Symposium on ambulatory surgery: principles, practice, pitfalls
John K. MacFarlane, MD
Canadian Journal of Surgery 1997;40(4):259-63.
Summary of a symposium presented at the annual meeting of the Canadian
Association of General Surgeons, Halifax, NS, Sept. 27, 1996
Participants were as follows: John K. MacFarlane (chairman), Professor,
Department of Surgery, University of British Columbia, Vancouver, BC; Douglas
Sinclair, Vice-President, Medicine, Queen Elizabeth II Health Sciences
Centre, Halifax, NS; Rudy Danzinger, Head, Department of Surgery, St. Boniface
Hospital, Winnipeg, Man.; Julius L. Stoller, Clinical Professor of Surgery,
University of British Columbia, Vancouver Hospital and Health Sciences
Centre, Vancouver, BC; Gayle Higgins, Associate Professor, Department of
Surgery, Dalhousie University, Halifax, NS; Andrus J. Voitk, Surgeon-in-Chief,
Salvation Army Scarborough Grace Hospital, Scarborough, Ont.; Nis Schmidt,
Clinical Professor, Department of Surgery, St. Paul's Hospital, Vancouver,
BC; John Heine, Clinical Assistant Professor, University of Calgary, Calgary,
Alta.; William Beilby, Education Coordinator, The Canadian Medical Protective
Association, Ottawa, Ont.; Mark Taylor, Lecturer, Department of Surgery,
University of Manitoba, Winnipeg, Man.
Correspondence and reprint requests to: Dr. John K. MacFarlane,
Department of Surgery, St. Paul's Hospital, 1081 Burrard St., Vancouver
BC V6Z 1Y6
© 1997 Canadian Medical Association
At the 1996 annual meeting of the Canadian Association of General Surgeons,
a symposium on ambulatory surgery was presented. What follows is a compilation
of the subject matter discussed by the 9 participating speakers. The impetus
for this symposium arose from the realization that the general surgical
enterprise in Canada, as elsewhere in North America, is increasingly dependent
upon ambulatory facilities for the delivery of patient care.
The Canadian Association of General Surgeons position statement (Can
J Surg 1996;39:183). In that position paper, Pollett emphasized
a number of fundamental principles, including the following:
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The numbers or percentages of procedures performed on an outpatient basis
should be determined by the health care needs of the population.
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The final decision regarding the appropriateness of outpatient surgery
should be made by the surgeon.
-
Quality of care and patient safety must not suffer.
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Ongoing evaluation must be a part of any ambulatory surgical program.
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Educational issues should be addressed.
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The impact of ambulatory surgery on clinical research should be accounted
for.
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Resources should be allocated to the organization of preoperative and postoperative
care for patients who undergo ambulatory surgery.
With the increasing pressure on hospitals' resource allocations there has
come a stimulus to increase the application of short stay surgery to a
broader range of procedures in general surgery. This symposium examined
the principles of ambulatory care surgery from the perspectives of the
administrator, the patient and the teacher. Newer applications of ambulatory
surgery to the management of endocrine, breast, biliary tract and perianal
conditions were discussed, and the pitfalls of the ambulatory setting for
general surgical procedures were described. The perspective of the Canadian
Medical Protective Association and the patient was detailed. A panel discussion
enlarged upon issues relating to quality assurance, readmission rates and
the appropriateness of the shift of traditional inpatient procedures to
an ambulatory setting.
The following is my summary of each presentation in the symposium. Although
we, as surgeons, are frequently loathe to change the way we do things,
the general discussion was aimed at increasing the awareness of those in
attendance of the possibilities and practicalities of increasing their
own use of the ambulatory setting for the surgical management of patients
who require general surgical procedures. Each participant brought to the
discussion his or her particular biases and points of view and although
some presented data to support their positions others presented a more
general discussion of the issues arising from the current push for increased
use of ambulatory facilities in our hospitals. Those attending were subjected
to a pre- and post-symposium objective test in an effort to highlight the
important points in the presentations.
