Providers work to draw the line: How sick is too sick for SDS?
Providers work to draw the line: How sick is too sick for SDS?
You’re seeing a range of patients, from infants to people in their 90s. Many of your patients, particularly the elderly, have significant medical conditions, and you’re offering outpatient procedures as complex as mastectomies. "Cost containment has caused a paradigm shift in the types of patients we’re seeing in ambulatory surgery," says Carolyn Greenberg, MD, associate professor of clinical anesthesiology at Columbia University College of Physicians and Surgeons and medical director of the Ambulatory Surgery Unit at Columbia-Presbyterian Medical Center in New York City.
Typically, insurance companies are not willing to pay for hospitalization of patients after procedures deemed outpatient unless the reasons for admission are found to be "medically sound." Translation: You’d better make other arrangements for a 92-year-old cataract patient who has only a 95-year-old spouse to care for her after surgery. "We need to make sure they’ll be in a safe, supportive environment when they leave," Greenberg says. "We need to make sure they have family support, proper escorts, aftercare at home, and that their caregivers can respond to a medical emergency and follow instructions."
These issues are not addressed at all by the insurance company, she says. "They provide a list of surgical procedures. They don’t consider medical, anesthesia, or social factors that will impact the outcome and the safety of the patient."
And dealing with the insurance companies isn’t the only problem that same-day surgery managers are having to address. A significant number of outpatient surgery procedures are moving to the physician office setting. In some states, such as California and Florida, state legislators have become concerned about protecting the public health and have begun to impose restrictions on the office-based surgery setting.
Walter G. Maurer, MD, chief of the section for ambulatory anesthesia and medical director of pre-surgical services in the department of anesthesia at the Cleveland Clinic Foundation, says, "We in the anesthesia community feel that if we can maintain standards and keep it appropriate, we can keep the ambulatory surgery safe and be able to offer guidelines to keep it safe without the heavy and sometimes broad hand of legislative intervention."
So where do you draw the line when selecting patients for ambulatory surgery? And how can you best prepare the ones you do select? One bit of guidance: Don’t rely on age or American Society of Anesthesiologists (ASA) classification alone as criteria, Maurer suggests. He points out that a retrospective review of 1,500 ambulatory cases showed no relationship between age and complications.1
And in a study of 13,000 patients who were medically well-controlled ASA III, there was no higher risk of postoperative complications than in ASA I and II, he says.2 "The important point here is that they were well-controlled and not unstable ASA III," Maurer says.
So if you don’t use those criteria, how do you determine whether patients are appropriate for ambulatory surgery? In addition to considering your setting, staff, and equipment, look at these areas:
o Be flexible.
"We find that being overly rigid over who can or can’t go home after surgery doesn’t help us," says Alisa C. Thorne, MD, medical director of ambulatory anesthesia at Memorial Sloan-Kettering Cancer Center and associate professor of clinical anesthesiology at Cornell University Medical College, both in New York City. One example: patients with obstructive sleep apnea.
"It’s a typical diagnosis that in the past would mandate post-op hospitalization even after most minor surgery that required anesthetic," Thorne says. "Over the years, we’ve starting doing cases like that early in the morning, followed by monitoring by PACU for several hours, and on a case-by-case basis, we may elect to send patients home.
"We’re finding that we’re much more successful on select cases to adopt a wait-and-see attitude. We have the luxury [of being a hospital]: We can always admit them."
o Ask the patient.
Since Thorne works in a cancer center, a significant number of patients have spent a lot of time in the hospital. "We find that in a decision about whether a patient could or should go home, frequently the patient has an opinion," she says. "That opinion, while not necessarily dictating their care, should be taken into consideration."
For example, a patient may be experiencing post-op nausea and vomiting. "Most places doing ambulatory surgery say that a patient’s post-op nausea and vomiting should be well-controlled before discharge," Thorne says. "Philosophically, it sounds great to do that. But in cases where patients are still vomiting, and given a choice of going home and vomiting or being admitted to the hospital and vomiting, they’d rather go home."
Be open-minded about post-op nausea and vomiting, she advises. "If they’re responsible and knowledgeable about their health, and they have care partners, there’s no reason patients couldn’t go home." Be sure to offer numbers to call if they have complications or concerns. Memorial Sloan-Kettering Cancer Center uses this policy, and the unplanned admission rate has been less than 1% since the center opened six years ago, Thorne says.
o Consider the magnitude of the procedure.
For patients who don’t have the "ideal" physical status or who have a fair number of under-lying medical issues, consider what type of procedure they are having, Greenberg says. For example, many patients have procedures that involve sedation. "That type of situation might be more amendable than having a much more complicated procedure in a patient who had a lot of underlying disease," she says.
o Optimize a patient’s medical condition.
For patients who have significant medical disease or a systemic disease that interferes with their daily activities, perform the prescreening before the day of surgery, preferably several days or weeks before surgery, Greenberg advises.
"Make sure they’re receiving maximum medical management, discuss their care with a primary care provider, do a history a thorough one and a physical exam," she says. "Also, obtain appropriate lab tests and perform any additional consultation that might be necessary."
Prescreen patients about aftercare arrangements as well, she says. Consider using "hospital hotels," 23-hour facilities, and/or home health care.
o Work with the insurance company.
For patients who need overnight care, Green-berg helps surgeons and patients outline the safety and medical issues to the insurance companies. Consider speaking to the medical director of the company, she suggests. For patients who are admitted, ensure the documentation is accurate regarding the reason for admission.
o Bring in medical consultants.
Anesthesiologists shouldn’t make a decision in a vacuum about whether patients are appropriate for ambulatory surgery, Thorne warns. Usually the pre-op clinic is the first time anesthesiologists and patients meet. "If there are multiple medical problems, frequently physicians have been following their condition for a number of years, and consulting with them before making a decision about whether it’s appropriate to make the procedure ambulatory surgery can be very valuable, rather than after seeing the patient for the first time."
Consultants shouldn’t make the decision, she says. "Far from it. But frequently they have val-uable information that makes for a better decision." For example, the physicians may be familiar with how patients recovered from previous procedures, and they may understand how much activity patients undergo in their daily routines. "They know patients over years, rather than 15 to 20 minutes in a presurgical clinic."
Physicians may have results of stress tests or EKGs that were performed in the office. "Their interpretation may help anesthesiologists decide not just whether to send the patient home, but the safest anesthetic for patients." These aren’t healthy 18-year-old patients having a 20-minute procedure, she emphasizes. "How sick is too sick keeps coming up as we see patients at the other end of the spectrum. It only makes sense to bring in their medical consultants to the decision-making process and learn as much as we can about their medical condition to plan the safest anesthetic and the safest recovery. They go hand in hand."
References
1. Meridy HWO. Criteria for selection of ambulatory surgical patients and guidelines for anesthetic management: A retrospective study of 1,553 cases. Anesth Analg 1982; 61:921-926.
2. Natof HE. Ambulatory surgery: Patients with pre- existing medical problems. Ill Med J 1984; 166:101.
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