Which of the following materials are needed to schedule an outpatient surgical procedure?

Criteria for Ambulatory Surgery

Ambulatory surgery comprises 70% or more of the case load in most pediatric centers. Multiple factors should be considered when evaluating whether a child is suitable for outpatient surgery. In most cases, the child should be free of severe systemic disease (ASA class 1 or 2). Other factors that may determine the suitability of a child for outpatient surgery are family and social dynamics. For instance, will this child be cared for by a responsible and capable adult? Is the child to be cared for by a single parent who must work? How far must the child travel to receive appropriate medical attention, if needed?

Well-controlled systemic illnesses do not necessarily preclude outpatient surgery, but these questions must be answered in advance in a cooperative fashion between surgical and anesthesia services. If a child has a moderate degree of impairment but the disease is stable and the surgical procedure is of minimal insult, outpatient surgery may be acceptable. However, ASA class 3 children who present for surgery without prior evaluation run the risk of delaying the turnover of cases where efficiency is often at a premium.

Abstract

ASC patients are anesthetized and their physical mobility is impaired, so they would be unable to escape from a dangerous situation such as a fire. Surgical procedure sites and fields are ripe for an unwanted, unexpected fire. Because all three basic elements necessary for combustion are present—fuel, oxygen, and an ignition source (often lasers)—a flash fire can occur unexpectedly during a critical procedure. All ASCs serving Medicare beneficiaries must be certified by the Medicare program, and are inspected or “surveyed” for compliance with fire and life safety codes. The objective of this guidebook is to provide a basic understanding of the overall fire and life safety code requirements for staff members of ambulatory surgery centers. The information and templates will provide an understanding and tools to help prepare for inspections and surveys.

INTRODUCTION/BACKGROUND

Outpatient surgery accounts for a significant percentage of anesthetics delivered annually in the United States. Many pediatric procedures, including myringotomy and tubes, endoscopy, circumcision, and hernia repair, are performed in infants and may occur on an outpatient basis.

Apnea is the most common serious adverse event after general anesthesia in an infant. Premature and former premature infants are at higher risk of apnea than healthy term babies; there is little evidence regarding apnea risk in term patients. In addition, infants (younger than 1 year) are at higher risk of intraoperative anesthetic cardiac arrest and other complications,1 and require careful anesthetic management by practitioners with training and ongoing experience in this population.

OUTPATIENT VERSUS INPATIENT SURGERY

Outpatient surgery has been routine for cataract extraction for many years. Glaucoma surgery leaves a filtering wound that disrupts the integrity of the eye and, unlike cataract surgery, may leave the eye hypotonous and susceptible to injury from external pressure or Valsalva's maneuvers. Nevertheless, many patients have undergone successful and uncomplicated outpatient filtering surgery,2 and many patients prefer not to stay in the hospital. In many places, particularly the United States, health plans do not authorize overnight stays for routine glaucoma surgery.

Surgical arrangements should be tailored to each patient's needs. There may be cardiac, pulmonary, or other systemic problems that require hospitalization either before or after surgery. Hospitalization may be indicated if there is a history of a complication in the other eye, if the patient is one eyed, or if there is risk of hemorrhage or other complication. Patients traveling from long distances may need to stay in a hotel or guest house for some portion of the preoperative or postoperative period. Although this is not as convenient as staying in the hospital, it is preferable to driving long distances for daily follow-up and is much less expensive than the hospital.

