The basic model for outpatient surgery has grown from lumps and bumps to a growing number of procedures that not very long ago required an overnight stay. By most measures, this new model of surgical services delivery will not cease any time soon. The forces driving this trend - minimally invasive technologies, new surgical techniques, advances in anesthesia and nausea control, and rising budgetary pressures - remain powerful. In fact, the more "minimally invasive" the approach to surgery, the more likely even patients with comorbidities will be going home sooner.

"We used to say that neurologic and cardiovascular surgeries were off the table as far as the freestanding ASC or HOPD goes," says Joni M. Steinman, the managing principal with AUSMS Healthcare Consultants in San Diego. "For many hospitals, outpatient surgery is the tail that now wags the dog in that it dominates their caseloads while not being per se the primary reason why they, as inpatient institutions, came into being to provide surgical services."

In the pages that follow, surgeons and administrators share how they've moved complex inpatient procedures to the outpatient setting.

Abdominal Hysterectomy

Mind Over Matter

Managing the patient's mindset is key to success when you're pushing the outpatient envelope.
Michael Vranich, DO, and Christine Frederick
Hazelwood, Mo.

At the HealthSouth North County Surgery Center, we perform abdominal and vaginal hysterectomies, abdominoplasties, modified radical mastectomies, unicompartmental knee replacements and thyroidectomies on an outpatient basis (23 hours or less). We push the "outpatient envelope" because we firmly believe most procedures can and should be done in the outpatient setting as long as patients are qualified. By "qualified," we mean healthy enough to avoid complications that may lead to an extended stay. Just as importantly, we also mean prepared. Patients must understand what to expect and be emotionally ready for the outpatient experience. This point is so critical that it will make or break any aggressive outpatient program.

When it comes to abdominal hysterectomy, for example, our surgical and anesthesia practices don't differ from those of the typical inpatient setting. What does differ is our approach to patient selection and patient education. As with many outpatient procedures, we can only accept relatively healthy patients. Patients who undergo abdominal hysterectomy and other procedures that require extended, 23-hour recovery are typically ASA class I or II.

We also manage patient expectations with as much emphasis and commitment as we manage their physical care. When patients know they'll be hospitalized for two to five days, they expect to be disabled and in pain. But when they know they are going home, patients develop heightened expectations of their own recovery abilities and, as a result, they often make remarkable progress.

Pre-operatively, we tell the patient what the procedure entails and describe how she will feel after surgery. We tell her when we expect her to ambulate and when she will go home. We outline our approach to pain control and assure the patient that we will be there at every turn to manage her discomfort and answer questions.

We keep up our end of the bargain by doing everything possible to relieve anxiety and pain. For example, we assess pain proactively by asking patients to evaluate their discomfort pre-operatively and communicate any post-op pain to the nurse immediately. We also make regular use of the 0-to-10 Numeric Rating Scale (NRS) during recovery. We treat pain pre-emptively with local anesthesia, and we don't hesitate to administer NSAIDs and narcotics at the first sign of post-op pain.

Our ratio of overnight care, which is one RN and one nurse tech to one or two patients, also helps us respond to patients very quickly. This not only helps alleviate anxiety, but also helps us stay ahead of the "pain game" and quickly catch any complications. This also enables us to wean patients from I.V. to IM or PO medications rather quickly.

We include detailed patient instructions in writing and call all patients the day after discharge to check on their emotional and physical status. These measures also help alleviate anxiety post-discharge.

By performing abdominal hysterectomy on an outpatient basis, we can safely cut the typical hospital stay down from two to five days to 23 hours. Our average cost per abdominal hysterectomy is around $800, and our reimbursement ranges from $1,100 to $1,900 per case.

Most importantly, our approach is in the patient's best interest. Strengthening patients' resolve to recover is an empowering and satisfying experience. Our patient satisfaction score for "overall satisfaction with the outcome of the procedure" is 96.3 percent, and our pain control ratings have been as high as 95 percent since we initiated our proactive use of the NRS. These scores are proof-positive that, when it comes to pushing the outpatient envelope, it's often an issue of mind over matter.

Dr. Vranich is a general surgeon with and Ms. Frederick ([email protected]) is the administrator of the HealthSouth North County Surgery Center.

Spinal Surgery

Outpatient Spinal Surgery: Not Just for Healthy Patients

We've taken "minimally invasive" to the extreme, and we're tackling cases that even inpatient facilities have rejected.
Angel Barber, RN, CLNC
DeFuniak Springs, Fla.

Time and time again, outpatient facilities have been blamed for "stealing" the cream of the crop and leaving the sick patients for the tertiary care hospital. Here at MicroSpine Surgery Center, we are turning this paradigm upside-down. Because we approach every patient with a "minimally invasive" philosophy, we are able to perform more than 17 significant spinal surgeries on patients with ASA ratings as high as IV on an outpatient basis.

