaders from the College of Hematologists stated that a few hospitals in Sri Lanka have already used the concept of day surgery unit for hematological patients, thus reducing hospital admissions. The teaching hospital Jaffna has such a model in place already. While they think that their day surgery practices might not be the same as the day surgery related services, some good practices and lessons learnt from these operations might be relevant and useful, which is worth a careful examination. Patient groups We organized the focus group discussions with the patients from the three hospitals: Colombo South Teaching Hospital, Nuwara-Eliya District General Hospital and Kalmunal Base Hospital. Overall, a large majority of the patients expressed their willingness to use the day surgery services proposed, as they believed there are benefits, if they do not have to stay overnight in the hospital: including reduction of actual and opportunity costs for their families (e.g. fewer family members’ hospital visits; less financial loss from work; etc.), avoidance of postponed surgeries, which have been common and therefore unnecessary stay in the hospital wards; Some patients said that they would be happy to go back home earlier, even if they have to travel by hiring an expensive vehicle, as staying in the wards of these public hospitals was not a pleasant experience. However, not all of these patients have held such positive views on the concept of day surgery units. Some have got a few concerns about their ability to come back to the hospitals timely, if unexpected medical conditions occurred, while others, particularly the poor are worried about the public transportation available in early morning and late evening. One very interesting information from a few poor patients is that the government may give them some financial subsidies, if they stayed in the hospital wards more than three nights. Under such a policy, there is surely a disincentive for the poor patients to use the day surgery unit. 15 As the key stakeholders pointed out above, there would be potential benefits emanating from the operation of the day surgery units in the hospitals of Sri Lanka. One obvious outcome would be economic gain/efficient improvement in public health service delivery. Due to the economic crisis and the spiraling inflation, more and more middle-class citizens in Sri Lanka will no longer afford the healthcare services provided by private hospitals, and many of them will return to the public health sector for inpatient care, including minor surgical procedures. In the context of spiraling inflation, private sector surgical costs are increasing rapidly and we found that a herniotomy and repair costs between Rs. 65,000 and Rs.120,000 and an incision and drainage of an abscess or an excision of a lump can range from Rs. 40,000 to Rs.150,000 (see Appendix V which presents average pricing info from two private hospitals). Hence, providing more surgical procedures in the day surgery units in the public hospitals, could not only improve the cost- effectiveness and efficiency of service delivery, but also reduce the financial burden on patients who may be forced to access the private services due to waiting lists in the government sector or minimize other opportunity costs related to spending more days in a government hospital. Recommendations and options for action This final part of the study report will first summarize key findings from the analysis of both quantitative data and the information derived from the interviews and focus group discussions with the key stakeholders in the health sector of Sri Lanka. It will then present a few options on the modalities of establishing the day surgery units in the public hospitals, and illustrate potential implementation challenges. The section will end with several general recommendations and supporting measures that are critical to the success of implementation of the day surgery units. Summary of the key findings  Globally, more and more countries have implemented the practices of day surgery units to undertake most of non-complicated surgical procedures, among others, in order to improve the cost-effectiveness and efficiency in healthcare delivery, according to the review of available literature and guidelines;  Overall speaking, a general openness, interest and acceptance of the concept of day surgery unit by all the stakeholders, including Directors/Senior Administrators, Surgeons, Anesthetists, Nursing officers, and other staff from the four study hospitals, as well as leaders from health professional associations at the national level in Sri Lanka. However, many of them have also raised a few concerns about lack of adequate health workforces, physical spaces, and other essential resources, as well as the absence of clear national policy and guidelines from the Ministry of Health at the moment;  De facto day surgery unit are in fact already operational in some forms of many hospitals in Sri Lanka, depending on, and developed by, individual consultants most of whom have experience with working in day surgery units when they were working overseas. Patients are admitted on the same day to the inpatient wards and discharged in the evening. Eye surgery on cataract is one of typical examples of this kind; 16  The patients who were hospitalized for the surgical procedures have got mixed feeling about the use of day surgery units. While most of those interviewed would be willing to take on the services as there are clear benefits, some of them have also got a few concerns and worried, particularly about safety and access to emergent healthcare, when required, after being discharged;  From the perspective of the public hospitals, main challenges in establishing a day surgery unit include shortage of surgeons and anesthetists in some hospitals, and lack of sufficient number of nurses in other places. Lack of physical space is another challenge in some study hospitals.  