Ambulatory Urology and Urogynaecology. Группа авторов

1 Principles of an Ambulatory Surgery Service

       Mark Salmon and Benjamin Patel

      According to the International Association for Ambulatory Surgery (IAAS), ambulatory surgery should be defined as ‘an operation/procedure, excluding an office or outpatient operation/procedure, where the patient is discharged on the same working day.’ The origins of ambulatory surgery can be traced back to the pioneering work of James Nicholl at the Glasgow Royal Hospital who reported 8988 paediatric day‐ case procedures between 1899 and 1908. Despite initial scepticism from the surgical profession, there has been a rapid expansion in the complexity and amount of ambulatory surgery in recent years: between 1989 and 2003 the percentage of elective surgery undertaken as day case in the UK increased from 15 to 70%. Many health services have set targets for the percentage of elective surgeries to be done as day‐case procedures, and in the UK this target is set at 75%.

      The rise of ambulatory surgery has been driven by technological advances that reduce the need for overnight hospital stays, enhanced recovery programmes that advocate early mobilisation, and the need for economic efficiency. With growing interest in ambulatory surgery, multiple associations have been formed promoting education, quality standards, and research in the field.

Infrastructure

      Ambulatory care is delivered in various environments, including

Free‐standing units, separate to inpatient units, are common in the United States, increasing in number from 67 in 1976 to over 4000 in 2004 (IAAS: day surgery). They may be multidisciplinary, serving a larger market, or uni‐disciplinary. Potential benefits include cost‐effectiveness and efficiency because it is easier to generate a streamlined care pathway and to encourage teamwork amongst healthcare professionals. Furthermore, they may have lower rates of hospital‐acquired infection. The disadvantage is that they are remote from a comprehensive medical facility with a full range of specialties including intensive care, meaning that there will occasionally be a need for outsourcing and transfer of patients. The need for low‐risk patients ultimately encourages stricter patient selection, self‐limiting the service. Most unplanned overnight admissions after ambulatory surgery are due to bleeding and longer‐than‐expected procedure length, with urological and gynaecological surgery accounting for a particularly high proportion of bleeding patients (Vaghadia 1998).

      Integrated self‐contained ambulatory units are located on a hospital site with their own dedicated theatres and personnel. They are generally seen as the ideal model for ambulatory surgery, benefiting from the comprehensive range of medical services provided by that hospital, whilst also specialising in providing a streamlined ambulatory service with one dedicated team well trained in ambulatory surgical care.

      Integrated non‐self‐contained ambulatory units vary significantly in set‐up: some may not have dedicated theatres or personnel. This makes the system inefficient, because there is a chance that low‐risk day‐case procedures may be cancelled, a streamlined patient pathway is often lacking, and unintended overnight stays arise due to difficulties ensuring safe discharge. However, if there is a dedicated ambulatory ward and theatres, this environment does have some benefits; it is easily expandable, meaning that as new procedures are transferred to day surgery, the same infrastructure can be used with appropriate retraining of staff.

Pre‐operative Assessment

      Once the decision to operate has been established and the intended procedure is planned as a day case, a dedicated pre‐assessment team, generally made up of trained nurses, should comprehensively assess the patient. This assessment should ideally take place in the same unit in which