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Ambulatory surgery growing at rapid pace
Linda A Burns
Ambulatory surgery growing at rapid pace Of the approximately 19 million surgical procedures performed annually in the United States,' experts hypothesize that 20%to 40% can be safely performed on an ambulatory basis. Ambulatory surgery has grown rapidly, and many hospitals, as well as independent freestanding centers, currently operate ambulatory surgery programs. In order to further discussion, it may be helpful to define ambulatory surgery, enumerate factors contributing to its growth, and review terminology for classifying programs. Definitions and terminology. Ambulatory surgery is defined as scheduled surgical procedures provided to patients who do not remain overnight in the hos-
Linda A Burns, MHA, is director of the Division of Ambulatory Care for the American Hospital Association. She received a bachelor's degree from Purdue University, Lafayette, Ind, and a master's in hospital administration from the University of Michigan, Ann Arbor.
260
pita1 as inpatients.* An organized ambulatory surgery program is a program specifically designed and managed to provide scheduled surgical procedures to ambulatory patients. Organized ambulatory surgery programs are offered by both hospitals and providers independent of hospitals. As hospitals' commitment to ambulatory surgery increases, hospital ambulatory surgery programs tend to exhibit one or more of the following characteristics: a separate cost center, a separate facility o r specifically designated surgical suites, a separate patient registration system, or separate preoperative or postoperative settings. Surgical procedures can be performed in a variety of settings, including the inpatient operating room suites, separate ORs dedicated to ambulatory surgery, a freestanding facility, or the emergency department. Like other ambulatory care programs, ambulatory surgery programs are classified according to their governance, management, and source of finan~ing:~ hospital-sponsored-completely governed, managed, and financed by the hospital hospital-associated-governed and managed by the hospital, financed through a contractual arrangement of shared expenses and revenues with physicians hospital as landlord-the physical facility where the program is lo-
AORN Journal, February 1982, V o l 3 5 , No 2
cated is owned by the hospital, but ambulatory services are not governed, managed, or financed by the hospital. Two terms describe the location of the faci 1i ty: hospital-based-located on t h e main hospital campus satellite-located away from the hospital campus. Some confusion has arisen over use of the term freestanding. To some, freestanding refers to a program that is both independent of a hospital’s governance and management and located in a facility physically separate from an inpatient facility. Others use the term to indicate only that a facility is physically separate from an inpatient facility. That is the interpretation used in this article. In summary, then, a freestanding ambulatory surgery center connotes a facility physically separate from a n inpatient acute care facility. Freestanding ambulatory surgery centers may vary, however, according to governance structures, types of ownership and sponsorship, comprehensiveness of services, and types of affiliation with hospitals. In other words, hospitals as well as independent providers can operate freestanding ambulatory surgery centers. Factors iizflueminggrowth. Although J H Nicoll, MD, a t the Royal Glasgow Hospital for Children i n Scotland, pioneered t h e concept in t h e early 19OOs, ambulatory surgery has gained widespread acceptance in the medical community within the past 20 years. Several factors have contributed to this. Rapid-acting anesthetics have minimized side effects of surgery, such as drowsiness and nausea. Moreover, the availability of analgesics to treat pain and manage nausea have reduced patients’ discomfort. Also, improved preoperative teaching by nurses and physicians has contributed to a smoother
