Same-day Surgery Patients Research Articles

Is the Compassion of Anesthesiologists Associated With Postoperative Pain and Patient Experience? A Prospective Cohort Study.

Patient perception of physician compassion may be associated with improved health outcomes, yet it is unclear whether it is associated with postoperative pain reduction or improved patient experience metrics in same-day surgery patients. We hypothesized that higher anesthesiologist compassion during the preanesthesia interview, rated by patients, is associated with lower postoperative pain via the anxiety pathway in same-day surgery patients. We also performed exploratory correlation analysis to assess whether compassion was associated with less opioid consumption and improved patient experience in same-day surgery patients. We conducted a single-center, prospective, observational cohort study in American Society of Anesthesiologists (ASA) physical status I to III patients scheduled to undergo same-day surgery with anesthesia. Compassion was scored using a validated 5-item tool. State anxiety (SA) and trait anxiety (TA) were measured using the State-Trait Anxiety Inventory. Pain scores were obtained using a 0 to 10 Likert scale. Daily opioid use was recorded. Patient experience was assessed using the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) and the Surgical Care CAHPS. Mediation analysis was used to assess the association between compassion and pain scores via the anxiety pathway. Spearman correlation was performed to test for association between the compassion score and the secondary outcomes. A total of 147 subjects completed the study with a median age of 50 years and 81% female. Fifty percent underwent breast surgery, 35% abdominal surgery, and the rest underwent gynecological and urological surgeries. The median (Q1-Q3) postoperative pain scores on postoperative days 0 and 3 days later were 4 (1.5-6) and 3 (1-5), respectively.Mediation analysis results showed a same-day anxiety-mediated effect (95% confidence interval [CI]) of compassion on pain of -0.08 (-0.13 to -0.02), attributing to 9% of the total effect. On postoperative day 0, an increase in compassion was associated with a significant average drop in pain of between 0.02 and 0.13. In addition, higher compassion was correlated with better patient experience metrics (ρ= -0.53 [95% CI, -0.64 to -0.39]). The study results suggest that an anxiety-mediated pathway exists through which compassionate care may help improve the patient's perception of postoperative pain on the day of surgery (before discharge from the hospital). Higher compassion was also associated with better patient experience metrics.

Implementation of Continuous Capnography Protocol in a Postanesthesia Care Unit for Adult Patients at High-risk of Postoperative Respiratory Depression

PurposeThis project aimed to implement a continuous capnography protocol in the postanesthesia care unit (PACU) for postoperative adult patients who are at high risk for respiratory failure. DesignA preintervention and postintervention quality improvement design with retrospective chart reviews evaluated patient demographics (age, weight, body mass index [BMI], perioperative fluid intake and output, use of intraoperative positive-end expiratory pressure), length of surgery, average length of PACU stay, incidence of respiratory events, and adherence to a PACU capnography protocol. MethodsPreimplementation data were collected from retrospective chart reviews over a 3-month period. A continuous capnography protocol was implemented for same-day surgery patients with a BMI of 35 kg/m2 or greater and who received general anesthesia. Postimplementation data were collected over 3 months in addition to adherence to the capnography protocol. This was presented using descriptive statistics. FindingsAge, length of surgery, weight, BMI, perioperative fluid intake and output, and use of positive-end expiratory pressure did not impact PACU length of stay. The average PACU length of stay decreased from 76.76 to 71.82 minutes postimplementation but was not statistically significant (P = .470). The incidence of respiratory events was 6% (n = 3). After the implementation of the continuous capnography protocol, adherence to the continuous capnography monitoring was 86% (n = 43). ConclusionsPatients who are at high risk for postoperative respiratory failure may benefit from continuous capnography monitoring in the PACU. Capnography monitoring may decrease PACU length of stay and provide earlier detection of pending respiratory depression or failure than pulse oximetry alone.