Preoperative Teaching and Parental Presence

Outpatient surgery is an intense experience for both parents and children. Many things happen within a short time span, and the emphasis on efficiency and throughput can limit the time that staff can spend in preparing each parent and child for all that will happen. Preoperative teaching programs have become common methods of education to help families understand what to expect on the day of surgery. These programs include preoperative tours of the outpatient surgery center, preoperative telephone calls, written brochures, and videotapes (Karl et al., 1990; Kleinfeldt, 1990; O'Byrne et al., 1997; Cassady et al., 1999; Bellew et al., 2002; Koinig, 2002). Whereas the explicit goals of these programs are education and the efficient transmission of information, an implicit goal is reduction of anxiety and undesirable behavioral consequences of the stress of the perioperative experience (Margolis et al., 1998). The first objective can be met by many, if not all of these programs, but the more far-reaching ones may be more difficult to attain. A study of 143 2- to 6-year-old children who were randomized to receive either an interactive teaching book or no intervention found more, not less, preoperative anxiety in the children who had received the book, but less aggression during induction and fewer behavioral changes 2 weeks after surgery (Margolis et al., 1998). A well-controlled and designed study found that preoperative teaching programs of various modalities had an effect of anxiolysis only in the holding area on the day of surgery; that effect did not extend effectively to the induction period itself (Kain et al., 1998b). Although parental satisfaction was clearly increased by parental presence during induction, and highly anxious children benefited from presence of a parent during induction, children's anxiety and behavior were more effectively modulated by the use of premedication (Kain et al., 1996; Kain et al. 1998a). Although these data might suggest that the expense and effort of elaborate teaching programs, when examined in a critical and rigorous manner, may not be as cost-effective as more modest programs combined with premedication, one must recognize that limited benefits have value as well. For the parent and child who are waiting for an hour in the preoperative area, a reduction in stress for that period alone is meaningful. Furthermore, the norm in many communities is that such programs are welcomed and expected by many parents; they can also serve as opportunities to educate and improve compliance with preoperative procedures and thereby reduce the incidence of case cancellation.

Part of the art of pediatric anesthesia, of course, is the ability to rapidly establish effective and reassuring communication with the parent and child. The rapport and trust that the anesthesiologist creates during the preoperative interview is also an important and effective method of reassurance and anxiolysis that can enhance the transition to the operating room. In the outpatient setting, where time is more constrained, the value of a quick game, magic trick, kind word, or even brief induction of hypnotic suggestion should not be underestimated. Bringing a security item, such as a blanket or favorite toy into the operating room, can provide additional comfort to the child. Having this item immediately available at the time of emergence may also be helpful (see Chapter 8, Psychological Aspects of Pediatric Anesthesia).

Summary

Successful ambulatory surgery depends on analgesia that is effective, has minimal adverse effects, and can be safely managed by the patient at home after discharge. A number of studies have established that the provision of effective postoperative analgesia is inadequate for a significant proportion of patients. Preemptive analgesia should be given to all patients unless there are specific contraindications. A standardized multimodal postdischarge analgesic regimen tailored to each patient's expected postoperative pain levels should be prescribed. Patient follow-up by telephone questionnaire confirms whether surgical procedures result in mild or moderate to severe postoperative pain and determines the effectiveness of treatment regimens.

Summary

In ambulatory surgical centers, the operation is performed in a friendly environment that is familiar to the patient and relatives. Each step from check-in before surgery to check-out after surgery is designed to allay fears and make the patient as relaxed as possible. It is important that the center has caring dedicated personnel, with compassion and a real willingness to cater to the needs of elderly persons, who are the typical eye patients. In addition, staff must be well trained and competent.

Outpatient ambulatory surgery is based on the fact that, with currently available techniques, complications are no greater than with inpatient cataract surgery in hospitals. The patient's acceptance is, however, much greater with ambulatory surgery. Everywhere in the world, outpatient cataract surgery has become the rule rather than the exception. Certified ambulatory surgical centers have been created that are as high in quality as major hospital operating rooms.

Questions for review and thought

List the significant advantages of ambulatory surgery.

List the possible disadvantages of ambulatory surgery.

Outline safety standards in a free-standing surgical facility.

What are the operative routines followed in your practice?

What are the preoperative testing routines before major surgery?

What medication, both ocular and systemic, is given before a cataract operation by your ophthalmologist?

What is the role of the ophthalmic medical assistant in the care of patients before and after cataract surgery?

What is the medical / legal responsibility of the ophthalmic assistant?

Self-evaluation questions

Answers, notes and explanations

True. The requirements for an ambulatory surgical center are as rigid as those of major hospital operating rooms. The details of the surgical procedure must be outlined in a standard operative report attached to the records.

False. All major surgery requires an informed consent form.

False. Drugs and biologic agents can be given orally or by eye drops by allied health personnel who have been trained to do this. Intramuscular or subcutaneous injections must be given either by a physician or by someone licensed in the state to invade tissue. This may be a registered nurse.