postoperative recovery of patients and reduced the length of inpatient stays. These developments have spurred interest in and acceptance of ambulatory surgery. Reasons for hospitnl i n v o l v e m e n t . Various factors motivate hospitals to establish or expand ambulatory services. For example, the advances in technology that have spurred changes in other sectors of medicine have also changed patterns of medical practice in ambulatory care. Surgical procedures that require specialized staff, equipment, and facilities are no longer confined only to the inpatient setting. Other influences are the changing demand for health services and shifting preferences of third-party payers and regulators to substitute ambulatory care for inpatient care to achieve cost savings a n d development of complementary inpatient services. Additional factors include diversification of risk, competitive influences, economies of scale and scope, mission statement of hospitals, teaching programs, and research programs. While these factors have been discussed in more detail in other article^,^ a few words can be said here about changing demand and competition. Demand refers to the willingness and the ability of consumers to purchase health services, and it should be distinguished from “need.” Estimates of need reflect a patient’s own judgment that health services are required or determinations by another party, such as physicians or relatives, that services are required. Need does not necessarily correlate with the patient’s ability and willingness to pay for services. Factors that increase demand for ambulatory services in general and ambulatory surgery in particular include the expansion of third-party insurance to include ambulatory care benefits, rising income levels, and the changing demo-
AORN Journal, February 1982, V o l 3 5 , N o 2
263
Table 1
Ambulatory surgery in hospitals Facilities used for ambulatory surgery in nonfederal hospitals in the 134 largest Standard Metropolitan Statistical Areas by bed-size category and t y p e of ownership, 1980 Total hospitals offering ambulatory surgery
Total nonfederal hospitals Bed-size category Fewer than 25 25-49 50-99 100-199 200-299 300-399 400-499 500 or more
T y p e of ownership Not-for-profit Church-related Other Investor-owned State and local government
No
010
A
B
C
D
1,506
70 5
86 4
93
12 7
23
4.7
11 57 157 395 300 227 142 21 7
39 3 37 7 46 7 70 8 83 6 86 0 89 3 77 0
90 9 96 5 95 5 91 6 85 7 833 81 0 75 1
00 35 51 53 a7 11 9 127 175
00 35 13 73 13 3 14 1 16 9 28 6
00 18 06 08 20 18 49 55
00 18 38 30 63 66 42 55
1,107 28 1 826 180
79 7 86 5 77 6 55 4
853 833 86 0 93 3
102 97 50
12 8 14 9 12 1 67
24 18 27 11
52 57 51 06
219
51 8
86 3
82
16 9
23
55
11 7
Source American Hospital Association 1980 Survey of Hospital Involvement with Health Maintenance Organizations Ambulatory Surgery and Freestanding Emergency Centers Hospitals 55 (July 1 1981) 70 Reprinted with permission A Hospitals with facilities used for both inpatient and ambulatory surqwy (percentage) B Hospitals with facilities used exclusively for ambulatory surgery located near inpatient facilities (percentage) C Hospitals with separate ambulatory surgery facilities located within hospital (percentage) D Hospitals with separate ambulatory surgery facilities located away from hospital (percentage)
~~
264
~~
~
-~
~
AORN Journal, Fehruarv 1982, Vol ‘l.5. No 2
~~~
~~
Other
(Oh)
Table 2
Most frequently performed surgical procedures Most frequent surgical procedures, United States 1. Biopsy 2. Dilatation and curettage, diagnostic 3. Hysterectomy 4. Ligation and division of fallopian tubes 5 . Tonsillectomy and adenoidectomy 6. Inguinal hernia 7. Cesarean section 8 . Oophorectomy 9. Cholecystectomy 10. Reduction of fracture with fixation
Most frequent ambulatory surgical procedures, Presbyterian Hospital of Dallas 1. Dilatation and curettage 2. Tonsillectomy and adenoidectomy 3. Cystogram and pyelogram 4. Myringotomy 5. Laryngoscopy 6. Dental extraction 7 . Breast biopsy 8. Bilateral ocular muscle procedure 9. Ganglionectomies 10. Scar revision
graphic structure of the population. Economic estimates suggest that demand for ambulatory services is sensitive to levels of health insurance coverage. Newhouse, Phelps, and Schwartz argue that expanded coverage of ambulatory services (physician plus ancillary services) will almost certainly cause a large increase in demand.5Thus, extension of ambulatory surgery benefits through employers’ health insurance plans, health maintenance organizations, and modifications in public insurance plans such a s Medicare and Medicaid could significantly increase demand for ambulatory surgery. With the cost squeeze on state Medicaid programs, selected states are formulating lists of surgical procedures that must be performed on a n ambulatory basis to be reimbursed by Medicaid. (Extenuating circumstances, such as secondary medical conditions, may permit exceptions for individual patients.) Ambulatory care benefits have expanded through the development of health maintenance organizations and selected private insurance plans. For example, from 1970 to 1976, the propor-