300 Patient Experience with Same Day Surgery for Artificial Urinary Sphincter Insertion - A Safe and Efficient Option

ABSTRACT Introduction Prior research has questioned the need for overnight observation (OBS) following artificial urinary sphincter (AUS) surgery. Objective We sought to analyze our institutional experience transitioning from OBS to same day surgery (SDS) for AUS surgery. Methods We retrospectively reviewed AUS surgeries performed by a single surgeon at our tertiary academic medical center between 08/2013 and 03/2020. Medical records were reviewed for patient demographics, immediate postoperative complications, timing of postoperative discharge, need for readmission, emergency department (ED) visit, outpatient phone call, or non-routine clinic visit within 7 days of discharge, and need for device explant or revision within 90 days of discharge. Patients were grouped based on discharge status: OBS vs. SDS. Catheters were removed prior to discharge (OBS group) or self-removed at home (SDS group) on the morning of postoperative day 1 (POD1). Cost savings associated with SDS were estimated using room and bed charges from a contemporary group of AUS patients (09/2017 through 08/2020). Student's t and Chi-squared tests were used to compare groups. Results We identified 528 men who met inclusion criteria. Men in the SDS group (n = 308) were more likely to have undergone a virgin AUS insertion and were slightly younger and healthier (Table). Men in the OBS group (n = 220) were more likely to suffer an immediate postoperative complication and to be readmitted within 90 days of surgery. The groups did not vary with respect to multiple other perioperative outcomes measures. Among patients who underwent AUS surgery between 09/2017 and 08/2020, those with OBS status (n = 39) had mean additional room and bed charges of $ 745 ± 302 vs. none for SDS patients (n = 183). Conclusions SDS for AUS insertion is safe, effective, and associated with significant cost savings. Routine overnight observation after AUS insertion appears to be unnecessary. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Same Day Discharge Versus Overnight Observation Protocols – Similar Outcomes Following Artificial Urinary Sphincter Surgery

To analyze our institutional experience transitioning from overnight observation (OBS) to same day surgery (SDS) for artificial urinary sphincter (AUS) procedures. Prior research has questioned the need for OBS following AUS surgery. We retrospectively reviewed AUS surgeries performed by a single surgeon at our tertiary academic medical center between 08/2013 and 01/2020. Patients were grouped based on discharge status: OBS vs SDS. Cost savings associated with SDS were estimated using room and bed charges from a contemporary group of AUS patients. We identified 525 AUS cases that met inclusion criteria. Men in the SDS group (n=318) were more likely to have undergone a virgin AUS insertion and were slightly younger and healthier. Men in the OBS group (n=207) were more likely to suffer an immediate postoperative complication (1% vs 0%, P < .01) and to be readmitted within 90 days of surgery (15% vs 5%, P < .01). The groups did not vary with respect to multiple other perioperative outcomes measures. Among patients who underwent AUS surgery between 09/2017 and 08/2020, those with OBS status (n=39) had mean additional room and bed charges of $ 745 ± 302 vs none for SDS patients (n=183). SDS for AUS insertion is safe, effective, and associated with significant cost savings. Routine overnight observation after AUS insertion appears to be unnecessary.

Post Anesthesia Care Unit Nurses’ Experience Caring for Opioid Tolerant Patients

<h3>Introduction</h3> Nearly 20% of same-day surgery patients regularly consume opioids, with the majority undergoing orthopedic or neurosurgery procedures for relief from chronic pain. Many have become opioid intolerant and subsequently, experience more pain and consume more opioids postoperatively than opioid naïve patients. Despite higher dosing, their pain is often unrelieved. Evidence-based guidelines include <i>preoperative identification</i> of opioid tolerant patients; however, postoperative nurses often learn of their patient's tolerance only after the patient exhibits an extreme reaction to pain. These experiences can be stressful and lead to nurse compassion fatigue and moral distress, particularly in a fast-paced post anesthesia care unit (PACU). <h3>Identification of the problem</h3> Several studies examine perioperative nurses' experiences with opioid tolerant patients in managing pain, though none explore the day-to-day personal challenges faced by nurses in the care of these patients. <h3>Purpose of the Study</h3> To explore PACU nurses' experiences in caring for opioid tolerant patients. <h3>Methodology</h3> A narrative research design was used. Six full-time PACU nurses with one or more years of PACU experience were recruited in Fall 2020. Subjects were asked to discuss an experience caring for an opioid tolerant patient and how they felt afterward. They were also asked to identify supports that would help them care for these patients. <h3>Results</h3> Interviews will be analyzed inward, outward, back in time, and forward in time to understand the participants' experience through five contexts – personal (feelings, reaction), social (environment, other people), past, present, future, and situation (professional practice). <h3>Discussion</h3> Narrative threads and their interpretation will be discussed to better understand how nurse's feelings are expressed and directed in professional practice. <h3>Conclusion</h3> This study made it possible to think about nursing practice in a new light through honoring experiences that are difficult to share yet are an important source of knowledge. <h3>Implications for perianesthesia nurses and future research</h3> Insights into the nature, causes, and strategies used to handle experiences caring for opioid tolerant patients will be identified as well as ways to better support nurses in the practice environment.

Postsurgical Follow-Up Phone Calls: Worth the Investment?

PurposeTo analyze differences in health confidence levels regarding discharge instructions between two groups of same-day surgery patients. DesignComparative and descriptive design. MethodsPhone surveys to two groups: those who received follow-up phone calls from a registered nurse (RN) and those who received standard care instructions at discharge only. FindingsIn 74 same-day surgery patients (n = 37 per group), all participants expressed high health confidence in implementing discharge instructions. Results revealed no higher health confidence levels in patients who received RN follow-up phone calls, no difference between groups attending postoperative appointments, and no relationships between subject demographics, health confidence level, and postoperative complications between groups. ConclusionsThe use of specialized RNs to conduct postoperative phone calls may not be cost effective. When RNs provide excellent instructions to patients in person, it may lead to sufficient patient health confidence. Personal and nurse-provided education should be considered a standard, and the outcomes of costly follow-up phone calls should be examined.

The Clinical Implications of Simultaneous Bilateral Chronic Ear Surgery for Patients with Asymmetric Hearing

Background and Objectives Surgery for bilateral chronic otitis media (COM) is usually performed sequentially, not simultaneously. The main reason is to prevent iatrogenic bilateral conductive hearing loss during recovery period. However, with asymmetric hearing loss, the difference in patient inconvenience between sequential and simultaneous surgery may be the same. This study evaluates the efficacy of simultaneous COM surgery in patients with asymmetric hearing.Subjects Materials and Method From 2012 to 2018, 9 patients underwent simultaneous bilateral COM surgery. The period of patients’ hospital stay, the success rate of tympanoplasty, tolerability for operation, and hearing thresholds were analyzed statistically.Results For the 8 same-day surgery patients, the mean hospital period was 4.4±0.7 days, which was much shorter than that of sequential surgery (8 days). Tympanoplasty was successful in all patients without complications. In the better side, the preoperative/postoperative mean air conduction thresholds (AC) were 62.97±12.89 dB/47.81±19.07 dB (p=0.017), the bone conduction thresholds (BC) were 46.72±10.31 dB/37.66±16.99 dB (p=0.161) and the air-bone gaps (ABG) were 16.25±8.81 dB/10.16±7.78 dB (p=0.176). In the worse side, the preoperative/ postoperative mean AC were 86.56±18.22 dB/72.18±29.43 dB (p=0.035), BC were 53.28± 11.10 dB/48.13±18.41 dB (p=0.173), and ABG were 33.28±11.22 dB/24.06±14.80 dB (p=0.500). In both ear, the postoperative AC and BC were better than or equivocal to those of the preoperative value, and the result was similar with each of the unilateral ear audiological results.Conclusion Despite the fact that there is no complete consensus to date, simultaneous bilateral COM surgery can be an option when patients have asymmetric hearing loss. Simultaneous bilateral COM surgery could save time, cost, and lead to similar results with sequential surgery, so it could be a considerable surgical option for patients with bilateral COM.

Same-Day Surgery for Mastectomy Patients in Alberta: A Perioperative Care Pathway and Quality Improvement Initiative.

Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived. The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected. SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise. Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.

Implication of UGT2B15 Genotype Polymorphism on Postoperative Anxiety Levels in Patients Receiving Lorazepam Premedication.