Among the key stakeholders, there has been a consensus that a policy framework, national guidelines, and administrative supports to overcome institutional barriers, particularly overall health system challenges should be effectively developed to guide the development/establishment of the practice in the whole country, as soon as possible. Choice of models for implementation Based on what we have learnt from the Singapore and Chinese experiences and the review of other international practices and guidelines, and most importantly, the analysis of the current situations of the study hospitals in Sri Lanka, we believe that different approaches may have to be taken, depending on individual hospital circumstances, as the availability of human, physical and financial resources varies and might be limited. Also based on the experiences from China and other countries, day surgery may be first piloted in tertiary/teaching hospitals, not small hospitals, due largely to the concern about post-operation needs. The ideal model of day surgery unit should be a dedicated care unit with an attached theatre and a dedicated team consisting of essential health professionals and supporting nursing and minor staff. However, if such resources are very limited in some public hospitals, using the existing surgical wards to start a day surgery on a planned basis, using routine theatre time, might also be an option in some circumstances. See flow chart outlining different options for day surgery. 17 The above diagram shows the flow of patients for elective day surgery. Patients are first seen at the surgical clinic where the surgical team decides on the surgery after careful evaluation. They are then referred to the anaesthetic clinic with the results of the necessary investigations for the anaesthesiologist to determine the fitness for day surgery. Thereafter the patient is given a day and time slot for the surgery with clear instructions on the necessary pre-op preparation. On the morning of the surgery the patient will be admitted directly to the dedicated day unit or in the absence of such an unit to the surgical ward. Depending on the resources available, the surgery will be conducted in a dedicated day theatre or even in the routine theatre as prior planned. The ideal flow would be : Day Unit Day Theater Day Unit Discharge / Follow up care On completion of surgery the patient will be discharged the same afternoon or early evening from the unit or the ward after post-surgical anaesthetic recovery and evaluation by the surgical team. Clear protocols should be laid down for discharge planning the same day. In all circumstances the patients should be given a telephone number to call in case of an emergency. Post-surgical follow up care could be arranged at the nearest hospital or primary care unit to utilize local services maximally and minimize overcrowding in busy tertiary hospital surgical clinics. However, the follow up care could be done in the surgical clinic or out-patient department of the same hospital if local services are inadequately resourced. In any situation, it is important to develop a pilot study plan which can be tested in a few selected hospitals before the scaling up of the implementation of this initiative. In either of the above models, the Ministry of Health, together with relevant medical associations (such as College of Surgeons and College of Anesthetists) may want to form a task force to develop a set of guidelines and protocols, including clinical auditing system, which aim to support the pilot day surgery 18 unit sites first and then scale up the implementation. Once that has been done, we propose for the Ministry of Health to select 2-3 hospitals at the different hospital levels, in different geographical settings, to pilot the above-mentioned models, with particular attention to the different situations and resources available in these hospitals. In the pilot hospitals, a technical working group consisting of relevant health professionals may be set up to lead the operation of the pilot studies. Based on the experiences from China, Singapore and other countries reviewed in this study, the day surgery practice may be first piloted in tertiary/teaching hospitals, not small hospitals, largely due to the concern about post-operation needs. Implementation through a step-by-step approach The following actions outlined here are proposed for the implementation of the day surgery unit in selected public hospitals in a step-by-step approach, with minimum financial commitments from the government. Patient Journey Pre-op  Establishing a dedicated anesthetic clinic for pre-operation assessment seems important and probably imperative, as not all hospitals offering surgical services have this facility at present. This could be seen as the first step in the provision of day surgery;  Where pre-op anesthesia unit or anesthesia manpower is inadequate to support general or regional anesthesia day surgery, procedures that only requires local anesthesia can be prioritized for implementation.  Patient education: The day surgery center should provide patients with clear information about their procedure, including the risks and benefits, recovery expectations, and follow-up care. This will help to ensure that patients are well- informed and prepared for their procedure. Op day  In order to minimize admission related delays for day surgeries, direct admission arrangements should be put in place for day surgery patients in the hospitals where the day surgery units will be piloted; In the meantime, the day surgery unit should consider simplifying admission procedures (e.g. a more concise admission form or simplified ward chart to reduce admin load for clinical and admin staff) given the low risk profile of day surgery patients  Have a barcoding or identification system for day patients ensuring priority for urgent investigations when required.  