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Ambulatory Extended Recovery: Coming to an Operating Theater Near You

2020; Lippincott Williams & Wilkins; Volume: 131; Issue: 3 Linguagem: Inglês

10.1213/ane.0000000000004984

1526-7598

Thomas R. Vetter, Girish P. Joshi,

Colorectal Cancer Surgical Treatments

See Article, p 699 GLINDA: Are you ready now? DOROTHY: Yes… GLINDA: Then close your eyes, and tap your heels together three times. And think to yourself -- "There's no place like home; there's no place like home; there's no place like home." DOROTHY: There's no place like home. There's no place like home. There's no place like home. There's no place like home. —The Wizard of Oz (1939) Noel Langley, Florence Ryerson, and Edgar Allen Woolf The concept of multimodal postoperative recovery programs—commonly referred to as enhanced recovery after surgery (ERAS) programs or "fast-track surgery"—was first proposed by Kehlet and Wilmore1 more than 20 years ago, when it was recognized that isolated, single clinical interventions were inadequate in addressing the problem of multifactorial perioperative complications and morbidity. Although simple in principle, collective experience and reported data during the interim 20 years have observed relatively slow progress in disseminating, implementing, and sustaining ERAS programs.2,3 This can likely be partly explained by the requirement for multidisciplinary collaboration, as well as cultural and organizational factors that frequently impede fundamental change in traditional patient care.2,3 Furthermore, the initial protocols for open colonic surgery included only a few essential principles of ERAS, whereas, the advent of more multifaceted and complicated ERAS programs and protocols have hampered implementation.2 From the contemporary perspective, the main issue still to resolve with ERAS programs is how to make further progress in achieving the ultimate goal of a risk-free surgical procedure.2 Thus future ERAS strategies should include a shift away from the conventional endpoints of early recovery and shortened length of stay to place more emphasis instead on mitigating postdischarge problems.2,4 However, at least in the United States, there are major health care policy changes that mandate continued attention on postoperative early recovery and reduced length of stay. No matter what the postoperative priorities, fundamentally transforming the traditional structures and processes of surgical and anesthetic care can indeed be challenging. Fortunately, there are innovators paving the way. In this issue of Anesthesia & Analgesia, Tokita et al5 provide a comprehensive description of a very innovative migration of complex cancer surgery from the hospital setting to an ambulatory extended recovery (AXR) setting of the Josie Robertson Surgery Center (JRSC) at Memorial Sloan Kettering Cancer Center (MSKCC). A key first question is "What is ambulatory extended recovery after surgery?" In 2003, the International Association for Ambulatory Surgery (IAAS) provided very pertinent, international consensus-based terminology (Figure 1).6 The IAAS has also made the following fundamental functional distinction:7Figure 1.: Basic terminology related to surgical encounter timeframes and synonyms.6 True ambulatory surgery is where patients are admitted, operated on, and discharged during the time frame of 1 working day (6–8 hours). There is no overnight facility stay. Ambulatory surgery with extended recovery is where patients are admitted, operated on, and stay for 1 night postoperatively with an overall stay up to 23 hours. To fully realize the potential expansion of ambulatory surgery, one must first understand the definition and current limitations of the different types of ambulatory surgery facilities. An ambulatory surgery center (ASC) is a freestanding facility that typically performs surgical procedures that do not require overnight stay. An ASC is not required to be associated with a hospital. An ambulatory surgery facility, which is not associated with a hospital, can perform surgical procedures stipulated on the current US Centers for Medicare & Medicaid Services (CMS) ASC covered procedures list. However, such an independent ASC cannot perform any procedures on the current Medicare inpatient-only (MIO) list (Figure 2). This significantly differs from a hospital outpatient department (HOPD), which is 100% owned by a hospital and is not limited in its procedural scope. Hospital-owned facilities can perform ambulatory surgery within the hospital, in a facility attached to the hospital, or in a facility physically separated from the hospital. In the United States, an HOPD is reimbursed at a markedly higher rate by CMS than an independent ASC. There are other significant differences between an independent ASC and an HOPD (Figure 2).8–10Figure 2.: Characteristics of an independent ASC versus a HOPD as defined by the US CMS.8–10 ASC indicates ambulatory surgery center; CMS, Centers for Medicare & Medicaid Services; HOPD, hospital outpatient department.Tokita et al5 accordingly note that organizationally, (a) the JRSC is part of the MSKCC and operates as a hospital-associated outpatient clinic; (b) the JRSC is attached to the Memorial Hospital