Managing the Ambulatory Care Unit
H. ROBERT CATHCART
The development of insurance for hospitalization and surgery began in the 1930s, just over 50 years ago. Now the payment system for health care is a major national issue. The efforts to control health care costs, led by the purchasers of health care—insurers, consumers, and employers who pay for health insurance—have resulted in revolutionary changes in the way physicians and hospitals use technology to perform their work more cost-effectively. This case presentation uses Pennsylvania Hospital as an example to illustrate how technology has facilitated these changes in response to financial demands.
A REDEFINITION OF HEALTH CARE COST PAYMENTS
In the early 1980s, the payment system for Medicare, the federal health insurance system for 31 million elderly and disabled, and Medicaid, which covers 24 million low-income Americans, was redefined by the federal government. Instead of reimbursing hospitals for their costs on a per diem basis, the government set fixed prices for about 500 different illnesses and treatments, known as diagnostic related groups (DRGs). As a result, a hospital is paid a predetermined amount for a specific case no matter what services are rendered or how long the patient stays in the hospital. In other words, hospitals are rewarded financially if they discharge patients sooner and perform fewer procedures.
Ten years ago, a physician's decision to perform surgery or ad-
mit a patient to the hospital for tests was rarely challenged. Now, the review of such decisions is an essential task for hospitals—most have a staff of professionals who scrutinize admissions and medical records to analyze the appropriateness of procedures, surgery, and general medical care. Some hospitals and insurers hire independent consultants who review and assess efficiency of health care providers.
The commercial insurers, including those employer-sponsored plans that cover 160 million Americans, have followed the lead of the federal government. Any inpatient admission or procedure must be called in to the insurance company by the physician for clearance and approval before payment will be authorized. Emergencies are an exception to this rule, but procedures must be carefully monitored to ensure that the hospital will be reimbursed. For example, if a person comes in to the emergency room with symptoms of a heart attack and is treated for that but then is found to have indigestion instead, the hospital is reimbursed only for treatment of indigestion. Once again, the onus is on the hospital to ensure accuracy of diagnosis and appropriateness of treatment.
Consumers are also more conscious of prices for health care because, depending on their insurance plan, they are held responsible for higher premiums, deductibles, and sometimes co-payments. Employers are acutely aware of cost control—the single largest expense for General Motors in manufacturing a car is paying for the employees' health benefits.
Second opinions on surgery are often required by insurance companies, and consumers also are more likely to seek professional confirmation of a diagnosis before they follow a doctor's advice. As a result, physicians have modified their practice routines to accommodate second opinions.
These external financial pressures mean that hospitals have to continually reexamine how they are doing business. Changes in technology have been one answer—to develop methods to permit more work to be done outside the inpatient hospital setting.
Technology has played an important part in the adaptation of hospitals to changes in payment systems, especially in surgical procedures. When Medicare stopped paying for surgery to be done in the inpatient operating rooms if it could be done in an ambulatory care setting, physicians, researchers, and engineers worked together to develop new techniques and instruments to advance
outpatient surgery. Procedures that had previously been cause for automatic admission to the hospital are being routinely performed on an outpatient basis, at great cost savings. And many minor procedures have been removed from the operating room environment altogether and are now performed in physicians' offices. Hospitals built operating rooms and larger facilities dedicated to ambulatory surgery.
In many cases, technology was already paving the way to make it easier for surgeons to perform procedures with less invasive methods under local anesthesia, so the patient could walk into the operating room and go home again in just a few hours. In turn, instruments and surgical techniques have been refined so that operations can be done in less time with less pain for the patient, resulting in shorter healing time and less risk of complications.
A good example of this kind of technological change is the role of the arthroscope in knee surgery. The arthroscope was developed in the 1960s as a diagnostic tool. The physician would make an incision in the knee joint, insert the arthroscope with a magnifying lens and light, and examine the interior of the knee in order to assess injury and plan for more extensive surgery. The ensuing surgery involved opening up the knee while the patient was under anesthesia and then using normal surgical instruments to remove foreign bodies or repair damaged ligaments.
