Introduction

In many countries, it’s impossible to imagine healthcare without Ambulatory Surgery. Accumulating evidence indicates that outpatient surgery offers significant advantages over inpatient surgery. Patients operated on an ambulatory basis report faster recovery and better psychological adjustment, given that selection of the procedure, preoperative preparation, the surgery performed and postoperative care, all were optimal.

The pronounced shift towards outpatient surgery has been made possible, for an important part, by an equally impressive technological revolution both in anaesthesia as well as in surgery, which has led to the development of approaches that require less postoperative care.

Moreover, ambulatory surgery is highly cost-effective. In its early days Ambulatory Surgery was the hobby of enterprising physicians, today, more and more health care insurers have to acknowledge that ambulatory surgery has financial advantages as well. From place to place, however, it appears that neither physicians nor healthcare governments are fully convinced of the advantages day surgery has to offer, and it will take much time and energy to change this attitude.

After a few remarks on history, this article focuses on strategies to emphasize the advantages Ambulatory Surgery has to offer. For the individual surgeon such includes not only a perfect operative technique: proper selection both of the procedure and the patient, and attention for the management of postoperative pain are important as well. The central theme should be: let’s first improve surgical treatment; a reduction in postoperative length of stay will follow then. Close collaboration with anaesthetists and nurses is essential to achieve this goal.

Moreover, it is advised that the individual day surgery unit should register clinical indicators, in order to keep an eye on overall quality of procedures. And finally, physicians and nurses should unite and strive to establish a national day-surgery association: some experiences in the Netherlands and with the International Association will be discussed.

Development of Ambulatory Surgery

Ambulatory or day surgery is a clinical admission for a surgical procedure, with discharge of the patient on the same working day. In the early days of surgery all operations were done on an ambulatory basis, since hospitals, both conceptually and as an institution, developed later in history.1 Ambulatory surgery in its present form is commonly said to have started in 1909 when James Nicoll, a paediatric surgeon from Glasgow, reported a series of 8988 children, operated upon on an ambulatory basis.2 The first report of Ambulatory Surgery performed in a free standing unit came from Ralph D. Waters, anaesthesiologist from Sioux City, Iowa, USA, who reported in 1919 on his Down-Town Anaesthesia Clinic, equipped for surgical and dental procedures under general anaesthesia.3 Finally in 1969, Ford and Reed, anaesthesiologists from Phoenix, Arizona, presented their concept of the Surgicenter®, designed ‘to provide quality surgical care to the patient whose operation is too demanding for the doctor’s office, yet not of such proportion as to require hospitalisation’.4 From that time on, the number of admissions for day surgery increased strongly in many countries, especially in the USA, Australia and Europe (United Kingdom, Belgium, France, the Netherlands and the Scandinavians). This increase was highly facilitated by innovations in surgical and anaesthetic techniques. The implementation of new surgical procedures, for example minimal invasive surgery like endoscopy, and new short-acting anaesthetics with minimal cardiovascular side effects made early discharge possible in a fast increasing number of cases. However, there is still quite some variation in the use of day surgery, at least among countries, but also in individual hospitals in many countries. The attractiveness of day surgery can be increased only when professionals in individual units render excellent patient care.

Selection of procedures and patients

A large number of surgical procedures can be done on an ambulatory basis. Day surgery (rather than inpatient surgery) must be regarded the standard for all elective surgery. It should be considered the principal option and no longer an alternative form of treatment.

However, not all patients can be treated on a day surgical basis. It is not the operation that is ambulatory, it is the patient! It is of paramount importance that all patients are carefully selected, taking social, medical (co-morbidity) and surgical criteria into account.

Preoperative assessment, the providing of information to patients and caretakers, appropriate treatment and follow-up after discharge: all require meticulous attention for detail.

For day surgery commonly acceptable general surgical procedures are operations for inguinal hernia, breast lesions and proctologic problems. Varicose vein surgery, venous access surgery and access surgery for haemodialysis are all performed by vascular surgeons on an ambulatory basis. But new techniques evolve rapidly, enabling an increasing number of general surgical and vascular procedures to be performed in day care with or without extended recovery.

Management of postoperative pain

Effective pain management after ambulatory surgery is important, not only for humanitarian reasons, but also because incomplete pain control contributes to postoperative nausea and vomiting (PONV), reduced mobility of the patient and delayed resumption of normal activities.5 Inadequate postoperative pain control is a significant cause of patient dissatisfaction with ambulatory surgery, may lead to many undesired effects, and sometimes unanticipated (re)admission. Prevention of pain is better than relief.6 In the selection of operative procedures, the amount of postoperative pain should be taken into account. For example, endovenous obliteration of varicose veins requires the extra investment of the necessary device and disposable catheters, but advantages as less post-operative discomfort and faster return to normal activities, as compared to conventional stripping, have been documented.7

Preoperative education of the patient is important, surgeons should not only explain exactly what they are planning on doing (give procedural information), but also provide their patients with sensory information, i.e. information about possible unpleasant feelings postoperatively.8 Only combined sensory-procedural information gives the most benefit in reducing pain. During the operation, everything should be done to lessen postoperative pain; hence the use of nerve blocks and/or infiltration of wound edges are highly recommended. Also pain management at home deserves attention to detail.