The Administrative perspective
Dr. Douglas Sinclair noted in his presentation that ambulatory surgery
has long been recognized as an alternative to traditional inpatient surgery
and alleviates many of the constraints currently present in our health
care system. The positive effects are felt not only by the hospital and
physician but also by the patient. Patients return to their homes quicker,
early ambulation assists in recovery and in the prevention of complications
of prolonged bed rest, and the patients' participation in self-care increases
their awareness of their condition. The convenience of returning to their
own homes sooner places less disruption on them and the family members.
For physicians, ambulatory surgery is often more easily scheduled and with
less requirement from on-site bedside follow-up, the efficient use of time
becomes an attractive incentive. Hospitals see ambulatory surgery as a
cost-containment strategy. However, several factors are necessary to ensure
that the benefits of ambulatory surgery are realized for the patient, the
physician and the hospital.
Diagnostic, therapeutic and support services must be physically close
to the ambulatory surgical area to ensure convenience and facilitate prompt
reporting. Renovation and service moves are often necessary, and the fiscal
impact of such adjustments may be significant. Efficient use of available
resources requires that the peak operating room times be made available
for ambulatory procedures, so that cases may be scheduled to maximize the
use of the recovery room staff and the physical facility. Nonambulatory
cases can then be scheduled in "off peak" times to ensure that overruns
do not disrupt the ambulatory surgical schedule. The effect of this shift
may change the way in which surgeon time is allocated.
The fiscal realities of increasing ambulatory surgery are:
-
An increase in ambulatory surgical volume with no change in nonambulatory
volume will only increase cost.
-
An increase in ambulatory surgical volume with a corresponding decrease
in nonambulatory surgical procedures will reduce cost when the avoided
patient-days are not used by other services.
-
The avoidance of an inpatient stay is the key cost-containment strategy
of ambulatory surgery. The determining factor for cost saving is not the
difference between the procedure cost as inpatient versus outpatient but
rather whether a patient-day stay is avoided.
Teaching in the ambulatory setting
In this study, Danzinger's goal was to train competent general medical
graduates and surgical specialists by meeting the following objectives:
the provision of appropriate space, time and environment for learning;
direction of learning to the appropriate student; and the provision of
exemplary patient care. Outpatient clinics must have sufficient rooms of
appropriate size and configuration that contain necessary special equipment
for teaching. The time available for these teaching clinics must be separate
and specified. Additional time is necessary to be dedicated to teaching
and to allow for evaluation.
Everyone involved must be aware of and prepared for teaching. This includes
patients, students and surgeons as well as clinic staff. The same principles
apply to the outpatient operating room. Surgeons must differentiate and
separate teaching skills to junior medical students and the patient, and
provide disease-focussed teaching of clinical clerks and graduated clinical
and teaching responsibilities assumed by specialty residents.
All of this necessitates planning of an appropriate physical-structures
curriculum and time management, faculty development and imparting the principles
of self-learning and continued education along with continuous evaluation
and feedback. Traditionally, we have done this reasonably well in the inpatient
environment. Now, our challenge is to achieve even better results in the
ambulatory milieu.
Patient preparation
Informed-consent discussions are an essential part of all surgical procedures,
according to Dr. Julius Stoller, but in addition thorough patient preparation
is of the utmost importance to achieve the best possible surgical outcome.
Patients remember very little of what they are told during an office
consultation and at worst may simply "get it all wrong." Thus, any information
must be given verbally and in writing. The written material for patient
preparation is best presented in a simple point-by-point form and presented
by the surgeon after the decision for surgery has been made. The patient
will examine it later in the calmer atmosphere of the home and re-examine
it the night before surgery and, if appropriate, postoperatively. A final
reminder to the patient in the recovery room before discharge will help.
However, it is neither acceptable clinical practice nor appropriate from
a medicolegal viewpoint to go to the extreme of merely presenting a handout
to the patient without an accompanying discussion. The documents presented
must be simplified, avoiding long and complex words. Medical jargon should
never be used. It is important that the document is presented in the patient's
first language, especially where large sections of the patient population
speak English as a second language. Liberal use of interpreting skills
is a necessity where appropriate. The document should not be long, yet
it must contain the appropriate elements of the planned procedure.