Early arthroscopic techniques were limited because the materials used to make the scope were stiff. The scope had a large diameter, so the incision had to be large enough to accommodate it. In addition, surgical instruments were large, making surgery in the small confines of the joint extremely difficult. With new materials, the more flexible fiber-optic scope can now probe into the joint without breaking, and the refinement of scopes and cameras allows the surgeon broader capabilities in the procedure. Now arthroscopy includes surgery as well as visualization; the site is magnified and projected on a television screen, which the surgeon watches as he or she operates. A typical arthroscopic knee procedure takes less than an hour to perform.
In the past decade, technology has developed to the point that the arthroscope and the surgical instruments now fit into a 4–5 millimeter incision. The surgeons work with tools that are smaller than a pencil and sutures that are finer than a human hair. Orthopedic surgeons who perform arthroscopic joint operations can now do procedures that were impossible before, such as actually mending damaged ligaments. This work is extending to other joints, such as shoulders, wrists, and ankles, that were previously
considered too small for outpatient surgery. Many arthroscopies are performed under local anesthesia, thus facilitating same-day surgery.
ESTABLISHING THE SHORT PROCEDURE UNIT
In 1985 Pennsylvania Hospital applied for a certificate of need to increase the number of operating rooms because of the large volume of surgical cases. Between 1980 and 1985, total surgical cases at Pennsylvania Hospital increased 24 percent, from 9,540 to 11,810, representing an average annual increase of 4.4 percent. Total surgical hours increased 42 percent, from 18,035 in fiscal 1980 to 25,524 in fiscal 1985. In fiscal 1984 the operating rooms were in use a total of 299 days, including 45 Saturdays. The average annual change in hours of surgery was 7.2 percent, nearly two-thirds greater than that of the growth in cases. This meant that patients scheduled for minor surgery might wait for many hours. It was apparent that what was needed was a facility that accommodated less complex procedures that did not require long periods of time in the surgical suite. Thus, whereas two rooms in the inpatient operating room suite had been designated exclusively for outpatient procedures, in 1983 the movement toward creating an outpatient operating room facility separate from the inpatient operating rooms had begun.
By 1985 the use of the inpatient operating facilities exceeded guidelines. Surgery was scheduled every weekday in three of the rooms from 8 a.m. to 8:30 p.m., or 12 1/2 hours. Scheduled surgical procedures were regularly being performed throughout the evening hours in those rooms, with cases beginning as late as 10:30 p.m. and sometimes continuing into the early morning hours. Urgent surgical cases that had not been scheduled, such as wound debridements and removal of ectopic pregnancies, occurred frequently and exacerbated the problem of extended hours. As a result, in 1985 the hospital opened a free-standing suite of two fully equipped rooms designed under the same specifications as the inpatient operating rooms. These outpatient rooms had all the equipment necessary for surgery, including anesthesia and radiological equipment, and a staff of perioperative nurses, scrub technicians, unit assistants, and clerical staff.
By establishing this Short Procedure Unit (SPU), the hospital was able to use all 12 rooms in one building for inpatient surgical cases and to centralize the entire outpatient program in an adjacent building. This configuration also enabled the hospital to
establish more reasonable schedules for both areas and achieve a more appropriate level of utilization in conjunction with state standards.
Soon two additional outpatient rooms were added to the SPU; then in 1987 another two rooms were added for a total of six. As these developments took place, outpatient procedures grew from 30 percent to 45 percent of the surgeries performed at Pennsylvania Hospital each year, and the sophistication of those operations increased correspondingly. In 1988, 5,800 of the 12,500 total surgical procedures were performed in the SPU, from cataract removal to in vitro fertilization, and most of those patients went home on the day of surgery to recover. In 1987 three services—obstetrics and gynecology, ophthalmology, and oral surgery—did 80 percent or more of their surgical procedures in the outpatient setting.
Effect on Quality of Care
What have these changes meant for patients? There are both obvious and subtle answers to that question. One obvious result is that smaller incisions and finer tools allow for less invasive procedures, so the body can heal more quickly. In addition, patients recover faster because anesthesia has been refined—in many cases, only local anesthesia is used, and in others, new drugs that dissipate more quickly have been developed. The more subtle implications for patients lie in their own changing role. Rather than entering the hospital days before an operation and relying on a nurse to monitor their care, the patients are responsible while at home for following the physician's instructions for preparing for surgery. For example, patients have to pay attention to what medications they take and the food they eat in the days before the operation, and often may be required to take nothing by mouth the night before.