Clinical indicators

It is recommended that units for Ambulatory Surgery use clinical indicators to monitor the overall quality of procedures. The International Association for Ambulatory Surgery (IAAS) advises the continuous registration of:

1. Cancellation of booked procedures, either failure of the patient to attend the day surgery unit (‘no show’ or ‘do not attend, DNA’) or after arrival of the patient, due to medical or organisational reasons,
2. Unplanned return to the operating room on the same day,
3. Unplanned overnight admission and
4. Unplanned return to the hospital after discharge home.

These indicators might be compared by data from other units or from the literature (benchmarking!) and might provoke the adaptation of certain procedures, when unsatisfactory results are obtained.9

Professionals, unite! The Dutch experience

Ambulatory surgery, in the Netherlands rather differently defined as a surgical procedure with a post-operatively required nursing time of at least 2 hours (up to a maximum of 8), is by now well established. The first units were founded in the seventies of the last century. In the beginning incentives didn’t come from the government but from local hospital managers who visited ambulatory surgical centres in the UK and the USA. From 1985 onwards day surgery expanded tremendously partly due to a greater awareness of doctors and patients, but also due to a government-induced reduction of the number of hospital beds, also leading to the fusion of many smaller hospitals with large ones. At this moment departments for ambulatory surgery are present in almost all hospitals, even in university hospitals: a few years ago, three university hospitals (Amsterdam, Groningen and Rotterdam) reopened their completely rebuild units for day surgery. In addition to these in-hospital units, many free-standing ambulatory surgery centres have been established. In 2004, 49 per cent of all operative procedures were performed on an ambulatory basis, and this figure is expected to increase to 65 per cent in the years to come. The data of the IAAS international survey on ambulatory surgery from the Netherlands are quite comparable with those from other countries like the United Kingdom, with minor exceptions only.10 For example, almost 65 per cent of all tonsillectomies with or without adenoidectomies (and even 97 per cent of all adenoidectomies) are done on an ambulatory basis in the Netherlands, against only 15 per cent in the United Kingdom. In both countries, a laparoscopic cholecystectomy still is seldom performed in day surgery, but it seems reasonable to believe that this figure will increase in the upcoming years.

But of course, the accumulated data of all hospitals in a country don’t tell the whole story: there might be huge differences in the amount of procedures performed between hospitals. This issue was investigated by Kroneman et al in 2003, who tried to link the number of certain procedures performed (curettage, cataract surgery and laparoscopic cholecystectomy) to available hospital-dependent variables as hospital size, number of beds available (a relative shortage of beds would promote ambulatory surgery?), number of GP’s (less burden on social network?), age of the population in the area (less ambulatory surgery in an elderly population?), etc.11 Unfortunately this approach wasn’t effective in explaining the results found, and it was concluded that more detailed data on physician partnership and hospital circumstances are needed to do so.

But a much more important issue than volume and types of procedures performed is quality improvement of day surgery. In 1994, the Dutch Association for Day Surgery (NVDK) was established for this purpose. The executive committee organises an annual congress for its members, and stimulates the publication of a quarterly journal (titled ‘KORTOM’ what can be translated as ‘in short’). But a very important step was recently taken by the publication of a National Standard for Ambulatory Surgery. The development of this standard was initiated by the government, who asked the Dutch Normalisation Institute (NEN, Delft, the Netherlands) to organise things. All parties involved in ambulatory surgery (departments for ambulatory surgery, patients/consumers, anaesthetists, surgeons, insurance companies, government) were invited to contribute to the composition of a protocol for ambulatory surgery. The Dutch Association was supposed to represent all departments for ambulatory surgery. The Standard focuses on the patient passing through the process of day surgery. An essential step in this process was strict requirements to be met. For example, in the guidelines, preoperative assessment has been given an important place. The role of the consulting nurse and the anaesthetist was clearly defined. But likewise the representatives of the patients/consumers appreciated the fact that it was agreed by all participants that in at least 80 per cent of cases the waiting-time for a scheduled appointment with a consultant should not exceed 15 minutes. The updated version of this National Standard is now in the process of evaluation. Once accepted every department for ambulatory surgery has the choice to use it or not. But certification of the unit might become difficult when the Standard is completely rejected.

