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.