Ambulatory Surgery Unit Research Articles

A Survey of Pain and Other Symptoms That Affect the Recovery Process After Discharge From an Ambulatory Surgery Unit

A Survey of Pain and Other Symptoms That Affect the Recovery Process After Discharge From an Ambulatory Surgery Unit

Tratamiento del hidrocele en cirugía mayor ambulatoria

To evaluate the results of this surgical treatment of hydrocele over the first four years of integration of the Urology Department in the Major Ambulatory Surgery Unit in our Hospital.From January 2000 to July 2004 we have performed 167 hydrocelectomies as ambulatory surgery in 152 patients (15 cases bilateral) with ages ranging from 16-87 years (mean 52.6). All procedures were performed under local anesthesia, using between 10-15ml of 1% lidocaine. The Lord's vaginalis plication technique was employed in 92% of the cases, leaving resection techniques for the remaining 8%, which presented certain degree of enlargement of the tunica vaginalis. We evaluated inclusion and discharge criteria, results, and degree of satisfaction by means of a questionnaire.Results are equivalent to those of inpatient surgery. Only one patient required admission to the hospital due to a postoperative complication, which was clearly independent of the ambulatory character of the process. Satisfaction with treatment was higher than 95%.Almost all patients with hydrocele are candidates to ambulatory surgery, significantly improving the cost-efficacy rate, without diminishing the quality of care or patient satisfaction.

Minilaparotomy myomectomy: A minimally invasive alternative for the large fibroid uterus

Study objective To assess the efficacy of performing myomectomies through 3- to 6-cm incisions for the removal of myomas up to 14 cm in diameter. Design A retrospective analysis of 139 myomectomies performed at our center from January 1995 through December 2003 (Canadian Task Force classification II-3). Setting A suburban medical center, part of a large prepaid health maintenance organization. Patients One hundred thirty-nine women. Interventions Myomectomies were performed through 3- to 6-cm suprapubic cruciate incisions using atraumatic elastic retractors with or without laparoscopic assist. Myomas were morcellated with a scalpel before being enucleated. The uterus was repaired in a classic three-layered closure in all cases. All procedures were performed in the ambulatory surgery unit of our hospital, which is part of the main operating room. Measurements and main results The median age of the patients in this series was 30.0 years (range 23–56 years). The median weight of the myomas removed was 275.0 g (range of 30–975 g). One hundred thirty-seven (98.5%) of 139 patients were discharged in 23 hours or less, with 24 patients leaving within 4 hours and 61 within 8 hours. The median length of stay was 6.0 hours, with two patients remaining hospitalized for 48 hours. The median operating time was 110 minutes (range 44–260 min). Estimated blood loss ranged from 50 to 2000 mL, with a median of 300 mL. Three hysterectomies were performed: one as an emergency for hemorrhage and two for recurrent myomas. Three patients developed wound seromas, and one developed a wound infection. Conclusions Minilaparotomy myomectomy is a safe, effective minimally invasive alternative to laparoscopic myomectomy. Early discharge and return to normal activities is comparable to laparoscopy and is far more cost effective. It affords the ability to palpate the uterus and close the myometrial defect easily with a standard three-layered closure making it particularly suitable for gynecologists with limited laparoscopic suturing skills.

Post-operative care and patient satisfaction after ambulatory surgery for breast cancer patients

Aim This study aimed to evaluate patient information provided, the management of post-operative symptoms and post-operative care, and patient satisfaction with ambulatory breast surgery over a 1-year period. Methods From January to December 2000, all breast cancer patients undergoing conservative breast surgery were offered surgery as an outpatient procedure at the Ambulatory Surgery Unit. Results Two hundred and thirty six patients underwent outpatient surgery. None were readmitted during the first night or the first week. Two hundred and nineteen patients completed a questionnaire. One hundred and sixty nine patients (group 1) underwent wide local excision (WLE) and 50 (group 2), WLE and axillary lymphadenectomy. Patients in group 2 experienced more pain at discharge from the hospital ( p≤0.01) and during the first week after discharge ( p≤0.00001) than patients in group 1. The mean overall satisfaction score was 8.97 on a scale of 1–10. Post-operative information provided by the surgeon before discharge from the hospital was rated 8.90 on a scale of 1–10 while information provided by the nurse was rated 9.33 ( p<0.0001). Conclusion Ambulatory surgery for breast cancer patients is safe and popular with patients, however, post-operative pain presents problem.

