PA PSRS Patient Saf Advis 2005 Dec;2(4):1,4-6.
Unanticipated Care After Discharge from Ambulatory Surgical Facilities
Emergency Medicine
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Introduction

Of the PA-PSRS reports in which patients required hospital-level care within hours or days of treatment at an ambulatory surgical facility (ASF), approximately 12% suggest that activities at discharge and during post-discharge follow-up may have contributed to the events. In a random sample of 100 of these cases, nine required hospital admission and three were treated in the emergency department.

Discharging a patient from an ASF is the culmination of services delivered but not the end of clinical responsibility. Unlike postoperative discharge from a hospital, ASF discharge occurs within hours of the surgical procedure; therefore, an abbreviated time is available to perform patient assessment and provide discharge instructions. During this observation period, heightened sensitivity on the part of the clinician helps to identify and address any physiologic changes from the patient’s preoperative state that would deem discharge unsafe. Additionally, the instructions given to the patient or caregiver—including information regarding how and when to contact the physician or when to seek emergent care—help to ensure a safe postoperative period.

Follow-Up Care

Once discharged home, the patient is dependent on the discharge instructions to know what to expect during recovery. The patient’s decision to seek follow-up care is based on his or her understanding and tolerance of the perceived acceptable postoperative expectations. Sometimes, the patient’s tolerance is beyond what one should be expected to endure. In other situations, a change in condition may be unintentionally provoked.

Patient called the surgeon and complained of severe pain. The office encouraged him to take his pain medication. When this did not work, he went to the ED. Patient was found to have urinary retention; a Foley catheter was placed. Medicated for pain with IM medication and discharged to home.

Patient discharged to home stable. Forty-eight hours later, notified doctor of bleeding. Had resumed taking ASA. Admitted to hospital for bleeding.

In the first case, it appears that assessment of the location of the patient’s pain may have been inadequate. In the second case, aspirin (ASA) resumption immediately after a procedure may have caused, or at least increased the risk of, bleeding. We do not know whether the patient resumed taking aspirin with or against advice given at discharge.

Managing Care Postdischarge

Discharge instructions are given to the patient to bridge the care from the ASF to the home, to help ensure the continuation of symptom relief and patient monitoring, and to indicate when the doctor should be notified and/or when follow-up care is needed. Typically, these instructions include a list of prescribed medications, diet and activity restrictions, side effects related to surgery and anesthesia, with emphasis on symptoms of complications related to the specific surgical intervention. Treatments, procedures, and follow-up tests are usually outlined in the instructions, as are postoperative appointments.1

PA-PSRS reports indicate that patients seek postdischarge medical intervention for a variety of reasons, but bleeding and pain are mentioned most frequently. A few reports also describe complaints of nausea/vomiting or urinary retention. In several reports, delays in seeking medical attention have occurred. Timely access to care may be related to patient compliance with discharge instructions; to a patient’s understanding of postoperative expectations; or to a patient’s convenient access to care.

Delays in seeking additional medical care may involve patients who experience bleeding or potential organ perforations, as the following cases indicate:

Patient with a history of ulcerative colitis had routine colonoscopy. During the procedure, two polypectomies and several biopsies were performed. Discharge to home without problems or complaints. Patient called the doctor’s office six days later with a complaint of bloody stool; this was the first bowel movement since the procedure. Patient was admitted, received a unit of PRBCs, and was discharged in 48 hours.

Patient reported to emergency room with complaints of abdominal pain three days post-colonoscopy with hot biopsy polypectomy. Diagnostic studies revealed free air in bowel. Perforation confirmed and colon resection performed.

Discharge instructions can emphasize specific information on the risks related to the procedure, such as bleeding, abdominal distention without flatus, or lack of bowel movement, and can instruct patients who experience these complications to contact the physician. Consider defining the time parameters related to the specific surgical procedure so that the patient and caregiver have clear directions regarding when to contact the physician and what to communicate.