Lorazepam is used as premedication for its anxiolytic properties. The UGT2B15 genotype is of importance for the metabolism of lorazepam. The clinical effect of genetic polymorphisms in UGT2B15 genotype on the treatment of anxiety levels in same-day surgery patients receiving lorazepam, however, is unknown. Three hundred ninety-eight same-day surgery patients of mixed sex (from a previous double-blinded randomized controlled trial who were assigned to either lorazepam [n = 198] or placebo [n = 200]) were assessed for the UGT2B15*2 variant allele. Anxiety was measured preoperatively and postoperatively by the State part of the State-Trait Anxiety Inventory. The difference between these 2 measurements served as outcome of the study. Analysis of variance was used to assess the State part of the State-Trait Anxiety Inventory difference for interactions among the following factors: UGT2B15 genotype status, treatment condition (lorazepam or placebo), patient sex, and preoperative anxiety score. The anxiety difference was complex in that the interaction of lorazepam and UGT2B15 genotype status also was dependent on the joint effect of patient sex and preoperative anxiety score (F = 7.15, P = .008). Further exploration showed clinical relevant results in patients with high preoperative anxiety scores. Striking was that females with high preoperative anxiety scores and genetically reduced lorazepam glucuronidation (UGT2B15*2 homozygotes) showed more postoperative anxiety reduction than males with the same genotype. UGT2B15 genotype contributes to postoperative anxiety reduction after lorazepam premedication. Future research that focuses on patients with high preoperative anxiety scores could help to gain a deeper understanding in the clinical relevance of the interaction between lorazepam and UGT2B15 genotype on postoperative anxiety levels.

Recovery After Same-Day Surgery in Patients Receiving General Anesthesia: A Cohort Study Using the Quality of Recovery-40 Questionnaire

The contemporary rise in the number of elective procedures performed in same-day surgery (SDS) requires that health care professionals increase their knowledge of patient satisfaction and recovery, including patient-assessed quality of life. This study investigates the quality of recovery (QoR) of anesthetized SDS patients. Data from SDS patients were collected from hospital records at T1 (the morning before operation), T2 (day 1 postsurgery), and T3 (day 4 postsurgery). The QoR-40 and three questions that addressed tiredness, hoarseness, and thirst were used to measure health status at T2 and T3. QoR-40 mean score at T2 was 175 (SD=17.5; n = 328) and T3 was 181 (SD=16.6; n = 340). QoR improved significantly from T2 to T3 as did tiredness, hoarseness, and thirst. Patients who underwent throat, nose, or ear surgery had the lowest mean score at T3, whereas gynecology patients had the highest mean score at the same time point. Stepwise multiple linear regression analysis found the main predictor of QoR to be tiredness at T2, needing assistance with daily activities, preoperative education, not being discharged home, length of anesthesia, self-assessed mental health at T1, and hoarseness at T2 (R2 = 0.469). SDS patients needing assistance with daily activities, self-assessed in compromised mental health, who have undergone a lengthy anesthesia, and have not been discharged home need information, education, and special follow-up care.

Opioid use among same-day surgery patients: Prevalence, management and outcomes.

To determine whether the prevalence of opioid use among patients requiring elective same-day admission (SDA) surgery is greater than the 2.5% prevalence found in the general population. Secondary objectives were to assess compliance with expert recommendations on acute pain management in opioid-tolerant patients and to examine clinical outcomes. A retrospective review of 812 systematically sampled adult SDA surgical cases between April 1, 2008 and March 31, 2009 was conducted. Among 798 eligible patients, 148 (18.5% [95% CI 15.9% to 21.2%]) were prescribed opioids, with 4.4% prescribed long-acting opioids (95% CI 3.0% to 5.8%). Use of opioids was most prevalent among orthopedic and neurosurgery patients. Among the 35 patients on long-acting opioids who had a high likelihood of being tolerant, anesthesiologists correctly identified 33, but only 13 (37%) took their usual opioid preoperatively while 22 (63%) had opioids continued postoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered preoperatively in 18 (51%), 15 (43%) and 18 (51%) cases, respectively, while ketamine was used in 15 (43%) patients intraoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered postoperatively in 31 (89%), 15 (43%) and 17 (49%) of the cases, respectively. No differences in length of stay, readmissions and emergency room visits were found between opioid-tolerant and opioid-naive patients. Opioid use is more common in SDA surgical patients than in the general population and is most prevalent within orthopedic and neurosurgery patients. Uptake of expert opinion on the management of acute pain in the opioid tolerant patient population is lacking.