77 Ambulatory Surgery and dental hospital Day Unit

77 Ambulatory Surgery and dental hospital Day Unit

Corrección del pene curvo en cirugía mayor ambulatoria

ObjectiveOTo evaluate the results obtained in the correction of the curved penis by means of Nesbit’s technique during the four first years of integration of our Service in the Major Ambulatory Surgery Unit (CMA) of our Hospital Patients and methodFrom January of 2000 to April of 2004 we intervened in ambulatory regime 21 patient suffering from curved penis (12 congenital and 9 with Peyronie´s disease) by means of Nesbit’s technique. The surgical-anesthetic performed procedure is described and also the criteria of inclusion and discharge are evaluated, as well as the results obtained and the degree of satisfaction by means of the elaboration of a questionnaire ResultsNone of the patients needed entrance for intrasurgery nor postsurgery complications. Thus, we obtained a null incidence of complications with the exception of the inevitable shortening of the penis, clearly independent from the regime of out-patient’s process. The degree of satisfaction with the received treatment has been superior to 95% ConclusionsThe practical totality of the susceptible patients for surgical correction of penile curvature are candidates to be included in a CMA program, improving obviously the relation cost-efficacy, not diminishing for that reason the welfare quality nor the degree of patients’s satisfaction

71 Why a medical director of an ambulatory surgery unit should be Interested In value analysis and process reengineering

Bariatric surgery can provide efficient weight loss and improvement in obesity-related co-morbidities in adults. Laparoscopic adjustable gastric banding (LAGB) comprised 30.3% of all bariatric procedures between 2009 and 2010 in the UK. This review evaluates the level 1 evidence for change in co-morbidities, quality of life (QoL) and weight provided by LAGB compared with other bariatric procedures.Systematic literature search of MEDLINE, EMBASE and CENTRAL (1988 to May 2011) was performed. Only randomised controlled trials (RCTs) were included. Studies with non-surgical comparators, open gastric banding procedures or adolescent participants were excluded. Primary outcome was change in co-morbidities. Secondary outcomes included QoL, weight loss, complications, operation time and length of stay.Five RCTs met the inclusion criteria. Vertical banded gastroplasty, sleeve gastrectomy and gastric bypass were compared to LAGB. Co-morbidities were reported in two studies and QoL in one. LAGB was comparable to other procedures for both of these outcomes. All five trials showed LABG to be effective in weight loss, however all comparative procedures resulted in greater weight loss. Operative time and length of hospital stay were significantly shorter with LAGB. Short-term complications were found to be consistently lower in the LAGB group. Evidence was divided with respect to long-term complications.Co-morbidities and QoL are poorly reported and showed no difference between LAGB and other bariatric procedures. Evidence suggests that LAGB is not the most effective surgical procedure to reduce weight. LAGB is associated with lower early complications and shorter operative time and length of stay, and therefore may be preferable to patients.

48 Gynaecologic ambulatory surgery unit: Vaginal surgery as a resort

48 Gynaecologic ambulatory surgery unit: Vaginal surgery as a resort

97 Evolution of quality indicators In a major ambulatory surgery unit: Ten years experience

97 Evolution of quality indicators In a major ambulatory surgery unit: Ten years experience

47 Gynecologic ambulatory surgery unit: Our 10 years experience

47 Gynecologic ambulatory surgery unit: Our 10 years experience

Effects of Bispectral Index monitoring on ambulatory anesthesia: a meta-analysis of randomized controlled trials and a cost analysis.