In addition to the instruction that relates to the operation planned,
there should be a second handout printed by the hospital's Department of
Surgery, indicating the location of the Ambulatory Surgical Reception area.
The document specific to the proposed surgery must contain postoperative
instructions and be personalized by the surgeon and reviewed preoperatively.
Practice -- breast
Pressures from bed closures and rationalization have made the surgeon aware
of patient populations that could be equally well served, or in some cases
better served, by converting inpatient surgery to day or short stay procedures.
The field of breast cancer treatment appears ideal for this transformation
according to Dr. Gayle Higgins.
The population addressed is that of patients who undergo modified radical
mastectomy, quadrant resection with axillary node dissection and complicated
open biopsy procedures. Traditionally many of these patients remained in
hospital for 5 to 7 days. The length of stay is often determined by the
management of drains.
These patients were examined specifically from the standpoint of pain
and nausea control, the formation of hematomas and seromas and technical
failure of drains. The increase in preoperative teaching with regard to
the management of drains and the intraoperative approach to the securing
of drains has been modified.
In the assessment of outcomes, Higgins's group examined the return to
the Emergency Department or family physician office and were concerned
mainly about technical failures and failure to control pain and nausea.
Of the 57 patients studied, only 2 returned to the Emergency Department.
Both had technical failure of the suction collector apparatus. No patients
returned with any other complications to the Emergency Department, the
family physician or the surgeon's office. An extra visit was added for
drain removal after 1 week. However, this was a time for the review of
pathology reports and for further planning in breast cancer management.
Although the amount of preoperative teaching was increased, especially
relating to drains, patients often were better served by brief postoperative
teaching with the drain in place, since the preoperative teaching was of
a hypothetical nature and seemed only to produce unnecessary anxiety.
In spite of enthusiasm for ambulatory surgery in this situation, elderly
patients living alone and coming from great distances could not be included.
A small number of patients had ongoing postoperative nausea, which prevented
their early discharge. Most patients are now being treated with short-term
stay and are experiencing no negative outcomes from this altered form of
management.
Practice -- biliary tract
In his presentation, Dr. Andrus Voitk reported that although laparoscopy
has enabled cholecystectomy to be practised on an outpatient basis, this
has not yet become routine (see article in this issue on page
284). Several reports in the literature have suggested that this can
be achieved safely for about 90% of all elective operations. With respect
to institutional practice, at his hospital the outpatient rate in the first
year of routine institution was 75%. Some problems were found with preselection
for inpatient care, inappropriate day surgery facilities and variation
in the individual surgeon's practice. Once these were addressed, the institutionalized
rate in the following year for outpatient surgery rose to 95%, suggesting
that institutions can achieve results similar to individual enthusiasts.
Prudence always dictates concern for the safety of this practice in high-risk
patients. Voitk noted that over 200 higher risk patients had been managed
as outpatients for laparoscopic cholecystectomy. Not surprisingly, a much
greater percentage (about 23%) of patients from this subgroup tend to be
admitted. However, the practice is very safe. A patient who remains stable
throughout the perioperative observation period could be safely discharged
home on the day of surgery without fear of instability or decompensation
later. In patients who had problems requiring admission, the problems become
evident during a 6-hour postoperative observation period.
The cornerstone of a satisfactory result is preparedness. This is achieved
by a thorough explanation, given preoperatively in the office, of what
to expect. The explanation is reinforced in a preadmission clinic, attended
by all of the patients slated for elective admission. Once they come for
surgery, the message is again reinforced by the day surgery nurses. These
2 programs have been a very important adjunct to the explanation initially
given in the surgeon's office. On discharge, patients are given written
instructions in addition to verbal instructions, and all patients are contacted
by telephone by a nurse 24 hours after operation.
All surgeons at the hospital embraced this routine on a voluntary basis
after educational sessions demonstrated to their satisfaction that the
approach was both safe and acceptable and gave results equivalent to those
of inpatient treatment. For this to succeed on an institutional basis,
all players -- nurses, surgeons and anesthetists -- must be enthusiastic
and on-side. In addition, the hospital administration must support the
effort by ensuring sufficient day surgery facilities. If day surgery facilities
are inadequate, patients may end up being admitted or surgeons may not
cooperate out of fear that their cases may be cancelled. If surgeons voluntarily
embark on this policy, they need not be forced into 100% compliance. Once
they gain sufficient experience with this approach, they will be convinced
of its advantages and will voluntarily embrace it. If individual differences
are brought to their attention they will be even more ready to correct
discrepancies voluntarily. Voitk noted that after 2 years of outpatient
cholecystectomy, the surgeons in his hospital would not consider reverting
to an inpatient policy because they were so satisfied with this approach.
Practice -- endocrine
In his presentation, Dr. Nis Schmidt considered the following with respect
to patients with parathyroid disease who undergo outpatient surgery: preoperative
preparation; management; postoperative complications; and cost benefit.
Patient preparation
Patients who require parathyroid surgery tend to be healthy, are usually
women in their mid-40s to 50s and do not need admission to hospital the
day before an operation. Laboratory investigations are done beforehand
in preparation for the procedure. Patients are required to fast from midnight
the day before surgery, and sometimes 1 g of cefazolin sodium is given
prophylactically at the time anesthesia is induced.
The younger patients are managed this way and, increasingly, older patients
are able to come to the hospital on the day of their operation. Schmidt's
group have admitted patients in their late 80s and even 90s for same day
surgery.
Postoperative patient management
After the operation, which averages just under 1 hour, with wound dressings
but no drains, the patient is observed for the day and overnight in the
Overnight Surgical Stay Unit. Calcium levels are measured routinely on
3 occasions between surgery and the following morning so that the rate
of calcium drop can be monitored. The following morning the calcium level
determined at 6:00 is important in deciding the time of discharge, what
symptoms the patient might have from hypercalcemia and the amount of calcium
to prescribe, which the patient will take for 10 days postoperatively.
Patients usually are discharged at 7:00. They are given an analgesic prescription
(low-dose Tylenol with codeine); calcium carbonate is prescribed 3 times
a day for 1 week. A home care nurse usually monitors the wound and removes
the clips and sutures on the fourth postoperative day. The patient returns
to the surgeon for follow-up at 2 weeks. In the meantime patients are instructed
to increase ambulation and diet progressively. As their comfort increases,
they can return to light activity but not vigorous physical work or recreational
activities.
Postoperative problems
Parathyroid surgery usually causes few problems with respect to the
surgical side. The most serious problem is recurrent laryngeal nerve dysfunction,
but the rate for this is less than 1%. Bleeding should be minimal since
there is usually no extensive dissection, and pain and swallowing should
be no problem. The patient does not need routine drainage of the neck,
the dressings usually can be light and, if there is no difficulty with
the wound at 12 hours after surgery, the incidence of later difficulties
is 0% in Schmidt's experience. Caution is recommended regarding indiscriminate
use of cautery; also, the judicial use of good ligation in neck veins can
avoid unexpected postoperative hemorrhage.
Cost analysis of overnight stay versus inpatient stay
The difference in the cost of doing overnight-stay parathyroid surgery
as opposed to admitted-patient parathyroid surgery is essentially the room
cost and greatly favours overnight-stay patient surgery, which might include
home care and some prescription costs. The savings are approximately $2300
per case which, for a large volume of parathyroid surgery, adds up. In
1995 it was over $100 000.
Summary
Overnight-stay parathyroid surgery has proved to be safe and effective.
The risk to the patient has been extremely small, the results of the surgery
have been unchanged from inpatient surgery and patient compliance has been
very good, with a high level of acceptance.
Practice -- hemorrhoidectomy
Careful patient selection is integral to a successful outcome of outpatient
hemorrhoidectomy, according to Dr. John Heine in his presentation. Preoperatively,
patients are informed of the anticipated amount of discomfort. Heine emphasized
the safety of the outpatient approach. To reduce the risk of admission
after the procedure, the majority of hemorrhoidectomies are carried out
with the use of intravenous sedation and a local perianal field block.
If a general anesthetic is necessary, Propofol is the agent of choice to
reduce the incidence of emesis. Postoperatively, nonsteroidal anti-inflammatory
medication is helpful in decreasing the need for narcotics, which can result
in fecal impaction.
In a series of 83 patients, 2 experienced postoperative bleeding, but
neither required reoperation or transfusion. One patient suffered impaction,
so a tap water enema was given. One patient required a single in/out bladder
catheterization for urinary retention. Thirty percent of patients identified
postoperative pain as a significant problem. Ten percent of patients visited
another health care professional before the scheduled 2-week postoperative
visit because of inadequate analgesia. None found it necessary to enlist
the support of a friend or family member during convalescence.
Approximately $1000 per case was saved by carrying out the procedure
on an outpatient basis. Outpatient hemorrhoidectomy would appear to be
safe, reasonably well-tolerated and cost-effective.
Pitfalls -- the Canadian Medical Protective Association
As reported by Dr. William Beilby, the Canadian Medical Protective Association
recently conducted a review of their experience with the professional liability
of general surgeons. Between Jan. 1, 1990, and Dec. 31, 1995, 627 legal
actions were concluded, all of which involved a general surgeon. Of these,
10% resulted from care provided to nonadmitted patients.
In the nonadmitted group, 45% resulted from care provided in the office,
36% in outpatient departments and 19% in same day surgery units. There
was no statistically significant difference between the legal outcomes
for the admitted and nonadmitted groups.
The most common clinical problem leading to litigation in the outpatient
group related to procedures on the breast. They were split evenly between
allegations of a delay in the diagnosis of a breast lump and complications
related to biopsies or aspirations. The most common complications were
pneumothoraces following fine-needle aspirations.
After breast procedures, the next most common clinical circumstance
related to the follow-up of orthopedic injuries. Half of the cases related
to a delay in the diagnosis of malalignment during follow-up. The main
allegation related to the fact that no radiographs were obtained during
follow-up visits.
Endoscopy-related complications of perforation and bleeding was the
third most common clinical circumstance. There were also 3 cases in which
there was an accessory nerve injury during posterior triangle node biopsies.
Pitfalls -- patient acceptance
The Manitoba Centre for Health Policy and Evaluation carried out a series
of investigations into the effect that early discharge of patients from
hospitals has had on the quality of care provided in Manitoba hospitals.
Dr. Mark Taylor from Winnipeg reported that quality of care for surgical
patients was assessed using the readmission rate as a marker.
Throughout Canada, there have been dramatic efforts to reduce health
care spending. This has led to the closure of a large number of hospital
beds accompanied by a shift to outpatient surgery and a reduction of length
of stay for most inpatient surgery. In Manitoba, gynecologic, orthopedic
and general surgical procedures were studied. For all categories there
were dramatic reductions in length of stay between 1989/90 and 1994/95.
This reduction was not accompanied by an increase in readmission rate.
A potential pitfall of the shift to short stay surgery is that readmission
rates could rise. For the surgery categories studied, there has been no
increase in readmission rates associated with reductions in length of hospital
stay. To the extent to which readmission rates can be held to represent
quality of care, there was no evidence of a decline in quality of care
as a result of the reduction in hospital beds.
Discussion and conclusions
In the panel discussion following the formal presentations, the adequate
preparation of the patient for ambulatory surgery was emphasized. Institutional
practices differ. However, all participants agreed that a well-prepared
confident patient is the key ingredient to a successful program. In the
clinical areas discussed, readmission rates were extremely low and attested
to the success of the programs. There was no increase in medicolegal actions
as a result of ambulatory care. The shift to ambulatory surgery in Canadian
general surgery is appropriate. A wide variety of procedures can be incorporated
into this expanding field. Careful monitoring of patient satisfaction,
readmission rates and surgical results is mandatory for a successful program.
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