Effects of a web-based preoperative education program for patients undergoing ambulatory surgery: a preliminary study

Increasing numbers of surgical procedures that were once done in hospitals are now being performed in ambulatory care settings. Provision of quality preoperative education in those settings has become a challenge. This article reports findings from a practice-based study where the nurses in a preoperative preparation center implemented a supplemental, web-based educational program for same-day surgery patients and assessed its outcomes (N = 69). The patients who used the web-based program in addition to usual care achieved significantly higher scores for anesthesia knowledge (t = 2.15, p = 0.04) and teaching satisfaction (t = 2.13, p = 0.04) than those who received usual care only. The findings demonstrate a great potential for use of web-based programs to improve patient education in busy preoperative care areas. A convenience sample with a small sample size was a major limitation. Further studies with large samples are needed to demonstrate tangible clinical outcomes.

Comparative Safety of Simultaneous and Staged Anterior and Posterior Spinal Surgery

Analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample. To study perioperative outcomes of circumferential spine surgery performed on either the same or different days of the same hospitalization. Circumferential spine fusion surgery has been linked to an increased adjusted risk in perioperative morbidity and mortality compared with procedures involving only 1 site. To minimize these risks, some surgeons elect to perform the 2 components of this procedure in separate sessions during the same hospitalization. The value of this approach is uncertain. Data collected between 1998 and 2006 for the Nationwide Inpatient Sample were analyzed. Hospitalizations during which a circumferential noncervical spine fusion was performed were identified. Patients were divided into those who had their anterior and posterior portion performed on the same and those performed on different days of the same hospitalization. The prevalence of patient and health care system-related demographics was evaluated. Frequencies of procedure-related complications and mortality were determined. Multivariate regression models were created to identify whether timing of procedures was associated with an independent increase in risk for adverse events. We identified a total of 11,265 entries for circumferential spine fusion. Of those, 71.2% (8022) were operated in 1 session. Complications were more frequent among staged- versus same-day surgery patients (28.4% vs. 21.7%, P < 0.0001). The incidence of venous thrombosis and adult respiratory distress syndrome also increased among staged candidates, while the trend toward higher mortality (0.5% vs. 0.4%) did not reach significance. In the regression model, staged circumferential spine fusions were associated with a 29% increase in the odds morbidity and mortality compared with same-day procedures. Staging circumferential spine surgery procedures during the same hospitalization offers no mortality benefit and may even expose patients to increased morbidity.

Normothermia and Patient Comfort: A Comparative Study in an Outpatient Surgery Setting

ASPAN guidelines for the prevention of unplanned perioperative hypothermia define normothermia as a core temperature between 36 and 38 degrees C and an acceptable level of warmth. Over a six-month period, more than 30% of the same-day surgery patients experienced hypothermic core temperatures on admission to the preoperative unit. The purpose of the study was to compare two preoperative warming methods (forced-air gowns vs traditional warmed cotton blankets) on oral body temperatures, and patients reported "thermal" comfort in ambulatory surgery patients. A repeated measures experimental design study included 150 subjects in Pre-op who were randomly assigned to either the control warmed blankets group or the experimental forced-air gown group. Oral temperatures and thermal comfort assessments were measured every 30 minutes while the patients were in Pre-op, and on admission and discharge from the Phase I PACU. There was no significant difference in postoperative temperature between the subjects warmed with blankets and the warm-air gowns. Subjects warmed with the warm-air gowns reported higher comfort scores after 30 minutes of warming than those warmed with blankets. The change in comfort score from baseline to 30 minutes post warming was greater in the warm-air gown group (P = .001), indicating that warm-air gowns contribute to patients' increased thermal comfort.

Reducing Surgical Site Infections at a Pediatric Academic Medical Center

Surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, increased length of stay, and increased hospital costs. Cincinnati Children's Hospital Medical Center (CCHMC) used reliability science to dramatically reduce the rate of surgical site infections. Key activities included the development and implementation of strategies to enhance the proportion of patients who receive timely antibiotic administration, a pediatric surgical site infection-prevention bundle, and procedure-specific pediatric surgical site infection-prevention bundles. Measures are presented in monthly reports and annotated control charts that are shared with the improvement team and organizational leadership and that are also posted on the hospital's patient safety intranet site. The Class I and II SSI rate decreased from 1.5 per 100 procedure days at baseline to 0.54 per 100 procedure days, a 64% reduction. The process has remained stable (within control limits) since August 2007. There were 33 fewer surgical site infections in fiscal year (FY) 2006 than in FY 2005, and 21 fewer in FY 2007 than in FY 2006. By December 2007, 91% of eligible same-day surgery patients received antibiotics within 60 minutes before a procedure, and 94% of patients undergoing inpatient surgery received antibiotics within 60 minutes prior to incision. Pediatric surgical patients can now expect a safer, more efficient experience with CCHMC's care system and reduced variation in care across CCHMC's surgeons and procedures. Sharing data on individual and collective provider performance was important in recruiting provider support. Examining data on any failures each day allowed assessment and correction, facilitating rapid-cycle improvement. Making the right thing to do the easy thing to do facilitated the behavior changes required.

Minimal impact urethroplasty allows same-day surgery in most patients

Objectives To present our evaluation of the safety and feasibility of decreasing the impact of anterior urethroplasty by minimizing the surgery time, maximizing adjuvant pain therapy, and using anesthetic agents that decrease the incidence and severity of side effects, which allows most patients to leave the hospital comfortably within 4 hours of surgery. Methods A retrospective chart review of 54 consecutive anterior urethroplasty patients from August 2000 to August 2004 (34 anterior anastomotic and 20 ventral onlay buccal mucosal graft urethroplasty) was performed. Results Historically, 27% of patients had undergone same-day surgery (SDS). After the initiation of minimal impact surgery and early discharge, 85% did so. All but one admission was planned (1 patient [2%] had hypotension in the recovery room and was admitted). No postoperative readmissions or emergency room visits occurred. The admitted patients had comparable stricture length to, but slightly older age (49 years compared with 42 years) than, the SDS patients. The perioperative complications were mild (small wound gap, small scrotal hematoma) and were seen in 5% of SDS patients and 0% of admitted patients. Late complications (chordee, mild erectile dysfunction, and urinary tract infection) were seen in 19% of SDS patients and 18% of admitted patients. The incidence of recurrences after a mean follow-up of 27 months was comparable (3% for the SDS and 6% for the admitted group). Conclusions Decreasing the impact of urethroplasty surgery allows safe early discharge for most patients. Unexpected admissions were uncommon, and we continue to plan for admission only for the extremely elderly, those with severe comorbidities, and those expected to undergo lengthy (longer than 5 hours) surgery.

Preoperative teaching received and valued in a day surgery setting.

