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46: Care of the Ambulatory Surgical Patient
Ambulatory surgery continues to grow rapidly, expanding in both the types of procedures performed and complexity of patients cared for. Providing quality nursing care in this setting requires a strong knowledge base, technical skills, and the ability to problem solve, along with clear communication and support for patients and families. The acute nature of surgery and anesthesia and potential complications demand the application of critical thinking and advanced nursing skills, while the short time frame of nursing care requires astute assessment and the ability to intervene rapidly and appropriately. More awake patients and family involvement place the nurse in the roles of educator, counselor, and support system to help the patient with proper preparation and be ready for safe care after discharge. Short-acting anesthetic agents and adjunctive drugs allow quick return to alertness and self-care with fewer unpleasant side effects. In addition, consumers have access to a wealth of information and may be more educated about care options, costs, and outcomes than in past generations. Current fast-paced lifestyles make the “in and out” care and same-day discharge a desirable choice. Cost-conscious consumers, advances in technology and medication, and reimbursement aspects also play a role in the growing trend toward ambulatory surgery.
ambulatory surgery; outpatient surgery; same-day surgery; perianesthesia
Ambulatory surgery (AS) continues to grow rapidly, expanding in both the types of procedures performed and complexity of patients under care. Providing quality nursing care in this setting requires a strong knowledge base, technical skills, and the ability to problem solve, along with clear communication and support for patients and families. The acute nature of surgery and anesthesia and potential complications demand the application of critical thinking and advanced nursing skills, while the short time frame of nursing care requires astute assessment and the ability to intervene rapidly and appropriately. More awake patients and family involvement place the nurse in the roles of educator, counselor, and support system to help the patient with proper preparation and be ready for safe care after discharge. Short-acting anesthetic agents and adjunctive drugs allow quick return to alertness and self-care with fewer unpleasant side effects. In addition, consumers have access to a wealth of information and may be more educated about care options, costs, and outcomes than in past generations. Current fast-paced lifestyles make the “in and out” care and same-day discharge a desirable choice. Cost-conscious consumers, advances in technology and medication, and reimbursement aspects also play a role in the growing trend toward AS.
Ambulatory Surgery (AS) Surgical and other procedures where the patient is expected to be discharged the same day and not require an overnight stay in the hospital. Terms synonymous with AS include outpatient surgery or same-day surgery.
Ambulatory Surgery Center (ASC) A standalone, separate facility from a hospital that may be on the same campus as or separate from other medical facilities where patients have surgical and procedural services performed. Depending on state requirements, the ASC may require licensure. Some, but not all, are also Medicare-certified.
Freestanding Ambulatory Surgery Center (FASC) Term used interchangeably with ASC.
Hospital Outpatient Department (HOPD) An area within a hospital that provides perioperative care for surgery patients who are discharged on the same day. These departments often function as a same-day admitting area for other surgical patients.
Joint Venture Surgery Center An ASC that has more than one ownership entity, such as a corporation and physicians, a hospital and physicians, or any combination thereof.
Third-Party Payer An organization other than the patient or patient’s responsible person (first party) or health care provider (second party) that pays health care claims. These may include insurance companies, health maintenance organizations, workers’ compensation boards, employers, attorney representatives, and federal or state government agencies.
While different terminology may be used, AS encompasses patients who have surgery and are discharged the same day. AS patients may be cared for in the hospital setting, often referred to as same-day or outpatient surgeries, in freestanding ambulatory surgery centers (ASCs), or in AS areas within an acute care setting. Patients may even have their procedure done in an office. The overall goal is to have the patient safely and efficiently discharged after the procedure.
Ambulatory surgeries were performed on children in the late 1800s and early 1900s in Scotland. The first AS program in the United States opened in 1961, with the first freestanding facility opening in 1970.1 More than 60% of surgeries in the United States are performed in an ambulatory setting, totaling more than 22 million surgeries each year.2 Based on data from the Centers for Medicare and Medicaid, the primary ambulatory procedures performed are orthopedic, ophthalmology, pain, endoscopy, podiatry, otolaryngology, obstetrics and gynecology, and dental.3 An opportunity to reduce health care costs for surgery, increase ease of use for patients, and create specialized centers to care for specific patient populations have all contributed to the growth in AS.