tion of the population under age 65 with insurance coverage for physicians’ office and home visits grew from 35.2%to 62.2%. Competition is related to demand. Some hospitals might want to establish or expand ambulatory services because of increased competition from other providers of ambulatory services. Traditionally, competition in the hospital industry has not taken the form of price competition. Rather, hospitals have competed with each other for population bases, which are the source of demand for health services. Examples are hospitals’ efforts to acquire new specialized technology and widen their scope of services to attract and retain physicians. The physicians, in turn, would hospitalize their patients in the facilities that have most successfully satisfied their medical practice requirements. In ambulatory surgery, there is selective competition among hospitals and between hospitals and independent groups of physicians. Ambulatory care providers seek patients who are able to pay for services because of increased income or third-party insurance. There
266
AORN Journal, February 1982, V o l 3 5 , No 2
may be price competition because th e population does not have as much insurance coverage for ambulatory services as i t does for inpatient care. Because patients may pay more ofthe costs of ambulatory care out of their own pockets, they will be more sensitive to charges. Thus, providers might attempt t o set their charges at prevailing community levels to remain price competitive. A hospital t h a t does not have excess demand for inpatient services might not plan a n ambulatory surgery program because t h a t would reduce its revenues from inpatient stays and increase excess bed capacity. If a competitor, such as another hospital or private physician gr oup, e s t a b l i s h e d an a m b u l a t o r y surgery program, however, the hospital might be prompted to initiate a program of its own. Competitive influences, then, may prompt some hospitals to establish or expand their ambulatory surgery programs. Data on ambulatory surgery. T h e American Hospital Association’s (AHA) “1980 Survey of Hospital Involvement with Ambulatory Surgery Programs” provides the first data on hospital ambulatory surgery programs. The survey determined which hospitals offer ambulatory surgery, the volume of procedures performed, the proportion of ambulatory surgery to total surgical procedures, and the type of facility used. Selected survey results a r e displayed in Table 1. Of the hospitals surveyed, 70% offer ambulatory surgery.6 Hospitals with ambulatory surgery are located i n every region of the country. Of these hospitals, 87% use their main surgical suites for inpatient an d ambulatory surgery. Of the total number of surgical procedures performed, a n average of 18% are performed on an ambulatory basis. Types of procedures. Medical practice patterns vary from region to region.
268
Where to find more information American College of Surgeons, 55 E Erie St, Chicago, 111 6061 1 (312) 664-4050. Has issued a policy statement on ambulatory surgery. American Health Consultants, Inc, 67 Peachtree Park Dr, Atlanta, Ga 30309. Publishes the monthly newsletter Same-Day Surgery. American Hospital Association, Division of Ambulatory Care, 840 N Lake Shore Dr, Chicago, 111 6061 1 . (312) 280-6456. Bibliography, list of programs in hospitals, and educational conferences. Also publishes the bimonthly report Outreach, with information about ambulatory surgery. Aspen Systems Corporation, 1600 Research Blvd, Rockville, Md 20850. (301)251-5000. Publishes the Journal of Ambulatory Care Management The August 1980 issue was devoted to ambulatory surgery. Single issues are $12.50 prepaid. Blue Cross and Blue Shield Association,676 N St Clair St, Chicago, Ill 6061 1 . (312) 440-6000. Has a national action plan for ambulatory surgery and information on reimbursement. ~~~~