Consider protocol led discharge in selected low risk procedures such as surgery performed under local anaethesia. This may relieve the workload on the surgical team who may be in operating theatre or clinic and sommethen the discharge process. Post-op follow-up  Setting up of a hotline for post-surgical emergencies. 19  The center should have a mechanism in place to coordinate with other healthcare partners to ensure continuity of care for patients. These partners include primary healthcare facilities or other provincial level care facilities.  Good practices/lessons learnt from the cataract eye surgeries should be carefully considered in the development and implementation of the post-op follow up activities. In any case, careful evaluation of patients in the pre-op and post-op is critically important to ensure the success of day surgeries. The concept of “Enhanced recovery after surgery - ERAS� should be embedded into the guidelines of practicing day surgery in Sri Lanka, as part of the comprehensive implementation plan. System enabler Organization and Governance  Set up a Day Surgery Management unit including a technical working group with representations from anesthetists, surgeons and nurses in pilot hospitals to operationalize the workflow and provide clinical governance.  Set up a robust quality assurance program including clinical audits to ensure that patients receive the highest quality of care. These should include systematic audit of surgical outcomes such as unscheduled return to OT, unscheduled admissions to hospital and other post-op complications  Elective surgical workflow should be separated from emergency surgical workflow as far as possible. The mixing of these two cohorts of patients will undermine the efficiency of the elective surgical workflow, regardless if whether these are inpatient or day surgical cases.  Given the large volume of wound debridement that are performed in operating theatres in some of the hospitals (e.g. Jaffna teaching hospital), consider a wound care unit with a simple procedure room (not equipped to OT standards) that can shunt this cohort of patient away from the precious OT resource Staff  Development of a comprehensive training and capacity plan, e.g. providing adequate in-service training for Medical Officers in anesthesia.  Consider re-allocation/re-deployment of surgeons, anesthetics, and senior nurses to the hospitals where the day surgery units require, by offering financial or other incentives, if necessary, to compensate for additional travel time and other inconveniences for them to participate in off-site day surgery. In so doing, the mitigation of mal-distribution of health workforce might to some extent be achieved.  Initiatives to optimize use of existing theaters by mobilizing different categories of staff including health assistants.  Consider theatre shifts for staff that achieve greater efficiency in utilization of existing theatres.  Training and engagement of provincial, district, and primary care staff to ensure seamless transition of care for the patients after discharge from the day surgery unit, Facilities 20  In terms of bed utilization, it is common for non-casualty surgical ward beds to be underutilized on non-casualty days. It is worth considering whether these beds could be better utilized for day surgeries.  Consider centralized bed management unit to optimize bed utilization across different wards  In instances where there is inadequate space or theatre facilities the exploration of setting up the day surgery units in close satellite base or district hospitals. This will particularly apply to large teaching hospitals where there is extreme competition for theatre time.  It is understandable that the “double decking� of true emergency patients may sometimes be necessary in the casualty ward, given the lack of bed resource and the exigencies of care. However, double decking of elective surgical patients should be discouraged as far as possible as it can lead to sub-optimal patient care and potential patient safety problems. The practice of double decking also reduces the incentive for the surgical team to reduce post-op LOS. Patients  A flexible approach considering patient needs which may differ based on social, financial, educational and cultural background. For example, pre-op preparation may be challenging for some patients, while for others finding transportation to hospital in the mornings or late evenings after discharge may be difficult. Some patients may have anxiety when discharged early and could prefer to stay a night prior to discharge.  Address general issues, such as insurance or samurdhi (government benefit schemes) requirements. The above schemes deem that for a patient to claim benefits they have to be in hospital for over 24 hours. Quality and Safety Setting up a day surgery center requires change in clinical practice and work flow. It will be prudent to put in place systematic measures and audit mechanisms to ensure quality and safety, including clinical audits, as well as system efficiency. This generally involves collection of data on pre-determined indices, for example:  Quality and safety/clinical audit o Unplanned admissions (patient could not be discharged for medical reasons) o Unscheduled return to OT o 30 days unplanned readmission o 30 days morbidity and mortality o Set up a reporting system to capture severe adverse events and near misses  System performance audit: o Number and type of surgery performed o Wait time to surgery (time of listing to next available operating theatre slots) o OT utilisation rate i.e. utilised slot vs available slots 21 o Duration of procedure, wheel in wheel out time (duration that the patient stayed in the operating theatre), turn around time (time taken between two consecutive cases) o Pre-op (admission) and post-op (discharge) processing time  Number of case cancellation and reasons for cancellation (avoidable versus unavoidable)  These data should be regularly reviewed by the Day Surgery Management Unit to identify opportunities for improvements. In summary, we propose the adoption of an integrated approach to the establishment of a couple of day surgery units, wherever possible, in piloting this new initiative. For example, the integrated approach to the operation of day surgery unit in the district general hospitals may involve active participation from nearby larger and smaller hospitals. Surgeons/anesthetists from the larger hospitals may be deployed to provide services, while the smaller hospitals may assist with post-op services. The teaching/tertiary hospitals may use, as mentioned above, the theater space in the nearby smaller hospitals to jointly run such a day surgery unit. Primary healthcare centers/clinics may also get involved in post-op follow up care. Challenges and coping strategies for the implementation To implement any of the above-suggested models of the day surgery units, the hospitals may face several challenges in the organization and management of such a new approach to service delivery, although more efficiency gain could be potentially achieved, as discussed. While most key stakeholders are supportive to the establishment of day surgery units, some health professionals may still not be keen to provide their full supports and cooperation, as they have legitimate concerns of such a new initiative. A consensus building need to get done in an appropriate way, as it is critically important to ensure that every key actor/plays in this new initiative is in the same page. Another challenge is that some existing human resource policies implemented in the health sector may lack of flexibility in either compensating the health workers for their over-time workload, or in the re-allocation/re-deployment of surgeons or/anesthetists to work outside of their primary duty hospitals. The Ministry of Health, together with other relevant government agencies, may need to re-visit these policies to accommodate these adequate needs. In addition, appropriate incentives should be developed to ensure the effective health staff recruitment and retention to serve the day surgery units in these hospitals. Besides the re-allocation of human and physical space resources, setting up the day surgery units in these hospitals while involve extra financial resource, e.g. essential equipment might be purchased to support the conduct and operation of a pilot study, especially the thorough evaluation recommended. The Ministry of Health at the moment may not be in a position to offer meaningful financial resource to support it. Hence, we would suggest that the World Bank either provide 22 modest grants to support and evaluate the pilot, or facilitate bi-lateral or other multi-lateral development agencies, or philanthropic foundations/trusts to provide assistances in this regard. 23 Appendices  Appendix I: World Bank’s TOR  Appendix II: Detailed methods and sources of data, main tools and instruments used  Appendix III: Field visit program and list of key stakeholders interviewed  Appendix IV: Additional hospital stay and procedure data  Appendix V: Surgery costs as reported from private hospitals in Sri Lanka  Appendix VI: Surgical procedures that are recommended for day surgery units 24 Appendix I: World Bank’s TOR The World Bank Terms of Reference-Firm Contract Sri Lanka Hospital Day Care Unit Feasibility Study and Implementation Plan A. PROJECT BACKGROUND AND OBJECTIVES Background Sri Lanka, with a population of 21.7 million, has a universal health care system that extends free healthcare to all citizens, which has been a national priority. State health services function under the purview of the Ministry of Health, Nutrition and Indigenous Medicine (MOH). The curative and preventive services are under the Provincial Ministries. The preventive care services are delivered through 354 medical officer of health areas, while the curative services are through a system of hospitals ranging from out-patients only and primary care institutions to tertiary care institutions and specialized hospitals. Private sector too is involved in the delivery of health care –close to 50% total health expenditure is by the private sector. Rapidly ageing population and the growing burden of NCDs will increase demand for long-term care that requires more resources. The concept of “Efficiency gains in health care� will assess efficiency gains in healthcare, examine sources of inefficiency in the provision of health services, and identify areas where efficiency gains could be expected to finance the growing demand for long-term NCD care for the rapidly aging population. Some of the sources of inefficiency in Sri Lankan health system include mainly: (i) mild or chronic medical conditions- cataract, hernia, upper GI endoscopy, assessment of Diabetic Foot, strokes, NCDs, chronic wounds, chronic Asthma etc. that can be treated either at primary health care institutions or through home care. This practice leads to high bed occupancy rates at tertiary and secondary hospitals, loss of human resource productivity as well as equipment at tertiary and secondary levels, and loss of productivity of patient families as well. (ii) lack of a proper back referral system, which promotes transfer of patients from higher level care institutions to a lower-level once specialist care is completed. (iii) non-optimal NCD management This concept comprises two components: 1) to identify areas of health care services that could be provided in more efficient modes, and 2) to examine the relative cost-effectiveness of services provided at different modes. The component 1 will identify services that are provided at higher-level hospitals, but could be managed at a lower-level health care (including community level). It will also identify services that can be provided as ambulatory care (day care) but typically managed as inpatients. Information will be collected from all levels of healthcare, with reasonable geographical representation. Based