Factors contributing to the trend of same-day procedures and early discharge include technological advances in instrumentation and equipment, along with improved surgical techniques and anesthesia protocol changes.4 As technology and medications have helped expand surgeries and procedures performed as outpatient, care of the aging population and those with underlying or complex medical histories has also grown in the outpatient setting. Many surgeries that previously would have required an overnight stay or several nights in the hospital have transitioned to outpatient surgeries. Examples include spinal procedures, advanced joint replacement procedures, hysterectomies, and laparoscopic gastric. In some cases, even cardiovascular and thoracic surgeries are performed on an outpatient basis. This shift in care requires careful planning including having the appropriate equipment, environment of care, and staff education to support new procedures in the ambulatory setting. AS will continue to expand as health care advances.
Perianesthesia nurses who work in the AS setting must be well educated and demonstrate accurate clinical assessment skills while applying critical thinking and patient-centered approaches to meet the needs of individual patients and situations. Nurses attend to and prepare patients and their families prior to surgery as well as throughout their postoperative needs. Nurses should adapt their communication based on the needs of the patient and their families to ensure understanding. In addition, they should provide effective and professional communication with colleagues and in their documentation. Nurses’ documentation skills and the forms used in the facility should allow for precise documentation of findings in minimal time. Implementation of the electronic medical record (EMR) has required yet another skill of the ASC nurse, combining the challenge of accurate computer skills with a continual focus on the patient rather than the equipment.
Patients discharged on the same day of their procedure require nursing care in a much-shortened time span. AS nurses place emphasis on rapid yet comprehensive patient assessment along with clear patient and family education. AS nurses encourage the patient’s self-care and self-responsibility from preadmission and through postdischarge. Nurses must address adherence to planned medical and nursing care and then must assess the patient’s ability, desire, and intentions to comply.
It is essential to recognize and address the social, emotional, and educational needs of patients in addition to their physical concerns. Unspoken questions may linger for patients and their families such as the final outcome of the procedure and concerns about health and well-being, financial burdens, doubts about the availability and quality of postoperative support after discharge, vulnerability, and whether full preoperative life activities can resume and how quickly. Nurses should create a safe environment for conversations and open communication around sensitive types of questions and discussions including issues such as elimination needs and sexual concerns that patients may be too shy or embarrassed to ask about.
Involvement of the family or another responsible adult who will provide support is integral to the overall plan of care. Thus, assessment of the caregiver’s abilities, willingness, and availability should occur before the day of procedure, allowing time for any necessary interventions
Regardless of the type of facility, the patient’s basic nursing needs remain the same. That care combines both critical assessment and monitoring during periods of high dependence, such as during anesthetic regional injections and immediately after general anesthesia or sedation, with periods when the patient is encouraged and taught how to assume responsibility for self-care. This care often is provided through a two-phase recovery process: the initial postanesthesia care unit (PACU) and a less care-intensive second phase unit from which the patient is eventually discharged.
Nursing care should promote wellness and self-care to the highest degree possible. Patients should be continually encouraged to think positively and to provide self-care as much as appropriate and possible. Orem’s general theory of nursing—a three-part theory regarding self-care, self-care deficit, and the nursing system—provides the basis for determining and using the patient’s personal strengths relating to self-care.5 This Self-Care Deficit Nursing Theory describes nursing planning and intervention appropriate to the ambulatory surgical patient. The nurse calculates the patient’s self-care demand and shares with the patient what must be done to regain or promote health in relation to postoperative recovery. Nursing actions revolve around teaching the patient and family, gaining acceptance of the prescribed actions, and then assessing the degree to which the nurse feels the patient can and will comply.
The concept of a self-fulfilling prophecy is a tool often used by managers to motivate a team. Likewise, nurses can apply the concept to help patients expect success and comfort. According to the principles of a self-fulfilling prophecy, an outcome is more likely to happen when the patient expects it. The outcome is preprogrammed by the patient’s outlook; therefore, the nurse’s focus on wellness and uneventful recovery can be an important tool to shape the mindsets of the patient and caregiver in a positive direction. Positive but honest, rather than negative, references are used in questions asked and information given. An example might be coaching a patient who reports they “always vomit” after surgery. The nurse, by allowing the patient to tell their story, may identify that the “always” was 15 years ago. The nurse can help the patient understand how with improved anesthetic agents there is now a much less chance of associated anesthesia-relative nausea. As the nurse, you can employ both nonpharmaceutical and prophylactic medication orders while explaining the added benefit to the patient and relaying concerns to the anesthesia provider. The nurses are also called upon to educate and redirect family members who want to describe their prior negative experiences in front of the patient who is waiting for their procedure and may already be nervous or concerned.
The AS nurse should work to assess the patient’s level of literacy when providing instructions. Misunderstandings place patients at increased risk for poor outcomes. The National Institutes of Health (NIH) Office of Communications and Public Liaison (OCPL) established the NIH “Clear Communication” initiative that focuses on achieving two key objectives of health literacy6:
- 1. Providing information in the form and with the content that is accessible to specific audiences based on cultural respect.
- 2. Incorporating plain language approaches and new technologies.
Using clear communication and plain language helps save time and can also reduce costs. Plain language is described as a strategy for making oral and written information easier to understand and incorporates the elements of7:
Organizing information so that the more important points come first.
- • Breaking complex information into understandable chunks
- • Using simple language and defining technical terms
- • Using the active voice
Patient-centered care should be provided for the diverse population served, encompassing gender, sexual orientation, race, culture, and those with physical or mental disabilities. An interpreter should be used for non–English-speaking patients and families throughout care, starting with the preoperative call or visit through discharge. Resources vary and may include in-person translators, over the phone or with technology video interpreters. Using plain language and avoiding medical terminology, along with written resources, and applying the teach-back method, where patients explain information in their own words, are important aspects of communication throughout care.
Preparing a surgical patient is a vital aspect of patient care, but even more so for the ambulatory surgical patients. Preparing the patient for discharge and care after surgery should begin at the time of planning/scheduling the surgery or procedure, in the provider’s office. Education should continue through the preoperative phone call with any instructions for prior to surgery, for the day of surgery, and what to expect after surgery. During the preoperative call or clinic visit, the nurse should verify that the patient has a ride home after the surgery, as well as a support person to hear and understand any additional discharge instructions and stay with them and help if needed based on type of surgery. If the patient does not have a ride or support person to be with them after surgery, the surgeon and anesthesia team should be notified, as additional or alternate arrangements may need to be made.
Assessment of the patient’s needs may lead to a provider’s referral to a home health provider for specialized nursing care, infusion therapy, pain management, physical therapy, or equipment-related needs. As much as possible, nurses should identify and anticipate these needs early, prior to the day of the procedure. If needs are identified before the day of the procedure, a referral can be made for equipment and supplies to be delivered to the patient’s home to ensure availability along with appropriate instructions for use. In addition, resources required for patient care and recovery at home may or may not be financially supported by payers. The earlier a postdischarge need is identified, the longer time can be allotted for solving challenges. Identifying concerns early during the preoperative call or clinic visit allows for exploration of other options to make sure that the patients’ needs are met and can be cared for safely. This also reduces the need for additional work and delays the day of surgery and potential increased length of stay in the perioperative area while determining the plan of care for the patient.
Careful preoperative selection and preparation of patients for outpatient surgery help reduce the risks of perioperative complications. Nonetheless, many patients may have significant physical, emotional, or social challenges, yet they return home soon after surgery or other procedures because of payer requirements. In addition to systemic illnesses that limit their ability to care for themselves and possibly increase the risk of perioperative complications, many people have limited social or family support. Nurses are especially challenged to prepare these more complex patients for an early transition to home. Community, health system, and payer resources must be effectively and creatively tapped.