Bemier MJ, Sanares DC, Owen SV, Newhouse PL Preoperative teaching received and valued in a day surgery setting. AORN J, 2003;77(3):563-4,568-9. The shift in health care to managed care has resulted in changes in service delivery, with a focus on achieving quality outcomes by cost-effective means. A consequence of this model is the shift of surgical procedures from the inpatient to the outpatient setting, which creates a challenge for providing preoperative teaching within a reduced timeframe, but also an opportunity to develop relevant research in the area of nursing care based on data collection. This article describes studies carried out by perioperative nursing staff at a university-based academic medical center. The two-phase study involved development and psychometric testing of an instrument, and the administration of the validated instrument to evaluate the substantive nature, scope, and value of the preoperative teaching provided to a sample of same-day surgery patients. A literature review specific to nurse and patient perceptions of valuable preoperative information was conducted. Relevant articles utilized a preoperative teaching questionnaire (PTQ) to survey nurse and patient perceptions regarding types of information valued in preoperative teaching. Following one study, researchers recommended expectations for the postoperative course and home pain management be included in preoperative teaching plans. Another study identified time limitations to provide patient information by 90% of nurses surveyed. In a third study, patients who perceived caring behaviors from nurses experienced less symptom distress and higher functional status postoperatively. Researchers also found that nurses and patients do not always concur on topics that are most important to patients. The study in this article was conducted in two phases. Phase I involved constructing a tool to measure the nature and value of preoperative teaching for patients undergoing same-day surgery. The PTQ included items from domains including: situational/procedural information, sensation/discomfort information, patient role information, skills training, and psychosocial support. Patients were asked whether they received specific teaching and then rated the value of the teaching for each item. Each item was rated using a I.ikert-type scale. Conlenl experts identified 26 items which were included in the preoperative teaching interview guide (PTIG) which were then rated on two scales, one used to determine whether or not patients received preoperative training and another to determine the value that patients placed on the teaching. In addition, six open-ended questions regarding patient satisfaction with the surgery and the preoperative teaching were developed. Demographic data including gender, race, age, education level, and annual household income was collected on all patients. The sample study included 50 patients who met the inclusion criteria of at least 18 years old, speak English, have undergone no other surgery in the past 2 years, and were discharged home following the surgery. …

Eliminating Intensive Postoperative Care in Same-Day Surgery Patients Using Short-Acting Anesthetics

Eliminating Intensive Postoperative Care in Same-Day Surgery Patients Using Short-Acting Anesthetics

Anesthetic considerations and techniques for oral and maxillofacial surgery.

Today, oral and (OMF) surgery encompasses a great range of surgical treatments, from simple tooth extractions to complicated reconstructive craniofacial procedures. This surgical specialty has emerged and evolved from the formal practice of dentistry, dating back to 1844, when two physicians opened the first school of dentistry in Baltimore. Over the next 100 years the specialty continued to take shape. Multiple societies were established, beginning in 1918 as the American Society of Exodontists. In 1921, it became the American Society of Oral Surgeons and Exodontists, in 1946 shortening the name to the American Society of Oral Surgeons. In 1977 the term maxillofacial was formally added, reflecting its current designation and finally describing the tremendous range of skills these specialists master and provide to patients. 1 From an anesthetic standpoint, these procedures may range from the routine application of local anesthetics and titration of intravenous sedation, to the administration of general anesthesia involving skilled airway management techniques, complicated invasive monitoring devices, hemodynamic instability, and significant blood loss. These patients range from ambulatory same-day surgery patients to critically ill inpatients presenting in community hospitals or university medical centers. This is a reflection of the overall growth of this surgical specialty, crossing over to other specialties, including otolarymgology, plastic surgery, and even general surgery. This chapter will present the management of the patient presenting for a variety of major OMF procedures. The relevant anatomic structures of the facial and cranial skeleton involved in these procedures will be reviewed. The preoperative evaluation and preparation, anesthetic concerns and complications, and postoperative management of patients presenting for OMF surgery will follow this. Topics will include exodontia, orthognathic surgery, trauma and infections, tumors, and reconstructive surgery.

Eliminating intensive postoperative care in same-day surgery patients using short-acting anesthetics.

A multidisciplinary effort was undertaken to determine whether patients could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria. A prospective, outcomes research study with a baseline month, an intervention month, and a follow-up month was designed. Five surgical centers (three community-based hospitals and two freestanding ambulatory surgical centers) were utilized. Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period. Outcome measures included PACU bypass rates and adverse events. Intervention consisted of a multidisciplinary educational program and routine feedback reports. The overall PACU bypass rate (58%) was significantly different from baseline (15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4-31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1-84.2%, P < 0.001). During the follow-up period, the average (SD) recovery duration for patients who bypassed the PACU was significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome. Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after adjusting for various surgical procedures. This study represents a substantial change in clinical practice in the perioperative setting. Same-day surgical patients given short-acting anesthetic agents and who are awake, alert, and mobile requiring no parenteral pain medications and with no bleeding or nausea at the end of an operative procedure can safely bypass the PACU.