Ambulatory surgery centers and alternative surgical locations

After studying this chapter, the learner will be able to:

• Compare the differences between hospital-based services and ambulatory surgery centers (ASCs).

• Distinguish between activities in fixed and mobile surgery locations.

• Describe key elements of human versus veterinary surgery.

Care delivered to a patient who is not confined to bed or in need of formal admission to a facility for a prolonged period.

Deployment

A term that refers to sending one or more active duty soldiers forward into an area where medical war support is needed. Average length of stay is 3 days.

DEPMEDS

A system of mobile military hospital components that are assembled and dismantled close to the location of military activity.

Monitoring

Clinical observation of a patient’s condition through continuous interpretation of vital signs, activities, and responses.

PAT center

Area of a facility designated for patient assessment and preprocedural examination.

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• Historical Perspective

• Flashcards

• Self-Assessment Activities

• Glossary

Ambulatory surgical setting

Ambulatory surgery can be defined as surgical patient care performed with general, regional, or local anesthesia without overnight hospitalization. Some ASCs offer diagnostic testing and radiologic examinations, such as mammography.

The following are organizations specifically for professional ambulatory surgical nurses:

• American Society of PeriAnesthesia Nurses (ASPAN); www.aspan.org

• American Academy of Ambulatory Care Nurses (AAACN); www.aaacn.org

• Association of periOperative Registered Nurses (AORN); www.aorn.org

AORN has established a specialty assembly for nurses who practice in the ambulatory setting. A chairperson and council are selected by the assembly membership to serve 3-year terms. AORN’s website has an ambulatory practice portal at www.aorn.org.

Ambulatory surgery programs

Various terms are used to describe ambulatory care facilities, including outpatient surgery, same-day surgical unit, day surgery, and ambulatory surgery center. Conceptually, an ambulatory facility has the following:

• Preprocedural testing and assessment area (PAT center)

• Admitting area

• Changing and dressing room with lockers and toilets

• Preoperative holding/preparation area

• OR

• Postanesthesia care unit (PACU) or access to a PACU

• Family waiting room

The decor of the ambulatory facility should be pleasing to enhance relaxation of the patient and family. Recliners are commonly available for postprocedure recovery. Many facilities have televisions with videocassette capability. Figure 11-1 depicts a sample floor plan that shows the various areas within an ASC. Priority patient parking areas should be conveniently located near the entrance to the facility, with parking spaces for disabled patients located nearest the entrance.

FIG. 11-1 Schematic of ambulatory surgery floor plan. *(Reprinted with permission Herman Miller, Inc.)*

Many hospital-based ASCs offer valet parking. The convenience of dropping off and picking up patients should be accommodated in the design of the facility. Studies have shown that this is a point of patient satisfaction. Space requirements for parking areas are determined by the numbers and types of surgical procedures to be performed.

The location of an ASC may vary. The Federated Ambulatory Surgery Association (FASA) indicates that a true ASC is not dependent on the main hospital and is physically independent in services, such as ORs, postprocedure care, and central service. ASCs are not designed to take emergency patients and typically employ fewer than 20 employees. Examples of outpatient surgery departments attached to hospitals include the following:

• Hospital-based dedicated unit. Patients come to a self-contained unit that is located within or attached to the hospital but physically separate from the inpatient OR suite.

• Hospital-based integrated unit. Ambulatory patients share the same OR suite and other hospital facilities with inpatients. The preoperative admission and holding area is shared. Ambulatory patients usually return to the same admission area for discharge after the procedure.

• Office-based center. Patients come to a physician’s office that is equipped for surgery. Many private surgeons, dermatologists, periodontists, and podiatrists perform surgical procedures in their offices with a local anesthetic. This office-based center may accommodate one or more surgeons in the same specialty, or it may be a multiphysician, interdisciplinary clinic. Although these are not always attached to a hospital, they are not considered an ASC by FASA.

Examples of ambulatory surgery centers by the definition of FASA are the following:

• Hospital-affiliated satellite surgery center. Patients come to an ambulatory surgery center that is owned and operated by a larger facility but geographically separate from it.

• Freestanding ambulatory surgery center. Patients come to a completely independent facility. Many of these facilities are owned and operated by physicians.

Accreditation of ambulatory facilities

The ASC should comply with standards set by the Accreditation Association for Ambulatory Health Care (AAAHC; www.aaahc.org), The Joint Commission (TJC; www.thejointcommission.org), the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF; www.aaaasf.org), the Ambulatory Surgery Center Association (www.ascassociation.org), and the American Osteopathic Association (AOA; www.osteopathic.org). These five patient advocacy and consumer groups advise patients to select facilities carefully and to look for accreditation and credentialing by professional and governmental agencies.

