Care of the Ambulatory Surgical Patient
Nancy Burden, MS, RN
Ambulatory surgery continues to grow, rapidly evolving in both number of patients and complexity of procedures. Providing quality nursing care in this setting requires a combination of strong technical and educational skills along with a healthy dose of common sense. The critical nature of surgery and anesthesia and potential complications demand the application of critical thinking and advanced nursing skills, while the short nature of the care cycle requires astute assessment and the ability to intervene rapidly and correctly. More awake patients and family involvement place the nurse in the roles of educator, counselor, and support system to help the patient experience proper preparation and prepare for safe aftercare in the home setting. Short-acting anesthetic agents and adjunctive drugs allow quick return to alertness and self-care with fewer unpleasant side effects. In addition, consumers are more educated and sophisticated than in past generations, and current fast-paced lifestyles lend themselves to “in and out” care.
Ambulatory Surgery (AS) Typical designation for surgery and other procedures where the patient is expected to be discharged within the same day or soon thereafter without the need for typical overnight hospital care.
Ambulatory Surgery Center (ASC) A facility separate from a hospital that may be on the same campus as or separate from other medical facilities. Depending on state requirements, the ASC may require licensure. Some, but not all, are also Medicare-certified.
Freestanding Ambulatory Surgery Center (FASC) Term used interchangeably with ASC.
Hospital Outpatient Department (HOPD) An area within a hospital that provides perioperative care for surgery patients who are discharged on the same day. These departments often function as a same-day admitting area for other surgical patients.
Joint Venture Surgery Center An ASC that has more than one ownership entity, such as a corporation and physicians, a hospital and physicians, or any combination thereof.
Third-Party Payers These are entities other than the patient or patient’s responsible person that pay costs of care. These may include commercial insurance companies, health maintenance organizations, worker compensation boards, employers, attorney representatives, and the federal or state government. The emerging trend for third-party payers is to mandate that surgical procedures be performed in the appropriate lowest cost setting for payment eligibility, moving along the continuum from hospitals to outpatient settings to physician offices. Ambulatory surgery and hospital industry organizations continually work with federal agencies to lobby for appropriate placement of procedures. Government payment decisions frequently result in commercial payers following suit; therefore, it is essential that business leaders remain current with regulatory changes.
Ambulatory Surgery Issues
A variety of factors drives the move toward outpatient surgery. Experience has shown the process to be successful and safe in both hospital outpatient departments and freestanding ambulatory surgery centers (ASCs). Clinical outcomes have not suffered from shortened postoperative hospitalization in appropriate cases. In fact, avoidance of a hospital stay can reduce the opportunity for health care–associated infection and medical errors. The future growth of ambulatory surgery (AS) remains dependent on the effects of a variety of issues including health care reform, the development of accountable care organizations (ACOs), Medicare and Medicaid legislation, third-party payer policies and other national and state influences. The great mobility of the population brings another challenge because families are scattered and the stronger family support systems of years past are reduced.
In addition to financial pressures to use the most cost-effective location for surgical procedures, other factors have contributed to the trend of same-day admission and early postoperative discharge. Technological advances in instrumentation and equipment allow more complex procedures to be performed while still supporting early discharge. Examples include spinal procedures, advanced joint replacement procedures, and laparoscopic gastric banding for weight loss, which has brought an increase in bariatric patients with their specific nursing care and environmental needs.
For patients who require nursing care in a much shortened time span, AS nurses place emphasis on rapid yet comprehensive patient assessment along with clear patient and family education. AS nurses encourage the patient’s self-care and self-responsibility for preadmission and postdischarge compliance with planned medical and nursing care and then must assess the patient’s ability, desire, and intentions to comply. In addition, nurses emphasize the patient’s early ambulation and return to normal life activities, patient teaching, and family involvement in the patient’s care.
It is essential to recognize and address the social, emotional, and educational needs of patients in addition to their physical concerns. Unspoken questions may linger for patients and their families such as the final outcome of the procedure and concerns about health and well-being, financial burdens, doubts about the availability and quality of postoperative support at home, vulnerability, and whether full preoperative life activities can resume and how quickly. Nurses should provide open doors for these types of questions and discussions including sensitive issues such as elimination needs and sexual concerns that patients may be too shy or embarrassed to ask about.
Involvement of the family or another responsible adult who will provide home support is integral to the overall plan of care. Thus, assessment of the caregiver’s abilities, willingness, and availability should occur before the day of procedure, allowing time for any necessary interventions. Postoperative complications such as nausea and vomiting, discomfort, or difficult ambulation might be considered minor or merely unpleasant for hospitalized patients who have nursing support. However, these problems become serious deterrents to early discharge and can lead to a prolonged stay, costly unplanned hospitalization, or unpleasant home recuperation.
Assessment of the patient’s needs may lead to a physician’s referral to a home health provider for specialized nursing care, infusion therapy, pain management, physical therapy, or equipment-related needs. If needs are identified before the day of the procedure, a referral can be in place and equipment and supplies delivered to the patient’s home to ensure their availability along with appropriate instructions for use. That said, nurses frequently encounter situations where resources are not identified before the day of procedure and may or may not be financially supported by payers. The earlier a postdischarge need is identified, the longer time can be allotted for solving challenges.
Nursing care should promote wellness and self-care to the highest degree possible. Patients should be continually encouraged to think positively and to provide self-care as much as appropriate and possible. Orem’s general theory of nursing—a three-part theory regarding self-care, self-care deficit, and the nursing system—provides the basis for determining and using the patient’s personal strengths relating to self-care.1 This Self-Care Deficit Nursing Theory describes nursing planning and intervention appropriate to the ambulatory surgical patient. The nurse calculates the patient’s self-care demand and shares with the patient what must be done to regain or promote health in relation to postoperative recovery. Nursing actions revolve around teaching the patient and family, gaining acceptance of the prescribed actions, and then assessing the degree to which the nurse feels the patient can and will comply.
The concept of a self-fulfilling prophecy is a tool often used by managers to motivate a team. Likewise, nurses can apply the concept to help patients expect success and comfort. According to the principles of a self-fulfilling prophecy, an outcome is more likely to happen just because the patient expects it. The outcome is preprogrammed by the patient’s outlook; therefore, the nurse’s focus on wellness and uneventful recovery can be an important tool to shape the mindsets of the patient and caregiver in a positive direction. Use positive, but honest, rather than negative references in questions asked and information given. An example might be coaching a patient who “always vomits” after surgery. First, you may identify that the “always” was 15 years in the past, to which you can honestly tell patients how improved anesthetic agents are now with much less chance of associated anesthesia-relative nausea. You might employ both nonpharmaceutical and prophylactic medication orders while explaining the added benefit to the patient and relaying concerns to the anesthesia provider. The nurses are also called upon to educate and redirect family members who want to explain all their terrible prior experiences in front of the waiting patient.
Regardless of the type of facility, the patient’s basic nursing needs remain the same. That care combines both critical assessment and monitoring during periods of high dependence, such as during anesthetic regional injections and immediately after general anesthesia or sedation, with periods when the patient is encouraged and taught how to assume responsibility for self-care. This care often is provided through a two-phase recovery process: the initial postanesthesia care unit (PACU) and a less care-intensive second phase unit from which the patient is eventually discharged.
More complex procedures are performed on sicker and older patients in the outpatient setting. Services such as 23-hour admission units, recovery care centers, and surgical specialty hospitals have provided a safety net of lengthier postoperative nursing care after more extensive procedures. Early discharge after complex procedures becomes more common as we gain more history of patient outcomes, the frequency and extent of complications, and the level of patient acceptance based on experience and research—for instance, with joint replacement procedures. According to McClellan and Berkheimer, who developed a highly successful same-day total joint program at an FASC in Pennsylvania, success is a result of (1) strong programmatic controls; all physicians agree to using an approved approach to care, (2) minimally invasive surgical technique, (3) exceptional regional pain control, (4) clear clinical leadership empowered by governance to make decisions, (5) advanced negotiation strategies with payers, and (6) active communication and coordination among all caregivers: surgeon, anesthesia provider, nursing, physical therapist, home health care, and medical equipment vendors.2
Without several shifts of nurses to prepare and educate patients and families before AS or to tend to the patient’s postoperative needs, AS nurses must be well educated and demonstrate accurate clinical assessment skills while applying common-sense approaches based on the needs of individual patients and situations. Nurses must be self-motivated and able to communicate both in professional terms with peers and physicians and in lay terms with patients and families. Documentation skills and the forms used in the facility should allow for precise documentation of findings in minimal time. Implementation of the electronic medical record (EMR) has required yet another skill of the ASC nurse, combining the challenge of accurate computer skills with a continual concerned focus on the patient rather than the equipment.
Probably most important from the patient’s viewpoint, the nurse working in AS should present a professional, positive, calm demeanor and show genuine interest in patients and their families. For the patient and family to feel confident and to trust the staff, genuineness cannot be overstated. Eye contact can be just that—eye contact. Or it can convey true concern. Words can be spoken by rote—and without much feeling—reciting the same discharge instructions that have been recited time and time again. Or the nurse can be truly in the moment, explaining, expressing, and educating in a heartfelt honest manner.
Assessment and Preparation of the Patient
Careful preoperative selection and preparation of patients for outpatient surgery help reduce the risks of perioperative complications. Nonetheless, many patients may have significant physical, emotional, or social challenges, yet they return home soon after surgery or other procedures because of payer requirements. In addition to systemic illnesses that limit their ability to care for themselves and possibly increase the risk of perioperative complications, many people have limited social or family support. Nurses are especially challenged to prepare these more complex patients for an early transition to home. There is no magic answer for the person who, at the last minute, does not have home support. Community, health system, and payer resources must be effectively and creatively tapped.