~
~~
Some surgeons feel comfortable performing selected surgical procedures on a n ambulatory basis that other surgeons would not. To provide some sense of th e types of procedures performed in hospital ambulatory programs, Table 2 displays t h e ten most frequently performed ambulatory surgical procedures i n Presbyterian Hospital of Dallas contrasted with the ten most common surgical procedures in th e US. Sources of information. Additional information is available. The AHA Division of Ambulatory Care offers a bibliography; a list of programs in varying sizes of hospitals; and educational conferences designed for administrators, physicians, and nurses interested i n establishing or improving ambulatory
AORN Journal, February 198.2. V o l 3 5 , No 2
s u r g e r y programs. T h r o u g h a t e c h n i c a l assistance program, AHA s t a f f c a n v i s i t h o s p i t a l s t o assist in d e v e l o p i n g and i m p r o v i n g an a m b u l a t o r y s u r g e r y p r o gram. T h e B l u e Cross a n d B l u e S h i e l d Assoc i a t i o n h a s issued a p o l i c y s t a t e m e n t a s k i n g individual B l u e Cross and B l u e S h i e l d p l a n s t o encourage a m b u l a t o r y s u r g e r y w h e n m e d i c a l l y appropriate. Information about reimbursement policies c a n b e o b t a i n e d f r o m t h i s organization. In addition, t h e A m e r i c a n College of Surgeons h a s issued a p o l i c y s t a t e m e n t endorsing t h e concept o f amb u l a t o r y surgery. Several p u b l i c a t i o n s p r o v i d e i n f o r m a t i o n on a m b u l a t o r y surgery. Prospects a r e bright f o r a m b u l a t o r y surgery. These p r o g r a m s a r e expected t o g r o w rapidly as incentives t o c o n t r o l costs i n c r e a s e a n d a s p a t i e n t s and physicians become m o r e knowledgeable a b o u t t h e options o f t h i s t y p e o f surgery. Notes 1. Hospita/ Statistics (Chicago:American Hospi-
tal Association, 1980) 20. 2. Linda A Burns, M S Ferber, "Survey indicates extensive ambulatory surgery programs by hospitals,'' Hospitals 55 (July 1 , 1981). 3. Linda A Burns, M S Ferber, "Definitions proposed for hospital roles in ambulatory care," Outreach 1 (August 1980) 2-4. 4. Linda A Burns, "Will multi-institutional systems serve as change agents to improve the management of ambulatory care?" Journal of Ambulatory Care Management 3 (August 1980) 1-17. 5. J Newhouse, C E Phelps, W B Schwartz, "Policy options and the impact of national health insurance," New EnglandJournal of Medicine 290 (June 13, 1974) 1345-1359. 6. lbid.
270
Oral medication calms pediatric outpafients A fear of injections is usually the biggest concern of children facing an outpatient hospital visit. Studies have shown that the injection of anesthetics in a crying, uncooperative, or combative child can lead to such postoperative personality changes as a morbid fear of hospitals, distrust of strangers, bedwetting, and temper tantrums. A simple mixture of a pain killer and a tranquilizer, given orally instead of through injections, however, greatly calms the children and reduces traumatic experiences, said R M Brzustowicz, MD, currently at the Children's Hospital Medical Center, Harvard University, Boston. Of children receiving the mixture, only 11YOcried in the operating room, compared with a crying rate of 34% among children who did not receive the premedication, he reported at the recent annual meeting of the American Society of Anesthesiologists in New Orleans. "This study demonstrates that an easily administered oral premedication can be used in an outpatient population to decrease operating room tears, without prolonging the recovery period," Dr Brzustowicz said. The study involved 159 patients from the Children's Hospital of Philadelphia's outpatient unit. The children, who were released from the hospital on the same day of their operation, were divided into two nearly equal groups. One group received an oral placebo consisting of sugar water, flavoring, and coloring. The other group was given a solution containing the sugar water with meperidine for pain relief, diazepam (a tranquilizer), and atropine to produce a dry mouth and prevent slow heart rates. Children receiving the medication had a significantly lower rate of crying and oral secretions, said Dr Brzustowicz.
