A Surgeon’s View on Ambulatory SurgeryPaper received: February 2006. Accepted: March 2006 Source of support: Nil.
Introduction:
In many countries, it’s impossible to imagine healthcare without Ambulatory Surgery. Accumulating evidence indicates that outpatient surgery offers significant advantages over inpatient surgery. Patients operated on an ambulatory basis report faster recovery and better psychological adjustment, given that selection of the procedure, preoperative preparation, the surgery performed and postoperative care, all were optimal.
The pronounced shift towards outpatient surgery has been made possible, for an important part, by an equally impressive technological revolution both in anaesthesia as well as in surgery, which has led to the development of approaches that require less postoperative care.
Moreover, ambulatory surgery is highly cost-effective. In its early days Ambulatory Surgery was the hobby of enterprising physicians, today, more and more health care insurers have to acknowledge that ambulatory surgery has financial advantages as well. From place to place, however, it appears that neither physicians nor healthcare governments are fully convinced of the advantages day surgery has to offer, and it will take much time and energy to change this attitude.
After a few remarks on history, this article focuses on strategies to emphasize the advantages Ambulatory Surgery has to offer.
For the individual surgeon it includes not only a perfect operative technique: proper selection both of the procedure and the patient, and attention for the management of postoperative pain as well. The central theme should be: let’s first improve surgical treatment; a reduction in postoperative length of stay will follow then. Close collaboration with anaesthetists and nurses is essential to achieve this goal.
Moreover, it is advised that the individual day surgery unit should register clinical indicators, in order to keep an eye on overall quality of procedures. And finally, physicians and nurses should unite and strive to establish a national day-surgery association: some experiences in the Netherlands and with the International Association will be discussed.
Development of Ambulatory Surgery:
Ambulatory or day surgery is a clinical admission for a surgical procedure, with discharge of the patient on the same working day. In the early days of surgery all operations were done on an ambulatory basis, since hospitals, both conceptually and as an institution, developed later in history (1). Ambulatory surgery in its present form is commonly said to have started in 1909 when James Nicoll, a paediatric surgeon from Glasgow, reported a series of 8988 children, operated upon on an ambulatory basis (2). The first report of Ambulatory Surgery performed in a free standing unit came from Ralph D. Waters, anaesthesiologist from Sioux City, Iowa, USA, who reported in 1919 on his Down-Town Anesthesia Clinic, equipped for surgical and dental procedures under general anaesthesia (3). Finally in 1969, Ford and Reed, anaesthesiologists from Phoenix, Arizona, presented their concept of the Surgicenter
®, designed ‘to provide quality surgical care to the patient whose operation is too demanding for the doctor’s office, yet not of such proportion as to require hospitalisation’(4). From that time on, the number of admissions for day surgery increased strongly in many countries, especially in the USA, Australia and Europe (United Kingdom, Belgium, France, the Netherlands and the Scandinavians). This increase was highly facilitated by innovations in surgical and anaesthetic techniques.The implementation of new surgical procedures, for example minimal invasive surgery like endoscopy, and new short-acting anaesthetics with minimal cardiovascular side effects made early discharge possible in a fast increasing number of cases. However, there is still quite some variation in the use of day surgery, at least among countries, but also in individual hospitals in many countries. The attractiveness of day surgery can be increased only when professionals in individual units render excellent patient care.Selection of procedures and patients:
A large number of surgical procedures can be done on an ambulatory basis. Day surgery (rather than inpatient surgery) must be regarded the standard for all elective surgery. It should be considered the principal option and no longer an alternative form of treatment.
However, not all patients can be treated on a day surgical basis. It is not the operation that is ambulatory, it is the patient! It is of paramount importance that all patients are carefully selected, taking social, medical (co-morbidity) and surgical criteria into account.
Preoperative assessment, the providing of information to patients and caretakers, appropriate treatment and follow-up after discharge: all require meticulous attention for detail.
For day surgery commonly acceptable general surgical procedures are operations for inguinal hernia, breast lesions and proctologic problems. Varicose vein surgery, venous access surgery and access surgery for haemodialysis are all performed by vascular surgeons on an ambulatory basis. But
new techniques evolve rapidly, enabling an increasing number of general surgical and vascular procedures to be performed in day care with or without extended recovery.
