Identifying the right patients for outpatient surgery can be tricky. Surgery centers must ensure patients have no conditions or take no medications that would jeopardize a safe surgical outcome. ASCs that receive funding from the Centers for Medicare & Medicaid Services (CMS) also must make certain patients are not expected to be hospitalized after surgery.
“CMS wants to make sure we are choosing patients that are appropriate to having surgery at an outpatient facility and will go home safely afterward,” says Missy Soliz, BSN, RN, quality and risk manager for Mississippi Valley Health in Davenport, IA. “You can’t just say, ‘We have strict and appropriate exclusions and won’t take a patient over X age or BMI,’ and leave it at that. While we do have some clear restrictions, there is more to it than that.”
The team must take into consideration the ASC’s capabilities and limitations, including staff expertise and training. The team also should consider:
• the patient’s current health status;
• the patient’s medical history;
• the procedure’s variables, including anesthesia type, invasiveness, duration, and estimated blood loss;
• the patient’s support at home and/or ability to take care of himself or herself effectively at home.
Soliz offers these tips on improving patient selection or screening:
1. Collaborate to improve safety. Proper patient selection and preadmission screening require a strong collaboration among the patient, the patient’s healthcare team, the surgeon, the anesthesia provider, and the surgery center’s team, Soliz says.
“The priority is patient safety, and the goal is the best possible outcome for the patient,” she says.
Keep in mind that safe patient care is a patient’s right.
“The ASC has a responsibility to collect a patient’s health history to help ensure that the patient is an appropriate candidate for the ASC setting,” Soliz says.
This requires collaboration with the patient’s healthcare team to ensure the patient is optimized for the specific, planned procedure, with the planned anesthesia type in the ASC setting, she adds.
2. Investigate patients’ particular risks. “More and more, we’re seeing sicker patients in the ASC,” Soliz says. “Sometimes, those patients don’t understand the risks pertaining to surgery and anesthesia.”
ASCs often do not maintain electronic medical records or access to all patients’ records from other providers. Hospital and medical reports often do not include the whole picture. Thus, ASCs must rely on patients’ memories and self-reports.
“There is a hope that all of these electronic medical records would communicate with each other, but we’re not there yet,” Soliz says. This leaves ASCs to rely on the patient’s knowledge, which can be problematic. “A common situation we see is we’ll ask them if they have any history of high blood pressure, and they’ll say, ‘Nope, I have no problem with that,’” Soliz says.
The truth is that the patient has been taking high blood pressure medication daily. But, in the patient’s mind, this is a fixed problem and no longer an issue.
“They don’t understand their personal health conditions and the potential risks of those conditions,” Soliz says.
ASC nurses can learn about problems that patients omit by comparing their answers with their list of medications. If a patient said she had no trouble with blood pressure, but the medication list includes a drug to lower blood pressure, then the nurse can ask and educate about the discrepancy.
“We call to clarify and say, ‘What is this medication for?’ During those nurse interactions, we educate them on the importance of these answers,” Soliz says.
During pre-surgery visits, nurses can go through the health information line by line. Nurses can ask patients about over-the-counter (OTC) medications and discuss which of the OTC and prescribed medications they can continue taking prior to surgery.
“We need to educate patients about supplements, including fish oil, which some physicians will say they cannot take before surgery because of the increased risk of bleeding,” Soliz says. “It may take some digging to uncover some of those health problems, and we might not find out about them until the day of service,” Soliz says. “We have cancelled patients on the day of service for problems we had not known about.”
Identifying all risk factors well in advance can save the patient the inconvenience and frustration of a last-minute change. Date-of-service cancellations also create issues for the ASC, disrupting operations, changing case order, and adding to the chaos, all of which collectively increase the stress on staff and risk to the patient.
3. Direct patients to input their health information electronically, when possible. Some surgery centers use an online preadmission health history form in which patients input their medical information and their medications. This helps reduce the nursing hours used for collecting health history information. Gathering this information via phone or in-person interviews is time consuming. Still, it is important that a nurse review these, Soliz says.
When a patient answers “yes” to a question, such as a question about experiencing heart problems, the electronic system provides a drop-down menu of heart problems to select.
“The system queues them on certain questions,” Soliz says.
Not all the information is accurate, but it gives ASC nurses additional data, which nurses can use in follow-up inquiries.
“We need to know if they need special instructions, and we need to know if we’ve uncovered something where the outpatient setting may not be the best for the patient,” Soliz says. “We look at their physical status, health condition, stabilization, and health diseases.”
Nurses also will see whether patients went to follow-up doctors’ appointments. “If a patient never went back to the doctor in a year, we are hesitant because this patient did not follow up as directed on this condition.”
This could mean the patient would fail to follow post-surgery instructions, which could lead to less positive outcomes.
4. Delve into patients’ social factors. ASCs must consider other patient factors, like transportation.
“Do they have someone to take them home?” Soliz asks. “And when we talk about support and getting a ride home, those are two different things. If they have a ride home and someone drops them off and leaves them there, that might not be the best thing for that patient.”
It’s important to make certain patients can perform self-care when they return home from surgery, she adds. “Is this something they can do?”