Fast tracking after ambulatory surgery is a new paradigm which involves transferring patients from the operating room to the phase II recovery unit (i.e. bypassing the postanaesthesia care unit). The success of fast trac...Fast tracking after ambulatory surgery is a new paradigm which involves transferring patients from the operating room to the phase II recovery unit (i.e. bypassing the postanaesthesia care unit). The success of fast tracking depends upon appropriate modification of the anaesthetic technique, which would allow rapid emergence from anaesthesia, and the prevention of common postoperative complications such as pain, nausea and vomiting using a multimodal approach. Implementation of a fast track program involves use of clinical pathways that would reduce hospital stay and ensure patient safety. Finally, the concept of fast tracking should be expanded to the overall postoperative recovery, not just bypassing the postanaesthesia care unit.
In Germany, discussions on the fees for statutory sickness insurance for ambulatory surgery has, in the last few years, become almost a symbol of dispute for the German health services. Outpatient surgeons complain about...In Germany, discussions on the fees for statutory sickness insurance for ambulatory surgery has, in the last few years, become almost a symbol of dispute for the German health services. Outpatient surgeons complain about the fact that the fees do not cover their services. They see innovation severely threatened by bureaucracy, profitability by planned economy, rights by reasons of State, aggravated by the 'reform' attempts of the Greens and Socialist coalition Federal Government. On the other hand their opponents complain about the money mindedness of the doctors. Intentional panic or real disaster? The fundamental consideration to clarify this question is based on a comparison of the German statutory medical insurance fees and private fees with our neighbours. In Europe an economic area with similar prices for goods, services and wages, even 'outpatient operations' services with comparable cost rates should be paid for at a corresponding level. Any discrepancies would give cause to look for an explanation by analysing the historic development of fees and the question of a fair comparison between operations and the non-operative services.
The aim of this study was to evaluate our 5 year experience in the surgery of umbilical (UH) and epigastric hernias (EH) on an ambulatory basis. Sixty three point seven of UH (88/138) and 68.4% of EH (13/19) could be suc...The aim of this study was to evaluate our 5 year experience in the surgery of umbilical (UH) and epigastric hernias (EH) on an ambulatory basis. Sixty three point seven of UH (88/138) and 68.4% of EH (13/19) could be successfully operated in our ambulatory unit. Morbid obesity, ASA III-IV and insulin dependent diabetes were exclusion criteria. After a preoperative local anesthesia infiltration with 1% lidocaine a repair was undertaken in all 101 patients under monitored anesthesia care. Most patients underwent a mesh hernioplasty as definite treatment. Only three patients could not be discharged on the day of operation. There has been a 2% recurrence rate in long term follow-up. These results demonstrate that two thirds of primary aponeurotic hernias can be satisfactorily operated on ambulatory basis.
The aim of this study was to describe the procedures and the postoperative outcome of arthroscopic anterior cruciate ligament (ACL) reconstruction when carried out a day case with extended recovery. Between December 1995...The aim of this study was to describe the procedures and the postoperative outcome of arthroscopic anterior cruciate ligament (ACL) reconstruction when carried out a day case with extended recovery. Between December 1995 and September 1998, 91 patients underwent surgery using bone-patellatendon-bone autografts and interference screw fixation. Additional surgical procedures were performed on 35 of the patients. The patient records were evaluated for a mean of 17 months (1-33 months) postoperatively. The course of treatment was. (1) Evaluation and KLT-arthrometer test 14 days preoperatively. (2) Surgery, cryocuff, bupivacain, paracetamol, NSAID and ketobemidon for postoperative pain control. (3) Discharge from hospital within 24 h. (4) Physiotherapy after 14 days. (5) Follow-up after 6 weeks with bandage removal and after 6 months. Eight patients required one further day of hospitalisation due to pain (four), nausea (one), haematoma (two) and prolonged anaesthesia (one). Five patients were readmitted to hospital for a mean of 8 (3-16) days postoperatively. Three patients underwent re-surgery due to haematoma/rupture of the scar. No deep infections were found. We concluded that this effective method of ACL-reconstruction can be carried out safely as a day case procedure with extended recovery to the benefit of the patients.
The drive for cost containment in the United States has lead anesthesiologists to re-assess the benefits of routine pre-operative laboratory and radiological testing. The value of routine tests has been questioned not on...The drive for cost containment in the United States has lead anesthesiologists to re-assess the benefits of routine pre-operative laboratory and radiological testing. The value of routine tests has been questioned not only by insurance companies but also by physicians. Common pre-operative laboratory and radiological tests are reviewed in the following analysis. Specifically, the use of such tests in children scheduled for ambulatory surgery is discussed. Current clinical practice patterns of pediatric anesthesiologists are included so that physicians may make conclusions on the basis of published literature and clinical practice of peers.