on interventions identified as potential areas 25 for efficiency-gains, Health Technology Assessments (HTA) will be performed for a limited number of services to examine the relative cost-effectiveness of services provided at different healthcare platforms and levels of care. Efficiency will also be examined from an overall resource allocation and utilization perspective. The evidence generated through this will help the MoH to revisit existing clinical guidelines for a more efficient provision of health services. Learning and knowledge exchange events will be organized to build capacity of MoH officials including study visits to relevant countries, to exchange ideas on lessons learnt in pandemic preparedness and NCD care for elders. Study tours are critical for GoSL officials to observe, learn and comprehend from real-world experience how the identified issues and potential solutions suggested by this ASA could be applied to day-to-day operations in strengthening pandemic preparedness and long-term care. Objectives The objective of the study is to assess the feasibility of setting up Day Care units at tertiary hospitals (TH), provincial general hospitals (PGH) and district general hospitals (DGH) to reduce hospitalization and improve efficiency. The Day Care unit would accommodate patients for the day and prepare for minor identified procedures- surgical, radiological and endoscopic. Presently these patients are admitted to hospitals for a number of days. Cost of operation/procedure itself will not change as the same is performed in the same operating theatre and by the same staff that is being done as an indoor procedure. Specific Objectives In the process of assessing the feasibility and drafting the implementation plan, it important to focus specific attention on : (I) reaching formal consensus with relevant organizations/stakeholders, as the establishment and operation of day care units involve collaborative work.(II) availability of necessary infrastructure at THs, PGHs, and DGHs including capacity and potential of staff that would be involved in the process .(III)possibility and potential to pilot the setting up in hospitals where space is available. B. SCOPE OF WORK The World Bank is hiring a consultancy firm with extensive experience in health care administration and service delivery, and hospital management Sri Lanka to undertake a feasibility study for setting up of Day Care Units at Teaching Hospitals (1), Provincial General Hospitals (1), District General Hospitals, (1) and Base Hospitals (3). The Scope of work involves: 26 • Identification of the hospitals for the feasibility study in consultation with relevant MOH officials, World Bank Task Team, Provincial and District health authorities. Selection should ensure that hospitals are geographically spread across the country • Undertake hospital visits to conduct facility surveys and key informant interviews to assess the readiness of facilities to set up day care unit, including the availability of space, necessary infrastructure, equipment and other administrative arrangements for setting up of Day Care Units, and examine the financial implications. • Revise and develop a list of services/medical conditions that can be managed in the day care unit and estimate the case-loads. • Assess the feasibility of appropriate follow-up for the day care (medical/surgery) interventions. • Conduct Key Informant Interviews to: (I) obtain perceptions and opinions of staff, at different levels, about Day Care Units; (II) assess staff capacity and their contribution to establishment, operation and maintenance of the facility;(III) assess the institutional arrangements through which the Day Care Units would be operationalized; (IV) assess the coordination and referral mechanism needed for the smooth functioning of Day Care Units. • Prepare feasibility report with recommendations C. Deliverables The following documents are expected to be delivered by the consultancy firm. • Inception note (activities and timelines) within one week of signing of contract. • Survey tool(Questionnaire) one week before commencement of work • Interim report for review by World Bank and MOH • Workshop/webinar to share findings • Final report. D. QUALIFICATIONS The selected Firm shall possess the following qualifications: 1. Experience of working in the health sector in Sri Lanka 2. Expertise of undertaking feasibility studies or program evaluations in the health sector, focused on health systems, hospital management and service delivery. 27 28 Appendix II: Detailed methods, data sources, main tools and instruments used METHODS Colombo South Teaching Hospital, Jaffna Teaching Hospital, Nuwara-Eliya District General Hospital and Kalmunai North Base Hospital were selected for the survey. Data collection was done in October and November 2022. We first investigated existing health information systems, the extent to which these are computerized and especially which relevant clinical and administrative data is available in these hospitals. Next, comprehensive data gathering was done in two phases; phase 1 quantitative data collection and phase II qualitative data collection. Quantitative Data Collection A tailored hospital survey was carried out using a three – part questionnaire. Section A. Hospital information -This section included general information about the hospital and available day services. We collected the type of hospital, population catchment area, number of beds, number of health professionals (doctors, nurses, anesthetists, and other medical technicians, etc.), number of specialties, wards, and available day surgery services. Section B: Information regarding surgeries performed in the hospital This section assessed general surgeries conducted in the hospital. Data were collected from three locations; the main general surgical theater, general surgical wards and hospital record room. The following table shells are the ones that were used to collect the data in a structured and consistent format. Table 1. Types of surgeries performed in operating theaters in the hospital per year Type of Surgery Minor Intermediate Major Total 1. General 2. Genito-urinary 3. Neuro-surgery 4. Orthopedic 5. ENT 6. Total number of surgeries Note: Please add surgeries not mentioned- from 11 onwards. 