Ambulatory surgery is growing in popularity worldwide. For example, 50-70% of surgical procedures in North America are performed on an ambulatory basis. Use of Bispectral Index (BIS) monitoring for titration of general anesthesia may allow use of less anesthetics, reduction in side effects, and faster patient recovery. MEDLINE and other databases were searched for randomized controlled trials examining the use of BIS monitoring versus standard practice in ambulatory surgery patients. Outcomes were extracted from these articles, and a meta-analysis was performed. One thousand three hundred eighty subjects from 11 trials were included in the meta-analysis. The use of BIS monitoring significantly reduced anesthetic consumption by 19%, reduced the incidence of nausea/vomiting (32% vs. 38%; odds ratio, 0.77), and reduced time in the recovery room by 4 min. However, these benefits did not result in significant reduction in time until patient discharge from the ambulatory surgery unit. Cost analysis using pooled costs to reflect North America, Europe, and Asia indicated that use of BIS monitoring increased the cost per patient by 5.55 US dollars because of the cost of BIS electrodes. The use of BIS monitoring modestly reduced anesthetic consumption, risk of nausea and vomiting, and recovery room time. These benefits did not reduce time spent in the ambulatory surgery unit, and cost of the BIS electrode exceeded any cost savings.

Enhancing our practice and providing a pediatric friendly environment in an ambulatory surgery unit

Background: Over the past year we have strived to improve care of pediatric patients undergoing surgical and interventional procedures. Our practice setting was m need of systems and environmental improvements. Objectives: Presently we are expanding our ambulatory pediatnc PACU to recover Same Day Admission (SDA) patients, in-house patients, and pediatnc patients having procedures in other departments. The goal of this process is to create a pediatnc friendly environment and respond to the current capacity management issues in the main PACUs. Implementation: The process included training and educational preparation in the care of acutely ill pediatric patients; adjustment of staffing patterns to provide later evening coverage; expand anesthesia coverage. In-services were provided to meet educational needs and staff were encouraged to attend PALS classes. A task force was formed to discuss systems issues and create a triage system for accepting the non-same day surgery PACU patients. Successful practice: The post anesthesia care of pediatnc patients is now smoother and more efficient. The staff has found their practice more challenging and rewarding Implications for penanesthesia nursing. The competing demands of bed capacity and patient care needs were the catalyst to improve our patient care and enhancement of our pediatnc ambulatory practice setting.

A survey of pain and other symptoms that affect the recovery process after discharge from an ambulatory surgery unit

Study objective To determine the significance of pain and other symptoms on the recovery process after ambulatory surgery, by surveying pain, analgesic use, and related aspects of recovery in the first 48 hours after discharge from an ambulatory surgery unit. Design Prospective, observational, surveillance survey. Patients A total of 175 patients were studied, 25 in each of 6 surgical groups including knee arthroscopy, hernia repair, pelvic laparoscopy, transvaginal surgery, surgery for breast disease, and plastic surgery. Interventions Patients were treated in a manner considered normal or “usual” for the surgeon and the institution. Measurements Pain scores (0 to 10), analgesic use, symptom frequency, symptom distress scores, activity level (% of normal), and satisfaction scores were obtained by telephone interview 24 and 48 hours after discharge. Group means (±SE), proportions and correlations between predictor variables were determined in relevant groups. Main results The response rate to postoperative telephone calls was 89% at 24 hours, and 82% at 48 hours. At 24 hours, maximum pain was >3/10 in 60%, or >7/10 in 20% of patients. Pain prevented or disrupted sleep in 46% of patients. Activity level was reduced to 33% of normal at 24 hours; pain was reported as the primary or secondary reason for limiting activity by 54% of patients. At 24 hours, average pain scores correlated inversely with activity (r = −0.49, p = < 0.0001); least pain score correlated best with satisfaction (r = 0.03, p = 0.0005). Conclusions Improvements in pain therapy after discharge appear warranted to provide more consistent pain relief, and hasten return to normal activity.

The Role of a Nurse Practitioner in an Ambulatory Surgery Unit

Nurses in advanced practice are expanding the roles they perform. Nurse practitioners (NPs) are the largest group of advanced practice nurses, and they have moved beyond primary care to practice in acute care environments, including perioperative settings. This article provides a brief overview of advanced practice nursing and describes the role of NPs in a hospital-based ambulatory surgery unit (ASU). The ASU NPs provide preoperative care and ensure that patients are ready for surgery, which minimizes OR delays.