AORN Journal, February 1982, V o l 3 5 , No 2
Ambulatory surgery growing at rapid pace Of the approximately 19 million surgical procedures performed annually in the United States,' experts hypothesize that 20%to 40% can be safely performed on an ambulatory basis. Ambulatory surgery has grown rapidly, and many hospitals, as well as independent freestanding centers, currently operate ambulatory surgery programs. In order to further discussion, it may be helpful to define ambulatory surgery, enumerate factors contributing to its growth, and review terminology for classifying programs. Definitions and terminology. Ambulatory surgery is defined as scheduled surgical procedures provided to patients who do not remain overnight in the hos-
Linda A Burns, MHA, is director of the Division of Ambulatory Care for the American Hospital Association. She received a bachelor's degree from Purdue University, Lafayette, Ind, and a master's in hospital administration from the University of Michigan, Ann Arbor.
260
pita1 as inpatients.* An organized ambulatory surgery program is a program specifically designed and managed to provide scheduled surgical procedures to ambulatory patients. Organized ambulatory surgery programs are offered by both hospitals and providers independent of hospitals. As hospitals' commitment to ambulatory surgery increases, hospital ambulatory surgery programs tend to exhibit one or more of the following characteristics: a separate cost center, a separate facility o r specifically designated surgical suites, a separate patient registration system, or separate preoperative or postoperative settings. Surgical procedures can be performed in a variety of settings, including the inpatient operating room suites, separate ORs dedicated to ambulatory surgery, a freestanding facility, or the emergency department. Like other ambulatory care programs, ambulatory surgery programs are classified according to their governance, management, and source of finan~ing:~ hospital-sponsored-completely governed, managed, and financed by the hospital hospital-associated-governed and managed by the hospital, financed through a contractual arrangement of shared expenses and revenues with physicians hospital as landlord-the physical facility where the program is lo-
AORN Journal, February 1982, V o l 3 5 , No 2
cated is owned by the hospital, but ambulatory services are not governed, managed, or financed by the hospital. Two terms describe the location of the faci 1i ty: hospital-based-located on t h e main hospital campus satellite-located away from the hospital campus. Some confusion has arisen over use of the term freestanding. To some, freestanding refers to a program that is both independent of a hospital’s governance and management and located in a facility physically separate from an inpatient facility. Others use the term to indicate only that a facility is physically separate from an inpatient facility. That is the interpretation used in this article. In summary, then, a freestanding ambulatory surgery center connotes a facility physically separate from a n inpatient acute care facility. Freestanding ambulatory surgery centers may vary, however, according to governance structures, types of ownership and sponsorship, comprehensiveness of services, and types of affiliation with hospitals. In other words, hospitals as well as independent providers can operate freestanding ambulatory surgery centers. Factors iizflueminggrowth. Although J H Nicoll, MD, a t the Royal Glasgow Hospital for Children i n Scotland, pioneered t h e concept in t h e early 19OOs, ambulatory surgery has gained widespread acceptance in the medical community within the past 20 years. Several factors have contributed to this. Rapid-acting anesthetics have minimized side effects of surgery, such as drowsiness and nausea. Moreover, the availability of analgesics to treat pain and manage nausea have reduced patients’ discomfort. Also, improved preoperative teaching by nurses and physicians has contributed to a smoother
