Question

Technology and reimbursement patterns have increased the amount of surgery performed on an ambulatory basis. Hospitals all over the country are experiencing a rise in the number of surgical patients who come into the hospital and go home on the same day; cases that previously required at least an overnight stay in the hospital. The move to outpatient treatment can significantly affect a hospital's use of beds and its overall organization. However, the move to outpatient care also poses some risks, especially to patients with difficult medical histories. The move from inpatient to outpatient care is driven by cost containment, as well as by new technologies. However, there are risks to care provided in the ambulatory setting. For example, advanced age (especially older than 70 years) is associated with increased hospital stay and perioperative morbidity and mortality. Additionally, the type of surgery is important in the risk assessment.

In the following three case scenarios, determine if the patient has an increased risk for surgical complications based on their current health status and medical history. Write a response for each scenario, and determine the following:

1. Does the patient's medical history pose a potential risk for complications prior/post surgery? Explain your reasoning.
2. Based on the patient's current health status and their medical history, should they receive surgery or be evaluated and treated outside of the ambulatory care setting? Explain your reasoning.

Case Scenario 1:

Mr. Rogers is a 51-year old male. During his pre-operative examination, he tells the nurse, "I have an ache in my right foot". He offers an explanation, suggesting, "I must have stepped on something or twisted my ankle. Maybe I got bitten by a bug when I was outside yesterday". The nurse notes that the patient's ankle is reddened, slightly swollen, and warm to the touch. However, his temperature is within normal limits. Mr. Roger's ankle is x-rayed and there is no fracture noted. He has full range-of-motion of his right ankle. Mr. Rogers has a preexisting medical condition of gout. He is scheduled for outpatient surgery on his thyroid.

Case Scenario 2:

Mr. Sanders is a 61-year old male who presents with nausea and has been vomiting for two days. He is also experiencing mental confusion. His blood glucose is 796 mg/dL. He is a newly diagnosed diabetic and has not been getting medical treatment. Intravenous regular insulin is administered to Mr. Sanders in order to bring his blood glucose level down to a normal level. Further tests show that his Hemoglobin A1C is 10.3%. Mr. Sanders has a preexisting medical condition of coronary heart disease and hypertension. He is scheduled for outpatient surgery on his thyroid.

Case Scenario 3:

Mrs. Miller is an 88-year old woman who presents with nausea, vomiting, and severe abdominal pain. Further tests reveal that her white blood cell count is 13,000/mm3. Her physical examination reveals that her abdomen is distended and very tender to the touch. Her doctor suspects that she has acute pancreatitis. Mrs. Miller has a preexisting medical condition of heart failure and gastroesophageal reflux disease (GERD). She is also scheduled for outpatient surgery on her thyroid.

Answer 1

Case Scenario 1:

No, the patient's medical history does not pose a threat on the surgery. He is having a preexisting medical condition known as gout that doesn't interfere with thyroid surgery. Mr. Rogers can be treated on an ambulatory basis since he does not have a condition that can interfere with his thyroid surgery. Although he is having redness and swelling in his ankle, he is having full range of motion and his X-ray is normal. He does not have fever also.

Case Scenario 2:

Yes, the patient's preexisting medical condition poses a threat on the surgery. Mr Saunders is likely to be suffering from diabetic ketoacidoais and requires treatment. His DKA needs to be managed first. His HbA1c is 10.3 which also needa to be controlled and brought to a normal level (less than 6).He is also suffering from coronary artery disease and hypertension.

He requires an evaluation and treatment outside the ambulatory setting since his health condition poses a risk of complication prior(cerebral edema, acute kidney failure, adult respiratory distress syndrome, etc) and post surgery (infection, bleeding, delayed wound healing, etc).

Case Scenario 3:

Yes, the patient's preexisting medical condition poses a risk on the surgery. Mrs. Miller is a geriatric. She is suffering from acute pancreatitis. Also she is having medical history of heart failure and GERD.

She requires evaluation and treatment outside the ambulatory setting since her health condition poses a risk prior (infection, kidney failure, diabetes, respiratory complications etc).