Postoperative Bleeding

In a study at the SUNY Health Science Center at Brooklyn, bleeding was found to be the primary reason for patients to seek emergency department care after a procedure in an ASF. The study suggested that patients be better informed about when bleeding is expected and that they receive instructions outlining what to do when bleeding occurs.2  Although some postoperative bleeding is to be expected, the amount of incisional bleeding can be clarified. It is important that the patient know how to apply pressure to the wound and to change or reinforce dressings, as well as when to contact the physician.3 Bleeding, although high on the list of reasons for seeking follow-up care, has remained low in volume, considering the high volume of surgical interventions at ASFs.3,4

Postoperative Pain Management

Pain after ambulatory surgery can be managed at home, but only when expectations of pain levels and anticipated relief from analgesia are clearly communicated.3 Patient education often addresses what degree of pain to expect. Pain or discomfort is best discussed when an objective system of monitoring is used, similar to what is applied at the ASF postoperatively. For example, if a verbal numeric rating scale of 1 to 10 is employed to assess pain in the postanesthesia care unit, the patient can be instructed to use this scale when communicating with the physician. Additionally, when informing patients of anticipated postoperative pain and time frames for analgesia, applying the same pain scale will help to eliminate ambiguity.

Objective parameters for measuring pain postoperatively are particularly important and allow for a smooth transition when a change in pain management occurs from postanesthesia to oral analgesia in home care.3,5 A speedy discharge with timely recovery can be projected if pain is well managed.1,3  In the following case, the patient initially may have had satisfactory relief postdischarge, but discomfort became unmanageable:

Patient had right-wrist fusion done and met criteria for discharge three hours after procedure. On the afternoon of the following day the patient was admitted to the hospital for pain relief per physician’s office.

Accrediting organizations such as the Joint Commission on Accreditation of Healthcare Organizations emphasize improved management of patients’ pain as the “right thing to do.”6 One article indicated that standardizing pain management, staff education, and standing orders improved pain management in the ambulatory setting.7 Preventive analgesia is suggested using a multimodal, synergistic approach with a nonsteroidal anti-inflammatory drug (NSAID), opioid, and local anesthetic.3,8  Critical to analgesia selection is the concomitant communication of side effects. Patients may choose less-than-adequate pain relief over analgesic side effects. It may be productive to explore this trade-off with the patient in an effort to identify the optimal pain-relief regimen with tolerable side effects,5 with the understanding that it is better to maintain control of pain than try to regain it after it has been lost.

Format of Discharge Instructions

Most ASFs have developed standardized forms covering the various discharge needs of the postoperative patient. These forms typically include reminders to the clinician to cover essential information, but total reliance on standardized forms can be problematic, as the following case indicates:

Patient resumed Coumadin post-op tonsillectomy and developed bleeding requiring admission to the hospital and return to the OR for cauterizing of bleeding site. Dr. signed standard discharge instruction sheet indicating patient to resume medication unless otherwise indicated.

A patient’s presurgical medications are usually resumed postoperatively, only after physician review of each medication and any related risks associated with the surgical procedure. PA-PSRS reports indicate that when patients fail to follow instructions and continue to take coumadin and ASA/NSAIDs postoperative bleeding requiring emergent follow-up care may occur. Patient education can obviate the risk of bleeding associated with these drugs.9

In response to the case reported above, this facility changed its medication documentation to prevent similar events from occurring to other patients. Now, anticoagulants are flagged on routine preoperative review with a “med alert” sticker to help ensure that clinicians recognize and are attentive to the risks associated with this type of medication.

Patient Compliance with Discharge Instructions

Traditionally, patients sign discharge instructions that indicate comprehension and represent an informal agreement that the recommendations will be followed. However, two telephone surveys of postoperative patients indicate that patients are not always compliant, especially with limitations on driving and recommendations to avoid alcohol and to have a caregiver available.10,11 The best method to ensure patient compliance has not been proven.