The ultimate goals of complication-free recovery and early discharge are supported by what occurs before surgery. Proper patient selection, preparation, and education all contribute significantly to eventual patient outcome. Comprehensive physical assessment, history taking, and evaluation of the patient’s social, emotional, and cognitive status are all essential to that care. The challenge for the AS nurse, however, is completing all those evaluations in a condensed time frame.
Nursing care also must reach beyond the facility into the patient’s home setting, including preoperative education that helps encourage preparation of a safe home setting for postoperative recuperation. Although nurses cannot be responsible for the actions of patients outside the facility, nurses do provide education, coaching, and suggestions for the patient’s pre- and postoperative care following discharge. The need to gain the patient’s confidence and cooperation and to ensure the involvement of a responsible adult cannot be overstated. Support and education of the caregiver is another component of the nursing role.
Before the day of surgery, while an onsite preadmission assessment could be ideal for history-gathering and physical assessment, a telephone contact before the day of the patient’s procedure is much more common. The industry has come to this more streamlined approach for a number of reasons including the busy lifestyles of the patient population, the economic restrictions of health care providers, the trend toward little or no diagnostic testing, and our current comfort with a telephone process. Although a physical assessment or facility tour cannot occur via telephone, other components of the preadmission care can be provided.
The Internet is another tool allowing patients and staff to share two-way information. Commercial and facility-developed assessment and educational tools allow patients to name their own time for providing preoperative health and demographic information. This does not preclude direct nursing interactions, but it provides a baseline from which to begin. Commercial and home-grown Internet sites are proliferating, and many take advantage of connectivity to laboratory and other diagnostic storage, providing a one-stop shop for the AS team to identify important patient information.
The Internet has become a common source of information, much of which is helpful, but some that is unreliable at best. Nurses should be prepared to evaluate the accuracy and value of such information and advise the patient toward appropriate sites. Examples of sites providing reliable information include the following:
Both the American Society of PeriAnesthesia Nurses (ASPAN) and the American Society of Anesthesiologists (ASA) websites provide information and brochures specifically geared toward patient education. The ASPAN website includes patient information on outpatient surgery, pain management, preanesthetic interview/testing, preverification checklist, and what to expect on the day of surgery, in preoperative holding, in the operating room, in the postanesthesia care unit, and if you are going home on the same day of surgery. The ASA website provides patient information related to outpatient surgery regarding types of anesthesia available, how to prepare for outpatient surgery, and what to know about the facility and physicians, in addition to risks, preparation, recovery, pain management, procedure specific, and pediatric content.8
Patients at high risk can be identified and may be asked to come to the facility for physical examination and anesthesia consultation. Early identification of significant risk factors allows time to correct any deficiencies or, if necessary, to reschedule the surgery to avoid day-of-surgery cancellations or unexpected postoperative complications and overnight admissions that are more costly, upsetting to the patient and provider, and generally time-consuming. See EBP box.
While each patient’s risk must be addressed individually to determine if outpatient surgery is appropriate, the following conditions put patients at an increased risk9,10:
- • Unstable ASA physical status classification III or IV (e.g., cardiac, renal, endocrine, pulmonary, hepatic, or cancer diagnoses)
- • Active substance/alcohol abuse
- • Psychosocial difficulties, that is, responsible caregiver not available to observe the patient on the evening of surgery
- • Poorly controlled seizures
- • Morbid obesity with significant comorbid conditions, that is, angina, asthma, obstructive sleep apnea (OSA)
- • Previously unevaluated and poorly managed moderate to severe OSA
- • Ex-premature infants younger than 60 weeks postconceptual age requiring general anesthesia with endotracheal intubation
- • Uncontrolled diabetes
- • Current sepsis or infectious disease necessitating separate isolation facilities
- • Anticipated postoperative pain not expected to be controlled with oral analgesics or local anesthesia techniques
The American College of Cardiology (ACC) and American Heart Association (AHA)11 reclassified clinical predictors of increased perioperative risk for a major adverse cardiac event (MACE) and/or perioperative stroke for patients undergoing noncardiac surgery into two levels (low and elevated) based on both the procedure being performed and patient characteristics. All risk factors should be considered before any surgery but especially before elective surgery that could wait until a more stable cardiac status can be attained. Active cardiac conditions for which the ACC and AHA recommend evaluation and treatment before elective surgery include unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valve disease, although these recommendations are not specific to AS. The provider will determine the need for adjunctive preoperative cardiac assessment. Smilowitz and Berger12 include an algorithm to assess perioperative cardiovascular risk in their review.
