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Traditionally invasive procedures shift to outpatient care
Traditionally invasive procedures shift to outpatient care Kelly Putnam, Managing Editor
A
major trend in surgical care throughout the past few decades has been the increasing number of procedures performed at ambulatory surgery centers (ASCs). According to data from the Centers for Disease Control and Prevention, visits to ASCs increased 300 percent between 1996 and 2006.1 In 2006, common procedures performed at ASCs included intestinal endoscopy procedures, lens extractions, and injections into the spinal canal.1 With improving minimally invasive techniques, anesthesia practices, and patient optimization, traditionally invasive and complex procedures such as joint replacement, colectomy, and spine surgeries now are being performed in the outpatient setting.
The Joint Commission for total hip and total knee replacement in October 2016.2 “We get our patients out of surgery and home in anywhere from six to 12 hours,” said Chris Moore, BSN, RN, CNOR, joint replacement coordinator at Ohio Specialty Surgical Suites in Canton, Ohio. “In the hospital setting, it almost always requires an overnight stay, if not two to three days in the hospital.” Moore said the facility was opened by a perioperative team who thought patients undergoing these procedures would fare better with the direct care offered in an outpatient setting; in the hospital, their patients were not ambulating soon enough and were at risk for adverse events such as infections, urinary retention, and blood clots.
The shift to outpatient care affects the roles and responsibilities of all members of the perioperative team. Surgeons must master minimally invasive techniques; perioperative RNs must learn new technologies and may need to take a more active role in patient education for preoperative care and postoperative recovery; and anesthesia professionals must carefully select and administer anesthesia medications to help ensure patients are awake and ready to go home the same day as surgery. “Today, non-operating room anesthesia accounts for about 33 percent of all cases, and that percentage has risen by more than one percent a year for the past five years,” said Richard Dutton, MD, chief quality officer for U.S. Anesthesia Partners in Dallas. “That really is a mega trend and probably it suggests that we should be making a huge shift in how we train residents, how we focus our science efforts, and how we think of ourselves—we’re not hospital-based physicians anymore.”
Patient selection and education Not all patients are eligible for same-day joint replacement surgery, and the perioperative team should perform thorough preoperative assessments to help ensure positive patient outcomes. According to Dutton, about 25 percent of their patients undergoing knee replacements go home the same day now. “That’s because of a comprehensive process that is built to move patients through quickly and select patients who are healthy and need simple, straightforward knee replacements,” he said. Patients may not be eligible for outpatient care if they have comorbidities such as obesity or diabetes, scar tissue at the surgical site from previous surgeries, or abnormal anatomy that requires special implants.
Optimizing outpatient joint replacement surgeries As evidence of the shift of procedures to outpatient care, Ohio Specialty Surgical Suites became the first ASC to receive advanced certification from
Because total knee and total hip replacement procedures are elective, the perioperative team has the opportunity to work extensively with patients before the surgery takes place. “I think the reason we are so successful is because of our preoperative preparation for the procedure,” said Moore. At her facility, patients participate in a mandatory education session with their support person (i.e., family member or friend who will help with postoperative care) three to four weeks before the scheduled surgery. The class is
http://dx.doi.org/10.1016/S0001-2092(16)30865-1
© AORN, Inc, 2016
December 2016 Vol 104 No 6 • Periop Briefing | P7
PERIOP BRIEFING
LEAD FEATURE
PERIOP BRIEFING
OUTPATIENT PROCEDURES
45 minutes long and may include up to four patients and their support people. During the class, patients learn what to expect after the procedure and begin practicing the movements and exercises they will do postoperatively. The team sends patients home with the supplies they will need (e.g., walker, skin cleaning solutions) and a comprehensive booklet that reviews the content of the class and includes checklists for their postoperative care. The AORN “Perioperative Patient Engagement Tool Kit” includes a handout for patients and families to help them set appropriate expectations for the patients’ surgeries.3 Some patients undergo further preoperative interventions that help them improve their general health before surgery. “Being obese and smoking are probably the two things that can prevent a patient from recovering quickly,” said Moore. Elective surgeries can be postponed while patients pursue these lifestyle modifications. The booklet that patients receive includes community resources for healthy living, such as places where patients can go to exercise, including local walking trails, and smoking