CHAPTER 1. Evolution of Perianesthesia Care
Jan Odom-Forren and Theresa L. Clifford
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Describe three of the earliest recovery rooms.
2. Name the decade when recovery rooms became commonplace.
3. Name the one historical event that contributed most to the advent of recovery rooms.
4. Name three advances in medical technology that led to an increase in ambulatory surgeries.
5. List three reasons for consumer acceptance of ambulatory surgery.
6. Describe the development of the American Society of PeriAnesthesia Nurses (ASPAN).
7. Describe three benefits brought to perianesthesia nursing by ASPAN.
I. EARLY BEGINNINGS
A. Early beginnings of recovery room and ambulatory surgery
1. Trephining of the skull and amputations identified in the year 3500 b.c. as evidenced by cave drawings
2. New Castle Infirmary, New Castle, England (1751): rooms reserved for dangerously ill or major surgery patients
3. Florence Nightingale, London, England (1863): separate rooms for patients to recover from immediate effects of anesthesia
4. Ambulatory surgeries performed at Glasgow Royal Hospital for Sick Children in Scotland from 1898 to 1908
a. Surgeries were performed on 8988 children.
b. Surgeries included orthopedic problems, cleft lip and cleft palate, spina bifida, skull fracture, hernias, and others.
c. None of the children required hospital admission.
5. Information from Glasgow Hospital presented at a meeting of the British Medical Association in 1909
6. Twentieth century
a. First general anesthesia in ambulatory surgery reported in Sioux City, Iowa, in 1918
b. 1920s and 1930s: complexity of surgeries increased
c. 1923: Johns Hopkins Hospital, Baltimore, Maryland, three-bed neurosurgical recovery unit opened by Dandy and Firor
d. World War II: recovery units created to provide adequate level of nursing care during nursing shortage
e. 1942: Mayo Clinic, Rochester, Minnesota
f. 1944: New York Hospital
g. 1945: Ochsner Clinic, New Orleans, Louisiana
h. 1940s and 1950s: early ambulation after surgery came into acceptance
B. Value of recovery room demonstrated in improving surgical care
1. Anesthesia Study Commission of the Philadelphia County Medical Society report (1947): one third of preventable postsurgical deaths during an 11-year period could have been eliminated by improved postoperative nursing care.
2. Operating Room Committee for New York Hospital (1949) stated that adequate recovery room service was necessary for any hospital that provided surgical services.
II. ACCEPTANCE AND DECLINE OF RECOVERY ROOMS
A. Impact of changing technology on patient care
1. 1950s: more knowledge of common postanesthesia complications
2. 1950s and 1960s: growth of surgical intensive care and postoperative respiratory support
3. Expanding complex surgical procedures
4. Expanding technology led to outpatient complex surgeries.
a. Microscopic surgeries abounded
b. New lasers were developed (yttrium argon gas, argon, carbon dioxide).
c. New laparoscopic instruments facilitated shorter, less invasive laparoscopic procedures.
d. More endoscopic procedures were being performed as outpatient procedures.
e. Video equipment and computer-assisted surgeries were now being performed.
f. Fiberoptics led to advances in ophthalmic surgeries, most of which are performed in outpatient settings.
5. Change in anesthesia techniques and medications
6. 1970s: recovery rooms managed routine postanesthesia patients, including ambulatory, routine, and critically ill patients receiving respiratory and circulatory support.
7. Many diagnostic procedures done in ambulatory settings
a. X-ray procedures
b. Laboratory tests
c. Physical therapy
d. Cardiopulmonary tests
e. Pain blocks
B. Recovery rooms lose viability and identity.
1. Staffing: shortage of skilled personnel
2. No organized body of knowledge pertinent to postanesthesia
a. Staff performance evaluated on the basis of trial and error
b. No territorial restrictions: in some places considered to be extension of operating room
c. No established standards of care
III. AMBULATORY SURGERY FOCUS
A. Ambulatory surgery programs established
1. The nation’s first ambulatory surgery program opened at Butterworth Hospital in Grand Rapids, Michigan, in 1961, and staff performed 879 ambulatory surgeries between 1963 and 1964.
2. A formal ambulatory surgery program began at the University of California–Los Angeles in 1962.
3. In 1968, the Dudley Street Ambulatory Surgery Center opened in Providence, Rhode Island.
4. The nation’s first freestanding surgery facility was opened in 1970 by Dr. Wallace Reed and Dr. John Ford in Phoenix, Arizona.
a. In 1971, the American Medical Association endorsed the use of surgicenters.
b. In 1974, the Society for the Advancement of Freestanding Ambulatory Surgery was formed, which was the precursor for the current Federated Ambulatory Surgery Association (FASA).
5. The American Society for Outpatient Surgeons (now known as American Association of Ambulatory Surgery Centers) was formed in 1978, paving the way for surgery being performed in doctors’ offices.
a. The 1980s brought a shortage of inpatient hospital beds.
b. In 1980, the Omnibus Budget Reconciliation Act authorized reimbursement for outpatient surgery.
c. In 1981, the American College of Surgeons (ACS) approved the concept of ambulatory surgery units (ASUs) as preadmission units for scheduled inpatients.
d. In 1983, Porterfield and Franklin advocated for office outpatient surgery.
e. The Society for Ambulatory Anesthesia was formed in 1984.