ambulatory license; and (c) all JRSC staff are employed at MSKCC. These specific organizational aspects of the JRSC might make its AXR model neither feasible nor appropriate in a conventional ASC—particularly from a financial perspective. According to US CMS Rule 42 C.F.R. §412.3(e), a hospital admission is classified as inpatient if the surgical procedure is on the MIO list, or if the provider expects that the hospital stay will cross 2 midnights. If a surgical procedure on its MIO list is performed in an outpatient setting or with postoperative observation status (minimum of 8 hours, but <24 hours), CMS might refuse to reimburse for the procedure. If a surgery is not on its MIO list, CMS will only reimburse for postoperative inpatient status if clinical documentation can justify the need for a greater than 2 midnight stay.11,12 Importantly, a documented comprehensive preoperative patient assessment, which applies objective, well-defined clinical criteria for recommending postoperative inpatient versus outpatient status,13 can validly and compliantly be provided by a Perioperative Medicine program and clinic.14 The initial, major challenge at MSKCC was thus identifying the types of surgical procedures—with historical average inpatient hospital stays of 2–4 days—that with suitable patient selection and management, could be safely discharged home after a single overnight stay.5 While technically qualifying as ambulatory or outpatient procedures from a regulatory standpoint and payer perspective, Tokita et al5 distinguish these more complex, short-stay, AXR procedures from conventional outpatient procedures after which the patient recovers and is discharged home in a few hours. Here again, a Perioperative Medicine program and clinic can play a very important role in implementing patient selection criteria and undertaking needed medical optimization for an AXR procedure.15,16 The MSKCC leadership and other organizational stakeholders were guided by a set of principles and a series of related questions in developing the JRSC, which are not only illustrative but also vital for other entities pursuing any such pioneering health care delivery model:5 How can we become national leaders in delivering high-quality and cost-effective day and short-stay surgery? How can we maximally standardize processes and procedures? How do we continually assess progress to innovate and improve? How can we apply new technology to streamline processes and allow staff to focus on patients? What are the optimal roles for nurses and advanced practice providers within this short-stay environment? Most importantly, how can we ensure that the needs and experience of the patient and their loved ones are considered and prioritized in everything we do? With more extensive surgical procedures being performed in an ambulatory setting, it is necessary that patient safety is not jeopardized. The ERAS principles that allowed the migration of these surgical procedures to the outpatient setting must still be applied. This would reduce unplanned hospital transfers from the ambulatory facility, as well as mitigate emergency department visits and acute care hospital readmission after discharge. These adverse outcomes might negate the cost-effectiveness of moving the surgical procedures to the outpatient setting. Future studies should investigate approaches to identify and manage postdischarge complications. This could be achieved with real-time electronic symptom monitoring systems similar to the one used by Tokita et al.5 In addition, such electronic systems can provide patient self-management advice that could reduce unnecessary emergency department visits. These systems could also directly assess patient-reported outcomes. Such monitoring would also allow identify the timeline of complications and classify them as medical versus surgical, and determine approaches toward preventing them. Medical complications can be addressed through modifying patient selection criteria and perioperative management. In contrast, surgical complications can be addressed through reassessment of perioperative care, as well as surgical technique and expertise. In summary, there has been a continued, and likely future sustained expansion of the number of ASCs and the number of procedures performed in ASCs, particularly in the United States but also worldwide.17–19 As insightfully observed by Philip,10 such outpatient surgery has been a success in the United States because of 2 important reasons: (1) a focus on efficiency, quality, and cost of care and (2) a focus on the patient and the role of humanism in medicine. The pioneering work of Simon and colleagues in creating the JRSC at MSKCC exemplifies these 2 fundamental tenets of health care value and humanism.5 Nevertheless, in order for AXR to achieve its ultimate yet still potential positive health care impact, it must be financially sustainable in an ASC setting. At least in the United States, this will require major, progressive changes to current CMS regulations and reimbursement. DISCLOSURES Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write and revise the manuscript. Name: Girish P. Joshi, MBBS, MD, FFARCSI. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Jean-Francois Pittet, MD.