Cut length of stay: Pay attention to meds
Cut length of stay: Pay attention to meds
While thorough clinical assessments, careful anesthetic choices, and polished surgical techniques all contribute to a shortened length of stay (LOS) for patients undergoing same-day laparoscopic surgery, patient education prior to surgery may have the most positive effect, managers say.
"We get the patient’s buy-in during the preoperative education," says Sandy Berreth, RN, director of St. Alexius Same-Day Surgery Center in Bismarck, ND. Nurses tell patients what sensations they might experience so patients are not alarmed after surgery. Because the patients know what to expect, St. Alexius’ laparoscopic cholecystectomy patients have a 4½-hour LOS, she says.
A positive attitude immediately after surgery is a critical part of a short LOS, says Sharon Gelinas, administrator of Doctors Hospital Surgery Center in Evans, GA. "Although we are very proactive with postoperative nausea and vomiting [PONV], some patients experience it," she says. "If they know ahead of time that PONV is a possibility, they are not discouraged if it happens."
In addition to preparing the patients for how they will feel after surgery, the staff at St. Alexius do everything possible to make the patients comfortable, says Berreth. "We keep patients well hydrated during surgery so we don’t have to force fluids on them in the PACU [post-anesthesia care unit] when they may be experiencing PONV. Once they can drink on their own and eat a cracker or piece of toast, we start them on pain medications by mouth."
The pain medications are started in the PACU. Patients are told to take them at the intervals prescribed by the physician even if they might not feel pain at the moment, explains Berreth. "We explain that proactive pain management for the first two days after surgery will speed their recovery."
Choice of anesthetics is important to reducing LOS, says Lauri Penton RN, PACU nurse at Doctors Hospital Surgery Center.
"Our anesthesiologists will use fentanyl, a longer-acting anesthetic, for long procedures and alfentanil, a shorter-acting agent, for shorter procedures," she says. "The goal is not to overdrug the patient so we can have them as awake as possible in PACU." A patient who is more alert can be treated more easily and earlier for PONV, cramping, and pain, Penton explains.
In addition to selecting the appropriate anesthetics, physicians can take steps when the patient is still in the operating room to make the patient’s recovery more comfortable. With laparoscopic procedures, the physicians at St. Alexius remove as much air from the abdomen as possible by pushing on the abdomen before trocars are removed, she explains. "We also put the patients in a sitting position as soon as possible after surgery so the remaining CO2 in the belly can easily rise." The sitting position helps avoid the discomfort experienced when the CO2 is trapped underneath the shoulder blades and diaphragm, she says.
Because cramping is a typical aftereffect of laparoscopic surgery, staff at Doctors Hospital Surgery Center administer ketorolac tromethamine (Toradol, Roche Pharmaceuticals, Nutley, NJ) wahile the patient is in the operating room, Penton says. Decreasing or eliminating cramping helps patients feel ready for discharge sooner, she adds.
reSources
A free copy of the June 2000 report to Congress can be obtaining from the Medicare Payment Advisory Commission Web site: www.medpac.gov. Or contact:
• Medicare Payment Advisory Commission, 1730 K St. N.W., Suite 800, Washington, DC 20006. Telephone: (202) 653-7220. Fax: (202) 653-7238. E-mail: [email protected].
The Federated Ambulatory Surgery Association has published Comparison of APCs for ASCs and HOPD payments. It is available for $20, including shipping and handling. To order, contact:
• Federated Ambulatory Surgery Association, 700 N. Fairfax St., Suite 306, Alexandria, VA 22314. Telephone: (703) 836-8808. Fax: (703) 549-0976. E-mail: [email protected].
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