The ultimate goals of complication-free recovery and early discharge are supported by what occurs before surgery. Proper patient selection, preparation, and education all contribute significantly to eventual patient outcome. Comprehensive physical assessment, history taking, and evaluation of the patient’s social, emotional, and cognitive status are all essential to that care. The challenge for the AS nurse, however, is completing all those evaluations in a condensed time frame.
Nursing care also must reach beyond the facility into the patient’s home setting, including preoperative education that helps encourage preparation of a safe home setting for postoperative recuperation. Although nurses cannot be responsible for the actions of patients outside the facility, nurses do provide education, coaching, and suggestions for the patient’s pre- and postoperative care at home. The need to gain the patient’s confidence and cooperation and to ensure the involvement of a responsible adult cannot be overstated. Support and education of the caregiver is another component of the nursing role.
Before the day of surgery, while an onsite preadmission assessment could be ideal for history-gathering and physical assessment, a telephone contact before the day of the patient’s procedure is much more common today. The industry has come to this more streamlined approach for a number of reasons including the busy lifestyles of the patient population, the economic restrictions of health care providers, the trend toward little or no diagnostic testing, and our current comfort with a telephone process borne out by history. Although a physical assessment or facility tour cannot occur via telephone, other components of the preadmission care can be provided.
The Internet is another tool allowing patients and staff to share two-way information. Commercial and facility-developed assessment and educational tools allow patients to name their own time for providing preoperative health and demographic information. This does not preclude direct nursing interactions, but it provides a baseline from which to begin. Commercial and home-grown Internet sites are proliferating, and many take advantage of connectivity to laboratory and other diagnostic storage, providing a one-stop shop for the AS team to identify important patient information.
Patients at high risk can be identified and may be asked to come to the facility for physical examination and anesthesia consultation. Early identification of significant risk factors allows time to correct any deficiencies or, if necessary, to reschedule the surgery to avoid day-of-surgery cancellations or unexpected postoperative complications and overnight admissions that are more costly, upsetting to the patient and physician, and generally time-consuming.
The 2014 report by the American College of Cardiology (ACC) and American Heart Association (AHA)3 reclassified clinical predictors of increased perioperative risk for a major adverse cardiac event (MACE) and/or perioperative stroke for patients undergoing noncardiac surgery into two levels (low and elevated) based on both the procedure being performed and patient characteristics. All risk factors should be considered before any surgery but especially before elective surgery that could wait until a more stable cardiac status can be attained. Active cardiac conditions for which the ACC and AHA recommend evaluation and treatment before elective surgery include unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valve disease, although these recommendations are not specific to AS. The physician will determine the need for adjunctive preoperative cardiac assessment. This 2014 report also includes a newly developed risk calculator.
Specific instructions necessary before the day of the procedure include arrangements for transportation and adult support, the projected length of stay, and general expectations on the day of surgery. The patient also should be instructed in the proper clothing to wear for ease of dressing after surgery, preparation of the home environment, physical restrictions after surgery, and any equipment or supplies to purchase or secure before arrival for surgery.
The AS nurse should work to assess the patient’s level of literacy when providing instructions. Misunderstanding places patients at increased risk for poor outcomes. The National Institutes of Health (NIH) Office of Communications and Public Liaison (OCPL) established the NIH “Clear Communication” initiative4 that focuses on achieving two key objectives of health literacy:
1. Providing information in the form and with the content that is accessible to specific audiences based on cultural respect.
2. Incorporating plain language approaches and new technologies.
Ideas regarding communication that emerged during the development of that communication tool can help nurses in their assessment both of their patients and their own approaches when providing health information.
• We must not blame the individual for not understanding information that has not been made clear to him or her.
• Everyone, no matter how educated, is at risk for misunderstanding health information if the issue is emotionally charged or complex.
• In almost all cases, physicians and other health professionals try to and believe they are communicating accurate information.
• In some cases, patients may believe they have understood directions but may be embarrassed to ask questions to confirm their understanding.
• Health care organizations and their systems and procedures have a significant role to play in ensuring understanding in the health care setting.
• It is increasingly difficult for people to separate evidence-based information, especially online, from misleading ads and gimmicks.
• The communication of “risk” in an effective and fair way continues to be a challenge for both the provider and the patient.
The non-English-speaking patient and family have challenges similar to those with low reading levels. Ross recommends the approach of using plain language rather than medical terminology, developing written resources that meet the abilities of the patients being served, and then asking patients to explain the instructions to assess their understanding.5
With the emphasis on safety in the perioperative period, involvement of the patient as fully as possible in safety practices is prudent. Boxes 46.1 and 46.2 provide information that can help raise the patient’s understanding and consciously set expectations for the overall safety plan. With the proliferation of antibiotic-resistant microorganisms today, prevention of surgical site infection must be a key focus for all health care providers and the patient. Evidence-based decisions are important to help reduce the potential for surgical site infection.