Introduction: The creation of Outpatient Surgery (OPS) units has allowed to reduce the costs and the waiting lists in an efficient fashion. We describe our series of patients operated on for abdominal wall defects, a pat...Introduction: The creation of Outpatient Surgery (OPS) units has allowed to reduce the costs and the waiting lists in an efficient fashion. We describe our series of patients operated on for abdominal wall defects, a pathology suitable for ambulatory surgery. Patients and methods: Between May 1994 and March 1998, 206 inguinal hernias, 23 femoral hernias, 47 umbilical-epigastric hernias and nine incisional hernias were operated on in an ambulatory surgical setting. The patients were selected following the selection criteria previously established (related to the patient, the environment and the surgical procedure). The average age was 45 years, and the distribution by sex, 210 men and 75 women. Spinal anesthesia was preferently performed. The surgical techniques employed were Lichtenstein's hernioplasty and Shouldice and Bassini procedures for inguinal hernias; Lichtenstein's plug technique for femoral hernias and simple closure or preperitoneal mesh for the middle line defects. Results: 44 patients needed readmitttance to hospital (failure of OPS), the most important causes being excessive pain, urinary retention and nausea/vomiting. There was no severe morbidity nor mortality. Conclusion: Surgery for abdominal wall defects constitutes a group of procedures suitable for efficient and low risk OPS programs.
Introduction: The creation of Outpatient Surgery (OPS) units to combine the quality of medical attention and rationalize costs allows for greater efficiency in the use of resources. Aim: To report our series of patients...Introduction: The creation of Outpatient Surgery (OPS) units to combine the quality of medical attention and rationalize costs allows for greater efficiency in the use of resources. Aim: To report our series of patients undergoing surgery at the OPS units integrated into our Hospital (Type II): Patients and method: Between May 1994 and March 1998, 832 outpatients, of a total of 5230, underwent surgery at our General Surgery Unit. The criteria for exclusion from the programme depended on the patient and the enviroment or resulted from the operation itself. Results: Mean patient age was 47.5 years; there were 420 males and 412 females. Surgery was performed for 229 inguinofemoral hernias, 47 umbilical-epigastric hernias, nine incisional hernias, 193 pilonidal sinuses, 156 mammary nodules, 65 varicose veins, 64 arteriovenous fistulae and 69 proctology operations. The most common anesthesia techniques performed were rachianesthesia and local anesthesia. Eight point seven percent of the patients required admission (OPS failure), the most frequent causes being excessive pain, orthostatic-syncopal hypotension, nausea and vomiting and urine retention. There was no morbidity or mortality. Conclusion: OPS is a highly efficient procedure for resolving the most common pathologies in General Surgery. The anesthesia technique was an important factor in the rate of failure.
Introduction: Outpatient surgery has been quickly accepted by many hospitals, showing a lot of advantages, both in the quality of health care and also in hospital management. Following this trend, our Hospital started op...Introduction: Outpatient surgery has been quickly accepted by many hospitals, showing a lot of advantages, both in the quality of health care and also in hospital management. Following this trend, our Hospital started operating an Outpatient Surgical Unit in May 1997. Objectives: Once we had reached our 'cruising speed', we thought it wise to make a critical review of our experience. Material and methods: We have reviewed 331 patients who underwent surgery during the first year of operation, with special attention to the acceptance of this type of surgery by the population in general, and to the changes in pre-operative and post-operative protocols that this process has caused. Results: The rate of admission was 3.02%, and all of them occurred after 24 h. We found 57 minor complications (spotty dressing, mild inflammatory signs) on the first day assessment, but only 16 patients had refered complications. 91.5% of the questionnaires sent back by the patients qualify the experience as good or excellent. Conclusions: Outpatient Surgery is a good solution for many surgical pathologies, as it is well accepted by the general population. Inclusion and exclusion parameters regarding age, architectural obstacles and post-operative care can become selectively more lax.