cessation groups. Moore said that in her experience, patients are motivated to change their behaviors when they know it improves their eligibility for procedures and the likelihood of positive outcomes. Patient recovery The minimally invasive surgical techniques used for outpatient joint replacement procedures reduce cutting of muscles and promote early ambulation. For patients to be discharged on the same day as surgery, anesthesia professionals need to administer the minimum amount of anesthesia necessary to keep the patient comfortable during the procedure. A few hours after surgery, the perioperative RNs at Moore’s facility encourage patients to get out of bed. Because patients may still be experiencing the effects of anesthesia when they are discharged and may require assistance while walking, the support people who will help the patients at home need to learn what to expect and how best to help. The team helps ensure that support people are ready to help patients by including them in the preoperative education classes. At Moore’s facility, the physical therapists on staff work collaboratively with the perioperative RNs and provide training to the RNs so they can help
P8 | Periop Briefing
the patients ambulate after surgery. Before each patient leaves, the team confirms that the patient’s first physical therapy session is scheduled for the following day. The team follows up with each patient via phone three days and 21 days after surgery. Indicators of success The Joint Commission awards certifications to programs offering total knee and total hip replacement procedures that demonstrate effective patient education related to each phase of care.2 Preoperative education should include comorbid assessments, risk factors, postoperative rehabilitation, and discharge planning to help patients participate in a shared decision-making process with their care providers. Throughout the continuum of care, providers should demonstrate consistent communication and collaboration. Moore’s team continues to work with The Joint Commission to optimize their program and implement documentation tools for data tracking. “The Joint Commission has been amazingly helpful for us through all of this,” said Moore. “They’ve given us so many good ideas and they’ve really inspired us to go above and beyond.”
Providing high-quality outpatient care Even with the success of programs like the joint replacement program at Ohio Specialty Surgical Suites, some clinicians and researchers have identified some areas of concern regarding the larger trend of more surgical procedures being performed at ASCs. A recent study of more than one million procedures performed at 86 freestanding ASCs in South Carolina found an average rate of postoperative acute care requiring admission to an inpatient facility of 17.3 per 1,000 procedures, indicating room for improvement in identifying patients who may require this type of care and providing better follow-up care.4 Ongoing research may help identify the surgical outcomes and acute care use of patients undergoing outpatient procedures as these procedures become more common. An analysis of outpatient surgeries by Erhun et al5 cited several potential issues with care provided at ASCs, including financial incentives for surgeons to perform surgeries that may be unnecessary and
ineffective communication among primary care physicians, patients, and surgeons. Using interactive patient decision aids, clinical decision support tools, and case coaching services through a third-party provider are a few ways to help ensure patients and care providers choose appropriate surgeries.5 Because surgeries performed at ASCs do not involve urgent circumstances or high-risk patients, care providers can implement standardized care plans that may improve efficiency and care quality.4
Conclusion Improved patient selection strategies, approaches to patient and family education, minimally invasive techniques, and anesthesia delivery practices contribute to the increasing number of joint replacement procedures performed in hospitalbased outpatient clinics and freestanding ASCs. The education of patients and their support people before surgery supports successful postoperative recovery and positive outcomes. As surgical care continues to shift to outpatient settings, patients and care providers should strive to develop evidence-based care plans that maximize the value of outpatient care.
© AORN, Inc, 2016
References 1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;(11):1-25. 2. Zhani EE. Ohio Specialty Surgical Suites awarded first advanced certification for total hip and total knee replacement. The Joint Commission. https:// www.jointcommission.org/ohio_specialty_ surgical_suites_awarded_first_adv_cert_total_ hip_and_total_knee_replacement/. Published October 18, 2016. Accessed October 28, 2016. 3. Perioperative Patient Engagement Tool Kit. AORN. https://www.aorn.org/guidelines/ clinical-resources/tool-kits/perioperative-patientengagement-tool-kit. Accessed November 11, 2016. 4. Molina G, Neville BA, Lipsitz SR, et al. Postoperative acute care use after freestanding ambulatory surgery. J Surg Res. 2016;205(2):331340. 5. Erhun F, Malcolm E, Kalani M, et al. Opportunities to improve the value of outpatient surgical care. Am J Manag Care. 2016;22(9):e329335.