postoperative recovery of patients and reduced the length of inpatient stays. These developments have spurred interest in and acceptance of ambulatory surgery. Reasons for hospitnl i n v o l v e m e n t . Various factors motivate hospitals to establish or expand ambulatory services. For example, the advances in technology that have spurred changes in other sectors of medicine have also changed patterns of medical practice in ambulatory care. Surgical procedures that require specialized staff, equipment, and facilities are no longer confined only to the inpatient setting. Other influences are the changing demand for health services and shifting preferences of third-party payers and regulators to substitute ambulatory care for inpatient care to achieve cost savings a n d development of complementary inpatient services. Additional factors include diversification of risk, competitive influences, economies of scale and scope, mission statement of hospitals, teaching programs, and research programs. While these factors have been discussed in more detail in other article^,^ a few words can be said here about changing demand and competition. Demand refers to the willingness and the ability of consumers to purchase health services, and it should be distinguished from “need.” Estimates of need reflect a patient’s own judgment that health services are required or determinations by another party, such as physicians or relatives, that services are required. Need does not necessarily correlate with the patient’s ability and willingness to pay for services. Factors that increase demand for ambulatory services in general and ambulatory surgery in particular include the expansion of third-party insurance to include ambulatory care benefits, rising income levels, and the changing demo-
AORN Journal, February 1982, V o l 3 5 , N o 2
263
Table 1
Ambulatory surgery in hospitals Facilities used for ambulatory surgery in nonfederal hospitals in the 134 largest Standard Metropolitan Statistical Areas by bed-size category and t y p e of ownership, 1980 Total hospitals offering ambulatory surgery
Total nonfederal hospitals Bed-size category Fewer than 25 25-49 50-99 100-199 200-299 300-399 400-499 500 or more
T y p e of ownership Not-for-profit Church-related Other Investor-owned State and local government
No
010
A
B
C
D
1,506
70 5
86 4
93
12 7
23
4.7
11 57 157 395 300 227 142 21 7
39 3 37 7 46 7 70 8 83 6 86 0 89 3 77 0
90 9 96 5 95 5 91 6 85 7 833 81 0 75 1
00 35 51 53 a7 11 9 127 175
00 35 13 73 13 3 14 1 16 9 28 6
00 18 06 08 20 18 49 55
00 18 38 30 63 66 42 55
1,107 28 1 826 180
79 7 86 5 77 6 55 4
853 833 86 0 93 3
102 97 50
12 8 14 9 12 1 67
24 18 27 11
52 57 51 06
219
51 8
86 3
82
16 9
23
55
11 7
Source American Hospital Association 1980 Survey of Hospital Involvement with Health Maintenance Organizations Ambulatory Surgery and Freestanding Emergency Centers Hospitals 55 (July 1 1981) 70 Reprinted with permission A Hospitals with facilities used for both inpatient and ambulatory surqwy (percentage) B Hospitals with facilities used exclusively for ambulatory surgery located near inpatient facilities (percentage) C Hospitals with separate ambulatory surgery facilities located within hospital (percentage) D Hospitals with separate ambulatory surgery facilities located away from hospital (percentage)
~~
264
~~
~
-~
~
AORN Journal, Fehruarv 1982, Vol ‘l.5. No 2
~~~
~~
Other
(Oh)
Table 2
Most frequently performed surgical procedures Most frequent surgical procedures, United States 1. Biopsy 2. Dilatation and curettage, diagnostic 3. Hysterectomy 4. Ligation and division of fallopian tubes 5 . Tonsillectomy and adenoidectomy 6. Inguinal hernia 7. Cesarean section 8 . Oophorectomy 9. Cholecystectomy 10. Reduction of fracture with fixation
Most frequent ambulatory surgical procedures, Presbyterian Hospital of Dallas 1. Dilatation and curettage 2. Tonsillectomy and adenoidectomy 3. Cystogram and pyelogram 4. Myringotomy 5. Laryngoscopy 6. Dental extraction 7 . Breast biopsy 8. Bilateral ocular muscle procedure 9. Ganglionectomies 10. Scar revision
graphic structure of the population. Economic estimates suggest that demand for ambulatory services is sensitive to levels of health insurance coverage. Newhouse, Phelps, and Schwartz argue that expanded coverage of ambulatory services (physician plus ancillary services) will almost certainly cause a large increase in demand.5Thus, extension of ambulatory surgery benefits through employers’ health insurance plans, health maintenance organizations, and modifications in public insurance plans such a s Medicare and Medicaid could significantly increase demand for ambulatory surgery. With the cost squeeze on state Medicaid programs, selected states are formulating lists of surgical procedures that must be performed on a n ambulatory basis to be reimbursed by Medicaid. (Extenuating circumstances, such as secondary medical conditions, may permit exceptions for individual patients.) Ambulatory care benefits have expanded through the development of health maintenance organizations and selected private insurance plans. For example, from 1970 to 1976, the propor-