Introduction: Ambulatory Surgery has emerged and developed in Spain in a similar way as in other occidental countries. Once established as a model for surgical care, results must be improved using objective quality indic...Introduction: Ambulatory Surgery has emerged and developed in Spain in a similar way as in other occidental countries. Once established as a model for surgical care, results must be improved using objective quality indicators to assure minimal morbidity, efficient use of resources and satisfaction of patients and family. Objective: To provide a list of quality assessment indicators in Ambulatory Surgery and to discuss the necessity of obtaining a general consensus regarding the complexity of both the operations and the patients undergoing surgery. Design: Prospective and descriptive study. Patients and Methods: The study was performed on 833 ambulatory patients operated on in the Ambulatory Surgical Unit of the Can Misses Hospital of Ibiza. Surgical specialities involved were General Surgery, Ophthalmology, Orthopaedics, Urology, Gynaecology, and E.N.T. All diagnoses and proceedings were classified according to the CIE-9 and DGR systems, showing as an example the codes related to the General Surgery department. Quality Indicators evaluated were: (a) unplanned admission index; (b) re-admission index; (c) emergency department consultations; (d) cancellation index; (e) substitution index; and (f) postoperative pain evaluation. Results: Specialities involved were: Ophthalmology 277 patients (33.2%), General Surgery 189 (22.8%), Orthopaedics 142 (17%), Urology 90 (10.8%), E.N.T. 79 (9.5%) and Gynaecology 56 (6.7%). Unplanned Admission Index was 7.2%; Re-Admission Index 0.4%; Emergency department consultation 1.6%; Cancellation Index 3.3% and Substitution Index 70%. The reasons for unplanned admission were due to specific complications in 36 cases (60.1%), followed by those secondary to an inadequate selection of the patient in 22 cases (36.6%). Conclusions: It is necessary to apply a series of Quality Indicators in Ambulatory Surgery. Their systematic evaluation may help us define national standards in order to continuously improve our results.
Objectives: The objective of this study was to confirm the ability of EMLA(R) cream (Eutectic Mixture of Local Anaesthetics, Astra, Sweden) to provide effective dermal analgesia after topical application on the skin of t...Objectives: The objective of this study was to confirm the ability of EMLA(R) cream (Eutectic Mixture of Local Anaesthetics, Astra, Sweden) to provide effective dermal analgesia after topical application on the skin of the dorsum of the hand 1 h before venous cannulation for anaesthetic induction. Material and Methods: Prospective, randomized, double blind study. We included 100 children, ASA I-III, distributed into three groups: Group EMLA (E, n=34), Placebo (P, n=33) and Control (C, n=33). Results: The EMLA group of patients (E) refered an evaluation of pain (visual analogical scale (mean=2.34+/-2.41), significantly smaller than the other groups (Placebo=5.54+/-3.40, Control=6.03+/-2.77). Conclusion: EMLA cream, when topically applied 1 h before venous cannulation, provides effective dermal analgesia for venous cannulation. No general or local adverse reactions were observed.
As length of Australian hospital stays decreased, concerns were raised about benefits of shorter stays for older people. We investigated personal characteristics, perceived health outcomes (SF-36) and service use of day-...As length of Australian hospital stays decreased, concerns were raised about benefits of shorter stays for older people. We investigated personal characteristics, perceived health outcomes (SF-36) and service use of day-only and other patients aged 70+, at one and 12 weeks after hospital discharge. Day-only patients were younger, had better self-reported health, were selected for orthopaedic, gastrointestinal and ophthalmic procedures and used similar levels of formal and informal services after discharge as people with longer stays. There was no evidence of ill effects of day surgery for older people, but improved selection and information giving procedures can improve outcomes.
There are comprehensive findings on the immediate recovery of patients from different types of anaesthesia, but more information is needed on how patients manage at home after ambulatory surgery. One hundred and seventy-...There are comprehensive findings on the immediate recovery of patients from different types of anaesthesia, but more information is needed on how patients manage at home after ambulatory surgery. One hundred and seventy-three elective knee arthroscopy patients were randomised into four different anaesthesia groups to receive either spinal anaesthesia (SA) with 5% lidocaine or general anaesthesia (GA) with propofol infusion, isoflurane inhalation or desflurane inhalation. The patients were interviewed over the phone on the next day and asked to complete a questionnaire after 1 week. One hundred and sixty-eight patients (97%) were reached by phone. The questionnaire was returned by 163 patients (94%). After 24 h, all the patients were satisfied with the type of anaesthesia they had received, but 2% of the SA patients would have chosen GA and 4.3% of the GA patients would have chosen SA for the next operation. Based on the questionnaires returned after 1 week, 8.3% of the SA patients would have wanted to have GA, and 4.7% of the GA patients would have wanted to have SA in the future. The incidence of nausea (4.2%) and vomiting (1.8%) was very low in the whole series, with no differences between the anaesthesia groups. Headache after 24 h was experienced by 15.7% of the SA and 10.3% of the GA patients. After 1 week, SA patients reported headache upon standing in 13.5% of the cases, backache in 36.5% and lower leg pain in 59.6%. The corresponding figures for GA patients were 4.5, 9.9 and 39.6% (P<0.05). In spite of the good immediate recovery profile in the all anaesthesia groups, the fact that SA patients reported a higher incidence of headache, backache and lower leg pain after 1 week may be signs of post spinal headache and transient neurologic symptoms (TNS). For overall patient comfort, GA might be a better anaesthetic choice in ambulatory surgery.