The 2011 updates for Ambulatory Care and Office-Based Surgery National Patient Safety Goals ^a include the following:

• Improve the accuracy of patient identification: Use a minimum of two patient identifiers (excluding the patient’s room number) when administering pharmacologic agents or blood, taking blood samples or specimens, or providing any treatments or procedures.

• Improve communications among caregivers: All verbal orders or results should be read back to the person delivering the information. Standardize a list of all abbreviations, acronyms, and symbols that are not to be used within the organization. Improve the timeliness of information exchange between the reporter and receiver regarding test results and values. Standardize the hand-off report of patient care to qualified personnel between phases of care.

• Improve medication safety: Standardize the numbers and concentrations of drugs within the facility, identify sound-alike/look-alike medications and limit their use to prevent error, and label all containers and delivery devices with the name and concentration of the drug. Discard any unlabeled medication containers.

• Reduce the risk of health care–related infections: Comply with Centers for Disease Control and Prevention (CDC) recommendations for hand hygiene. All deaths or permanent injuries associated with health care–related infection are treated as sentinel events.

• Identify and reconcile patient medications across the continuum of care: All home and hospital medications are identified and relayed to all caregivers in the hand-off report.

• Reduce the risk of surgical fires: Staff education should include spark, fuel, and ignition sources, including oxygen concentration under drapes, as a source of surgical fire.

Licensure of ambulatory surgery centers is required in 43 states. Requirements for licensure are similar to those for accreditation. Inspection visits are scheduled on a routine basis. Ambulatory centers are highly regulated by governmental agencies. Approximately 85% of ambulatory surgery centers are approved for Medicare. Accreditation and credentialing of a facility can be attained with, but is not limited to, the following:

• Compliance with structural standards

• Establishment of policies and procedures that support competent standards of care

• Appropriate credentialing of personnel

• Emergency preparedness

• Appropriateness of procedures performed at the facility

According to statistics compiled by the CDC, approximately two thirds of all surgical procedures performed are done on an ambulatory or outpatient basis safely and without complications. Some smaller facilities limit the use of ambulatory surgery to procedures that can be performed with local or regional block anesthetics. Facilities with PACU capability allow surgeons to perform procedures with the patient under general anesthesia.

Although procedures performed in an ambulatory care facility are usually of short duration (15 to 90 minutes), the appropriate selection and evaluation of patients are essential. Patient care and anesthesia management also are crucial factors in the experience of the ambulatory surgical patient.

Some facilities are prohibited from performing complicated laparoscopy because of the risk for injury to the patient. (More information can be found at the Federated Ambulatory Surgery Association website at www.fasa.org.)

Patient selection for ambulatory surgery

After a surgical procedure, patients may prefer to recuperate at home rather than in the hospital. These patients may be candidates for ambulatory surgery, depending on the nature and extent of the surgical procedure and on the patient’s ability to follow instructions or to receive adequate care at home. Consideration is given to the duration and complexity of the surgical procedure, the risk of anesthesia, and the probability of postoperative complications.

Patients are carefully screened before being considered safe candidates for ambulatory surgery. The following are some of the criteria considered:

1. General health status. Acceptable patients are in class I, II, or stable III of the physical status classification of the ASA. Patients are evaluated physically and emotionally to determine the possibility of complications during or after the surgical procedure.

The Centers for Medicare and Medicaid Services (CMS) December 2010 rule ^b requires three separate health assessments before a patient is placed on the OR bed. The three assessments include:

a. A complete medical history and physical examination (H&P) no earlier than 30 days before the intended surgical procedure. The H&P must be redone if 30 days have passed.

b. A physical assessment on arrival at the surgery center to validate that no changes have occurred since the H&P was performed. Care is taken when discussing private information in the ASC cubicles. Other patients can overhear conversation through the divider curtains.

c. A preanesthesia evaluation to assess the safety of administration of anesthesia before the patient enters the OR.

2. Results of preoperative tests.⁴ Patients may have tests on admission the morning of the surgical procedure, but preferably these tests are performed before the scheduled surgery date so the results can be evaluated. This prevents cancellation on the day of surgery if test results are unsatisfactory. Test results are placed on the chart that accompanies the patient to the OR. Preoperative tests may include the following: