Archive May 2017 XVIII, No. 5

Going Outpatient?

Patients who used to pack overnight bags for these 5 procedures are now home in time for lunch.

Bill Donahue, Senior Editor


outpatient surgery OUT IS IN Less invasive approaches, rigid patient selection and advances in pain management have made many procedures ideal for outpatient settings.

Extended Care Surgery Centers

One factor that's driving more complex surgeries to the outpatient setting: legislation that essentially lets ambulatory surgery centers operate as extended-care facilities.

In Oregon, for example, House Bill 2664 ( would let as many as 16 ambulatory surgery centers increase the maximum allowable stay for patients to 48 hours, or even 52 hours, based on patient safety. The bill would essentially let these surgical facilities offer more complex surgeries that require longer recovery times, though it would also require them to have 24-hour staffing.

Anesthesiologist David Shapiro, MD, the past president of the Ambulatory Surgery Center Association, says he expects more "blurring of the lines" in the near future.

"We're starting to see this natural evolution," says Brian R. Gantwerker, MD, the founder of The Craniospinal Center of Los Angeles (Calif.). "A lot of surgery centers have applied for 23-hour admission status, and I believe we'll continue to see legislation allowing surgery centers to basically become mini-clinics."

What kind of effect will this trend have on hospitals? It's too soon to tell, says Dr. Gantwerker, but, he says, it will be "interesting" to watch.

— Bill Donahue

When Harbinder S. Chadha, MD, started his career in 1998, orthopedic surgery was mostly a hospital-based affair. Back then, a hip-arthroplasty patient would be admitted the night before the surgery, and then recuperate in the hospital for 5 to 14 days afterward. It was pretty much the same for an ACL repair.

My, how times have changed. Today, Dr. Chadha does about 150 total joint replacements per year. Patients arrive in the morning, have the surgery and, barring any complications, are back at home in their own beds later the same day.

Total joints are just one example of procedures that were once "inpatient only" but are now being done routinely in outpatient settings. He sees this steady migration as a classic example of providers simply giving consumers what they want.

"Patients have been driving this," says Dr. Chadha, who practices at the Otay Lakes Surgery Center in San Diego, Calif. "They wanted their independence in controlling their pain medication, they wanted their autonomy and they wanted their privacy. They knew they could gain all those by having us get them home quicker."

For David Shapiro, MD, a Tallahassee, Fla.-based anesthesiologist and past president of the Ambulatory Surgery Center Association, the procedures now being performed in outpatient facilities were "unimaginable" 20 or even 10 years ago. He credits seismic shifts in 3 distinct areas: less invasive approaches to surgery; more effective assessments of patients and their home-care situations; and advances in pain management.

"Patients have come to expect 100% perfection from their surgery, no matter where it's being performed," he says. "The care in outpatient facilities tends to be equal to inpatient or even better. We've also seen the rapid deployment of new drugs that are more potent, with a faster onset and offset, which means we can give deeper anesthesia without any lingering effects beyond the immediate post-operative period."

Patient satisfaction aside, Dr. Chadha believes surgery in outpatient settings has eased the burden on the U.S. healthcare system. This includes not only a reduction in costs associated with length of stay, but also a drop in expenses tied to treating surgical site infections. He cites his own facility's track record: a single ACL infection in more than a decade of operation.

Assuming an outpatient facility practices careful patient selection, has the right staffing and equipment, and can effectively manage the patient's post-operative pain and prevent nausea and vomiting, there's almost no end to the kinds of procedures that can — and will — be done in an outpatient setting. On the following pages, we explore 5 procedures that continue to gain steam in outpatient settings: bariatric surgery, hysterectomy, robotic prostatectomy, spinal surgery and total joint replacement.

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