Is there a role for ambulatory management of emergencies?

The Public Health Code includes the practice of ambulatory surgery. The regulations are well defined and different from the practice of out patients' care. Good practice of this surgery necessitates the will and involvement of the patient, the support of his/her family which means that the operated patient is not alone when he/she returns home after surgery and a medical team remains in contact with the patient. The majority of hand trauma surgical procedures can be performed by ambulatory surgery. Only operations necessitating permanent post-operative care and specific treatment as in the case of intense pain and surgical procedures in multi-trauma require traditional hospitalisation. To this day, there is no or very little litigation related to this surgical practice; the rules and professional obligations are the same as those for surgery with traditional hospitalisation. There are less risks of hospital infections because the operated patient spends only a few hours in the hospital. The rules specify that the proper functioning is under the responsibility of the co-ordinator of the ambulatory surgery unit.

Encuesta nacional sobre manejo preoperatorio y criterios de selección de pacientes en las unidades de cirugía mayor ambulatoria españolas

BackgroundThe objective of this study was to determine both the selection and preparation criteria in patients in various Spanish ambulatory surgery centers, as well as the impact of these criteria on their results. The results were compared according to the type of functional structure of the units (autonomous or integrated). Material and methodsWe performed a cross sectional, descriptive study through postal survey. The survey contained the following items: type of unit, surgical procedures, selection criteria, preoperative assessment and management, and qualitative and quantitative indexes of the activity performed in 2000. A total of 123 units were included with a response rate of 39%. ResultsThe selection criteria showed a high degree of consensus. The outpatient anesthesia clinic was used for preoperative assessment by 97.9% of the units. Most units routinely requested preoperative tests (hemostasis and hemogram by 89%; biochemical parameters by 72.9%) and to a lesser extent chest X-ray (33.3%) and electrocardiogram (35.4%). The introduction of procedures for the management of coexisting diseases was scarce (25-64.6%). Units using the outpatient anesthesia clinic in all patients had a lower cancellation rate (1.5% vs 4.4%). Autonomous units were significantly more likely to accept patients with high surgical-anesthetic risk than integrated units. Autonomous units also showed a significantly lower number of admissions (1.2% vs 1.9%, p = 0.003), mean stay (240 min vs 367 min, p = 0.002), and recovery time (150 min vs 212 min, p = 0.001) than integrated units. No statistically significant differences were found in the remaining parameters. ConclusionsScientifically based protocols for patient selection, preoperative assessment and perioperative management of distinct processes and for the rational use of laboratory tests should be more widely used. The need for an outpatient anesthesia clinic for preoperative assessment was notable. The results of our survey indicate that better results in performance indexes are achieved in autonomous ambulatory surgery units than in integrated units. Given the possibility of defining and validating quality standards, further multicenter studies should be performed.