Surgical checklist. Checklists are important to jog one's memory that all items necessary for preoperative and postoperative evaluations are available and the results tabulated. Such information as A-scan measurements may be critical when the time comes for surgery. A checklist is vital.

IM. The injection is given into the muscle mass.

Per os. When medication is given orally, it is often written per os, meaning through the mouth.

b. Office treatment rooms. Office treatment rooms usually do not have the sterility required for major surgery. They also are not adequately equipped for respiratory or cardiovascular emergencies that could potentially occur.

b. Orbital tumor. Orbital tumors may result in bleeding postoperatively, which may require blood transfusions. There also is a possible danger that there could be an invasion of adjacent tissue or some unusual tumor found that requires more extensive dissection.

d. An attending nurse at all times. An attending nurse is not required at all times. Often the physician may supervise a great deal of the ambulatory surgery personally. The ophthalmic medical assistant can be trained to be responsible for a great deal of the patient's care.

Preoperative assessment

The admission, operation and discharge of a patient within a day requires accurate forward planning, with the procedure occurring on a scheduled day at a scheduled time. Day surgery pioneered the role of preoperative assessment, performed up to 6 weeks prior to surgery. As a result nursing, anaesthetic and surgical assessment on the day of admission is both rapid and minimal. Pre-assessment of patients also ensures that ‘on the day’ cancellation for clinical reasons is rare. Cancellations not only waste hospital resources but cause distress to patients and their families and often disrupt work commitments.

To maximise day surgery throughput, pre-assessment may be accomplished by:

automatic assignment to day surgery of all patients undergoing a procedure included in the BADS's trolley of procedures (Box 3.1) or the Audit Commission's updated basket of procedures (Box 3.2);

hospital-wide pre-assessment for all elective surgical procedures (with procedure-specific exclusions for major surgical procedures such as major bowel resection and aortic aneurysm repair).

Successful pre-assessment should focus on educating the patient and their carers about their condition, identifying any preoperative risk factors and optimising the patient's condition. All three aspects need to be performed well in order to maximise success on the day of surgery. Strict assessment criteria ensure patient safety, and identifying any anomalies at pre-assessment allows for timely correction of these factors. Day surgery pre-assessment is best performed by trained nurses in nurse-based pre-assessment clinics. The availability of a consultant anaesthetist to deal immediately with some queries and concerns further improves efficiency. The most common treatable exclusion factors are hypertension and identifying an overnight carer for patients living on their own.

Pre-assessment clinics use a patient questionnaire to screen for social and medical problems. Most questionnaires follow a standard format to screen and triage the suitability of patients for day surgery. Questionnaires should address the generic status of the health of the patient, but additional questions may be added for specific surgical specialities.

Patient information leaflets should also be available covering both general day surgery information and information specific to the proposed operation. These may have been issued at the outpatient consultation where first-stage consent is usually obtained. The later pre-assessment visit allows the patient to ask questions that may have arisen since their consultation, and subsequent discussion leads to better understanding by the patient and family, and may reduce anxiety levels.29 Involvement of the patient at this stage permits flexibility and choice regarding their operating date and improves non-attendance rates.

AAAASF

The American Association for Accreditation of Ambulatory Plastic Surgery Facilities, Inc. was formed in 1980. In 1992, the AAAASF was created to provide accreditation of all American Board of Medical Specialties (ABMS)-certified surgical specialties office-based surgery units. Its program follows the guidelines provided in the 1994 American College of Surgeons publication, “Guidelines for Optimal Office-Based Surgery.”2 The “AAAASF accreditation programs help facilities demonstrate a strong commitment to patient safety, standardize quality, maintain fiscal responsibility, promote services to patients and collaborate with other health care leaders.”3 The AAAASF claims to be the only accrediting organization that mandates 100% compliance with standards that include peer review as a means to demonstrate safety and quality measures in the accredited facilities. The AAAASF holds office-based facilities to hospital standards, requires surgeons (interventionalists) to be board certified and have hospital privileges for any procedure they perform, requires the use of anesthesia professionals for deeper levels of anesthesia, requires a safe and clean surgical environment that meets stringent standards and requires peer review.