Outpatient hospitalization is a mode of medical or surgical care in which the patient stays in the hospital for less than 12 hours. This formula has many advantages, in particular: the comfort and satisfaction of the patient who “sleeps at home”, the safety of care with less exposure to infectious risks, the reduction of costs linked to hospitalization, etc.
The ambulatory shift is one of the four objectives of the three-year ONDAM plan (National Health Insurance Expenditure Objective), which aims to support a structural change in the health system over the 2015-2017 period.
The CHU is resolutely part of this movement surgery and has made the development of day care a strong focus of its 2016-2020 establishment project, its ambition also being to position itself at the heart of the patient’s care pathway in close connection with all the professionals of the territory of health.
Stays are getting shorter and shorter, so in 2015, nearly 58% of stays recorded at the CHU were less than 24 hours and the day surgery rate was 29.5% with 10,944 stays (less than 12 hours) . This rate has increased by 44% since 2010.
The goal is to reach 50% in day surgery by 2020 . To do this, quantified objectives have been set at each center with an outpatient surgery unit and tools to help develop this care have been deployed (software for managing calls the day before and the next day, etc.) .
Outpatient management should be the preferred mode of medical hospitalization. The activity in a day hospital therefore requires the identification of beds or even units within numerous departments.
The objectives are to establish a reference charter specifying the optimal scope of these structures and then to organize units on this basis by promoting groupings and the pooling of resources. Development prospects will also be based on changes in care techniques, the introduction of intermediate billing between day hospitalization and external activity, etc.
Finally, as a majority of the patients taken care of are domiciled outside the department, the possibility of offering a hotel reception structure ( Maison Saint-Jean – Pellegrin hospital group ) represents an asset for the development of innovative practices in optimal comfort conditions for our patients.
The strategy of the CHU of Bordeaux concerning outpatient medicine consists above all in grouping together isolated places to form day hospitals (HDJ) , because the organization of full hospitalization services is not made to accommodate outpatients.
A coordination group for the development of outpatient medicine , led by Prof. Michel Dupon , head of the infectious and tropical diseases department , Prof. Noël Milpied , head of the hematology and cell therapy department and Florence Nègre-Le Guillou, director of quality and risk management and referent director “ambulatory medicine”, met with the centers identified as those with potential for developing or grouping ambulatory activities.
Between 2013 and 2016, 102 places in outpatient medicine were created across all the centres, which currently makes a total of 352 places at the CHU .
Examples of outpatient surgery performed at the bordeaux university hospital :
Oncology-radiation therapy dermatology-hematology-palliative care : creation of 5 additional HDJ places (21 places in total) during the consolidation of dermatology in Saint-André.
Creation of a first inter-pole day hospital in Saint-André in 2017 (6 places) bringing together activities from the cardio-thoracic , internal medicine and digestive system, endocrinology and nutrition (ADEN) poles.
Ambulatory surgery is booming in public hospitals with an increasingly large volume of patients and the performance of increasingly heavy surgeries. Risk management is intimately associated with all stages of the ambulatory patient journey.
The pre and postoperative phases are essential elements of the patient journey in day surgery. The contact one or two days before the intervention makes it possible to recall the preoperative instructions (fasting, hygiene, etc.) and to confirm the arrival of the patient.
Contact on D+1 or within 72 hours postoperatively is also imperative (pain, nausea-vomiting, hematoma, other medical problem, satisfaction, etc.).
This technical development and the expertise developed have been at the origin, for this surgery deemed complex, of a reduction in per and postoperative morbidity
(reduction of bleeding, reduction of pain, smaller scars) as well as durations of hospitalization and recovery .
After the initial implementation, in 2015, of an enhanced rehabilitation after surgery (RAAC) program, the development of an outpatient treatment protocol for kidney tumors was logically necessary. The “AMBURein” protocol, coordinated by Dr Jean-Christophe Bernhard and supported by the DGOS and INCa as a pilot project developing outpatient cancer surgery, is thus the subject of a prospective medical evaluation (safety and satisfaction patients) and medico-economic.
Since September 2016, 12 patients have already benefited from this new “clinical path” involving perfect multidisciplinary collaboration. (surgeons, anaesthesiologists, paramedical teams from the outpatient surgery unit, urology unit team, consultation unit and secretariat of the urology department). Emphasis is also placed on the town-hospital relationship, informing the general practitioner and pre-therapeutic patient education by setting up a dedicated nurse consultation.