Making a Case for Preoperative Testing in the Outpatient Surgical Setting

By David Taylor MSN, RN, CNOR, CVOR

The surgical environment is fast paced and oftentimes unpredictable. In fact, patient acuities are higher and the care they need is more complex. Yet the ambulatory market is constantly evolving.

Health care professionals with a creative mindset actively seek out opportunities to improve operational and clinical efficiencies. They also look to help their organization function more effectively to improve its market position. Rather than waiting to adjust to industry changes these professionals make changes to their business model quickly to create market trends or keep up with innovations. Their fast action has allowed them to surpass hospital-based surgical programs and secure a greater percentage of the market share.

Much has changed in the field of surgery in the past century. Long gone are the days of admitting patients a week before surgery and keeping them hospitalized for weeks postoperatively. Today’s physicians can diagnose, treat and manage disease processes along with chronic conditions once thought to be intractable. Surgical procedures are becoming safer and more effective than ever in part because of advanced surgical techniques, new devices and innovative technology. Surgeons are not alone. Much of the advancement in surgery can be attributed to advances in anesthetic and nursing care. The knowledge gained from technological innovation and advancements in medicine have been tremendous assets in an ever-changing profession that is rapidly moving forward.

As a result of medical advancements ambulatory surgery centers (ASC) are experiencing tremendous growth in recent years. The first freestanding ASC was established in Phoenix, Arizona and opened on February 12, 1970. Wallace Reed, MD, and John Ford, MD, wanted to provide convenient, timely and cost-effective surgical services to patients in their community, thus avoiding the more impersonal and less efficient setting of hospitals.1 Five surgeons performed cases at the center on opening day, and four of those patients required general anesthesia.2

From 1996 to 2006 the rate of visits to freestanding ASCs increased approximately 300 percent with over 57 million procedures performed. In comparison, the rate of visits to hospital-based surgery centers remained largely unchanged during the same period.3 Patients who were once believed to be unsuitable for ambulatory surgery are now considered to be appropriate candidates as medical advancements improved and the use and selection of anesthesia provided in the ambulatory setting rapidly evolved. Surgical procedures once believed to be unsuitable in the outpatient setting are now routinely performed regardless of the patient’s age. Those same procedures are now routinely performed earlier in the day so patients can be discharged in the late afternoon or early evening hours.4

As the types of procedures performed in the outpatient setting continue to expand, it is inevitable that patients with higher co-morbidity will influence how surgical care is provided. As the outpatient market sees greater volume as a result of their efficient processes and lower costs, accurate patient selection and appropriate scheduling will be essential to ensure safe patient outcomes. Instituting optimal planning is essential to prevent negative outcomes, sentinel events and increased cancelations and/or delays on the day of surgery (DOS). Managing the aforementioned will be key to future success in this market.

In a 2012 report, the American Hospital Association explored the question, “Are Medicare patients getting sicker?” They found that approximately four out of five seniors affected by chronic conditions with two-thirds having at least two or more chronic conditions. It is expected that these numbers will continue to grow as the Medicare population grows.5 This trend isn’t just in the Medicare population. Dr. Edward J. Merrens of Dartmouth Medical School and director of Dartmouth-Hitchcock Medical Center’s Hospital Medicine Program describes hospitalized patients as sicker on average than a decade ago and illnesses that once required hospitalization are now being treated on an outpatient basis. He goes on to say, “We are caring for inpatients today who might not have survived to this point years ago. So clinic physicians’ twice-a-day rounds to care for their hospitalized patients are no longer enough.”6

With the growing prevalence of chronic conditions it is imperative that health care organizations, particularly those in the ambulatory market, make clinical and operational improvements to their patient preparation and selection process to ensure successful outcomes and maximize the benefits of risk assessment that identify patient factors, which can significantly increase the risk for complications.7 Proactively managing the surgical patient preoperatively will help to reduce the cost of care, initiate postoperative teaching for the more complicated patients, minimize cancelation rates and/or delays and improve the patient experience enjoyed by the outpatient world.

Patients who present with significant medical histories and multiple co-morbidities require additional planning prior to the actual surgical encounter. One way to minimize these challenges is to create or strengthen pre-surgical testing (PST) services. Patient preparation, scheduling and pre-registration DOS discharge planning and post-surgical recovery are all interconnected. Accurate scheduling is essential to optimize planning and pre-surgical testing which lends itself to a collaborative approach between anesthesia and the pre-surgical nursing teams.

By systematically completing the necessary level of PST services days or weeks before the surgical encounter, an ACS can help minimize complications and ensure appropriate consultation prior to surgery. Enhancing patient preparedness and creating a more friendly and thorough experience, as well as build confidence in the patients served, will allow the ambulatory market to continue with its high patient satisfaction ratings. From a business perspective, organizations who better prepare patients for surgery can avoid costly delays, reduce or eliminate unexpected cancelations and mitigate negative outcomes, which could unnecessarily require greater length of stay (LOS) or transfer of care.

Enhancing the patient preparedness process not only creates a more friendly and inviting experience for the patient, it provides a thorough look into their health history which can help the ambulatory market avoid unnecessary hospital readmissions and postsurgical procedures. The PST team could be made up of registered nurses, support technicians such as laboratory and radiology personnel as well as an anesthesia provider. Each component plays a role in the preparation and care of that patient.