December 2016 Vol 104 No 6 • Periop Briefing | P9
PERIOP BRIEFING
OUTPATIENT PROCEDURES
A
major trend in surgical care throughout the past few decades has been the increasing number of procedures performed at ambulatory surgery centers (ASCs). According to data from the Centers for Disease Control and Prevention, visits to ASCs increased 300 percent between 1996 and 2006.1 In 2006, common procedures performed at ASCs included intestinal endoscopy procedures, lens extractions, and injections into the spinal canal.1 With improving minimally invasive techniques, anesthesia practices, and patient optimization, traditionally invasive and complex procedures such as joint replacement, colectomy, and spine surgeries now are being performed in the outpatient setting.
The Joint Commission for total hip and total knee replacement in October 2016.2 “We get our patients out of surgery and home in anywhere from six to 12 hours,” said Chris Moore, BSN, RN, CNOR, joint replacement coordinator at Ohio Specialty Surgical Suites in Canton, Ohio. “In the hospital setting, it almost always requires an overnight stay, if not two to three days in the hospital.” Moore said the facility was opened by a perioperative team who thought patients undergoing these procedures would fare better with the direct care offered in an outpatient setting; in the hospital, their patients were not ambulating soon enough and were at risk for adverse events such as infections, urinary retention, and blood clots.
The shift to outpatient care affects the roles and responsibilities of all members of the perioperative team. Surgeons must master minimally invasive techniques; perioperative RNs must learn new technologies and may need to take a more active role in patient education for preoperative care and postoperative recovery; and anesthesia professionals must carefully select and administer anesthesia medications to help ensure patients are awake and ready to go home the same day as surgery. “Today, non-operating room anesthesia accounts for about 33 percent of all cases, and that percentage has risen by more than one percent a year for the past five years,” said Richard Dutton, MD, chief quality officer for U.S. Anesthesia Partners in Dallas. “That really is a mega trend and probably it suggests that we should be making a huge shift in how we train residents, how we focus our science efforts, and how we think of ourselves—we’re not hospital-based physicians anymore.”
Patient selection and education Not all patients are eligible for same-day joint replacement surgery, and the perioperative team should perform thorough preoperative assessments to help ensure positive patient outcomes. According to Dutton, about 25 percent of their patients undergoing knee replacements go home the same day now. “That’s because of a comprehensive process that is built to move patients through quickly and select patients who are healthy and need simple, straightforward knee replacements,” he said. Patients may not be eligible for outpatient care if they have comorbidities such as obesity or diabetes, scar tissue at the surgical site from previous surgeries, or abnormal anatomy that requires special implants.
Optimizing outpatient joint replacement surgeries As evidence of the shift of procedures to outpatient care, Ohio Specialty Surgical Suites became the first ASC to receive advanced certification from
Because total knee and total hip replacement procedures are elective, the perioperative team has the opportunity to work extensively with patients before the surgery takes place. “I think the reason we are so successful is because of our preoperative preparation for the procedure,” said Moore. At her facility, patients participate in a mandatory education session with their support person (i.e., family member or friend who will help with postoperative care) three to four weeks before the scheduled surgery. The class is
http://dx.doi.org/10.1016/S0001-2092(16)30865-1
© AORN, Inc, 2016
December 2016 Vol 104 No 6 • Periop Briefing | P7
PERIOP BRIEFING
LEAD FEATURE
PERIOP BRIEFING
OUTPATIENT PROCEDURES
45 minutes long and may include up to four patients and their support people. During the class, patients learn what to expect after the procedure and begin practicing the movements and exercises they will do postoperatively. The team sends patients home with the supplies they will need (e.g., walker, skin cleaning solutions) and a comprehensive booklet that reviews the content of the class and includes checklists for their postoperative care. The AORN “Perioperative Patient Engagement Tool Kit” includes a handout for patients and families to help them set appropriate expectations for the patients’ surgeries.3 Some patients undergo further preoperative interventions that help them improve their general health before surgery. “Being obese and smoking are probably the two things that can prevent a patient from recovering quickly,” said Moore. Elective surgeries can be postponed while patients pursue these lifestyle modifications. The booklet that patients receive includes community resources for healthy living, such as places where patients can go to exercise, including local walking trails, and smoking cessation groups. Moore said that in her experience, patients are motivated to change their behaviors