29 Method notes: We intended to learn what types of surgeries are conducted in all surgical disciplines in the hospital per year. In surgical theaters, all surgical performances were graded as minor, intermediate, and major by the theater staff and reported to the hospital record room. We collected this information from the hospital record room to find out these three types of surgeries done in the whole hospital throughout 2019. Table 2. Surgical procedures done in all general surgical wards in the hospital Count Count Surgery Type ICD CODE Jan- June 2019 Jan- June 2022 Eg. 1. Inguinal Hernia Repair (IHR) K40 200 190 2. Excision of Breast Lump Note: 3. Hydrocelectomy 4. Laparoscopic Cholecystectomy 5. Incision and drainage (I & D) 6. * *Please add surgeries not mentioned- from 5 onwards. Method notes: The hospital record room gets patient information from all wards. There the surgical diagnoses were coded by ICD 10 and included in an electronic medical record-keeping system. All surgical procedures conducted on patients admitted to all general surgical wards during the period of January–June 2019 and January–June 2022 in the hospital were extracted from this database. Some of the data collected from the record room were not informative. For example I & D is common procedure to treat any infection that has turned into an abscess. Therefore, to collect detail information we had to collect data from the surgical wards. Table 3. Detail information on patients admitted to a general surgical ward during BHT number ICD code Duration of stay in Address the Hospital Eg. 12345 K40 5 No5, Richmond hill RD, Kohuwala Method notes: To obtain precise information on surgical operations and patient details we selected two surgical wards one female and another male to collect this data. The information was obtained regarding different surgical procedures, the duration of the patient’s stay at the ward, and the patient’s area of residence. To identify the surgical procedures conducted on patients we referred to the surgical theater record book and extracted information related to the patient’s bed head ticket number. 30 Table 4. Day surgery unit/mini theater performance in 2019 Type of surgery Number 1. Admissions 2. Discharges 3. Transferred to wards 4. I & D 5. C & D 6. Method notes: If a day surgical unit was functioning at the hospital we planned to collect data from their records but none of the hospitals had this facility Section C: Information on existing specialized day units Table 5. Haematology procedures Procedure ICD diagnosis Count Count January – January – March 2019 March 2022 Method notes: If specialized surgery units were available in the hospital we obtained their performance from January-march 2019 and January– march 2022. Table 5. Eye surgeries Procedure ICD diagnosis Count in Count in January -June January -June 2019 2022 Method notes: If specialized surgery units were available in the hospital we obtained their performance from January-March 2019 and January– March 2022. Qualitative data collection Qualitative data collection was done through focus group discussions and several key informant interviews. A structured questionnaire (annex….) was developed separately for interviews with the administrative staff of the ministry of health, the administrative staff of each hospital, hospital surgeons, hospital nurses and patients. All discussions and interviews were recorded with permission from the participants. 31 Following are the key informant interviews conducted  Ministry of Health and Colleges 1) Administrative staff of the Ministry of Health-Director general health service, deputy directors, director planning 2) Cancer Control Program - Director and the administrative staff 3) College of Surgeons – president, secretory and the council members of the College 4) College of anesthetist - president, secretory, council members of the College 5) College of hematologists – president and secretary The structured interview questionnaire included several key areas of concern: a) rationale for establishment of a day surgery unit and acceptance of this concept in the health system b) policies or measures available at the national level for supporting the development of surgical day units c) potential barriers/obstacles/challenges to establishing day surgery units.  Hospital staff 1) Administrative staff of the hospital-Hospital director, deputy directors, medical officer planning, administrative officer, matron. 2) Consultant surgeons in each hospital, consultant anesthetists, consultant hematologist etc 3) Nurses: theater sisters, theater nurses, surgical ward sisters and surgical ward nurses The interviews concerned a) experience re day surgery services b) organization of day surgery unit if the service was to be implemented in the hospital. Here we inquired about their perspectives on potential operations of the day surgery unit in terms of institutional arrangements using existing resources. Specifically, we inquired about the necessary infrastructure, availability of space, equipment, administrative capacity, financial situation, IT facilities and medical record-keeping systems. c) procedures/services that can be prioritized in the day surgery units, in terms of practicality/feasibility, safety and acceptance. d) challenges in setting up and functioning a day surgery unit.  Patients 1) Patients who are awaiting minor surgeries 2) Patients who have undergone minor surgeries Patients were interviewed relating to their preference for day surgery, convenience and difficulties they expect to encounter if such a facility is established. 