tion of the population under age 65 with insurance coverage for physicians’ office and home visits grew from 35.2%to 62.2%. Competition is related to demand. Some hospitals might want to establish or expand ambulatory services because of increased competition from other providers of ambulatory services. Traditionally, competition in the hospital industry has not taken the form of price competition. Rather, hospitals have competed with each other for population bases, which are the source of demand for health services. Examples are hospitals’ efforts to acquire new specialized technology and widen their scope of services to attract and retain physicians. The physicians, in turn, would hospitalize their patients in the facilities that have most successfully satisfied their medical practice requirements. In ambulatory surgery, there is selective competition among hospitals and between hospitals and independent groups of physicians. Ambulatory care providers seek patients who are able to pay for services because of increased income or third-party insurance. There
266
AORN Journal, February 1982, V o l 3 5 , No 2
may be price competition because th e population does not have as much insurance coverage for ambulatory services as i t does for inpatient care. Because patients may pay more ofthe costs of ambulatory care out of their own pockets, they will be more sensitive to charges. Thus, providers might attempt t o set their charges at prevailing community levels to remain price competitive. A hospital t h a t does not have excess demand for inpatient services might not plan a n ambulatory surgery program because t h a t would reduce its revenues from inpatient stays and increase excess bed capacity. If a competitor, such as another hospital or private physician gr oup, e s t a b l i s h e d an a m b u l a t o r y surgery program, however, the hospital might be prompted to initiate a program of its own. Competitive influences, then, may prompt some hospitals to establish or expand their ambulatory surgery programs. Data on ambulatory surgery. T h e American Hospital Association’s (AHA) “1980 Survey of Hospital Involvement with Ambulatory Surgery Programs” provides the first data on hospital ambulatory surgery programs. The survey determined which hospitals offer ambulatory surgery, the volume of procedures performed, the proportion of ambulatory surgery to total surgical procedures, and the type of facility used. Selected survey results a r e displayed in Table 1. Of the hospitals surveyed, 70% offer ambulatory surgery.6 Hospitals with ambulatory surgery are located i n every region of the country. Of these hospitals, 87% use their main surgical suites for inpatient an d ambulatory surgery. Of the total number of surgical procedures performed, a n average of 18% are performed on an ambulatory basis. Types of procedures. Medical practice patterns vary from region to region.
268
Where to find more information American College of Surgeons, 55 E Erie St, Chicago, 111 6061 1 (312) 664-4050. Has issued a policy statement on ambulatory surgery. American Health Consultants, Inc, 67 Peachtree Park Dr, Atlanta, Ga 30309. Publishes the monthly newsletter Same-Day Surgery. American Hospital Association, Division of Ambulatory Care, 840 N Lake Shore Dr, Chicago, 111 6061 1 . (312) 280-6456. Bibliography, list of programs in hospitals, and educational conferences. Also publishes the bimonthly report Outreach, with information about ambulatory surgery. Aspen Systems Corporation, 1600 Research Blvd, Rockville, Md 20850. (301)251-5000. Publishes the Journal of Ambulatory Care Management The August 1980 issue was devoted to ambulatory surgery. Single issues are $12.50 prepaid. Blue Cross and Blue Shield Association,676 N St Clair St, Chicago, Ill 6061 1 . (312) 440-6000. Has a national action plan for ambulatory surgery and information on reimbursement. ~~~~
~
~~
Some surgeons feel comfortable performing selected surgical procedures on a n ambulatory basis that other surgeons would not. To provide some sense of th e types of procedures performed in hospital ambulatory programs, Table 2 displays t h e ten most frequently performed ambulatory surgical procedures i n Presbyterian Hospital of Dallas contrasted with the ten most common surgical procedures in th e US. Sources of information. Additional information is available. The AHA Division of Ambulatory Care offers a bibliography; a list of programs in varying sizes of hospitals; and educational conferences designed for administrators, physicians, and nurses interested i n establishing or improving ambulatory
AORN Journal, February 198.2. V o l 3 5 , No 2
s u r g e r y programs. T h r o u g h a t e c h n i c a l assistance program, AHA s t a f f c a n v i s i t h o s p i t a l s t o assist in d e v e l o p i n g and i m p r o v i n g an a m b u l a t o r y s u r g e r y p r o gram. T h e B l u e Cross a n d B l u e S h i e l d Assoc i a t i o n h a s issued a p o l i c y s t a t e m e n t a s k i n g individual B l u e Cross and B l u e S h i e l d p l a n s t o encourage a m b u l a t o r y s u r g e r y w h e n m e d i c a l l y appropriate. Information about reimbursement policies c a n b e o b t a i n e d f r o m t h i s organization. In addition, t h e A m e r i c a n College of Surgeons h a s issued a p o l i c y s t a t e m e n t endorsing t h e concept o f amb u l a t o r y surgery. Several p u b l i c a t i o n s p r o v i d e i n f o r m a t i o n on a m b u l a t o r y surgery. Prospects a r e bright f o r a m b u l a t o r y surgery. These p r o g r a m s a r e expected t o g r o w rapidly as incentives t o c o n t r o l costs i n c r e a s e a n d a s p a t i e n t s and physicians become m o r e knowledgeable a b o u t t h e options o f t h i s t y p e o f surgery. Notes 1. Hospita/ Statistics (Chicago:American Hospi-
tal Association, 1980) 20. 2. Linda A Burns, M S Ferber, "Survey indicates extensive ambulatory surgery programs by hospitals,'' Hospitals 55 (July 1 , 1981). 3. Linda A Burns, M S Ferber, "Definitions proposed for hospital roles in ambulatory care," Outreach 1 (August 1980) 2-4. 4. Linda A Burns, "Will multi-institutional systems serve as change agents to improve the management of ambulatory care?" Journal of Ambulatory Care Management 3 (August 1980) 1-17. 5. J Newhouse, C E Phelps, W B Schwartz, "Policy options and the impact of national health insurance," New EnglandJournal of Medicine 290 (June 13, 1974) 1345-1359. 6. lbid.
270
Oral medication calms pediatric outpafients A fear of injections is usually the biggest concern of children facing an outpatient hospital visit. Studies have shown that the injection of anesthetics in a crying, uncooperative, or combative child can lead to such postoperative personality changes as a morbid fear of hospitals, distrust of strangers, bedwetting, and temper tantrums. A simple mixture of a pain killer and a tranquilizer, given orally instead of through injections, however, greatly calms the children and reduces traumatic experiences, said R M Brzustowicz, MD, currently at the Children's Hospital Medical Center, Harvard University, Boston. Of children receiving the mixture, only 11YOcried in the operating room, compared with a crying rate of 34% among children who did not receive the premedication, he reported at the recent annual meeting of the American Society of Anesthesiologists in New Orleans. "This study demonstrates that an easily administered oral premedication can be used in an outpatient population to decrease operating room tears, without prolonging the recovery period," Dr Brzustowicz said. The study involved 159 patients from the Children's Hospital of Philadelphia's outpatient unit. The children, who were released from the hospital on the same day of their operation, were divided into two nearly equal groups. One group received an oral placebo consisting of sugar water, flavoring, and coloring. The other group was given a solution containing the sugar water with meperidine for pain relief, diazepam (a tranquilizer), and atropine to produce a dry mouth and prevent slow heart rates. Children receiving the medication had a significantly lower rate of crying and oral secretions, said Dr Brzustowicz.
AORN Journal, February 1982, V o l 3 5 , No 2