Highlights from our first issue
Highlights from our first issue
Pioneers were on the cutting edge
In celebration of our 20th anniversary, Same-Day Surgery shares some excerpts from our first issue in April 1977:
• Most hospitals should set up ambulatory surgery units, Davis says. Many hospitals are concerned that this type of surgery, which is gaining popularity nationwide, will siphon off minor surgery cases, leaving hospital beds empty and hospitals in a financial crisis. "But, I feel strongly that the concept benefits every participant," says James E. Davis, MD, chief surgeon of Durham General Hospital (until recently called Watts Hospital) in Durham, NC.
"The time has come to push it even further than we have. If a hospital has empty beds, administrators should be innovative enough, alert enough, and resourceful enough to close down those beds or divert them to other uses. If, by adding ambulatory surgery, an administrator can better serve his clientele, maybe he can close down a few more beds and come out economically better."
• Reed sees quality maintenance vital to concept expansion. The expert was frank on the controversial question of whether hospitals are a good setting for ambulatory surgery. Wallace A. Reed, MD, ambulatory surgery pioneer and co-founder (with John Ford, MD) of the world-famous Surgicenter in Phoenix, says he believes that hospitals could not do successfully what Surgicenter is doing and maintain the same high quality of care because "they would be competing with themselves. There is nothing to give the hospital an incentive to develop an active outpatient program, except where beds are in short supply, because bed occupancy is the lifeblood of a typical community hospital inpatient structure. In such a situation, the outpatient gets bumped from the surgery schedule for the inpatient or for an emergency that comes up.
"The conventional hospital structure simply is not geared to providing ambulatory surgery," Reed says. "At Surgicenter, we provide this type of care much more efficiently, and much more lovingly. We try to demonstrate compassion. We want some love to be evident between the patients and the people serving them."
• Anesthesia, facility are keys to outpatient laparoscopy. "I don’t know that I’d like to go so far as to say laparoscopy is ideal for the same-day approach, but it certainly is highly suitable," notes Louis Keith, MD, of Chicago. "A lot depends on the setting. Unless you get the full weight of the hospital behind the same-day concept, it’s a losing game. There are still hospitals which cannot get their same-day act together." Keith says he admits all his laparoscopic patients as inpatients the night preceding surgery "only because I cannot hassle the hospital bureaucracy into getting everything ready for same-day surgery." He reports that his hospital has outpatient operating rooms, but they are not utilized, so outpatients must be "worked in" between inpatient surgery cases. This causes to be "bumped" from the surgery when emergencies arise. "If laparoscopies can be done in a separate outpatient department, they can easily be done same-day. Except for the hospital bureaucracy and inefficiency, I have no reservations about performing this procedure on outpatients."
A major difficulty in performing laparoscopies on an in-and-out basis is that "the surgeon is aware that laparoscopy carries with it risks similar in many ways to major surgery," says Richard M. Soderstrom, MD, of Seattle. "We are entering the abdomen and can do a lot of surgery through the laparoscope but the patient sometimes sees it as only a nick in her navel and can’t understand why her bill is so high."
The question of the type of anesthesia general or local revealed strong opinions. A provocative view was put forward by John Levinson, MD, of Wilmington, DE. "I find that the average American woman cannot tolerate discomfort: She gets so upset if she has a little that we perform all our cases here under general."
Levinson explained that for the past five years, he has been in charge of teaching laparoscopies under a Johns Hopkins University program in Southeast Asia, "and there I teach it exclusively under local. The Asian woman seems to be more stoic and tolerates minor discomfort much better."
"Many patients have read Ladies Home Journal and are convinced that because they are having same-day Band-Aid’ surgery, they’re not going to have any pain," says Louis Keith, MD, of Chicago. "The pain is minor, and the patient could go home as soon as she is recovered from the anesthesia, but because her attitude is that she is not going to have any discomfort, she is devastated when she experiences even a little." Because of this "psychological" factor, Keith says he leaves it up to the patient to decide whether she feels like leaving the hospital the same day or wants to stay additional days.