The International Association for Ambulatory Surgery (IAAS)

In 1995, the International Association for Ambulatory Surgery was established in Brussels, Belgium. The Dutch Association was one of its founding members. One of the major challenges of IAAS is to maintain a high quality of ambulatory surgery, and to improve the development of ambulatory surgery all over the world. To do so, IAAS initiates the organisation of an International Congress every 2 years. Since 1993, IAAS also publishes the journal Ambulatory Surgery. Membership of IAAS is available for all National Associations for Ambulatory Surgery.

To promote the understanding of people active in ambulatory surgery, IAAS documented all national definitions, with translations in English, of the words day surgery, office-based surgery, extended recovery, etc. This list of definitions is available at the IAAS Central Office.

In order to keep track of the numbers of ambulatory surgical procedures performed, IAAS initiates from time to time (preferably every two year, but this seems to be too frequent due to the labour-intensity of the task) the collection of national data, not from member countries only: provided the availability of a reliable contact, every country might participate. The core-issue was the selection of a basket of 20 procedures, suitable to cover all essential aspects of day surgery. Procedures in the final basket included not only hernias and varicose veins, but also laparoscopic cholecystectomy and laparoscopic-assisted vaginal hysterectomy. The collected data were first published in 1998,12 the second set in 2000,10 a third survey of this kind will be published soon. These surveys document the variability in the number of procedures performed, and stimulate the discussion of reason and outcome, for example during the annual meeting of the representatives of all member countries, where delegates after reporting their local data discuss the obstacles present. No country is perfect yet, or maybe ever will be perfect! Obstacles almost always focus on problems with reimbursement of the procedures performed, and/or lack of interest of the medical profession in ambulatory surgery: both problems are not easily solved.

An interesting approach was used by the National Health Service (NHS) in the United Kingdom: in order to increase the number of procedures in some hospitals the NHS Modernisation Agency appointed and trained medical professionals (surgeons, anaesthetists, nurse-managers) to exert peer pressure to speed-up things, hopefully with great success.

To improve the quality of ambulatory surgery, this year IAAS will publish a handbook on all aspects of day surgery, including organisation, anaesthesia and surgery.13 The section on surgical procedures is written by consultants of all surgical specialities, and contains a wealth of procedures, at this moment or in the near future, possible to be performed in an ambulatory setting. Some of the near-future operations include the laparoscopic fundoplication (Nissen fundoplication) for gastro-oesophageal reflux disease, or insertion of an endo-prosthesis for aortic aneurysm. It might be concluded that IAAS played and will continue to play a significant role in the promotion of Ambulatory surgery.14

References

1. Davis JE. Major Ambulatory Surgery. Baltimore-London-Los Angeles-Sydney: Williams & Wilkins, 1986.
2. Nicoll JN. The surgery of infancy. Br Med J 1909; 2 : 753.
3. Waters RM. The down-town anesthesia clinic. Am J Surg 1919; 33 : 7.
4. Ford F, Reed W. The Surgicenter®. An innovation in the delivery and cost of medical care. Ariz Med 1969; 26 : 801.
5. Tong D, Chung F. Postoperative pain control in ambulatory surgery. Surg Clin N Am 1999; 79 : 401-30.
6. Armitage EN. Postoperative pain - prevention or relief? (Editorial). Br J Anaesth 1989; 63 : 136-8.
7. Rautio T, Ohinmaa A, Perälä J, Ohtonen P. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: A randomized controlled trial with comparison of the costs. J Vasc Surg 2002; 35 : 958-65.
8. Suls J, Wan CK. Effects of sensory and procedural information on coping with stressful medical procedures and pain: a meta-analysis. J Cons Clin Psych 1989; 57 : 372-9.
9. Collopy B, Rodgers L, Williams J, Jenner N, Roberts L, Warden J. Clinical indicators for day surgery. Amb Surg 1999; 7 : 155-7.
10. De Lathouwer C, Poullier JP. How much ambulatory surgery in the World in 1996-1997 and trends? 2000; 8 (4) :191-210.
11. Kroneman M, Van Oort M, Groenewegen P, De Jong D. Variation in day surgery among Dutch hospitals: the development of a model to explain variations. Amb Surg 2003; 10 : 73-9.
12. De Lathouwer C, Poullier J-P. Ambulatory Surgery in 1994-1995: the state of the art in 29 OECD countries. Amb Surg 1998; 6 : 43-55.
13. Lemos P, Jarrett PM. IAAS recommendations for the development of day surgery programmes (In press). 2006.
14. Roberts L. Day surgery - National and international. From the past to the future. Amb Surg 2006; 12 : 143-5.

#Printed with the permission of the Editor, Day Surgery Journal of India
*Past President IAAS, Department of Surgery, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands.