Ambulatory surgery issues

A variety of factors drives the move toward outpatient surgery. Foremost, experience has shown the process to be successful and safe in both hospital outpatient departments and freestanding ambulatory surgery centers. 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. However, the future growth of ambulatory surgery remains dependent on the effects of a variety of issues, including healthcare reform, the development of accountable care organizations (ACOs), Medicare and Medicare legislation, third party payer policies and other national influences. The great mobility of the population in the United States brings another challenge as 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. Technologic advances in instrumentation and equipment allow more complex procedures to be done with less invasiveness and physical trauma. Examples include 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, ambulatory perianesthesia nurses place emphasis on rapid yet comprehensive patient assessment along with complete understandable patient and family education. Ambulatory surgical nurses encourage the patient’s self care and self responsibility for preadmission and postdischarge compliance with the 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.

Recognizing and addressing the social, emotional, and educational needs of patients as well as the physical needs are important. Unspoken questions may linger for patients and their families, such as relating to 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.

Home support is essential because the patient returns there quickly after surgery. Involvement of the family or another responsible adult is integral to the overall plan of care. Postoperative complications such as nausea and vomiting might be considered minor or merely unpleasant for hospitalized patients who have nursing support. For ambulatory surgical patients, however, these problems become serious deterrents to discharge and can lead to a prolonged stay, costly unplanned hospitalization, or unpleasant home recuperation.

Assessment of the patient’s medical, surgical, and social needs may lead to a physician’s referral to a home health provider for general medical care, infusion therapy, pain management, physical therapy, or equipment-related needs. If needs are known before the day of the procedure, this referral can be in place, with equipment and supplies delivered to the patient’s home to ensure its availability as soon as the patient arrives there.

Nursing care in this setting should promote wellness and self care to the degree possible. Patients should be continually encouraged to think positively and to provide self care as is appropriate and possible. Orem’s general theory of nursing, a three part theory regarding self care, self care deficit, and nursing system, provides the basis for determining and using the patient’s personal strengths relating to self care.¹ The Self-Care Deficit Nursing Theory describes nursing planning and intervention that is 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. Nurses can use 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.

Whether the patient has surgery in a hospital setting, a freestanding ASC, or a physician’s office, the basic nursing needs remain the same. That care combines both critical assessment and monitoring during periods of high dependence, such as 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 complex procedures. Early discharge after more 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.

Without several shifts of nurses to prepare and educate patients and families before ambulatory surgery or to tend to the patient’s postoperative needs, ambulatory surgical nurses must possess certain characteristics. Foremost, clinical assessment skills must be accurate and rapid. Nurses must be self motivated and able to communicate both in professional terms with peers and physicians and in lay terms with patients. Documentation skills and the forms used in the facility should allow for precise documentation of findings in minimal time. Probably most important from the patient’s viewpoint, the nurse working in ambulatory surgery should present a positive, calm demeanor and show genuine concern for and interest in patients and their families.

Assessment and preparation of the patient

Careful preoperative selection and preparation of patients for outpatient surgery help to 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 insurance 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.

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 ambulatory surgical 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 to 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 preoperative 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, an on-site preadmission assessment is ideal for the nurse to establish a rapport with the patient, secure the patient’s history, complete a physical assessment, help to reduce patient anxiety, provide comprehensive preoperative instructions, identify potential risk factors, and take steps to reduce those risk factors on or before the day of surgery. However, 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, all 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. Box 46-1 shows the work of one ambulatory surgery center to increase the use of such a tool using a quality improvement process.

BOX 46-1 Quality Assessment and Performance Improvement in the Ambulatory Surgery Center

Study objective

To increase the use of an online system for gathering patient preoperative information.

Background and reason for study

The gathering of correct and comprehensive medical information is essential when providing surgical care. Anesthesia, physician, and nursing staff members all need and seek the most accurate and current information about medications, allergies, health, and past surgical or anesthesia experiences to be able to properly plan care for each patient.

The opportunity for an online option to allow patients and staff members to generate a clear document was available through a number of different commercial products. One Medical Passport System (Passport) created by Medical Web Technologies was chosen as an add-on to the software program used by the ambulatory surgery center (ASC). As with any new process, there was mixed response from staff members, ranging from excitement to refusal to use the new tool. Staff education, encouragement, and the positive leadership of management lent itself to improved use. However, we identified an opportunity to improve usage by staff members and patients.

