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Office Surgery:
Minor Procedures May
Involve Major Risks
By Malcolm D. Paul, M.D., FA.C.S.
Plastic & Reconstructive Surgery
Newport Beach, CA
Chair, CAP Education/CME
Committee

Surgeries performed outside the hospital now far outnumber inpatient procedures, culminating a 30-year trend. Ambulatory surgery (a.k.a. "come & go," "in & out" or "day care" surgery) increases patient convenience and significantly lowers costs, compared to inpatient surgery. The total expense for most outpatient surgeries may represent only a fraction of the cost of traditional inpatient procedures. But, pursuit of lower costs must be balanced by guarantees of quality, efficacy and patient safety.

We have all heard about seemingly healthy individuals who died, or suffered "near death" experiences, while undergoing "minor" ambulatory procedures. Local news media have carried stories of mishaps involving liposuction, radiologic, dental and other normally low-risk procedures. Several specialty organizations are expected to publish practice guidelines for procedures in ambulatory settings later this year.

In 1996, the California legislature responded to this patient safety issue by passing Health and Safety Code section 2216: "On or after July 1, 1996, no physician and surgeon shall perform procedures in an outpatient setting using anesthesia, except local anesthesia or peripheral nerve blocks, or both, complying with the community standard of practice, in doses that, when administered, have the probability of placing a patient at risk for loss of the patient's life-preserving protective reflexes, unless the setting is specified in Section 1248.1. Outpatient settings where anxiolytics and analgesics are administered are excluded when administered, in compliance with the community standard of practice, in doses that do not have the probability of placing the patient at risk for loss of the patient's life-preserving protective reflexes."¹ Section 1248(c) defines "outpatient settings" as "any facility, clinic, unlicensed clinic, center, office, or other setting that is not part of a general acute care facility . . ." Acceptable "outpatient settings" include Medicare-certified ambulatory surgery centers, licensed clinics or office facilities, and accredited outpatient settings, among others.²

These patients should be closely monitored, by specially-trained staff, for signs of respiratory or cardiovascular depression, which are the primary complications. In order to minimize the risks and to maintain an acceptable level of patient safety, several key functions should be performed in conjunction with ambulatory surgery:

1. Patient and Procedure Selection: Procedures associated with excessive blood loss or fluid shifts, or postoperative pain that is difficult to manage with conventional oral analgesics, may require highly specialized equipment or postoperative care. Patients with serious coexisting diseases should be carefully evaluated and be in stable condition before outpatient surgery. Avoid patients with limited ability to understand and to follow instructions, or inability to participate in their own pre- and post-operative care.

2. Preoperative Assessment: Careful planning is necessary to avoid costly delays and cancellations. Computerized information gathering systems help to identify and quantify preoperative risk factors and involvement of the anesthesiologist or nurse-anesthetist at an early stage is recommended.

3. Patient Preparation: Dealing with the patient's predictable anxiety is paramount, and use of tranquilizers or sedatives may be helpful. Also, medication to minimize common side effects (e.g., nausea and vomiting) will help to make the experience more pleasant for both patient and family.

4. Choice of Anesthetic Technique: Plan the use of general, regional and local anesthesia, taking into account the patient's condition and the type of surgery. For certain patients and specific procedures, use of local-only anesthesia supplemented by IV sedation may reduce side-effects, shorten the post-anesthesia recovery period, and lessen psychomotor impairment.

5. Operative Monitoring: For accreditation, Health and Safety Code Section 1248.15 requires the availability of onsite equipment, medication, and trained (i.e., licensed or certified) personnel to facilitate outpatient surgical procedures. Appropriate use of ECG, pulse oximeter, capnography (CO₂), blood pressure monitoring and skin temperature measurement will detect problems early, and provide the time to react.

6. Postoperative Analgesia: Whether postoperative pain is likely to be adequately managed by the patient at home will often determine if a procedure can be performed on an outpatient basis. The patient should have a knowledgeable care-giver at home to assist in the use of postoperative medications.

7. Postoperative Complications: By far, nausea and vomiting (or retching) constitute the most common postoperative complications. Prophylactic use of antiemetic agents should be considered.

8. Discharge Criteria: Planning for prompt recognition of the various phases of recovery will help to avoid premature discharge. Obviously, patients who are excessively drowsy, nauseated or suffering from unrelieved pain are not ready for discharge. The minimal time periods during which patients should be observed and determined to be symptom-free will depend upon the patient's condition, the nature of the procedure, as well as the anesthetic technique. Patients should be accompanied home by a friend or family member.

As the use of office and outpatient procedures continues to grow, so must reasonable safeguards to ensure quality and patient safety. As discussed above, and in footnote below, work continues on these issues.

² Health and Safety Code SECTION §1248.1