In fact, we have even performed major spinal surgeries on patients who were rejected by the hospital due to poor overall health status.

Our most popular procedures are transfacetlaminoforaminoplasties (TFLFs) and cervical and lumbar discectomies, but our surgeon also performs outpatient corpectomy, hemilaminectomy, endoscopic thoracic spinal surgery, facetectomy, joint surgery (sacro-iliac, lumbar facet, cervical facet), scoliosis surgery, and even bioabsorbable fusions, hardware removals and other procedures. In every case, there are three essential components to our "minimally invasive" approach: anatomic restoration, endoscopic technique and conscious sedation.

• Anatomic restoration. Although we are a surgery center, we aim to perform only as much surgery as is truly needed to restore pain-free anatomy. The key to achieving this goal is accurate diagnosis. Rather than assuming every abnormal MRI finding contributes to back pain, we diligently diagnose the specific cause of pain before operating. Whenever there is doubt, which is the case in about half of patients, we perform discograms or diagnostic blocks to isolate the exact cause of pain. We thereby eliminate the possibility of implanting unnecessary hardware (which is particularly prone to biomechanical failure in the spine) or performing unnecessarily extensive surgery, like fusions, to correct asymptomatic abnormalities.
• Endoscopic technique. Our surgeon performs all procedures endoscopically with fluoroscopic assistance, using a combination of off-the-shelf and custom instrumentation. Because the surgeon works through a small portal, some procedures can be rather long and tedious. For example, during TFLF, he removes just 1 mm of bone at a time to ultimately open up the foraminal canal and relieve nerve root impingement. For all procedures except hardware removals, incisions are just one- to three-quarters of an inch long. Endoscopic technique not only expedites post-op healing but also reduces the risk of wound infection.[1]
• Conscious sedation. For all procedures, our anesthesiologist sedates patients with a unique blend of I.V. agents, which also includes an antiemetic. Even though they are prone, patients are not intubated. This ability to keep patients awake during these procedures is absolutely essential for two reasons. First, patients help us localize the area of chronic pain by responding to nerve stimulus. This way, the surgeon can be sure he will operate on the right spot, thereby increasing the chances for clinical success and reducing the risk of iatrogenic nerve damage. Second, this lets us perform these procedures on patients with comorbidities. The anesthesiologist can detect the onset of intraoperative complications well before a monitor would because he constantly communicates with patients. In a patient with mild heart disease, chest pain will likely occur before there is any indication of cardiac malfunction on an EKG. By minimizing the depth of anesthesia, we also minimize the potential for anesthesia-related complications. Our anesthesiologist typically refuses patients only when they have serious co-existing conditions that require treatment.

Without question, our spinal program can be challenging for our entire team. The endoscopic technique, which among other things requires the surgeon to have excellent three-dimensional visualization skills, and the anesthesia approach are technically challenging. As with any surgery, we must be prepared for serious complications, such as significant blood loss, neurological damage and dural leak. On average, however, our maximum blood loss is 100cc, and dural leakage is extremely rare. During the five years that our physician has been performing minimally invasive spinal surgery here, we have not noted any cases of iatrogenic nerve damage.

Reimbursement can also be difficult to obtain, since Medicare still considers these surgeries inpatient procedures. Still, although we are not yet able to contract with many payers, our center is financially viable. Our charges typically range from $4,000 to $8,000 per procedure, and we receive payment from patients themselves and workers' compensation plans, as well as from payers on an out-of-network basis. Less than 10 percent of our patients are local; given the novelty of our approach, we draw patients from around the world.

Although some patients do require an injection on the first post-op day for control of incisional pain and/or nerve irritation, we have documented an overall success rate of 70 to 80 percent for most procedures. We measure "success" using pre-established overall functionality, headache and neck disability indices, as well as VAS scores, the Oswestry spinal questionnaire, disability scores and employment status. These success rates are similar to or better than conventional spinal surgery success rates of 50 to 70 percent, and we feel this is particularly significant given that the vast majority of our patients have had prior, failed spinal surgery.

For the first time in many of our staff's careers, we are able to see the fruits of our labors almost instantly. When patients who needed a wheelchair to come to us walk out of the center virtually pain-free just a few hours later, we know we are truly helping them.

Ms. Barber ([email protected]) is the administrator of the MicroSpine Spine Surgery Center.

Reference
1. Martins JW, de Figueiredo Neto N. Endoscopic surgery for thoracic spine. Critical review. Arq Neuropsiquiatr. 1999;57(2B):520-7.

Mastectomy

It's in the Patient's Best Interest

There are enormous psychological benefits to sending patients home soon after surgery.
Douglas J. Mirsky, MDCM
Ottawa, Ontario

When President Clinton derisively labeled outpatient breast cancer surgery as "drive-through mastectomy" in his 1997 State of the Union address, he did breast cancer patients a disservice. I have been performing outpatient lumpectomy and mastectomy for two years now, and this approach helps patients recover faster.