Why are ambulatory surgical patients admitted to hospital?: Prospective study

Background: Once Ambulatory Surgery (AS) has been demonstrated to be an effective alternative to hospitalisation for many surgical patients, it is necessary to establish clinical indicators to evaluate objectively the quality of care that is being given. Hypothesis: The unplanned admission index (UAI) is a valid and easy indicator of the management and quality of care in ambulatory surgery units. Design: Prospective study. Setting: Public regional hospital level I (less than 200 beds). Main outcome measure: Unplanned admission index (UAI). Patients and methods: Between September 1997 and October 2000, 3502 patients were operated on in our ambulatory surgery unit. The analysed surgical services were General surgery (844 patients), Orthopaedics (646 patients), Urology (499 patients), ENT (329 patients), Ophthalmology (1007 patients) and Gynaecology (177 patients). A prospective study of all the patients was made, with analysis of the following parameters: (1) global and accumulated UAI (per months and years); (2) UAI by surgical specialities; (3) UAI by causes; (4) UAI by type of operation; (5) UAI by type of anaesthesia; (6) case-mix, according to average weight of diagnostic related groups classification (DGR). Results: The global UAI was 4.1%. By specialities, the UAI was 10.7% in Gynaecology; 6.1% in ENT; 5.9% in General surgery; 3.4% in Orthopaedics; 2.3% in Ophthalmology and 2% in Urology. The most frequent causes of unplanned admission were haemorrhage: 15.9%; more extensive surgery than anticipated: 15.3%; postoperative pain: 12.5%; nausea and vomiting: 10.4%; and drowsiness and dizziness: 6.9%. The types of operation with the highest UAI were, gynaecological laparoscopy: 50%; hysteroscopy: 26%; haemorrhoidectomy: 25%; septoplasty: 22%; strabismus surgery: 11%; orchiopexy: 11%; hydrocelectomy: 10%; inguinal hernia repair: 8%. Conclusions: (1) Classification of UAI by specific causes of admission and incorrect selection of patients may detect on-line problems and allow the application of concrete solutions to reduce the UAI index. (2) In order to compare the results amongst different ambulatory surgery units, an international classification of ambulatory patients must be applied. In the same way, an objective index to evaluate the surgical complexity and the patients' morbidity should be developed. (3) The assessment of processes and results should be based on the selection of standard indicators with systematic and periodic measurement.

Ambulatory Anesthetic Care for Electroconvulsive Therapy (ECT) in Psychiatric Patients

We experienced two cases of electroconvulsive therapy (ECT) through ambulatory surgery units. In case 1 patient was a 17 year old male with depressive disorder and the case 2 patient was a 64 year old male also with depressive disorder. A trial of various antidepressants had proved ineffective. They were treated with six ECTs for each case. The case 1 patient complained two times of myalgia suspected to be due to the adverse effects of succinylcholine administration and the case 2 patient showed tachycardia and hypertension due to sympathetic stimulation after application of the current, but the two cases were successfully cared for by ambulatory surgery unit and discharged without severe complications. Perioperative care for individuals who undergo outpatient ECT is similar to the care provided for scheduled ambulatory surgery. Successful performance of ambulatory ECT requires collaboration by psychiatrists, anesthesia care providers, skilled perioperative nurses, affected individuals, and family members.

Preoperative assessment and discharge planning for older adults undergoing ambulatory surgery

Based on this survey, the prevalence of chronic illness and disability in older adult patients with respect to current ambulatory surgery practices is worrisome, especially the fragmentation of patients' care as they progress from the decision to undergo procedures, to preoperative assessment, to postoperative discharge. Ambulatory surgery unit nurses, case managers, surgeons, and office staff members must work together to better optimize time and resources. As baby boomers age, the number of older adults undergoing ambulatory surgery will increase. It is essential for ASU staff members to be cognizant of the special needs of older adult patients. Timeliness, patient education, and appropriate coordination and follow-up of care are important ingredients to successfully plan care for older adult patients undergoing ambulatory surgery. Nurses can play a pivotal role in this success.

Effectiveness of a clinical guide for the treatment of postoperative pain in a major ambulatory surgery unit

A retrospective study to evaluate a clinical guide for the treatment of postoperative pain in our One Day Surgery Unit (ODSU) is presented. A total of 2783 patients, treated during 1 year, were studied. Postoperative pain was evaluated 24 h after surgery by phone-call using a visual analogue scale (VAS) and a verbal response scale (VRS). Results were analysed by groups of analgesia and pain scale values. Admissions due to insufficient analgesia were also evaluated. Mean values obtained in all analgesic groups in relation to the VAS were lower than 2.5. It was found that 86% of patients presented a value of VAS<3, while 84.6% had a VRS value 2. Only two patients were admitted for uncontrolled postoperative pain. The level of postoperative analgesia in our patients was satisfactory. Despite this continuous evaluation of the clinical guides for the treatment of postoperative pain, the use of new powerful analgesic drugs is necessary because the surgical complexity in ODSU is increasing and patients with associated diseases are increasingly accepted.