Another factor that was seen as determining the appropriate type of anesthesia was the laparoscopist’s experience. Says John I. Fishburne Jr., MD, of Winston-Salem, NC, "A physician should have done at least a hundred, and probably more, before attempting to do them in an ambulatory care environment, outside, outside a conventional operating room, under local anesthesia."
Adds J. Benjamin Younger, MD, of Birmingham, AL, "A physician has to have a great deal of experience to use local. For most physicians, taking into account their particular setting, I think they would probably be better off doing them under general. Because my hospital is totally a teaching hospital where I have residents and students, general is definitely better. This is because having the extra observers probably adds an additional five minutes to a case."
Our rates per procedure are cheaper’
• Administrator says close empty hospital beds. J. Barry Johnson, administrator of Phoenix Baptist Hospital, believes his unit "can provide ambulatory surgical care cheaper than the private facilities because of the sharing of employees and services, and because when purchasing supplies we can take advantage of the whole hospital volume. Our rates per procedure are cheaper, and we can pass on all these savings to the patients."
• Ford warns same-day facility not always advisable. Ambulatory surgery pioneer John L. Ford, MD, believes it is "going too far to say that every hospital should have an ambulatory surgical unit. All hospitals can provide for doing some outpatient surgery, and many in small communities can just do it in their existing emergency rooms. It isn’t going to be as good, but they simply can’t afford a separate unit. Provision for some kind of ambulatory surgery is a useful thing for every hospital, but only if it is scaled appropriately for the needs of the individual community and the size of the hospital."
• Nurse director describes debut of Humana facility. Sandra M. Parke, RN, director of DaySurgery in St. Petersburg, FL, explains, "The nursing done here is different than that done in an inpatient OR. All the nurses rotate throughout the entire facility a nurse will work in the operating room this week, in the recovery room next week, and the week after that, she’ll be in the preparation area.
"Therefore, there is much more patient contact than you would find in a regular OR. I need nurses who really want closer patient contact, who want to try something new, who want a challenge, and who are outgoing and vivacious by nature. The trend in operating room nursing today is to get closer contact with the patient, but there are many OR nurses who really don’t care for that. These would not be happy at DaySurgery, and so they are the ones to stay in the inpatient operating room."
• National Blue Cross open to reimbursement of same-day facilities. Since Blue Cross became interested in ambulatory surgery, Bradley Yost, Blue Cross Association’s director of health care benefits, says, "I think rather dramatically, plans are establishing relationships with the freestanding facilities."
He cites the fact that 22 plans are presently reimbursing the freestanding facilities, "and that’s up from eight in 1975." He points out that this statistic must be balanced with the fact that not all plans currently have the freestanding surgical facilities in their areas. "If the plan isn’t providing the benefit," he asserts, "it’s likely that the providers aren’t delivering the service, or it is being delivered on a low-volume, informal basis." Also, he says, the latest association survey shows that 50 of the 69 plans reimburse for ambulatory surgery in a hospital-based program.
• Real Solutions: Integrating Services to Provide a Continuum of Care, Society for Ambulatory Care Professionals (SACP) 1997 Annual Meeting and SACP/AHA Hospital Home Care Symposium April 13-16, St. Louis. For more information, contact Glen Brown, SACP Director of Marketing and Communications, One N. Franklin, Chicago, IL 60606. Telephone: (312) 422-3907. Fax: (312) 422-4577.
• Same-Day Surgery Conference June 8-10, Atlanta. Sponsored by American Health Consultants, publisher of Same-Day Surgery. For more information, contact: Customer Service, P.O. Box 740056, Atlanta, GA 30374. Telephone: (800) 688-2421 or (404) 262-7436. Fax: (800) 284-3281. E-mail: [email protected].
• St. Moritz Aesthetic Surgery Conference June 29-July 2, St. Moritz, Switzerland. For more information, contact Pamela Feldman, The Professional Image, 359 San Miguel Drive, Suite 303, Newport Beach, CA 92660. Telephone: (714) 760-1522.
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