Ambulatory Urology and Urogynaecology. Группа авторов
discontinuation of anaesthetic agents, allowing the patient to emerge from anaesthesia, recover airway reflexes and resume motor activity. Classically, this occurs in the post‐anaesthesia care unit (PACU), before stepping down to the day‐surgery unit (DSU). The modified Aldrete scoring system can be used for determining when patients are fit for discharge from PACU (Aldrete 1995).
There is a growing trend towards ‘fast‐track’ of patients directly from the operating theatre to the DSU, bypassing PACU. This is (i) safe as many patients achieve step‐down criteria from PACU as soon as they arrive, and (ii) economically efficient as PACU is more labour intensive. Complication rates in PACU are low, with one group demonstrating rates of 8%, of which only 0.7% were respiratory or circulatory (Duncan 1992).
One group achieved fast‐track rates of over 80% in simple orthopaedic procedures, with patients being successfully discharged home earlier (Duncan 2001). Fast‐track is more achievable with desflurane and sevoflurane‐based anaesthesia (Song 1998) and with BIS, ensuring minimum necessary anaesthesia and quicker recovery (Song 1997).
The modified Aldrete scoring system is limited in deciding whether patients are fit for fast‐track as it does not consider pain, nausea, or vomiting which are generally addressed in PACU. White's criteria (White 1999), or the WAKE score (2011) are more appropriate. Ultimately, patient safety should always be maintained and a clinical judgement should be made as to whether fast‐track is appropriate.
Achieving adequate pain relief is an important factor for patient satisfaction and should be managed with objective methods of pain evaluation and evidence‐based protocols for pain control. Utilisation of ibuprofen and celecoxib have been demonstrated to improve recovery (White 2011), probably because they are associated with lower opioid requirements and reduction of oedema. Units have developed protocols with routine use of multimodal analgesia, including nonsteroidal anti‐inflammatory drugs (NSAID), local anaesthetic techniques, and opioids as necessary. These protocols and methods have demonstrated improved post‐operative pain control and patient satisfaction (Elvir‐Lazo 2010).
Intermediate Recovery: Discharge Criteria
There is an increasing pressure for rapid discharge of patients. However, this must be balanced with the risks associated with premature discharge, including readmission, complications, and legal consequences. Several scoring systems exist, guiding clinicians about safe discharge. The Post Anaesthesia Discharge Scoring System (PADS) (Chung 1995) is one utilised example and includes observations, patient orientation, bleeding, and post‐operative symptoms including pain and nausea. Post‐operative voiding and tolerance of oral intake are also included in this scoring system.
The type of anaesthesia and surgery can be a determinant of post‐operative voiding function. Specific to pelvic‐floor procedures is the effect of anaesthesia on bladder function. The insertion of the mid‐urethral sling has been performed under both regional and local anaesthetic, with regional anaesthesia having been found to increase the rates of post‐operative urinary retention (Adjusted OR = 4.4, 95% CI 1.9, 10.2) (Wohlrab 2009), a factor that could influence length of stay. A systematic review looking at the effect of anaesthesia on bladder function, found the dose of intrathecal local anaesthetic used with regional anaesthetic, as well as the potency of the anaesthetic used, to correlate with the duration of bladder dysfunction (Choi 2012). Encouragingly, a retrospective review of 119 patients who were discharged the same day as undergoing outpatient tension‐free vaginal tape (TVT) surgeries found no significant difference in the need for catheterization among patients who received spinal anaesthesia compared to those who received general or local anaesthetic with sedation (Barron 2006).
Voiding before discharge has been a core concept in ambulatory surgery, because of the concern that patients may develop urinary retention, bladder atony, and subsequently renal complications. However, there is good evidence (Pavlin 1999) that patients at low risk of urinary retention can be discharged without needing to void, but with clear instructions to seek medical attention if unable to void within eight hours of discharge. On the other hand, the literature and opinions are mixed regarding patients at high risk of retention. Guidelines support that those who have not voided within three hours post‐operatively should receive bladder scanning; if >600mls is present, then they will need catheterisation with trial without catheter (TWOC) in the community (Pavlin 1999).
Tolerance of oral fluids was also previously mandated before discharge. However, several studies have proven that this does not improve outcomes and may even worsen rates of nausea and vomiting (Jin 1998, Kearney 1998), making this a historic requirement.
Once discharge criteria have been met, patients should be supplied with adequate analgesia and clear instructions to take it regularly to prevent breakthrough pain. Prepackaged medication is convenient, prevents delays, and eliminates the need for a patient or carer to visit the pharmacy. Patients should be given clear verbal and written instructions on what they should and should not do, alongside contact details in case of emergency or concerns about symptoms or complications. Patients should be discharged with a responsible adult to accompany them, and those who have had a general anaesthetic should be advised to avoid alcohol and driving for 24 hours.
Late Recovery: Care After Discharge
Patients are discharged from ambulatory surgery once their baseline physiological states have returned. Although major complications and morbidity are rare (Warner 1993), residual symptoms and side effects are not uncommon. Patients need to be followed up in the community. This can happen through telephone consultations (Kamming 2004), GP/nursing follow‐up, outpatient clinics or ‘mhealth apps,’ on smartphones (Hwa 2013, Armstrong 2014). A dedicated contact phone number or routine follow‐up call the next day, may help avoid unscheduled emergency or general practitioner visits after discharge. Telephone follow up has reported high satisfaction rates (>90%) with all women preferring it to an office visit (Schimpf 2016). Ambulatory centres should consider this as a routine part of their postprocedure care. Follow‐up should consider pain, nausea, bleeding, oral intake, voiding, bowel function, fever, sore throat, disorientation, and psychological status.
Setting Up an Ambulatory Centre
Planning a new ambulatory unit is a major undertaking. A board team, consisting of at least a surgeon, anaesthetist, nurse, and project manager should be set up. Market research must be performed, considering demand and financial viability. Local health authorities and regulatory bodies must be involved. The location must be identified taking into account transport links, and infrastructure must be decided upon.
Staff must be recruited and appropriately trained. Nurses must be educated in pre‐operative triage/assessment and be trained in assessing patients post‐operatively for discharge using standardised protocols. They should be able to engage the patient and family in the process of ambulatory surgery to ensure compliance and success. Anaesthetic teams must be trained in appropriate techniques for day surgery. Surgical teams must stay up to date with guidelines, such as the British Association of Day Surgery (BADS) directory, which makes recommendations on which procedures are appropriate in the ambulatory setting. All groups should demonstrate competency in dealing with emergency scenarios.
An ambulatory surgical checklist should be developed and tailored to different specialities. Staff should be trained in communication skills. The ‘Situation‐Background‐Assessment‐Recommendation (SBAR)’ tool is a useful framework. Formal training in teamwork should ideally be given, generating a patient‐centred culture of safety. Systems should be established to deal with unprofessional behaviour, mistakes, and complaints. An audit and quality improvement team must be set up. Staff must be trained in hand hygiene and infection control.
The design of the unit is central to its success. The capacity must be determined, including theatre number and bed number. From this, an estimate of size can be extrapolated. The board team and architect must decide on build type, storage, and sterilisation facilities. They then must consider which ‘model’ to follow. The ‘racetrack’ model has a uni‐directional flow path, meaning