Patients who take routine medications need instructions from the attending health care provider or anesthesia provider about which medications should be taken on the morning of surgery, usually with a small sip of water. Medications most often continued until the time of surgery include antihypertensives, cardiac antiarrhythmics, coronary artery dilators, bronchodilators, and respiratory inhalants (should be brought on the day of surgery). Patients with diagnosed sleep apnea may be asked to bring their continuous positive airway pressure (CPAP) device with them on the day of their procedure.
Precise instructions regarding blood thinners should be given by the patient’s provider. Specific information about insulin and diet for patients with diabetes can help to avoid wide swings in glucose levels. Medication instructions are the responsibility of the provider; however, they are often confirmed, reinforced, and clarified by nursing personnel.
Patients should be encouraged to fill prescriptions for postoperative medications before the day of surgery to avoid delays at home. If patients have not yet received any prescriptions, they should know to be prepared to obtain medications if it is likely that prescriptions will be given on the day of surgery.
Specific instructions necessary before the day of the procedure include arrangements for transportation and adult support, the projected length of stay, and general expectations on the day of surgery. The patient also should be instructed on the proper clothing to wear for ease of dressing after surgery, preparation of the home environment, physical restrictions after surgery, and any equipment or supplies to purchase or secure before arrival for surgery.
Parents of small children may be asked to have two adults accompany the child—one to drive and one to attend to the child during transit home. In some institutions, supporting adults are instructed that they must remain at the facility throughout the patient’s stay. In others, only parents of minors or special needs adults are required to remain on site. Patients and families should be told about such expectations ahead of time.
More complex procedures are performed on sicker and older patients in the outpatient setting. Elderly patients who may have been primarily seen in an acute care setting or stayed one or more nights in the hospital after surgery are having more and more cases done on an outpatient basis as well. Older patients may have more underlying medical conditions and be taking more medications that require additional time to manage and educate the patient in order to optimize their care and reduce adverse events.13 In addition, the patient may be a primary caregiver for another family member. In this situation the patient will need to arrange not only care for themselves, but also for their family member. While this goes beyond the immediate care of the ambulatory surgical patients, it is an important aspect to keep in mind as it can delay discharge or put the patient at risk for not having the support they need to recover.
Fasting requirements are routinely defined per facility with the anesthesia department. Additional instructions may come directly from the provider based on type of procedure. Requirements are less stringent today than the past. Traditional guidelines for “nothing after midnight” have been challenged and are now rarely used. The ASA provides the following fasting guidelines for healthy patients undergoing elective procedures that involve anesthesia and sedation.14
|Minimum Fasting Hours†|
|Light meal** (e.g., toast and clear liquid)|
|Meal with fried or fatty foods or meat|
|8 or more|
*These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the guidelines does not guarantee complete gastric emptying. †The fasting periods noted above apply to all ages. ‡Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. §Since nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period. **A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Additional fasting time (e.g., 8 or more hours) may be needed in these cases. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.
From: ASA. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration*. Anesthesiol. 2017;126:376–393. Available at: pubs.asahq.org/anesthesiology/article/126/3/376/19733/Practice-Guidelines-for-Preoperative-Fasting-and?_ga=2.37038886.70275856.1664501902-1941909908.1664501902.
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