The aim of this study was to evaluate the results of the Gilbert repair for primary treatment of indirect inguinal hernias performed as day cases. From September 1996 to September 1998, 145 patients who were admitted for...The aim of this study was to evaluate the results of the Gilbert repair for primary treatment of indirect inguinal hernias performed as day cases. From September 1996 to September 1998, 145 patients who were admitted for ambulatory surgery underwent Gilbert tension-free repair for treatment of unilateral inguinal hernia. Sex, age, the American Society of Anaesthesiologists (ASA) preoperative assessment score, type of anaesthesia, operating time, postoperative recovery, postoperative pain, morbidity, mortality, recurrence, return to work and the normal daily activities were assessed. The mean follow-up was 21 months (range 12-36). Gilbert's classification, type 2 and 3 hernias were the most common. Spinal anaesthesia was used in 73% of patients. Mortality was zero. Four patients developed postoperative haematomas, two urinary retention, three seromas, and two wound infections. During the follow-up period, only two recurrences of hernia were noted (1.4%). In conclusion, these data show that Gilbert repair is a safe operation, which is simple to learn. It can be performed on an outpatient basis, with a low complication rate, a low level of pain and a short recovery period. Although it seems to have a low risk of recurrence, a long-term follow-up is needed.
The efficacy of a multimodal analgesic approach for ligation excision haemorrhoidectomy was evaluated in a prospective series of 62 patients. Opioid was given as intravenous fentanyl intra-operatively, as part of a stand...The efficacy of a multimodal analgesic approach for ligation excision haemorrhoidectomy was evaluated in a prospective series of 62 patients. Opioid was given as intravenous fentanyl intra-operatively, as part of a standardised general anaesthetic technique, followed by post-operative parenteral fentanyl or oral oxycodone as required. Pre-emptive local anaesthesia was provided via ischiorectal fossae and haemorrhoid pedicle infiltration. The non-steroidal anti-inflammatory drug indomethacin was administered rectally at the end of surgery and regularly orally for 5 post-operative days. A wide range of pain scores was recorded post-operatively but all mean scores were between 2 and 3. Pain was highest at the time of the first bowel action but this was successfully managed in the patient's home. Patient satisfaction with their pain management was achieved in 95% of patients. We conclude that the multimodal analgesia technique combined with pre-operative patient education leads to successful pain control following haemorrhoidectomy.
Improved anaesthetic techniques and the increase in minimal access surgery over the past 20 years has had a considerable impact upon the pattern of nursing care required by the surgical patient. In order to adapt to thes...Improved anaesthetic techniques and the increase in minimal access surgery over the past 20 years has had a considerable impact upon the pattern of nursing care required by the surgical patient. In order to adapt to these changes some day surgery nurses have opted for an extension to their role while the majority have expanded their remit and perform nursing interventions within a multi-skilled role. Amid these changing patterns, the nursing profession has been active in conducting research into best practice concerning day surgery. Consequently, a great deal of information is available regarding areas for possible growth. One possible growth area which is also a vitally important issue for patients prior to day surgery is anxiety management. A future nursing role could involve formal anxiety management implicit within a multi-skilled role and as part of an expanded role. The role possibilities are discussed together with an information provision plan as both are central to the effective handling of pre-operative fears.
Ambulatory surgery was introduced to Asia in the 1990s. Acceptance of ambulatory surgery by oriental patients remains largely unknown. A telephone survey was conducted to evaluate the level of patient satisfaction follow...Ambulatory surgery was introduced to Asia in the 1990s. Acceptance of ambulatory surgery by oriental patients remains largely unknown. A telephone survey was conducted to evaluate the level of patient satisfaction following ambulatory inguinal hernia repair. A total of 157 patients (61%) completed the telephone survey. More than 90% of the respondents expressed satisfaction with regard to the pre-operative, operative and post-operative service. The majority of the respondents (>80%) preferred to undergo day surgery again in case of hernia recurrence. Our findings prove that ambulatory surgery has a high level of acceptance in Chinese patients and supports the expansion of a day surgery service in Hong Kong.