Standardized ambulatory surgery protocol reduces unplanned postoperative returns

Standardized clinical processes for open inguinal hernia repair reduced patients’ postoperative pain and unplanned returns to the emergency room after surgery, according to the results of a study presented earlier this week at Clinical Congress. 

The authors, a group from Kaiser Permanente Southern California, reported on the region-wide implementation of an eight-step ambulatory surgery care protocol that spanned preoperative, intraoperative, and postoperative phases of care. Key elements included preoperative patient education and preferential use of monitored anesthesia care (MAC). 

The genesis of the project began more than five years ago, when the time that patients were spending in the hospital for same-day surgery varied more than 100 percent across 25 Kaiser surgical locations in Southern California. In response, Kaiser researchers collected more than 40 local best practices for time-efficient patient flow and clinical processes, and implemented those practices throughout the health care system. The variation across facilities decreased, and, more importantly, the time that patients spent in the hospital on the day of surgery was reduced by more than 50 percent in many cases, reported lead study author Sean O’Neill, MD, PhD, general surgery resident physician and Robert Wood Johnson Foundation Clinical Scholar, University of California, Los Angeles. 

The current eight-step protocol came about as a quality check on that improved efficiency. “Although we had reduced the amount of time that patients spent in the hospital, and thus were successful in sending them home faster, did that reduction simply mean that we were going to end up having more of them come back to the emergency department or urgent care?” Dr. O’Neill said. 

Therefore, the group developed a standardized protocol that incorporated local best practices and Enhanced Recovery After Surgery concepts from the literature. These elements included patient preoperative education, giving postoperative prescriptions to patients preoperatively, preoperative carbohydrate drinks, use of multimodal non-narcotic analgesia, preferential use of monitored anesthesia care (MAC) when feasible, generous use of local anesthetic and field blocks, limiting IV fluids to less than 500 mL intraoperatively, and a follow-up phone call within 72 hours of discharge. This protocol was rolled out region-wide and examined closely over a 14-month period from June 2015 to July 2016. 

The researchers evaluated the effect of the protocol on several metrics, including total time spent in the hospital, maximum pain score in the post-anesthesia care unit, postoperative nausea and vomiting, and the rates of unplanned returns to care to the emergency department (ED) or urgent care (UC) after surgery for open inguinal hernia repair. 

An unplanned visit to the ED or UC often indicates a failure in either the preoperative, intraoperative, or postoperative phases of care, explained Steven R. Crain, MD, a general surgeon from Woodland Hills, CA, and principal study author. “When people return to the ED for pain control, urinary retention, constipation, or nausea and vomiting after same day inguinal hernia repair, we feel that those returns could have been prevented if our perioperative care routines had addressed them up front,” Dr. Crain said. 

For the present study, the researchers collected data from 2,390 patients who had an ambulatory open inguinal hernia repair procedure in 2015–2016, calculated the rate of unplanned returns to a hospital ED or UC center, and identified the factors that had the most effect on patient outcomes in the immediate postoperative period.

The overall rate of unplanned visits to an emergency department or urgent care center was low: 6.3 percent for any reason, and 2.8 percent for preventable causes (pain, urinary retention, constipation, or nausea and vomiting). The authors found that two aspects of the protocol were particularly influential: preoperative patient education, and the use of MAC instead of general anesthesia. 

Patients who received comprehensive preoperative education were less likely to return to the hospital in the immediate postoperative period than their counterparts who did not receive the education. “The preoperative education was done both in the clinic when the operation was scheduled and on the same day of the procedure,” Dr. O’Neill said. “Instead of handing the patient a packet of information and letting them read or interpret it later (or never), this educational process set expectations ahead of time so that patients would know what to do if they experienced the typical symptoms associated with less urgent postoperative events, including fluctuating levels of mild pain, constipation, and nausea. Many unplanned returns for care can be prevented if patients are educated and empowered to do the best things to care for themselves postoperatively.”

MAC, or twilight sleep, more effectively reduced postoperative pain scores than general anesthesia. “The use of monitored anesthesia care in our facilities varies widely,” Dr. Crain said. “It is used only for about 20 percent of patients in some surgical centers and up to 80 percent in others. This form of anesthesia can never be used on all patients because of conditions like sleep apnea or obesity, but it may be appropriate for far more patients than it is currently used for. As a result of this study, we have set specific goals for increasing the use of MAC yearly.”

This standardized pathway for ambulatory surgical care, with a particular emphasis on patient education and preferential use of MAC, is being rolled out to additional surgical specialties across Kaiser Permanente Southern California. “With these standardized pathways, we’re able to improve the quality of care for the patient and the efficiency of health care delivery for the organization,” Dr. Crain said.