Surgical Recovery in the Express Lane
The more things change in surgery trends, such as the fundamental shift toward outpatient procedures, the more things stay the same with human nature.
“Our data show most men want to go home after surgery because they know they will be cared for,” said Dr. Lee Fleisher, an anesthesiologist at Johns Hopkins University Medical School in Baltimore. “Women, on the other hand, are more reluctant as a group because they tend to be the caregivers in the family. They don’t figure to get the same attention.”
Yet Fleisher said most patients, women or men, are pleased to go home if the medical staff fully explains the risks and disadvantages of staying overnight in the hospital, which includes a greater possibility of infection and the tendency for stable patients to be basically ignored.
A number of medical breakthroughs have made surgery a much safer proposition in the last 10 to 20 years and certainly much more than half a century ago. More than 70% of surgeries now are performed on an outpatient basis, translating to patients going home one to four hours after a procedure, on average. It appears that most patients are satisfied with this, even if insurance companies pushed the trend initially to prevent the additional costs of hospital room rates.
In 1981, according to SMG Marketing Group Inc., a medical research firm, there were about 4 million outpatient surgeries in this country. A decade later, the number was up to 17 million. This year, nearly 34 million outpatient surgeries are expected. During the same 20 years, inpatient procedures have dropped to 9.3 million from 15.6 million.
One reason for the overall increase in surgeries is that elective surgery, indeed, has been elected more. There were nearly 20 million surgeries in 1981, and more than 43 million will be done this year. Another reason is the emergence of freestanding outpatient surgery centers and procedures performed in doctors’ offices. About 21% of surgeries are performed at freestanding surgery centers, which are required to be accredited and checked for performance review, and another 26% in physicians’ offices, where regulations are practically nonexistent. The remaining 53% of outpatient surgeries are done in hospital settings, either mixed in with inpatient procedures in the main hospital building or at a connected facility that has full and near-instant access to emergency medical services.
Human nature is decidedly part of the upward and out-the-door pattern. “One of the biggest changes is the willingness of doctors and patients to try it,” said Dr. Bill Hopkins, a general surgeon at Advocate Christ Hospital in Oak Lawn. “Fifteen to 20 years ago, a breast biopsy meant the woman stayed three nights in the hospital,” he said. “Now we do it in four to five hours. A mastectomy required up to 12 days. These days many women go home the next day.”
With the efficient hospital departures come new issues about going home when care is still needed, albeit not around the clock and not hooked up to heart and breathing monitors. For instance, women undergoing breast surgery will be sent home with specific instructions (and frequently a video for support material) about how to deal with any drainage. Patients inspect their own wounds and change the dressing. Loved ones need to be similarly educated, including the potential for pneumonia or clotting problems in the legs if a patient recovering at home doesn’t get up and move around enough. What’s more, caregivers need to be lined up when a longer home recovery is expected.
Nurses play a vital role in follow-up with all surgical patients.
“Our protocol is to ask detailed questions of each patient on the day after surgery,” said Dr. James Boffa, a general surgeon at Swedish Covenant Hospital in Chicago. “We specifically want to know about pain. The patients are clearly told they can call a nurse or doctor at any time if there is a problem.”
Boffa is less concerned about patient skills at self-care and more focused on maintaining medical control. Sometimes a patient does need to be kept overnight because of complications, a decision to more closely observe the patient or to administer intravenous pain medications that cannot be done at home.
“Insurance companies dictate post-op period in too many cases,” Boffa said. “It is wrong and frustrating to be arguing with someone [from the insurance company] who doesn’t understand medical procedures.”
Medical centers now employ discharge planners who coordinate any necessary hospital stays after surgery. Even so, most surgeons still must fill out paperwork to persuade insurance carriers to grant or extend a stay. Also typical is that insurers require outpatients to be certified before any procedure can be performed.
Fleisher said about 25% of mastectomies are same-day procedures. Knee surgery tracks at a high end of 85% in his studies, he said; vaginal hysterectomies are a low-end barometer, at 8%. Outpatient hernia procedures have become routine, with patients returning to work in one week compared with six weeks in previous decades.
“I did my first one on a medical student about 17 or 18 years ago because he didn’t want to miss any of his studies,” Hopkins said.
Surgeries to remove a child’s tonsils are practically all on a same-day basis and have been for about 15 years. Part of the reason is the risk for complications is quite low. Only 1 in 200 kids returns to the hospital with bleeding, which rarely proves serious.
Through it all, complications from surgery have declined impressively. It is estimated that about 1 in every 250,000 people dies from surgery, although the number could be closer to 1 in 50,000 if all inpatient surgeries are included. That’s still 50 times safer than in 1960.
At the American Society of Anesthesiologists meeting last fall, Fleisher provided a striking study about safety. An analysis of more than 1 million elderly patients showed that only 1.6% of outpatient surgeries resulted in complications requiring hospital admission, which compares favorably with patients in a general population.
“The findings are highly reassuring for older adults,” Fleisher said.
Interestingly, cataract surgery, a procedure that tends to be most often performed on the older-than-65 set, is considered about the safest operation possible.
The outpatient surgery that still amazes a veteran physician like Hopkins is gallbladder removal, which is called larparoscopic cholecystectomy. “It is one of the more remarkable procedures,” Hopkins said. “The surgery used to require four to five nights in the hospital with a tube in the patient during recovery. Now it’s an outpatient surgery for most people [research shows 60%, up from 10% in 1994, while most others go home after one night’s stay] and patients are playing golf in two weeks.”
A driving force behind outpatient gallbladder removal and many other surgeries is the technological breakthrough of the laparoscope.
It is a device with a fiber-optic light and tiny camera that magnifies an image onto a video monitor. Doctors can do their work using the laparoscope for guidance while making a mere three or four incisions measuring no more than a quarter-or half-inch. The smaller incisions lead to significantly less post-operative pain and faster recovery times because muscles and bones are not cut or manipulated.
The laparoscope was first applied in the early 1990s to gynecological surgeries such as the dilation and curettage procedure to diagnose and treat problems with the uterus. Women avoided three-day hospital stays. Gallbladder removal quickly followed, and now the technique is used extensively.
Other medical advances have contributed to same-day surgeries. More precise imaging techniques, such as magnetic resonance imaging and miniaturization of instruments, have contributed to faster turnarounds for patients.
Prominent among the surgical breakthroughs is the newer type of anesthesia. Rapidly acting medications are more effective at sedating the patient and bringing him or her back to consciousness, all with fewer side effects of grogginess or nausea. The new drugs are a big reason for the drop in death rates and hospital stays.
“The anesthetic agents are so much better,” said Dr. Neil Swissman, a Las Vegas-based anesthesiologist and president of the American Society of Anesthesiologists. “The monitoring is better too.”
