A procedure performed in an ambulatory setting does not necessarily mean it is dangerous, but a patient with pre-existing conditions and comorbidities could transform a routine surgery into something riskier. Presurgery assessments can reveal issues related to high risk for transfer, readmission, and overnight stay.
“It’s nice if you have a pathway in place involving multiple disciplines, including the anesthesiology group, the local primary care practice, and a cardiologist in case the patient needs a consult,” says Niraja Rajan, MBBS, staff physician at Penn State Health, and medical director of Hershey Outpatient Surgery Center. “I tell surgeons that as soon as they see patients in their clinics, they could set that ball in motion to give us more time to optimize the patient.”
Because the goal of ambulatory surgery is to send the patient home on the same day as the procedure, staff must assess risks that could derail those plans. “You need to make sure you’re not taking care of someone who cannot withstand the procedure you are about to perform on them so they [do not] end up getting transferred back to the emergency department,” Rajan says.
Through prehabilitation, surgery centers can address exercise capacity, nutritional status, mental health, and manage expectations.
“A lot of prehabilitation programs will ask patients to increase activity, as permitted, before surgery. They give nutritional advice to help [patients] eat better so they don’t come into surgery in a poor nutritional state,” Rajan explains. “Some require behavioral therapy. Although there’s not strong evidence in favor of that, it could be useful in some populations.”
For instance, cognitive behavioral therapy could help patients manage their expectations for post-surgical pain and outcomes. It could prevent patients from returning to the emergency department or acute care setting because they did not understand what they were supposed to do after a procedure.
One of the most important risk factors to assess is frailty, which concerns how well a patient can handle a procedure. “If they start out frail, they’re not very resilient, and even normal stresses of surgery may be too much for them to handle,” Rajan cautions.
Sleep apnea is another risk factor. If a surgical patient has sleep apnea and has not been using a CPAP device, then clinicians could encourage the patient to use one. “If the procedure is painful, and the patient [with sleep apnea] requires opioid pain medication, the person may not be able to be discharged on the same day,” Rajan explains. “We don’t want to send them home to take opioid medication and then have them run the risk of falling asleep and having obstructions of airways.”
It helps if the surgery center creates a decision-making algorithm, customized to make decisions regarding patients’ risk factors. For example, some surgery centers do not have the equipment to handle obese patients. Leaders can choose to either purchase the necessary equipment, or exclude these patients from same-day procedures. “If we’re going to start seeing bigger patients, we need to make sure we have the equipment to deal with them,” Rajan says.