Fig. 1.1
Ambulatory surgery visits and discharges of hospital inpatients with procedures: United States, 1996 and 2006 (revised)
Fig. 1.2
Rates of ambulatory surgery visits by facility type: United States, 1996 and 2006
HCPCS code | Short description | Non-facility price (office-based surgery) ($) | Facility price (hospital/ASC) ($) |
|---|---|---|---|
58565 | Hysteroscopy sterilization | 1,874.61 | 450.29 |
58353 | Endometr ablate thermal | 1,009.13 | 227.47 |
58555 | Hysteroscopy dx sep proc | 309.15 | 198.10 |
57461 | Conz of cervix w/scope leep | 327.06 | 196.31 |
57460 | Bx of cervix w/scope leep | 288.73 | 170.16 |
52000 | Cystoscopy | 203.12 | 128.60 |
Furthermore, patients intimidated by the thought of having to go to the “hospital” for “surgery”, may be somewhat comforted and calmed at the prospect that the same procedure can be done by the physician she knows and trusts in the reassuring environment of the office where she receives her routine gynecologic care.
Establishing an office-based surgery component to one’s practice, however, should not be embarked upon without serious consideration of the possible pitfalls. Thoughtful planning and consideration must be given to the risks of complications inherent in any surgical procedure, but then also the implications of how one will manage those complications in the setting of the office. As with current scrutiny of volumes of surgical cases and their proposed reflection on the skills maintained by the surgeon, an office-based surgery practice may be less efficient if more complex procedures are done infrequently, such that the staff is less familiar with the steps of the procedure. An office procedure complication can derail the physician’s schedule if in the midst of a busy office day, and any delays in the ability to access emergency backup can unnerve even the most capable clinician. Strict policies and protocols for staffing, facilities, equipment, standards (sterilization, postoperative observation, appropriate post-anesthetic milestones), and patient flow and workflow can help to minimize the hazards due to inconsistencies. One of the advantages of the out-patient or office setting is that there is little to no external regulatory requirement. This is also one of the drawbacks and cause for concern: lack of external oversight puts more of the onus of maintaining quality control, auto-policing, and upholding standards on the physician and the office staff.
After all of the considerations for setting up the office-based surgery program, obtaining the best equipment, training the staff, establishing protocols, and transferring the surgical skill set from the operating room to the office procedure room, these well-laid out plans will be for naught if adequate attention and respect are not devoted toward ensuring appropriate patient selection, pre-procedure evaluation, and management. Selecting the right patient for office-based surgery is of paramount importance as not all patients are candidates for office-based surgery.
Patient Selection
Success of the office-based surgery program requires appropriate patient selection. The patient should be counseled and educated appropriately so as to have reasonable expectations regarding what the procedure will accomplish, an understanding of the procedure itself, risks of the procedure, anticipated outcomes (immediate and long-term), pain during the procedure and immediately afterward, an understanding that the patient will have some level of awareness during the procedure, and the anticipated immediate post-procedural course.
Unrealistic expectations begin with patients’ perceptions that ambulatory surgery procedures are “routine” or “minor.” On the contrary, invasive procedures that were performed on an inpatient basis only a few years ago are now performed on an outpatient basis. Physicians may also view outpatient procedures as “routine,” making them less apt to spend as much time educating an outpatient about possible complications as they would an inpatient. Patients may expect to walk out of the ASC [ambulatory surgery center] or hospital-based unit pain-free immediately after surgery [3].
The patient must be willing and able to comply with preop medical/drug therapy (e.g., hormonal thinning of the endometrial lining prior to endometrial ablation), as well as postoperative requirements (e.g., effective contraception for 3 months after hysteroscopic sterilization until tubal occlusion can be confirmed).
Patient history. As part of the initial evaluation of the patient, it is assumed that a complete history is obtained, including:
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Past medical history
Medical complications/comorbidities
Hypertension, pulmonary disease, sleep apnea, diabetes, renal disease, liver disease, neurologic disease
Anxiety, depression
History of severe vagal reactions
Developmental delay (impact on ability to comply with pre-/intra-/post-procedural instruction)
Consider risk factors such as age, obesity, exercise capacity, diagnosis of obstructive sleep apnea (particularly in the patient undergoing conscious sedation)
Current medications (including over-the-counter and herbal preparations)
Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs) for 2–3 days before surgery, substituting acetaminophen if necessary. Vitamin E and some herbal agents, such as ginkgo, can also prolong bleeding times and should be avoided before surgery.
For most patients, the risk of thrombotic events from discontinuing antithrombotic agents (e.g., aspirin, clopidogrel, warfarin) outweighs any increased risk of bleeding with their continued administration [4, 5]. Patients who are taking aspirin for primary prevention of cardiovascular disease or for an indication other than antiplatelet therapy (such as pain control), should discontinue aspirin 7–10 days before surgery.
Allergies (reactions to medication, latex, iodine, local anesthetics)
In addition to allergies (or reported allergies) to medications, inquire about reactions to latex, iodine, local anesthetics, and adhesive tape. Reactions to these items used commonly in the office setting may resemble allergies. Reactions including psychomotor or anxiety-related actions, vasovagal syncope, and sympathetic stimulation can simulate allergic reactions. Reports of dyspnea, syncope, light-headedness, and hypotension may be associated with both allergic and non-allergic reactions. However, signs such as wheezing, pruritus, angioedema are suggestive of true allergic reaction.
Psychomotor reactions—Psychomotor reactions or anxiety-related symptoms include hyperventilation (manifested by dyspnea and tachypnea), paresthesias in the fingers or peri-oral area, dizziness, palpitations, tachycardia, nausea, or simply “not feeling good” [6, 7].
Vasovagal syncope—Vasovagal syncope is usually associated with bradycardia (rather than tachycardia) and pallor (rather than flushing). These differences can be helpful in distinguishing it from anaphylaxis.
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