when they know it improves their eligibility for procedures and the likelihood of positive outcomes. Patient recovery The minimally invasive surgical techniques used for outpatient joint replacement procedures reduce cutting of muscles and promote early ambulation. For patients to be discharged on the same day as surgery, anesthesia professionals need to administer the minimum amount of anesthesia necessary to keep the patient comfortable during the procedure. A few hours after surgery, the perioperative RNs at Moore’s facility encourage patients to get out of bed. Because patients may still be experiencing the effects of anesthesia when they are discharged and may require assistance while walking, the support people who will help the patients at home need to learn what to expect and how best to help. The team helps ensure that support people are ready to help patients by including them in the preoperative education classes. At Moore’s facility, the physical therapists on staff work collaboratively with the perioperative RNs and provide training to the RNs so they can help
P8 | Periop Briefing
the patients ambulate after surgery. Before each patient leaves, the team confirms that the patient’s first physical therapy session is scheduled for the following day. The team follows up with each patient via phone three days and 21 days after surgery. Indicators of success The Joint Commission awards certifications to programs offering total knee and total hip replacement procedures that demonstrate effective patient education related to each phase of care.2 Preoperative education should include comorbid assessments, risk factors, postoperative rehabilitation, and discharge planning to help patients participate in a shared decision-making process with their care providers. Throughout the continuum of care, providers should demonstrate consistent communication and collaboration. Moore’s team continues to work with The Joint Commission to optimize their program and implement documentation tools for data tracking. “The Joint Commission has been amazingly helpful for us through all of this,” said Moore. “They’ve given us so many good ideas and they’ve really inspired us to go above and beyond.”
Providing high-quality outpatient care Even with the success of programs like the joint replacement program at Ohio Specialty Surgical Suites, some clinicians and researchers have identified some areas of concern regarding the larger trend of more surgical procedures being performed at ASCs. A recent study of more than one million procedures performed at 86 freestanding ASCs in South Carolina found an average rate of postoperative acute care requiring admission to an inpatient facility of 17.3 per 1,000 procedures, indicating room for improvement in identifying patients who may require this type of care and providing better follow-up care.4 Ongoing research may help identify the surgical outcomes and acute care use of patients undergoing outpatient procedures as these procedures become more common. An analysis of outpatient surgeries by Erhun et al5 cited several potential issues with care provided at ASCs, including financial incentives for surgeons to perform surgeries that may be unnecessary and
ineffective communication among primary care physicians, patients, and surgeons. Using interactive patient decision aids, clinical decision support tools, and case coaching services through a third-party provider are a few ways to help ensure patients and care providers choose appropriate surgeries.5 Because surgeries performed at ASCs do not involve urgent circumstances or high-risk patients, care providers can implement standardized care plans that may improve efficiency and care quality.4
Conclusion Improved patient selection strategies, approaches to patient and family education, minimally invasive techniques, and anesthesia delivery practices contribute to the increasing number of joint replacement procedures performed in hospitalbased outpatient clinics and freestanding ASCs. The education of patients and their support people before surgery supports successful postoperative recovery and positive outcomes. As surgical care continues to shift to outpatient settings, patients and care providers should strive to develop evidence-based care plans that maximize the value of outpatient care.
© AORN, Inc, 2016
References 1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;(11):1-25. 2. Zhani EE. Ohio Specialty Surgical Suites awarded first advanced certification for total hip and total knee replacement. The Joint Commission. https:// www.jointcommission.org/ohio_specialty_ surgical_suites_awarded_first_adv_cert_total_ hip_and_total_knee_replacement/. Published October 18, 2016. Accessed October 28, 2016. 3. Perioperative Patient Engagement Tool Kit. AORN. https://www.aorn.org/guidelines/ clinical-resources/tool-kits/perioperative-patientengagement-tool-kit. Accessed November 11, 2016. 4. Molina G, Neville BA, Lipsitz SR, et al. Postoperative acute care use after freestanding ambulatory surgery. J Surg Res. 2016;205(2):331340. 5. Erhun F, Malcolm E, Kalani M, et al. Opportunities to improve the value of outpatient surgical care. Am J Manag Care. 2016;22(9):e329335.
December 2016 Vol 104 No 6 • Periop Briefing | P9
PERIOP BRIEFING
OUTPATIENT PROCEDURES