32 Appendix III: Field visit program and list of key stakeholders interviewed Date Study Team Organization Key Stakeholders Participants Phase 1- Quantitative Data Collection Sept. 29, 2022 Thyagi Ponnamperuma, Colombo South Meeting with Dr. Sagari (Thurs) Durga Pulendran, Teaching Hospital Kiriwandeniya (Director CSTH). Kinkini Udalamaththa (CSTH) Sept. 30, 2022 Durga Pulendran, Colombo South Meeting with Matron and ward (Thurs) Kinkini Udalamaththa Teaching Hospital visit to collect data from the records. Oct. 12, 2022 Shehan Williams Nuwara-Eliya District Meeting with Dr. M. Seneviratne, (Wed) Durga Pulendran, General Hospital Director and Key admin Officials Kinkini Udalamaththa Oct. 13, 2022 Durga Pulendran, Nuwara-Eliya District Meeting with Dr. Shafrana, Kinkini Udalamaththa General Hospital Medical Officer of Planning and ward visit to collect data from the records. Oct 17, 2022 Shehan Williams Kalmunai North Base Meeting with Dr. Mathan- Deputy (Mon) Durga Pulendran, Hospital Medical Superintendent. Ward Kinkini Udalamaththa visit to collect data from the records. Oct 25, 2022 Shehan Williams Jaffna Teaching Meeting with Dr. (Tue) Durga Pulendran, Hospital (JTH) Shathiyamoorthy, Director (JTH) Kinkini Udalamaththa and Key admin Officials Oct 26, 2022 Durga Pulendran, Jaffna Teaching Meeting with Dr. Nithyanandan- (Wed) Kinkini Udalamaththa Hospital Medical Officer of Planning and ward visit to collect data from the records. Phase II- Qualitative Data Collection 33 Nov 13, 2022 Shenglan Tang, World Bank Sri Lanka Deepika Attygalle and Di Dong (Sun) Shehan Williams, Hiang Khoon Tan, Thyagi Ponnamperuma, Truls Ostbye, Ruklanthi de Alwis, Durga Pulendran, Kinkini Udalamaththa Nov 14, 2022 Hiang Khoon Tan, Jaffna Teaching Meet with Jaffna Teaching (Mon) Ruklanthi de Alwis, Hospital Hospital Director Dr. Durga Pulendran Sahtiyamoorthy Stake Holder Interviews 1. Surgeons, 2. Hematologist 3. Anesthetist 4. Nurses Nursing Staff Mr. S. Ravindran Mr. S. Panchalingam Mr. T. panchalingam Mrs. M. Gnanachandran Mr. T. Mouleeswaran Mr. K. Senthil Kumar Ms.R. Thevaamirthadevy Ms. S. Sellaththamby Ms. N. Senthilkumar Mrs. K. Kumaraseelan Ms.B. Thamilchelvan Ms. K. Chandrakumar Surgeons Dr. V. Suthagaran-General Surgeon, Dr. S. Giridaran-Consultant General Surgeon, Dr. K. Umashankar- Consultant General Surgeon, Dr. T. Sooriyakumar- Consultant Heamatologist Others Dr. Sathiyamoorthy- Director Dr. S. Nithyanandan-MO Planning, Dr. S. Surendrakumar –Dean, University of Jaffna, Nov 14, 2022 Shenglan Tang, Ministry of Health Sri Meeting DG -Min.of Health and (Mon) Shehan Williams, Lanka other officials 34 Thyagi Ponnamperuma, Truls Ostbye, College of Dr.G.A.P.D.Weerawardhena Kinkini Udalamaththa Hematology Dr. Nilmini Wijesooriya College of Dr. Chamila Liyanage Anesthetists Dr. Sandya Samaraweera Dr.L.A.P.Perera Dr. Vinodini wanigasekara Dr.Chamil Perera Nov 15, 2022 Ruklanthi de Alwis, Jaffna Teaching Meeting with Consultant (Tue) Durga Pulendran Hospital Hematologist-Dr. T. Sooriyakumar and tour of Day surgery hematology unit at Jaffna Teaching Hospital Nov 15, 2022 Shenglan Tang, Colombo South Stake Holder interviews at CSTH (Tue) Shehan Williams, Teaching Hospital Thyagi Ponnamperuma, Colombo (CSTH) Nursing Truls Ostbye, K. A. D. Rupika Kinkini Udalamaththa W. A. M. Nilanthi S. H. S. Rangi P. L. S. Silva Admin and Medical, Surgical staff Dr. Sagari Kiriwandeniya Director Dr. S. Sai Niranjan -Deputy Director Dr. Niranjan Dr. Ranasinghe- Consultant Hematologist Dr Y R Samaraweera- Consultant Hematologist Dr. K. Vijayasinghe-Consultant Surgeon Dr. P. Kirupakaran- OMF Surgeon Dr. K. Paranthamalingam- Surgeon-Dental Dr. Rajiv Rajendra Consultant Surgeon Dr. Vasuki VS Eye Dr. D Jayasekar VS ENT Nov 16, 2022 Thyagi Ponnamperuma, District Hospital Stake Holder Interviews (Wed) Truls Ostbye, Nuwareliya 1. Surgeons, Kinkini Udalamaththa 2. Hematologist 3. nesthetist 35 4. Nurses Dr. M. Seneviratne- Director Dr. D. S. Manathunga Deputy Director Dr. E. M. M. S. F. Shafrana MO Planning Priyanka Menaka Ratna Admin. Officer H. M. Vimalavati N. L. Vijaya Goonawardena- Nursing sister Sanjay Premarathna M. D Ratnayake - Nursing sister Nov 17, 2022 Thyagi Ponnamperuma, Nuwara Eliya Hospital Meeting with Director and Key (Thus) Truls Ostbye, Admin. Officials Kinkini Udalamaththa Dr. M. Seneviratne -Director Dr. D. M. A. H. Dissanaike -ENT surgeon Dr. L. Kumaragama VS Dr. Sonali Gunathilaka- Consultant Endocrinologist Dr. A. A. S. D. Athurupana- Consultant Rheumatologist Dr. Prasad Abesinghe VS Dr. G. Anusha-Consultant Hematologist Dr. Duleeka Dissanayake- Gynaecologist Dr. Shafrana MO Planning Dr. KDT Dinupa- Dermatologist MTS Gayathri B. V. K. M. Bopemme-emergency physician Dr. Manjula Herath OMF Surgeon Dr. Thaha MM -GUS Dr. S. P. Rajesh Consultant Oncologist Nov 17, 2022 Shenglan Tang, Kalmunai Base Stakeholder interviews (Thus) Shehan Williams, Hospital Dr. Muraleeswaran Medical Durga Pulendran Superintendent Dr. Mathan, Deputy Medical Superintendent Mr. M. Kenthiramoorthy- Accountant Mrs. L. Sujendran-Matron 36 Mr. T. Thevaarul-Admin officer Mr. P. Selvakumar-NOIC quality unit Mr. S. Srigaran-NOIC infection control Mr. T. Uthayathas NO infection control Ms. Dharshika-Diet Clark Dr. Roshan Consultant Pediatrician Dr. M. M. Ikram Consultant Anaesthetist Dr. S. Varun Prasad Consultant Orthopedic Surgeon Discussion at the Surgical Ward Dr. N. A. M. Nizmy HO Dr. A. M. Fazmir S H O Surgery Mr. K. Sivanathan- Nurse in charge Dr. W. S. S. Wijeyaratne SHO Surgery Dr. D. M. Imjad SHO Surgery Dr. D. D. Kariyawasam HO Mrs A. Rishalini -Nurse Mrs. S. Satheeskanthan- Nurse Nov 18, 2022 Shenglan Tang, College of Surgeons Members of College of Surgeons (Fri) Shehan Williams, Thyagi Ponnamperuma, Dr. Kavinda Rajapakse, Truls Ostbye, Dr. Amila Jayasundara, Kinkini Udalamaththa Dr. Suminda Ariyaratne, Dr. Nissanka Jayawardhene, Dr. Gayan, Dr.L.A.P.Perera, Dr. Vinodini, Dr.Jeewa, Dr.Sanjeewa Thalgaspitiya Nov 18, 2022 Shenglan Tang, World Bank Sri Lanka Deepika Attygalle and Di Dong (Fri) Shehan Williams, Thyagi Ponnamperuma, Truls Ostbye, Ruklanthi de Alwis, Durga Pulendran, Kinkini Udalamaththa 37 Appendix IV: Additional hospital stay and procedure data CUMULATIVE HOSPITAL RESULTS 35.00 Frequency (%) 30.00 25.00 29.57 20.00 15.00 10.00 5.00 12.15 12.13 9.94 8.68 6.99 6.22 5.70 4.80 3.80 0.00 Top procedures Figure 1. Top ten surgical procedures conducted in all four hospitals. Combined data obtained from the electronic medical record keeping system for all four hospitals from January to June 2019. 