B. The ambulatory surgery concept proliferated in the 1980s.
1. Hospital-affiliated ambulatory surgery accounted for 9.8 million operations (45%) performed within hospital settings by 1987.
2. By 1988, 984 freestanding outpatient surgery centers performed more than 1.5 million surgical operations.
3. By 1989, there were 984 Medicare-participating freestanding ambulatory surgery centers in the United States.
4. The list of approved procedures that can be conducted in surgery centers was expanded in 1987 by the Health Care Financing Administration (HCFA), now known as the Centers for Medicare and Medicaid Services.
5. In 1989, HCFA revised the payment schedule for outpatient surgeries performed on Medicare patients.
C. Freestanding recovery sites
1. In 1979, the first freestanding recovery care center opened in Phoenix, Arizona.
a. Patients were transported directly to the recovery care center from hospital post anesthesia care units (PACUs), from the ASU, and from physicians’ offices.
b. Some patients were transferred there from hospitals on their second or third postoperative day.
2. The limits of stay for recovery care centers are defined by state regulation.
3. In the 1980s, the concept of 23-hour units led to guest services being developed for patients living more than 1 hour away from the site where the surgery was to be performed (hospital hotels; medical motels).
a. Freestanding medical motels are considered a comfortable, affordable, convenient place to recuperate.
b. Patients are cared for by family members.
c. Home health nurses make visits, or a nurse is stationed onsite.
4. In 1996, data from the National Center for Health Statistics Data Center
a. An estimated 31.5 million surgical and nonsurgical procedures were performed during 20.8 million ambulatory visits in 1996.
b. An estimated 17.5 million (84%) of the ambulatory surgery visits were in hospitals and 3.3 million (16%) were in freestanding centers in 1996.
c. In 2000, 63% of all surgeries were performed in outpatient settings.
5. In 2005, there were more than 4200 ambulatory surgery centers that provided over 12 million surgeries annually.
D. Economics of ambulatory surgery
1. Cost control, a primary force in the development of ambulatory surgery
a. In 1988, 58% of surgery centers contracted with health maintenance organizations and 52% with preferred provider organizations.
b. In 1990, the American Hospital Association reported that more than 50% of all hospital-based surgical procedures were done on an outpatient basis.
c. In the 1990s, 23 home observation units (recovery centers) were established in the United States.
d. The percentage of outpatient procedures approved for payment under Medicare increased.
(1) In 1982, 450 procedures approved
(2) By the early 1990s, 2500 approved procedures
(3) On July 1, 2003, 282 additional procedures added
e. Third-party payers require many surgeries to be performed in an ambulatory setting to avoid the cost of hospitalization.
f. Many freestanding centers have contractual arrangements with managed care plans, rehabilitation centers, and nursing homes.
g. Outpatient facilities eliminate the costs of cafeteria, laundry, and the need for 24-hour staffing.
h. Outpatient procedures eliminate unnecessary lab, x-ray, and electrocardiogram services.
i. Patients recovering in 23-hour units are considered nonhospitalized for purposes of reimbursement by Medicare and third-party payers.
E. Legislation encouraged growth of ambulatory centers.
1. Relaxation of legislation began to occur in the 1980s.
2. By 1987, the Omnibus Budget Reconciliation Act provided for less reimbursement to hospitals, providing rates equal to those for ambulatory surgery centers.
3. The Omnibus Budget Reconciliation Act of 1989 again increased the reimbursement rates for assigned surgical procedures in ambulatory centers.
4. Ambulatory centers became certified by accepted certifying agencies.
F. Consumer acceptance of ambulatory surgery
1. Awareness
a. Increased marketing led to increased consumer awareness.
b. Greater awareness led to greater demand for surgery in ambulatory settings.
c. Consumers saw more physician involvement in ambulatory settings.
d. Patient consumers felt more involved and took part in decisions.
e. Few problems were seen with quality of care.
2. Convenience
a. Flexible hours
b. Early admission and same-day discharge
c. Less time lost from work
d. Units easily accessible
3. Wellness philosophy well accepted
a. Patients could walk to the operating room.
b. Patients could recover on stretchers or in recliners.
c. Parents could remain with children during induction; parents and sometimes families could be present postoperatively.
d. Patients were able to keep dentures, eyeglasses, and hearing aids with them.
e. Patients felt more involved in decision-making for their care.
f. Family visitation encouraged in phase I PACUs
4. Reimbursement
a. Reimbursement provided by Medicare for outpatient procedures for the elderly made ambulatory surgery a viable alternative.
b. Employers were paying less, and consumers found ambulatory settings less expensive, making outpatient surgery an attractive option.
IV. EMERGENCE OF ORGANIZED RECOVERY ROOM GROUPS
A. Need to identify a special body of knowledge and skills required for practice
1. Groups form to develop educational opportunities.
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a. Nineteen groups organized in United States
b. Florida Society of Anesthesiologists initiated yearly seminar in 1969.
(1) Attended by nurses from United States and Canada
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