Ambulatory Care Quarterly

Inpatient and SDS: One unit or two?

Opinions differ on cost and staff efficiency

As the number of same-day surgery procedures increases, managers are constantly faced with the need to find ways to expand their ability to handle more cases. If you’re a hospital-based surgery manager, do you look at increasing the size of your surgical unit that handles both inpatient and outpatient surgery, or do you look at separating inpatient from same-day completely? Does one approach ensure more success than the other does? Which approach is more cost-effective, efficient, and attractive to patients and surgeons?

Finding what works for your facility

According to experts, the answers to these questions depend on each facility’s own unique situation. A separate unit does result in some procedure and recovery time decreases, according to a study conducted by Peter Mollenholt, MD, administrative director of DayStay at Oregon Health Sciences University Hospital in Portland.

Mollenholt conducted his study in two parts, before and after the inpatient and outpatient units at that facility split. In a paper he presented at the most recent annual meeting of the Park Ridge, IL- based American Society of Anesthesiologists, anesthesia preparation times of fewer than 15 minutes increased from 50% to 75% after splitting the units because inpatient cases required more anesthesia preparation.

While anesthesia start-to-finish times did not significantly change, recovery room length of stay (LOS) did shorten considerably, he says. Recovery room LOS of fewer than 30 minutes jumped from 7% of cases for the combined unit to 20% of cases for the separate same-day surgery unit, and LOS of 30-60 minutes went from 14% for the combined unit to 55% of cases for the separate unit. Because same-day surgery cases usually require a shorter length of stay in recovery, a separate unit allows a more efficient turnover of recovery beds, says Mollenholt.

"While these results focus on anesthesia services and recovery times, they demonstrate a more efficient operation with a dedicated same-day surgery center," he says.

Susan Bales, RN, MBA, director of surgical and obstetrical services at Promina DeKalb Medical Center in Decatur, GA, disagrees with Mollenholt on this point, saying that her experience is that combined units are more efficient in many cases. A combined unit is more cost-efficient for equipment, supplies, and staff because everything is in one place, she says. "In the late ’80s, we had completely separate inpatient and outpatient units," says Bales. In 1990, the hospital renovated the surgical area, combining the separate operating room areas into one, says Bales. "At the time, we were seeing an explosion in the number of outpatient procedures and did not believe that we could accurately calculate the number of outpatient rooms we would need," she explains.

The feel of a separate facility

Physically, there was no room to build contiguous separate units that would enable inpatient operating rooms to handle outpatient overflow, so the best decision was one unit, Bales explains. There is a pleasant, comfortable same-day surgery admission area with its own entrance from the outside that handles same-day surgery admissions and a.m. admissions for inpatient surgery, says Bales.

"This gives the patient the perception of entering a same-day surgery center rather than a hospital," she says. There is one recovery unit that handles all patients, she adds.

There are a number of benefits to a combined unit, but the biggest benefit is physician satisfaction, says Bales. "An orthopedic surgeon can book one room for the entire day to handle all of his or her procedures," she says. This means the surgeon doesn’t have to go from one area for inpatient surgery to another for same-day surgery. It also means that the surgeon doesn’t run into delays as a result of another surgeon’s procedure taking longer than expected in the OR booked by the orthopedist, she explains.

Overcoming resistance

Going from one area of the hospital to another when the units are separated is a major complaint at first, says Mollenholt. "Our surgeons hated it," he admits as he describes his hospital’s opening of a separate day surgery center on the hospital campus. The majority of surgeons didn’t think the center was convenient, even though it was connected to the hospital by a walkway, he says.

To combat the surgeons’ dissatisfaction, Mollenholt emphasized the benefits of block scheduling and an operating room schedule that isn’t disrupted by emergency and trauma cases. "Now they realize that access to our operating rooms is actually more flexible than the main OR," adds Mollenholt.

Procedure delays due to emergency surgeries are one disadvantage of a combined unit, says Bales. "We have a very busy emergency department, so we have days when less critical procedures are delayed," she explains. "Same-day surgery patients expect us to honor their appointment time, and they’ve made arrangements at work and at home," she admits.

Bales’ staff and the surgeons try to get all of the same-day surgery procedures done on the day scheduled so the patient doesn’t have to come back, she adds. Although it is tough to find operating room nurses who like to work inpatient and same-day surgery cases, the flexibility of her staff is a bonus, Bales says. Because her operating rooms are set up to handle any type of procedure and her staff are trained to work with any surgeon, the schedule can be juggled throughout the day to utilize the operating rooms efficiently, she adds.

If a hospital administration is planning to split the inpatient and outpatient units, it is important to hire a manager and director of nursing for the separate same-day surgery facility who are advocates of same-day surgery, says Mollenholt. "The people running the program have to be interested in same-day surgery advances and believe in the advantages of separate units," he says.

[For more information about separate vs. combined surgical units, contact:

Susan Bales, RN, MBA, Director of Surgical and Obstetrical Services, Promina DeKalb Medical Center, 2701 N. Decatur Road, Decatur, GA 30033. Telephone: (404) 501-5333. Fax: (404) 501-1621.

Peter Mollenholt, MD, Administrative Director, DayStay at Oregon Health Sciences University Hospital, 3181 S.W. Sam Jackson Park Road, L217, Portland, OR 97201. Telephone: (503) 494-4929. E-mail:]