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 and researcher 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 percent 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 total 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 right in doctors’ offices.
About 21 percent of surgeries are performed at freestanding surgery centers, which are required to be accredited and checked for performance review, and another 26 percent in physicians’ offices, where regulations are practically nonexistent.
The remaining 53 percent 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.
Watching for problems
Nurses play a vital role in follow-up phone calls 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 on the city’s Northwest Side. “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 and documented before any procedure can be performed.
Speedy recoveries
Fleisher said about 25 percent of mastectomies are same-day procedures. Knee surgery tracks at a high end of 85 percent in his studies, he said, while vaginal hysterectomies are a low-end barometer at 8 percent.
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.
Evaluating the risk
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 percent of outpatient surgeries resulted in complications requiring hospital admission, which compares favorably to 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 over-65 set, is considered about the safest operation possible. Fleisher said it qualifies for the classic reassurance, “It’s like going to the dentist.”
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 percent, up from 10 percent in 1994, while most others go home after one night’s stay] and patients are playing golf in two weeks.”
“I was up moving around the house and garden the next day after surgery,” said Linda Katauskas, 50, a Lemont resident who recently underwent a same-day larparoscopic cholecystectomy at Advocate Christ Hospital.
The latest tools
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.
Improved anesthesia
Prominent among the surgical breakthroughs is the newer type of anesthesia. Rapidly acting medications are more effective at sedating the patient and bringing him back to consciousness, all with fewer side effects of grogginess or nausea. The new drugs are a big reason for the drop in both 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.
“Every patient has an EKG, and you can get readings on oxygen levels in the bloodstream and what gases are exhaled. Forty years ago there was one EKG for every hospital floor. Doctors and nurses used it when a patient was in serious trouble.”
Swissman has been a physician for 40 years, which he said qualifies him to know “same-day surgery” is an outmoded term. The up-to-date description is “ambulatory surgery.”
“An anesthesiologist works before, during and after ambulatory surgery,” Swissman said.
“We can greatly reduce postoperative pain. I encourage patients to get back to normal life as soon as possible. I don’t want them driving or consuming alcohol, but they can enjoy the rest of the day.”
A look back
Hopkins recently got a firsthand look at how anesthesia has transformed surgery recovery times. He visited Honduras in March to provide free surgeries to needy patients. Less expensive anesthetic medicines were used (the newer ones were cost-prohibitive). “The patients were zonked for 24 hours, compared to patients back here who are up and alert in one to two hours,” Hopkins said.
Although insurance companies typically are vilified for cutting medical costs with bottom-line regard for the patient, the new anesthesia drugs and high-tech laparoscope and other equipment don’t necessarily reduce surgery costs and might even increase them. Decreasing hospital stays simply help offset any increased expense in the operating room.
“The biggest savings comes in how long people have to stay home from work or other productive parts of their lives,” said Dr. George Mesleh, chief of surgery at Advocate Christ Hospital in Oak Lawn. “It used to be people were recovering for four to eight weeks. Now it’s maybe a week. That’s a big difference in a person’s everyday life.”
New moms benefit from hospital stay
Doctors have never liked the term, but “drive-through deliveries” received widespread media attention in the mid-1990s. Women routinely were sent home from the hospital within 24 hours of having a baby. Hospital officials said insurance companies started the trend. Insurance carriers countered by pointing to the doctors.
In 1996, state lawmakers in Illinois ended the finger-pointing by passing a bill that requires insurance companies to allow mothers and their newborns to stay in the hospital at least 48 hours after the birth (a woman undergoing Caesarean section was approved to remain in the hospital two additional nights). The law does make some exceptions for small businesses and companies with self-insured health plans, but it’s estimated that at least two-thirds of Illinois’ new mothers are entitled to two nights in the hospital. The public outcry and subsequent state law apparently worked to quell the controversy.
“We experienced the 24-hour phenomenon,” said Kathy Garrett, a nurse and clinical educator for the Family Birthing Center at West Suburban Hospital in Oak Park. “But that’s in the past. It’s sort of old news. We’re back to 48 hours, which I think is a good thing.”
Unlike ambulatory surgery patients, who mostly want to go home the same day as their procedures, Garrett said most new moms welcome the overnights at the hospital.
“Exhaustion is the number one factor,” said Garrett. “Most moms know at home they can’t send the baby to the nursery so they can take a nap.”
Nurses routinely will ask questions about a woman’s support system at home, especially when it seems shaky. West Suburban nurses send new mothers home with an impressive booklet covering many major issues, including getting help at home.
Another important feature of a longer hospital stay is the expanded opportunity for nurses such as Garrett to educate new mothers about everything from breast-feeding to proper car seat usage to how much crying is normal.
“We also want to address Mom and her feelings about the new baby and motherhood,” said Garrett.
— Bob Condor