My experience is supported by research suggesting that outpatient breast surgery/axillary lymph node dissection patients recover 10 days faster than their inpatient counterparts.[1] There are enormous psychological benefits to sending patients home soon after surgery. The outpatient experience minimizes the trauma of surgery, and thereby lets patients maintain a sense of control and keep their spirits up. In addition, unless the patient is elderly or has severe systemic disease(s), there is no clinical reason why qualified surgeons cannot perform lumpectomy or a simple or modified radical mastectomy on an outpatient basis.

Any ambulatory facility that performs these traditionally inpatient cases must establish a well thought-out, solid infrastructure to ensure quality care. This is because the ambulatory approach shifts some of the burden of care to the patient's family and support network. To lay the groundwork for performing outpatient mastectomies at your hospital or ASC, I recommend forming a steering committee, led by your chief surgical proponent of outpatient mastectomy, to achieve these goals:

• Identify the benefits. Potential clinical and psychological benefits include improved patient morale,1 quicker recovery, excellent patient satisfaction[2] and equivalent if not improved safety.[2-5] My own experience suggests that the rates of post-op complications are similar (roughly 10 percent) for admitted patients and outpatients. In one recent study, however, patients who underwent outpatient breast conserving procedures or mastectomy had fewer wound infections when compared with their inpatient counterparts (6 vs. 1 percent) and no hospital readmissions due to wound infections or complications (2 vs. 0 percent).[2]
• Secure commitments. The administrative challenge inherent in any successful outpatient breast surgery program is steep. Among other things, you will need to develop clinical pathways that map out every step in the patient care process from admission to post-op physiotherapy, including a compassionate and strong patient education program and ensured availability of home-care nurses. Successful outpatient breast cancer surgery programs include extensive patient and family counseling about treatment options, laboratory and radiologic tests, drain and wound care, arm exercises, lymphedema precautions, insurance issues and recovery expectations. In addition, a home-care nurse program is critical because, in the uncomplicated case, the surgeon typically does not see the patient again until her second post-op week. The home-care nurses provide analgesia supervision for the first eight post-discharge hours, often re-visit the patient 24 to 48 hours later to monitor healing and ensure that the patient adheres to her physiotherapy regimen, and remove drains on the fifth post-op day. The physician must also expend more effort, because outpatient breast cancer patients often require more short-term post-op visits to the attending physician.
• Assess anesthesia support. Since mastectomy can pose a significant risk of PONV, pre-, intra- and post-op antiemetic anesthesia strategies are crucial to outpatient success. These strategies are essential to successful PONV prevention: pre-op administration of IV antiemetics before administration of any other medications, opioid-sparing anesthesia technique, use of post-op muscle relaxants for alleviation of pectoralis muscle spasms when post-op pain is high, and close post-op PONV/pain monitoring and management.
• Evaluate cost. As with any surgery, it costs less to send the patient home than to admit her. In one study at the University of Oklahoma Breast Institute, hospital charges declined by 85.4 percent when patients chose outpatient breast cancer surgery.[2] Once post-op home-care nursing costs are considered, outpatient mastectomy remains at 25 percent less expensive than the same inpatient procedure.[4]
• Gauge interest of the staff and public. To optimize the chances for success, get the community involved. Invite local breast cancer support groups to attend your meetings and share their perspectives. Although mastectomy is not a particularly painful procedure as far as cancer surgery goes, it is extremely traumatic psychologically. Volunteer visiting networks do wonders for patient morale and recovery.

Clearly, you can't rush into outpatient mastectomy. All of the pieces - surgery, anesthesia, nursing, educational support, post-op home-care, community support and facility commitment - must fit together to make outpatient mastectomy a success. When they do, however, patients receive high-quality care and a big psychological boost.

Dr. Mirsky ([email protected]) practices at The Ottawa Regional Women's Health Breast Centre in Ottawa, Ontario.

References
1. Margolese RG, Lasry JC. Ambulatory surgery for breast cancer patients. Ann Surg Oncol. 2000;7(3):181-7.
2. Dooley WC. Ambulatory mastectomy. Presented at the 54th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 7-10, 2002. Amer J Surg. 2002;184:545-9.
3. Tan LR, Guenther JM. Outpatient definitive breast cancer surgery. Am Surg. 1997;63(10):865-7.
4. Evans WK, Will BP, Berthelot JM, et al. Breast cancer: better care for less cost. Is it possible? Int J Technol Assess Health Care. 2000;16(4):1168-78.
5. Ferrante J, Gonzalez E, Pal N, Roetzheim R. The use and outcomes of outpatient mastectomy in Florida. Am J Surg. 2000;179(4):253-9. a