Sample Discharge Record

A sample comprehensive discharge record can be found in the Association of periOperative Registered Nurses (AORN) Ambulatory Surgery Principles and Practices. This sample form lists pertinent criteria, including the following issues mentioned in PA-PSRS reports:12

  • ASA or ASA product resumption
  • Doctor notification in the following instances:
    • Elevated temperature over 100˚F
    • Ineffective pain management
    • Nausea/vomiting or excessive bleeding
    • Inability to urinate by [specify time]
    • No bowel movement after 24 hours 

In addition, the article “Patient Care after Discharge from the Ambulatory Surgical Center” addresses the general discharge needs of the surgical patient and details various surgical complications, risks, and suggested methods of symptom management.1

Conclusions

An American Journal of Surgery article states that “unplanned admission following ambulatory surgery is relatively rare but could reflect overall quality in terms of the system, physician, and patient.”9 With the volume of ambulatory surgical services growing exponentially, providing safe care beyond the walls of the ASF is everyone’s goal.13 Comprehensive discharge instructions include critical information for the patient and caregiver and provide for both optimal patient outcomes and staff satisfaction in delivering quality care.

Consider whether your facility’s discharge protocol addresses the following elements:

  • Managing care beyond the ASF by providing well-defined, objective criteria for seeking follow-up care or physician contact.
  • Discussing pain management expectations, trade-offs, and alternatives with the patient.
  • Addressing incisional bleeding, dressings, pressure dressings and when to contact the physician for further intervention.
  • Reviewing preoperative medications and postoperative resumption of medications, with special attention to anticoagulants.
  • Reinforcing the risks related to specific instructions, such as driving within 24 hours postoperatively or lacking a supportive caregiver.
  • A comprehensive discharge checklist.  

Notes

  1. Marley R, Swanson J, Patient care after discharge from the ambulatory surgical center. Journal of PeriAnesthesia Nursing. 2001 Dec;16(6):399-417.
  2. Twersky, R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesthesia Analog. 1997 Feb, 84(2):319-24.
  3. Reiling R. McKellar D. Outpatient surgery. ACS Surgery. Medscape  [online] 2004 [cited 2005 June 17]. Available from Internet: http://www.medscape.com
  4. Vaghadia H, Scheepers L, Merrrick PM. Readmission for bleeding after outpatient surgery. Candian Journal Anaesthesia. 1998 Nov:45(11):1079-83.
  5. Gan, TJ, Lubarsky, DA, Flood, EM et al. Patient preferences for acute pain treatment. British Journal of Anaesthesia. 2004 Mar; 92(5): 681-8.
  6. Improving the quality of pain management through measurement and action. Joint Commission on Accreditation of Healthcare Organizations and National Pharmaceutical Council, Inc. [online] 2003 [cited 2005 Aug 1]. http://www.jcaho.org
  7. Woodley KS, Case study in brief improving ambulatory surgical pain management. Joint Commission Journal on Quality and Safety. 2004 Jan;30(1):36-41,1.
  8. Redmond M, Florence B, Glass PS. Effective analgesic modalities for ambulatory patients. Anesthesiology Clinics North America. 2003 Jun;21(2);329-46.
  9. Greenburg AG, Greenburg JP, et al Hospital admission following ambulatory surgery. American Journal of Surgery. 1996 Jul;172(1):21-3.
  10. Correa R, Menezes RB et al, Compliance with postoperative instructions: a telephone survey of 750 day surgery patients. Anaesthesia. 2001 May;56(5):481-4.
  11. Cheng CJ, Smith I, et al A multicentre telephone survey of compliance with postoperative instructions. Anaesthesia. 2002 Aug:57(8):805-11.
  12. Ambulatory surgery: principles and practice: standards and recommended practices for ambulatory surgery, Vinson, NJ, ed. Association of Perioperative Registered Nurses. Denver, CO: AORN, 2003 140-141.
  13. Fleisher, L. Ambulatory surgery centers proliferate. Physician’s News Digest. [online] 2005 [cited 2005 Aug 1]. http://www.physiciansnews.com/cover/705.html.
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