HOME SWEET HOME Sending healthy surgical patients home prevents them from spending time in the hospital, which should be reserved for sick kids who truly need round-the-clock care.

Most of my pediatric adenotonsillectomy patients are complication-free following surgery and head home without issue. So can a procedure performed approximately 250,000 times each year in the United States be done safely in the outpatient setting? Yes, I've proven that. But it has to be done in the right types of facilities on the right types of patients, who are cared for by properly trained perioperative teams. The decision to discharge patients is based on a host of clinical and environmental factors unique to individual patients, but sending patients home on the day of surgery is something surgical facilities can and should start to consider.

My patients (and their parents) are a select group. They live within an hour-and-a-half of New York—Presbyterian Hospital, a tertiary care medical center in New York City where I operate, so they're not driving as far for care as they might in less-well-served areas. We exclude children who have medical conditions such as severe asthma, bleeding disorders, cranio-facial abnormalities and morbid obesity — anything that would place them in a high-risk population.

Presby is filled with incredible pediatric anesthesiologists and nurses who understand how to maintain safe, efficient care. Nurses spend more time with surgical patients than physicians do, so having seasoned RNs who work as a team is essential to performing these cases on an outpatient basis. The recovery room staff is highly trained in monitoring pediatric adenotonsillectomy patients, having undergone in-services with anesthesiologists and otolaryngologists. An anesthesiology resident works in the PACU and is available for nurses to consult if questions or concerns arise during recovery. Plus, I'm always around and available.

The kids undergo a great deal of observation by highly trained caregivers before being discharged. We assess underlying medical conditions that could raise red flags, and review surgeries to determine if they were routine or more difficult than expected. Patients have to tolerate a minimum of 6 to 8 ounces of fluid, depending on their age. Their oxygen saturation level needs to be above 95% for at least 2 to 3 hours after the administration of pain medication.

Communication among all caregivers and frank discussions with patients' parents or guardians are essential elements in determining when and if patients are ready for discharge. Ask parents or guardians how comfortable they are caring for their children at home. They must ensure kids continue to tolerate fluids and watch out for excessive lethargy and labored breathing. Can you trust them to recognize complications? How far does the family live from the nearest hospital? You need to pick the kid and the at-home caregiver when identifying cases that can be done as outpatient.

DAY CARE Children who receive expert perioperative care can be sent home safely.

CLINICAL EVIDENCE
Few Complications
Following Adenotonsillectomy

Adenotonsillectomy can safely be performed in young children with minimal complications, so it's time to start reevaluating the need for mandatory admission of all children younger than 3 years old, study results show.

For research published in the April 2012 issue of JAMA Otolaryngology-Head & Neck Surgery, I reviewed the outcomes of 86 pediatric patients I operated on between January 2003 and October 2009 at New York—Presbyterian Hospital, a tertiary care medical center in New York City. There were minimal post-op complications, and notably no respiratory issues — no one required intubation or significant supplemental oxygen. None of the patients had post-op problems that necessitated admission. Dehydration was the most common complication.

Recent studies, including mine, have proven the safety of outpatient adenotonsillectomy, but the American Academy of Pediatrics and the American Academy of Otolaryngology-Head and Neck Surgery hesitate to issue national recommendations for sending all children home the day of surgery. The groups must be certain the procedure can be completed safely in every type of facility, from my tertiary care facility in New York City to community hospitals in the rural Midwest.

If more studies show that pediatric adenotonsillectomy patients can be discharged safely, the AAO-HNS and AAP would feel more comfortable making recommendations stating physicians can use discretion in deciding when patients can go home. In the meantime, rely on good clinical sense when determining who can be discharged on the day of surgery and who can't.

— Jacqueline E. Jones, MD

Clinical considerations
Newer techniques such as partial tonsillectomy lead to less post-op pain and swelling, which definitely eases recoveries. However, a majority of my patients undergo traditional tonsillectomy. That they recover nicely is telling, and offers promise for the potential of performing these procedures in same-day settings.

Up until about 2 years ago, I'd use Tylenol with codeine to control post-op pain. The problem with the Tylenol-codeine combo, other than the FDA-issued black-box warning for its use in pediatric tonsillectomy and adenoidectomy patients, is that some patients hypermetabolize codeine, turning most of the drug into morphine. Hypermetabolizers who struggle with obstructive sleep apnea — as many of these patients do — have a higher degree of respiratory suppression. Because of all these factors, we now use oxycodone in the recovery room to make patients comfortable.

We've standardized our anesthesia technique, which includes the routine use of dexamethasone to decrease post-op airway edema as well as newer classes of antibiotics and antiemetics to reduce post-op complication risks.

We employ a step-down recovery unit with well-trained nurses. Patients often spend a couple hours in the regular recovery room then move to the step-down unit for another couple hours until they're ready for discharge. Overall, patients remain under our care for about 5 hours post-op.

Where we stand
I used to admit all of my patients, but parents started to wonder why their kids had to stay in the hospital when they were seemingly fully recovered from surgery. It was hard to argue. I began to check on admitted patients around 9 p.m., after they'd been in the hospital for 8 hours. Most were doing great. After a couple years of monitoring patients' recoveries, I decided to see if we could start sending some of them home on the day of surgery. My research showed we could. Now I admit all children 2 years and younger and reevaluate them at 6 hours post-op for possible discharge. Children older than 2 years are registered as outpatients and only admitted if complications arise.