**9. Challenges and future**

Considering the complexity and cost associated with hospital admissions and inpatient treatment, continuous shift in care from inpatient admission and treatment to outpatient care in the form of day care surgery has been witnessed globally in recent years [13]. Office procedure, OPD care and minor surgery were first included in day care surgery but with advancement of skill, technology and infrastructure even major surgery with proper preoperative work up, modern anesthesia and proper post-operative care with communications properly, adequate transport and back up plans to manage the complications with round the clock operation theater team with anesthesia team in alert and prepared mode for the any events to be managed in the operation theater. Development of health sector in new dimensions with development of day care surgery is optimum utilization of the resources and conserving the scarce fund of the patient for the payment of hospital bills very true and innovation for the underdeveloped nations. On the other hand, in developed nations, day care surgery almost crossed the half mark of all elective surgeries many years back and now almost 75% of the all elective surgeries are day care surgery. The challenges associated with establishment of day care surgery services are many and may appear at first review, insurmountable and may include lack of guidelines, lack of regulatory bodies and lack of supervision in poorly developed parts of the globes. Standard protocols and practices may be defined and set to identify the core concept of day care surgery. First challenge is upgradation of present health services to gear up for practice and all-elective acceptance of the day care surgery. Although there are still problems to be solved at the national level, such as training, this should not hinder the exploration of the development of local services. This is not necessarily very complicated. Simple methods such as the plan, execute, research and act (PDSA) cycle can be a very effective tool for initiating change, because the roles and perspectives of all relevant clinical and management resource groups are determined from the beginning. The plan here is the service change to be implemented (for example, to start a level 2 community surgery service). This involves mapping patient paths to show all relevant procedures and administrative processes surrounding patient management, thereby identifying potential gaps, bottlenecks, and barriers to change. During this process, questions about meeting visit goals, advance appointments, labor, capital flow, facilities, multidisciplinary team agreements, and patient information adequacy can be identified. To do is to implement changes to the service, rather than introducing this "wholesaler", it is better to test a small number of patients first to assess the impact. Research involves collecting data before and after implementing changes to observe and learn from the consequences. The bill involves determining what changes need to be made before it is fully implemented. Community surgical pathway planning should not be based on cost reduction, because experience shows that if community capacity meets previously unrecognized but clinically relevant needs, the costs of services may increase.

Second and biggest challenge is scope of day care surgery expansion which is limited by poor resource, technology limitations and infrastructure development and many advanced endoscopic, laparoscopic and intervention radiology procedures may not be included in day care surgery due to above limitations. Endocrine surgery, laparoscopic hernioplasty, laparoscopic cholecystectomy and laparoscopic fundoplication may be always in day care surgery with technology, skill and infrastructure. Proper post-operative care after use of an updated and advanced modern anesthesia system is essential in all day care surgery for acceptance in practice as well as patient centric outcomes [14, 15].
