Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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This can translate into providers in the OR and PACU having to hold the patient's head for long periods of time. In the COVID-19 era, it also means close, prolonged patient-provider contact. Coughing is another concern that's receiving more scrutiny during the pandemic. Though not without controversy, the practice of deep extuba- tion — removing the endotracheal tube or laryngeal mask airway (LMA) while the patient is still under anesthesia — is gaining interest. It has been shown to reduce the incidence of coughing, dysrhythmias, hypertension, laryngospasms, and intraocular or intercranial pressures. Deep extubation also allows the surgical team to move patients to recovery before they wake up, speeding up OR turnover times. It can lead to air- way obstruction, however, because the airway can still collapse due to anesthesia, so an interim airway should be placed to maintain adequate ventilation and oxygenation. Deep extubation success also relies on staff skill levels in PACUs, which vary among facilities and affect the level of post-anesthe- sia care that can be utilized. Evolve and adapt In the early days of outpatient surgeries, most of the emphasis was on identifying patients who could be candidates for surgical care outside a traditional hospital. Usually, the patients were quite healthy. Today, the patient populations are broader, and the surgeries are more involved. The country's approxi- mately 5,800 ambulatory surgery centers provide a large range of increasingly complex procedures, particularly in the field of spine and orthopedics. More involved procedures can be performed in the ambulatory setting because of advances in mini- mally invasive surgical technology. Less damage to tissues typically results in less pain, less blood loss, decreased postoperative care, fewer complications and shortened healing time. And because the quality of care is going up while case costs remain lower than the same surgeries performed in acute care facilities, outpatient surgeries are expected to con- tinue to grow. Research firm Sg2 predicts that 85% of surgeries will be performed in the outpatient set- ting by 2028. Growth isn't just about numbers, it's about evolu- tion. Has anesthesia kept up with the progress sur- geons have made? Adopting new tools and tech- niques isn't easy. After all, the biggest barrier to change is current practice. The LMA, for example, was originally intended as an alternative for hand- mask ventilation. It has also proved to be an alterna- tive to elective endotracheal intubations, especially in outpatient anesthesia, and an option for securing a difficult airway. The LMA is widely used today, but it took about 10 years for providers to embrace it, despite its ease of use, lower anesthetic require- ments and other benefits. As outpatient surgery caseloads increase, the pace of change must acceler- ate to deliver higher level and more efficient care. Of course, concerns about costs come into play. Value analysis committees are tasked with com- paring a new device's cost to the equipment it replaces. The challenge with this approach is that the product being replaced has likely been on the market for decades, and the price is low. Even if a new device works well and providers want it to do their jobs to the highest standard, it can be diffi- cult to access it. If staff can't obtain a solution in a timely way, they may end up using workarounds to achieve their goals. To stent airways open, for example, a survey of 293 anesthesia providers indicated that 52.8% had used nasal airways orally because the longer tubing of a nasal airway reaches lower into the pharynx than a traditional oral airway. This off-label practice indicates the need for a new option in airway man- agement and newer devices exist to address this issue. This is a good example of a desire for change outpacing implementation. As ambulatory surgery practices mature, surgical facilities must remember some of the factors that have made them successful: being nimble, innova- tive and responsive to the needs of patients and staff. They can be the leaders in adopting new approaches, tools and technologies that improve patient outcomes and satisfaction, while also easing staff burden, shortening turnaround times and reducing expenses. OSM Dr. McMurray (rmcmurra@umn.edu) is an educator in the anesthesia program at the University of Minnesota. J A N U A R Y 2 0 2 1 • O U T P A T I E N T S U R G E R Y . N E T • 6 3