70.00 60.00 FREQUENCY (%) 50.00 59.08 40.00 30.00 39.24 20.00 10.00 1.68 0.00 Cataract other day Other (cannot be procedures done as day provedures) PROCEDURES Figure 2. Eye surgeries conducted in all four hospitals in 2022. Combined data obtained from the electronic medical record keeping systems for all four hospital from January to June 2022. 38 SURGICAL PROCEDURES CONDUCTED IN INDIVIDUAL HOSPITALS COLOMBO SOUTH TEACHING HOSPITAL Table 1. Top ten surgical procedures during January to June in 2019 in Colombo South Teaching Hospital. Patient Duration ICD Percentage 600 Procedure Count of stay code (%) 490 (Days) 500 FREQUENCY (COUNT) 1. I&D abcess L02 490 2.45 23.68 400 353 288 300 2. Sebaceous cyst L72.1 353 2.92 17.06 200 excision 200 180 145 123 104 95 91 3. SF ligation I83 288 1.00 13.92 100 0 4. Inguinal hernia K40 200 3.00 9.67 5. Para umbilical K42 180 5.40 8.70 hernia 6. Excision of breast N63 145 2.00 7.01 lump PROCEDURES 7. Appendectomy K35 123 3.29 5.94 Figure 3. Top ten surgical procedures conducted between January to June 2019 in Colombo South 8. Carpal tunnel G56 104 0.50 5.03 Teaching Hospital. decompression 9. Excision of breast N61 95 2.00 4.59 abcess 10. Perineal abcess K61 91 3.29 4.40 Note: Data obtained from the electronic medical record keeping system between January to June 2019. 39 KALMUNAI NORTH BASE HOSPITAL Table 2. Top ten surgical procedures conducted during Jan to June in 2019 in Kalmunai North Base Hospital. 500 430 450 400 FREQUENCY (COUNT) 350 ICD Patient Mean Hospital Percentage Procedure 300 Code Count Stay (Days) (%) 250 205 200 158 150 1. I&D of abcess L02 430 2.17 39.41 102 79 100 33 32 27 50 13 12 2. Appendectomy K35 205 2.88 18.79 0 3. Inguinal Hernia K40 158 3.16 14.48 Repair 4. Foreign body L92. 102 0.27 9.35 removal 3 5. FNAC 79 0.00 7.24 PROCEDURES Figure 4. Top ten surgical procedures conducted 6. Thyroidectomy 33 2.75 3.02 during January to June 2019 in Kalmunai North Base Hospital. 7. Excision of N63 32 1.58 2.93 breast lump 8. Colonoscopy 27 3.00 2.47 9. SF Ligation I83 13 2.18 1.19 10. Laparascopic 12 4.65 1.10 Cholecystectom y Note: Data obtained from the electronic medical record keeping system from January to June 2019. 40 TEACHING HOSPITAL JAFFNA Table 3. Top ten surgical procedures conducted during Jan to June in 2019 in Jaffna teaching Hospital. Mean ICD Patient Percentage Procedure Hospital code Count (%) Stay (Days) 1. I&D abcess L02 102 3.64 21.66 2. Inguinal hernia K40 76 4.84 16.14 120 102 3. Appendectomy K35 62 3.15 13.16 100 FREQUENCY (COUNT) 76 80 4. Wound toilet Z48 44 5.25 9.34 62 60 44 5. Excision of N63 40 5.14 8.49 40 37 40 34 breast lump 27 25 24 I83 37 3.00 7.86 20 6. SF ligation 0 7. Sebacious cyst L72.1 34 3.50 7.22 excision 8. Para umbilical K42 27 2.94 5.73 hernia 9. Perineal K60 25 6.00 5.31 fistulectomy PROCEDURES 10. Perineal abcess K61 24 2.60 5.10 Figure 5. Top ten surgical procedures conducted Note: Data obtained from the electronic medical record keeping system from during January to June 2019 in Jaffna Teaching January to June 2019 Hospital. 41 DISTRICT GENERAL HOSPITAL NUWARA ELIYA Table 4. Top ten surgical procedures conducted during January to June of 2019 in Nuwara Eliya District General Hospital. Mean ICD Patient Percentage 140 Procedure Hospital Code Count (%) 120 FREQUENCY (COUNT) Stay (Days) 129 100 120 1. I&D of abcess L02 129 2.33 19.69 80 82 60 72 2. Foreign body T16 120 1.67 18.32 40 55 53 removal (Ear) 39 20 35 35 35 3. Appendectomy K37 82 2.45 12.52 0 4. Perineal abcess K61.0 72 2.83 10.99 5. Excision of N63 55 3.39 8.40 Breast Lump 6. Excision of N61 53 3.00 8.09 breast abscess PROCEDURES 7. Inguinal Hernia K40 39 2.74 5.95 Repair Figure 6. Top ten surgical procedures conducted 8. Para Umbilical K42 35 2.50 5.34 during January to June 2019 in Nuwara Eliya District Hernial repair General Hospital. 9. Skin graft T86.8 35 5.00 5.34 10. Thyroidectomy E06.9 35 3.00 5.34 Note: Data obtained from the electronic medical record keeping system from January to June 2019. 42 APPENDIX V: Surgery cost as reported from private hospitals in Sri Lanka 2022 Average total cost Surgery type (Sri Lankan Rupees) 1. Cataract 114,000 2. Surgical extraction of teeth 69,000 3. Hernia repair 92,000 4. Saphenofemoral ligation 220,000 5. Circumcision 100,000 6. Cystoscopy 92,000 7. Laparoscopic Cholecystectomy 220,000 8. Laparoscopic Female sterilization 100,000 9. Excision of breast lumps 68,000 10. Arthroscopic procedures 150,000 11. Carpal tunnel release 80,000 12. Incision and drainage of abscess 50,000 13. Sebaceous cyst and other small lumps 70,000 14. Appendectomy 250000 43 8 College Road Singapore 169857 T 6516 7666 F 6221 7396 www.duke-nus.edu.sg A school of the National University of Singapore Appendix VI: Surgical procedures that are recommended for day surgery units Reccomended list of surgical procedures for day surgery units: 1. Cataract 2. Surgical extraction of teeth 3. Grommet insertion 4. Hernia repair 5. Varicose vein removal 6. Circumcision 7. Cystoscopy 8. Laparoscopic Cholecystectomy 9. Laparoscopic Female sterilisation 10. Excision of breast lumps 11. Arthroscopic procedures 12. Carpal tunnel release 13. Incision and drainage of abscess 14. Sebaceous cyst and other small lumps 15. Appendectomy 44 8 College Road Singapore 169857 T 6516 7666 F 6221 7396 www.duke-nus.edu.sg A school of the National University of Singapore