Management of postoperative pain:
Effective pain management after ambulatory surgery is important, not only for humanitarian reasons, but also because incomplete pain control contributes to postoperative nausea and vomiting (PONV), reduced mobility of the patient and delayed resumption of normal activities (5). Inadequate postoperative pain control is a significant cause of patient dissatisfaction with ambulatory surgery, may lead to many undesired effects, and sometimes unanticipated (re)admission. Prevention of pain is better than relief (6). In the selection of operative procedures, the amount of postoperative pain should be taken into account. For example, endovenous obliteration of varicose veins requires the extra investment of the necessary device and disposable catheters, but advantages as less post-operative discomfort and faster return to normal activities, as compared to conventional stripping, have been documented (7).
Preoperative education of the patient is important, surgeons should not only explain exactly what they are planning on doing (give procedural information), but also provide their patients with sensory information, i.e. information about possible unpleasant feelings postoperatively (8). Only combined sensory-procedural information gives the most benefit in reducing pain. During the operation, everything should be done to lessen postoperative pain; hence the use of nerve blocks and/or infiltration of wound edges are highly recommended. Also, pain management at home deserves attention to detail.
Clinical indicators:
It is recommended that units for Ambulatory Surgery use clinical indicators to monitor the overall quality of procedures. The International Association for Ambulatory Surgery (IAAS) advises the continuous registration of:
1) Cancellation of booked procedures, either failure of the patient to attend the day surgery unit (‘no show’ or ‘do not attend, DNA’) or after arrival of thepatient, due to medical or organisational reasons,
2) Unplanned return to the operating room on the same day,
3) Unplanned overnight admission and become difficult when the Standard is completely rejected.
The International Association for Ambulatory Surgery (IAAS):
In 1995, the International Association for Ambulatory Surgery was established in Brussels, Belgium. The Dutch Association was one of its founding members. One of the major challenges of IAAS is to maintain a high quality of ambulatory surgery, and to improve the development of ambulatory surgery all over the world. To do so, IAAS initiates the organisation of an International Congress every 2 years. The next congress will be organised in Amsterdam, the Netherlands, from April 15
th–18th, 2007 (www.iaascongress2007.org). Since 1993, IAAS also publishes the journal Ambulatory Surgery. Membership of IAAS is available for all National Associations for Ambulatory Surgery.To promote the understanding of people active in ambulatory surgery, IAAS documented all national definitions, with translations in English, of the words day surgery, office-based surgery, extended recovery, etc. This list of definitions is available at the IAAS Central Office.
In order to keep track of the numbers of ambulatory surgical procedures performed, IAAS initiates from time to time (preferably every two year, but this seems to be too frequent due to the labour-intensity of the task) the collection of national data, not from member countries only: provided the availability of a reliable contact, every country might participate. The core-issue was the selection of a basket of 20 procedures, suitable to cover all essential aspects of day surgery. Procedures in the final basket included not only hernias and varicose veins, but also laparoscopic cholecystectomy and laparoscopic-assisted vaginal hysterectomy. The collected data were first published in 1998 (12), the second set in 2000 (10), a third survey of this kind will be published soon. These surveys document the variability in the number of procedures performed, and stimulate the discussion of reason and outcome, for example during the annual meeting of the representatives of all member countries, where delegates after reporting their local data discuss the obstacles present. No country is perfect yet, or maybe ever will be perfect! Obstacles almost always focus on problems with reimbursement of the procedures performed, and/or lack of interest of the
medical profession in ambulatory surgery: both problems are not easily solved.An interesting approach was used by the National Health Service (NHS) in the United Kingdom: in order to increase the number of procedures in some hospitals the NHS Modernisation Agency appointed and trained medical professionals (surgeons, anaesthetists, nurse-managers) to exert peer pressure to speed-up things, hopefully with great success.
To improve the quality of ambulatory surgery, this year IAAS will publish a handbook on all aspects of day surgery, including organisation, anaesthesia and surgery (13). The section on surgical procedures is written by consultants of all surgical specialities, and contains a wealth of procedures, at this moment or in the near future, possible to be performed in an ambulatory setting. Some of the near-future operations include the laparoscopic fundoplication (Nissen fundoplication) for gastro-oesophageal reflux disease, or insertion of an endo-prosthesis for aortic aneurysm. It might be concluded that IAAS played and will continue to play a significant role in the promotion of Ambulatory surgery (14).
Reference List:
1. Davis JE. Major Ambulatory Surgery. Baltimore- London-Los Angeles-Sydney: Williams & Wilkins, 1986.
2. Nicoll JN. The surgery of infancy. Br Med J 1909; 2:753.
3. Waters RM. The down-town anesthesia clinic. Am J Surg 1919; 33:7.
4. Ford F, Reed W. The Surgicenter
-------