Canadian Association of General Surgeons' position statement on ambulatory care

Canadian Journal of Surgery 1996; 39: 183

Striking changes are occurring in the delivery of Canadian health care. Technologic advances, hospital reorganization and funding cuts have all had a profound effect on the way in which health care in general and general surgical services in particular are delivered. One of the major determinants of these changes is the reduction in funding, which has resulted in a need to obtain maximum benefit for the scarce health care dollar. This, in turn, has increased the demand for ongoing outcome evaluation, the development of clinical practice guidelines and other mechanisms to assure quality of care.

For general surgery, one of the most notable changes is the shift in the delivery of service from inpatient to outpatient care. Patients who undergo surgery that previously required prolonged hospitalization are now being treated as outpatients. Patients requiring inpatient treatment frequently are admitted to hospital on the day of surgery. Technologic advances, such as laparoscopic surgery, have facilitated this shift to outpatient-based surgery.

There are some economic and medical advantages that derive from this shift to ambulatory care. However, there is a danger that economic considerations will sometimes override medical considerations. The Board of Directors of the CAGS agrees with and encourages outpatient-based surgery provided certain principles are adhered to. These include the following:

• It is unethical to define fixed numbers or percentages of procedures that must be performed on an outpatient basis. The numbers or percentages should be determined by the health care needs of the population. For certain individuals even minor procedures may be performed more safely in the hospital setting.
• The final decision regarding the appropriateness of outpatient surgery should be made by the surgeon, taking into account the individual circumstances of the patient and his or her condition.
• Quality of care and patient safety must not suffer because of the shift to outpatient services.
• There must be ongoing evaluation of the impact of ambulatory surgery on the overall health and well-being of the population and of patients who undergo such surgery.
• There should be ongoing evaluation of the impact of the shift to ambulatory services on the education of medical students and residents.
• There should be ongoing evaluation of the impact of ambulatory-based surgery on clinical research.
• There must be adequate resources and organizational structures to ensure good preoperative evaluation, postoperative care and follow-up of patients who undergo ambulatory surgery.