Ambulatory anesthesia and discharge: an update around guidelines and trends

Abstract

Purpose of reviewProvide an oversight of recent changes in same-day discharge (SDD) of patient following surgery/anesthesia.Recent findingsEnhanced recovery after surgery pathways in combination with less invasive surgical techniques have dramatically changed perioperative care. Preparing and optimizing patients preoperatively, minimizing surgical trauma, using fast-acting anesthetics as well as multimodal opioid-sparing analgesia regime and liberal prophylaxis against postoperative nausea and vomiting are basic cornerstones. The scope being to maintain physiology and minimize the impact on homeostasis and subsequently hasten and improve recovery.SummaryThe increasing adoption of enhanced protocols, including the entire perioperative care bundle, in combination with increased use of minimally invasive surgical techniques have shortened hospital stay. More intermediate procedures are today transferred to ambulatory pathways; SDD or overnight stay only. The traditional scores for assessing discharge eligibility are however still valid. Stable vital signs, awake and oriented, able to ambulate with acceptable pain, and postoperative nausea and vomiting are always needed. Drinking and voiding must be acknowledged but mandatory. Escort and someone at home the first night following surgery are strongly recommended. Explicit information around postoperative care and how to contact healthcare in case of need, as well as a follow-up call day after surgery, are likewise of importance. Mobile apps and remote monitoring are techniques increasingly used to improve postoperative follow-up.

Outpatient vs Inpatient Single-Port Robotic Urologic Surgery: Perioperative Outcomes and Complications

“…Labs were performed prior to discharge only if driven by clinical suspicion or patient had relevant preoperative comorbidities. 13…”

“…Moreover, in order to be eligible for SDD, most patients were required to have a caregiver drive them home and be present with them for the first 24 to 48 hours after surgery. 13 If not possible, patients were sent to the inpatient ward for overnight stay. Finally, in order to obtain accurate postoperative outcomes, patients were subsequently seen in routine visits at approximately 1 week, at 1 month, and at 3 to 6 months.…”

“…Subsequently, if pain persisted, patients were managed with nonopioid oral analgesics. 13 If patients were deemed unfit for SDD, they would still go through the protocol and subsequently placed in the inpatient ward for inpatient stay.…”

Ambulatory anesthesia: restructuring for success

“…There are three phases of recovery from anesthesia and surgery. For each phase, scoring systems have been developed by the ASA as support tools for medical decision making and traditional scores remain valuable and valid [25 ▪ ]: the Modified Aldrete score is used for decision making regarding the transition from the closely monitored and highly staffed Phase 1 to Phase 2 [26]. The modified Post Anesthetic Discharge Scoring System (PADSS) [27] replaced the previously used, simply time dependent discharge criteria for releasing patients from the PACU and may be used before discharging patients to their homes.…”

“…Also, the responsibility of care for phase 3-recovery is handed over to private caregivers in the ambulatory setting. Thus, communication with the patients themselves and the caregivers who serve to accompany patients for the first hours, is of special importance [25 ▪ ]. Care escalations (referring to unplanned admissions) create immense costs and may even be not financially covered [35].…”