The practice of medicine is changing, and several general trends have emerged. These trends are an increased focus on efficiency and cost of care, and an increased focus on the patient and humanism in medical care. Ambulatory anesthesia practice reflects these same trends.
Trends: Location of Care:
Ambulatory surgical procedures represent a large and increasing fraction of surgery being performed. In the USA, the percentage of outpatient surgery grew from 20% in 1981 to 76% in 2001 [1]. This represents an increase in the total number of ambulatory procedures from 3.9 to 33 million operations per year. Projections for the next five years suggest additional growth to 83% of all USA surgeries, representing 41.7 million operations per year. Most outpatient procedures are being done in hospital-based ambulatory surgery units, 45% in 2001. In addition, there is dramatic growth in the number of ambulatory surgery procedures being performed in non-hospital settings. Procedures done in freestanding ambulatory surgery centers increased to 17% in 2001. The newest segment of ambulatory surgery growth has been in procedures performed in the surgeon’s office, 14% in 2001, and projected as 20% in 2006. We are seeing the continuing shift of more complex operations and procedures from the inpatient hospital to the outpatient settings in all the various forms.
Trends: Patient-Focused Approach:
Anesthesia that is specifically tailored for ambulatory surgery involves a multi-component integrated approach [2,3]. Our approach to these patients must change to meet their specialized needs, so that they can continue with their lives as usual with minimal disruption. This approach may be condensed into a Philosophy of ambulatory surgical care, with two major tenets: 1) The ambulatory surgery patient is not sick; and 2) The patient is the most important person in his/her health care team [4]. Selection of appropriate patients involves both medical and psychosocial stability. Information about patients is primarily acquired through a thorough history and physical examination, but only minimal screening laboratory tests. Evaluation of the information must be done in advance to avoid last minute delays and cancellations, whether or not the patients are seen in the facility before the day of surgery.
Trends: Patient Education:
Patients’ cooperation is essential in all stages of the ambulatory surgical experience, from preparation through recovery at home, and patients’ expectations about what will happen must be appropriate so that they are satisfied with their care [5]. This requires good preoperative and postoperative education. Education must address the patients’ educational needs and informational needs (what they want to know). The patient has become the focus of the ambulatory surgical experience, and should be invited to participate in all decisions that are not truly medical judgment issues.
Trends: Anesthetic Approaches:
Most importantly, the growth of ambulatory anesthesia is tied to anesthesiologists’ desire to improve the quality of patient care [5]. We need to identify what is high quality, effective ambulatory anesthesia. Such an anesthetic must provide a smooth onset and have good intraoperative conditions. All phases of recovery must be rapid, starting with early wake-up, continuing through the intermediate recovery phases that lead to patient discharge from the facility, and continuing with late recovery which culminates in the patient’s return to normal function. From the patients’ perspective, these attributes are important whether or not they will be leaving the facility in an hour or in days. Therefore, the new anesthetic approaches developed for ambulatory anesthesia which facilitate prompt return to normal function are important for all patients.
Trends: Anesthetic Drugs and Techniques:
The anesthetic drugs used for ambulatory patients must have consistent onset and offset times, permitting rapid changes in levels of drug effect and rapid awakening. In addition, the anesthesiologist must specifically focus on minimizing the postoperative side effects of anesthetic drugs. Premedication may be used to aid in the reduction of fear and anxiety, but psychologic support is very effective and has no adverse effects [2]. Our choice of anesthetic agents and techniques should aim for a high quality of recovery, looking to optimize postoperative side effects. Each of our newer, and future, drugs has particular attributes, and anesthetic techniques should be utilized to take advantage of these attributes. Often, there are unappreciated system-based impediments that impact recovery more than the differences between specific anesthetic drugs. Specialized ambulatory anesthesia also includes an increased awareness of the cost of the entire patient care visit. This includes but is not limited to the acquisition costs of the anesthetic drugs. Cost-effectiveness is the value obtained for the money spent, and this has become one of the central concerns of modern anesthesia practice [6].
Trends: Recovery and Discharge:
The two major recovery problems that limit our ability to reach patient goals are pain and nausea. Management of these problems requires a multimodal approach, which begins with the anesthetic plan and continues into the recovery period. Pain management encompasses local anesthetic infiltration, nonsteroidal antiinflammatory drugs, and supplemental bolus opioids given near the end of surgery. Nausea management encompasses adequate patient hydration, avoidance of solid foods postop, and a nonemetogenic anesthetic considering induction agent and minimized opioid. These are supplemented by antiemetic drugs as indicated.
Recovery and discharge care can be enhanced by the use of routine orders, forms and checklists to reduce unnecessary work. Standardized, outcome-based recovery criteria should be used to assess and document readiness for both PACU Phase 1 (medical discharge) and Phase 2 (physical discharge) [3]. The final phase of ambulatory anesthesia care is postdischarge patient followup, to assess medical outcome and patient satisfaction. While major adverse outcomes are rare, minor side effects are common after ambulatory surgery and anesthesia (86%) [5]. These side effects are not complications but rather occur commonly enough to be expected. Drowsiness is the most common effect persisting after discharge. Aches and sore throat are common in intubated patients. Headache and dizziness also occur, but nausea and vomiting after discharge are less common. Patients may take 2-3 days before being able to resume their usual activities. Intraoperative awareness occurs. Information about these known side effects should be incorporated into the preoperative patient education and into an anesthesia consent form. Patient satisfaction also needs to be assessed, and our care should focus on what is important to them [7].
References:
1. SMG Forecast of surgical volume in hospital/ ambulatory settings. Chicago, SMG Marketing Group, Inc., 2001.2. Philip BK. Ambulatory anesthesia. Sem Surg Oncol 6, 177-83, 1990.
3. Philip BK. Anesthesiologist as manager in the U.S.A: The ambulatory surgery experience. In: Gullo A, ed. Anaesthesia, Pain, Intensive Care and Emergency Medicine. Milano, Springer-Verlag, p.1003-11, 1996.
4. Philip BK. New approaches to anaesthesia for day case surgery. Acta Anaesth Belg 48, 167-174, 1997.
5. Philip BK. Patients’ assessment of ambulatory anesthesia and surgery. J Clin Anesth 4, 355-358, 1992.
6. Philip BK. Practical cost-effective choices: ambulatory general anesthesia. J Clin Anesth 7, 606-13, 1995.
7. Tarazi EM, Philip BK. Friendliness of OR staff is top determinant of patient satisfaction with outpatient surgery. Amer J Anesthesiology 25, 154-157, 1998.