Patient selection not determined by 1 factor

Age, procedure, and health status combined

The patients are sicker and older, and the procedures are lengthier. This is the challenge faced by surgeons and outpatient surgery staff. How do you make sure the patients that enter your outpatient program are appropriate for outpatient surgery?

There is no one answer to this question, says Beverly Philip, MD, professor of anesthesia at Harvard Medical School and medical director of the Day Surgery Unit at Brigham and Women's Hospital in Boston. When setting the policy for patient selection within your outpatient surgery program, you must take into account: the skill and experience of your staff; the comfort level of the staff in dealing with sicker patients and longer recovery times; the experience of the surgeon; and the availability of medical backup in an emergency, she suggests.

Don't forget to look at the capabilities of your facility as well, Philip points out. "Elderly and sicker patients don't bounce back as quickly, so you need the space and the time to allow them to take longer to recover," she explains.

Every outpatient surgery program should develop a clear policy of who is and who is not acceptable as a patient, says Philip. In addition to basing policies on your program's capabilities, be sure to follow guidelines created by the American Society of Anesthesiologists (ASA) in Park Ridge, IL, she recommends.

Be sure that all staff members are able to respond to emergencies and follow a plan that has been developed specifically for your facility, says Philip. If transfer to another facility is needed, have that plan in place ahead of time, she says. "Accreditation requirements and regulatory requirements do differ, so some programs may need a transfer agreement; others might require the surgeon to have admitting privileges at a nearby hospital," she says. Whatever route you take, have the plan in writing with all staff members aware of the procedure. "Just [cold-] calling 911 is not satisfactory," she adds.

Basing your patient selection criteria only on age, health status, or procedure won't work well, says Gail Avigne, RN, director of surgical services at Shands Hospital at the University of Florida in Gainesville. "Our population is getting older, so we see more older patients, but a healthy 70-year-old can be at lower risk than a sick 45-year-old for a surgical procedure," she says. For this reason, Avigne's facility uses a combination of the ASA Physical Status Classification System and an evaluation of the surgical procedure's risk, she says. "We like to handle patients who are ASA 1 or 2, but we will take patients who are ASA 3 for some procedures,"

Low-risk procedures, such as for cataracts, are appropriate for higher-risk patients, but lengthy procedures, even cosmetic surgery, are questionable, says Avigne. "If a procedure is going to last longer than four hours, we require the medical director's and the nurse manager's approval," she explains.

The medical director of an outpatient surgery program is usually an anesthesiologist and can decide the appropriateness of a procedure, agrees Philip. If, however, the medical director is not an anesthesiologist, include the anesthesia provider in the decision process. The anesthesiologist can best determine how long the patient will require for recovery and how safe it will be for the patient to go home because they are responsible for the medical care of patients throughout recovery and they see how different patients react, she explains.

Everyone needs to set selection criteria

All outpatient surgery programs, office-based, freestanding, and hospital-based need to develop their patient selection criteria to produce the best patient outcomes and to provide the same high level of care in all settings, suggests Philip.

"Office-based practices need to ensure that procedures performed are within the scope of practice [of the health care practitioners and the capabilities of the facility]," she says.

Even hospital-based programs need to have boundaries to ensure patient safety, says Philip. The resources and backup available in an emergency make it possible for a hospital-based program to accept higher-risk patients, but choose the patients carefully, she says. It is not acceptable to just admit a lot of patients because the patients were not appropriate candidates for outpatient surgery, she says. "Most hospital-based outpatient surgery programs should admit no more than 1% to 2% of their patients for overnight stays."

Not only should your policies be clear and firm about which patients are appropriate and which are not appropriate for your staff and surgeons' use, but written policies also will help you when patients are insistent that they be treated as outpatients, says Avigne. "It is important that the patient understand that you are not making an arbitrary decision but a decision that is based on research and concern for patient safety," she explains. "Patients need to understand that even if the surgery is minimally invasive, all surgery carries some risk, and the patient's health status can increase that risk."

Sources/Resource

For more information about patient selection, contact:

  • Gail Avigne, RN, Director of Surgical Services, Shands at the University of Florida, 1600 S.W. Archer Road, Gainesville, FL 32608. Phone: (352) 265-0023. E-mail: avignga1@shands.ufl.edu.
  • Beverly K. Philip, MD, Director of the Day Surgery Unit, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.

To access copies of the American Society of Anesthesiologists' guidelines for outpatient surgery, go to www.asahq.org. Select "Clinical Information" on the left navigational bar, then select "Standards, Guidelines, and Statements" on the right navigational bar. Choose "Ambulatory Anesthesia and Surgery" or "Office-Based Anesthesia" from the list of guidelines.