It was difficult to get a true percentage of how many Passport records are completed compared with the patient load for that month, because Passport records are completed for future months as well as in the month of the patient’s procedure. Thus, the percentages captured are of the ratio of Passport records completed in any month to the number of cases in that month. This number was not statistically accurate, but it gave us satisfactory data for trends upon which to make changes in the action planning and team education needed to improve.

Before implementation of the Passport system, we spoke with other ASCs using the system. We discussed the basis for the change in process to an electronic method of history retrieval. Those key reasons are:

1. To obtain more accurate information when the patient has quiet time at home to concentrate on the questions

2. To reduce illegibility of patient and nurse writing

3. To reduce potential for error in transferring information from a preadmission sheet onto other chart pages (The Passport system transfers essential information such as allergies onto the admitting, anesthesia, and admitting forms.)

4. To reduce nursing time for people who have completed their Passport records ahead of the preadmission testing (PAT) call. The nurse has the data available to review and only ask questions where gaps or concerns are found.

5. To increase the ease of meeting CMS requirements for written and verbal notifications before the day of surgery

Current Passport usage was determined to be only 27%, whereas associated ASCs had 54% to 100% compliance. After discussion with the team, a stretch goal of 75% was set—just less than the 81% average of the other three ASCs. The team and leadership brainstormed ideas for improving the Passport usage and implemented actions throughout the year.

Action steps

ACTION	RESPONSIBLE PARTY	METHOD
Engage all staff	Administrator, manager	Educate team, encourage all team members go online to create personal Passport record, brainstorm ideas to encourage patient and nurse use
Improve physician office assistance	Administrator	Create new flier and deliver to offices; ask for more direction of patients to web site by office
Increase e-mail notifications to patients	Administrator, schedulers, physician advocate	Encourage physician offices to secure e-mails and provide those email addresses to the ASC
Increase e-mail notifications to patients	Registrars	Ask patients on all business calls about e-mail address and their use; consider common scripting
Improve ease of web site access	Physician advocate	Meet with corporate marketing to seek better linkage
Improve ease of tool	Director	Remove redundant or unnecessary questions from Passport
Provide more encouragement to patients to use site	Registrar or PAT	Telephone assistance to get into the site, positive communication to patients
Encourage nurse use	Administrator	Communicate necessity to all staff members; provide reward and recognition
Team education	Director, administrator	Provide ongoing modules to team for understanding success factors; use graphs and support documents
Data sharing	Information systems support	Provide information on usage; track improvements
Tracking and team education	Administrators, nurse managers	Ongoing review of processes and ways to encourage patients to use the online system
Assignment change	Manager	Change in process to move a specific nurse into PAT role on weekly basis

Outcome and conclusion of study

Over time, the level of Passport usage improved to 67.9%, ending the year with a December rate of 60.6%. Although the stretch goal of 75% was not met, the significant improvement in Passport usage was celebrated. Efforts continue to encourage patients to complete their own online Passport records. It is important to continue to focus on this effort and brainstorm further actions to meet a new goal of 85% of patients.

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 to the institution, upsetting to the patient and physician, and generally time consuming.

A report by the American College of Cardiology (ACC) and American Heart Association (AHA)² has identified major, intermediate, and minor clinical predictors of increased perioperative risk.

These 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 valvular disease, although these recommendations are not specific to ambulatory surgery. The same report identifies cardiac risk based on the type of procedure as low (less than 1%) for the following noncardiac surgeries: endoscopic and superficial procedures, cataract and breast surgery, and ambulatory surgery.³ The physician will determine the need for adjunctive preoperative cardiac assessment.

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.

With the emphasis on safety in the perioperative period, involvement of the patient as fully as possible in safety practices is prudent. Boxes 46-2 and 46-3 provide information that can help to raise the patient’s understanding and consciously set expectations that the patient and family will be part of the overall safety plan. With the proliferation of antibiotic-resistant microorganisms today, prevention of surgical site infection should be a key focus for all health care providers and the patient. Evidenced-based decisions are important to help reduce the potential for surgical site infection.

The Internet has become a common source of information. Nurses should be prepared to evaluate the value and accuracy of such information and advise the patient toward appropriate sites. Examples of sites providing information include the following:

The American Society of PeriAnesthesia Nurses web site provides patient information on the following³:

Patients who take routine medications need instructions by the attending physician or anesthesiologist about which medications should be taken on the morning of surgery, usually with a small sip of water. Medications most often continued until the time of surgery include antihypertensives, cardiac antiarrhythmics, coronary artery dilators, bronchodilators, and respiratory inhalants (should be brought on the day of surgery).

Precise instructions regarding blood thinners should be provided by the patient’s physician. Specific information about insulin and diet for patients with diabetes can help to avoid wide swings in glucose levels. Medication instructions are the responsibility of the physician; however they are often confirmed, reinforced, and clarified by nursing personnel.

Patients should be encouraged to fill prescriptions for postoperative medications before the day of surgery to avoid delays at home. If patients have not yet received any prescriptions, they should know to bring money or insurance cards to obtain medications if it is likely that prescriptions will be given on the day of surgery.

Parents of small children are asked to have two adults accompany the child—one to drive and one to attend to the child during transit home. In some institutions, supporting adults are instructed that they must remain at the facility throughout the patient’s stay. In others, only parents of minors or special needs adults are required to remain on site. Patients and families should be told about such expectations ahead of time.

Freestanding ASCs have an additional requirement imposed by the Centers of Medicare and Medicare Services (CMS).⁴ In ASCs that are Medicare certified, before surgery all patients, not just those covered by Medicare, must be provided with both verbal and written information about their rights and responsibilities, the ASC policy on advance directives, and any physician financial interest in the ASC. Three informational items must be provided to the patient before signing the consent for treatment. For clarity, the nurse should document the time of the notification and the time the consent is signed to verify that standards were met.

Preoperative goals

The primary goals of patient preparation for ambulatory surgery are focused on identifying and reducing the potential risks related to surgery and anesthesia, reducing the potential for surgical site infections through strict adherence to standard precautions, verifying the patient’s true understanding, and promoting each patient’s quick return to self care. This preparation includes a significant shift of responsibility to the patient and family by educating them and then encouraging and evaluating their actions. Although patient preparations may not necessarily be identical for inpatients and outpatients, they should meet the same quality standards of care. Nurses who admit and prepare patients for surgery must be thorough in their assessments. They must be prepared professionally and have adequate equipment to intercede effectively in emergencies.

The essential outcome of patients remaining infection free begins in the preoperative area and continues throughout their stays. The opportunity for surgical site and other acquired infections can be reduced by basic cleanliness of the environment, strict adherence to medical asepsis and sterile process, meticulous hand hygiene, safe injection practices, proper skin preparation which avoids shaving, proper antibiotic selection and timing, and the good health of the providers within the unit.

An important way to provide a safe experience for the ambulatory patient is to consistently apply safety policies in the same manner for all patients. A surgical safety checklist like the one developed by the World Health Organization (WHO) provides a method to document all essential areas of care at three points in the continuum of patient care: before anesthesia induction, before the skin incision, and before the patient leaves the operating room.⁸ The tool that can be downloaded from the WHO web site is intended as a baseline, and modifications are encouraged to fit the specific types of care provided in a surgical setting.

Intraoperative period

Intraoperative care of the ambulatory surgical patient parallels that of all surgical patients. Specific nursing responsibilities include maintaining asepsis; properly preparing the operative site; providing for patient safety in identification, transfer, and positioning; assisting the anesthesia team; maintaining confidentiality; protecting the patient’s dignity; maintaining a safe environment; correctly handling and labeling specimens in the presence of the patient; and documenting and reporting the intraoperative care and events. Before initiating the procedure, a time-out period must be enforced in which every participant in the operating room stops what they are doing and focuses on the identification of the correct operative site, side, procedure, patient, and implants.

Because of the trend to reduce or eliminate preoperative sedative medications and the common use of topical, regional, or local anesthesia, patients may be more awake and aware of their surroundings. As a result, monitoring and controlling the appropriateness of any discussions that occur near the patient is an important nursing role.

In addition, the increased use of registered nurse–administered sedation or analgesia demands competency of the perioperative nurse in monitoring, dysrhythmia detection, medication effects and side effects, and effective reversal agents. The nurse’s knowledge base should also include related cardiac and respiratory anatomy and physiology, airway management, and resuscitative techniques. The availability of emergency supplies and support personnel must be ensured before the procedure begins. In particular, flumazenil and naloxone—specific reversal agents for benzodiazepines and opioids, respectively—should be immediately available for treatment of serious respiratory or cardiac depression related to the sedative drugs. Advanced Cardiac Life Support (ACLS) certification is appropriate for nurses monitoring and sedating patients for procedures. During each reappointment cycle, the procedural physician responsible for patient care during nurse-monitored sedation and analgesia should demonstrate competency in the appropriate physiologic and pharmacologic concerns, including rescue methods and drugs and the preprocedural assessment and documentation of the airway and anesthesia risk level.

Postanesthesia period

Recovery of ambulatory surgical patients often occurs in several stages. After general or major regional anesthesia or after intraoperative complications in any patient, a two-phase recovery is typical. Phase I begins when the patient arrives in a fully equipped and staffed PACU. When the patient regains consciousness, lucidity, and physiologic stability and meets PACU discharge criteria, transfer to a less-intensive care unit is appropriate. Phase II of recovery is usually completed in a department equipped with lounge chairs and more homelike surroundings where families reunite and where the patient’s self care is encouraged. After sedation or local or regional anesthesia, which has a limited effect on physiologic stability, the patient may be transferred from the procedure room directly to the phase II level of care as long as they meet predetermined criteria for care in that setting. This latter process is typically called fasttracking.

The American Society of Perianesthesia Nurses has published a position statement that any fasttracking plan should be a collaboration of the anesthesiology department and perianesthesia services. Guidelines should include appropriate patient selection, preoperative education of the patient and family, appropriate selection and management of anesthetic agents, assessment criteria used to determine readiness for bypassing PACU care, discharge criteria, and monitoring and reporting of patient outcomes.⁹

Phase I and phase II care are not necessarily based on a physical location, rather the intensity of nursing monitoring and interventions. As a result, some facilities keep a patient in one postoperative location, but alter the level of care to conform with phase I and phase II standards.

Postdischarge follow-up

Mechanisms should exist for assessing and documenting patient outcomes and patient and family satisfaction with the care provided by the ambulatory surgical unit. Telephone calls and written surveys that can be returned by mail are two means of providing that follow-up. Written surveys most often address satisfaction issues, but evaluation of the patient’s recuperation from anesthesia and surgery requires a more aggressive and timely approach.

In many communities, the standard of care is that patients are telephoned within the next few days after surgery to ascertain their clinical condition, safety, and comfort level. Such a contact can serve as a valuable resource for patients who may have symptoms that should be evaluated by their physicians or questions about which they are embarrassed or reluctant to telephone and ask their physicians. Not only is the patient’s safety and medical condition supported, but the nursing staff also can identify the effectiveness of current modes of care. Other reasons for a postdischarge call include promotion of the facility’s caring attitude, identification and reduction of medicolegal issues, marketing, the meeting of accrediting and regulatory standards, and closure and a sense of job satisfaction for the nurses.

In some instances, a second call may be made at a date several weeks after the patient’s discharge for the goal of assessing a particular concern related to a quality improvement or risk management study, such as a study on postoperative infection or the satisfaction of vision changes after cataract surgery. Documentation of patient contacts via telephone should become a permanent part of the medical record. This level of follow-up after the patient’s discharge closes the loop of the evaluation phase of the nursing process in the ambulatory surgery setting.

In addition, Joint Commission standards now require a 1-year follow-up to identify infections in patients who have had implantable devices placed during their procedures. This is another imposed regulation that must be met to help reduce the potential for surgical site infections by understanding and investigating events.¹⁰

Summary

The number of patients who have surgery in the outpatient setting has continued to increase. Sicker patients and more complex procedures are performed in these settings. The ambulatory surgery nurse must be cognizant of special requirements for preparation and discharge of the ambulatory surgery patient and must also be prepared for any complications that can occur in the PACU setting. This chapter provided an overview of care of the ambulatory surgery patient. Details of the care of patients who are in the PACU, require care for complications, or are undergoing specific procedures may be found in the appropriate chapters in the book.