Establishing new criteria to identify the level of pre-surgical testing needed for each patient could be established utilizing evidence-based practices not only in an ASC setting but in a hospital-based program as well. For example, creating categories identifying patients undergoing such procedures as a joint replacement, spine, vascular, cardiac, abdominal or a craniotomy may need one level of screening. In addition, identifying patients that have significant medical histories and co-morbidities such as a cardiac history, liver disease, chronic respiratory history, diabetes mellitus, or blood disorders;8 the patient would be required to schedule an appointment with the PST team. Patients not scheduled for one of the aforementioned procedures and those that do not present with one of the co-morbidities would only require a telephone health screen with a PST registered nurse.9 This collaborative approach helps grow volumes by eliminating the unknowns and safeguards surgical outcomes.

In addition to categorizing patients, a well-designed PST team could incorporate a standardized scheduling process that incorporates pre-operative order sets used for all procedures to ensure adequate information is obtained for a safe patient experience. Lastly, the PST process could develop a set of pre-anesthesia guidelines for laboratory testing. By creating and using set criteria or protocols the process can identify what level of pre-surgical testing is needed for each patient type. With respect to the level categories, not all procedure types listed will be performed in an ASC setting. However, it is important to point out that a growing number of procedures are being approved for this setting. This is particularly important because, according to 2010 data, 48.3 million surgical and nonsurgical procedures are being performed in hospital and ASC settings.10

Standardizing a new system for safer surgery will require a commitment not only from the administrators of the organization but also from surgeons who schedule procedures and an agreement among anesthesia providers to form a consensus on a protocol-driven approach to patient preparation.9 Each party will need to champion the process changes in order to avoid status quo and to improve negative outcomes.

Pre-surgical testing is only part of the equation. Baby boomers are reaching the age of Medicare eligibility at the rate of 10,000 a day. This group is exhibiting a growing prevalence of chronic conditions and risk factors for those conditions.5 As this generation ages, their health care usage will increase, which will drive procedure volumes for many specialties. The ambulatory market needs to continuously evaluate the increasing need for more nursing care, as required in this setting, to care for these patients.11 Along with the appropriate level of health care providers, it will be necessary to have the appropriate supplies and equipment on hand and readily available in the event of an emergency. This will help prevent unforeseen transfers of care. The ambulatory market is expected to continue growing. Surgical procedures that were once hospital based will merge and eventually move to the outpatient market. In order for ACSs to be successful and grow their reputation, volume and abilities to deliver quality care on a day-to-day basis they will need to address the total care of the patient population.

With the Affordable Care Act (ACA) and the movement to a value-based payment model, the focus on quality has never been higher. ASCs offer high patient satisfaction rates and low infection rates while offering consumers a convenient and cost-effective alternative. With a push to move more inpatient volumes to the ambulatory setting it will be important to manage patient needs preoperatively because the PST process optimizes the patient’s condition prior to their planned procedure.12 The vigilant management of patient risk factors will allow the ambulatory market to leverage resources efficiently to improve performance as well as outcomes in the operating room and postoperatively. This will give ASCs an advantage over hospital-based surgical programs. It will also ensure that the last patient of the day has the same opportunities for success, recovery and discharge home as the first.

1. http://www.ascaconnect.org/ASCA/AboutUs/WhatisanASC/History/ accessed 12/3/2017
2. Rechtoris, M., 50 things to know about the ambulatory surgery market., July 22, 2015 http://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/50-things-to-know-about-the-ambulatory-surgery-center-industry.html accessed 12/6/2017
3. Cullen K. A., Hall, M. J., Golosinskiy, A. Ambulatory surgery in the United States, 2006. National Health State Report 2009; 28(11): 1-25 http://www.ncbi.nlm.nih.gov/pubmed/19294964 accessed 12/4/2017
4. Lichtor, J. l., General information on Ambulatory Anesthesia, Stanford Medicine Ether, http://ether.stanford.edu/asc/general_info_ambulatory_anesthesia.html accessed 12/13/2017.
5. Are Medicare Patients Getting Sicker?, American Hospital Association Trend Watch, December 2012, www.aha.org/…/tw/12dec-tw-ptacuity.pdf accessed 12/5/2017
6. Merrens, EJ, Meeting 24/7demands, Dartmouth Medicine http://dartmed.dartmouth.edu/summer05/html/grand_rounds.php accessed 12/3/2017
7. Gupta, A., Gupta, N., Setting up and functioning of a preanaesthetic clinic. Indian Journal of Anesthesia 54(6) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016569/ accessed 12/4/2017
8. General Anesthesia, Patient trusted medical information and support http://patient.info/doctor/general-anaesthesia accessed 12/4/2017
9. Ellis, S., Young, D., Peters, J. A., ‘Hybrid’ Pre-Op Assessment Model Increases OR Efficiency at Nebraska Hospital. Anesthesiology News, March 2013, VOL39 NO3 Posted March 22, 2003
http://www.anesthesiologynews.com/ViewArticle.aspx?d=Policy%2B%26%2BManagement&d_id=3&i=March+2013&i_id=937&a_id=22716 accessed 12/4/2015
10. Hall, M. J., et al. Ambulatory Surgery Data from Hospitals and Ambulatory Surgery Centers: United States, 2010. National Health Statistics Reports NO 102, February 28, 2017
11. Why a Column on Ambulatory Best Practices?, AORN Journal May 2014, VOL 99, NO 5.
12. Pre-Procedural Preparation Toolkit 2007 NSW Health http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2007_018.pdf accessed 12/13/2017