After the surgery, they must be aware of their own healing processes, paying attention to their incision scars and reactions to any medication, as well as keeping up with any postoperative exercises or precautions delineated by the physician. Surgeons and perioperative nurses alike comment on the effect this has on patient recovery: as they become more involved in the process, they take more responsibility and are more aware of their own physical changes. As a result, patients often assume independence sooner and may help the physician by being more attuned to changes in their own system. In addition, the elderly in par-
ticular often do better when they convalesce in the familiar environment of their own home.
What do these shifts to outpatient procedures mean for surgeons? First, here is an explanation of how surgery commonly takes place. The operating suite is very busy, with many procedures going on simultaneously. Nurses, technicians, and resident physicians are involved from the start of an operation, setting up the room and the instruments and preparing the patient. A surgeon uses time efficiently to complete a number of operations in as few hours as possible. Since the SPU at Pennsylvania Hospital is in a separate building from the inpatient operating rooms, surgeons cannot always perform both types of procedures in the same morning. In response to that situation, they now schedule full or half days in the SPU, organizing surgeries to take place on specific days of the week. This makes scheduling more efficient for the nurses, who can plan the setups for orthopedics, otorhinolaryngology, or urology, for example, because they know for the most part which surgeons are on the roster each day of the week.
Rather than fragmenting their time between the inpatient and outpatient surgical areas, anesthesiologists work full days in the SPU. In addition, when patients come into the hospital for preadmission testing several days before the surgery, they are interviewed by a member of the anesthesiology staff. At that time, the appropriate course is planned and patients are given instructions regarding their preoperative preparation.
The role of the perioperative nurses who work in the SPU has also changed. In contrast to the circulating nurses in the inpatient operating room, who talk to the patients and reassure them just before they are anesthetized, the nurses in the SPU greet them while they are still in their street clothes, discuss their preoperative preparation, and walk with them after they have changed to help them onto the operating table. The nurses in the SPU have an important educational role with the patients and their families, answering questions and clarifying issues for them. After the requisite recovery period, the nurses ensure that the patients leave the SPU safely. Nurses telephone patients the day after surgery to see how they are doing and to follow up on instructions for medications or any other questions the patient may have.
The first scheduled surgery in the SPU is at 7:30 a.m., and the last at 4 p.m. The unit averages 25 surgical procedures each day, Monday through Friday.
One of the most common procedures performed on an outpatient basis throughout the country is cataract removal; nationally, it accounts for 66 percent of Medicare ambulatory surgery expenses. At Pennsylvania Hospital, 94 percent of the cataract surgery is done on an outpatient basis. A cataract is a clouding of the lens of the eye, which blocks the passage of light to the retina and impairs vision. A cataract is usually the result of natural aging, though sometimes it results from trauma. To correct this condition, the ophthalmologist removes the cloudy lens and replaces it with a plastic intraocular lens. This procedure is particularly significant as the population ages. Physicians comment that since the aging population is more active, their expectations for good vision are higher, and this results in higher demand for cataract surgery.
As with knee surgery, cataract surgery was revolutionized by the introduction of microscopes that allowed the use of very small instruments. A needle is inserted in the 4–5 millimeter incision, and the cloudy lens is pulverized by ultrasound. In recent years a technique has been developed that enables the lens capsule to be left in the eye, cleaned thoroughly, then used to hold the plastic implant in place. This results in less disturbance to the eye, less pain, and fewer adverse reactions. The very fine sutures make it possible to have smaller, safer wound closures, and that leads to a much quicker healing process. As in arthroscopic knee surgery, a video camera is attached to the scope so assistants, nurses, and observers can view the work on a television screen. In ophthalmologic surgery, however, the surgeon looks through a microscope, which permits depth perception not possible in television.
Technology permitted making just a small incision, but the diameter of the hard plastic lens was wider than the incision needed to be for the surgery. Ophthalmologists are now beginning to use a softer lens made of silicone that can be folded in half to fit into a smaller incision.
Other instruments used in the procedure, such as those for irrigation and aspiration, have also been improved greatly in recent years. These tools let the surgeon draw the cataract material out while flushing the eye at the same time. These functions formerly were determined by how high the surgeon held the bottle of fluid and how quickly the assistant pulled on a syringe. Now the surgical team uses foot-pedal controls and computer-guided, mechanized suction to manipulate the flow, achieving much greater accuracy.
TECHNOLOGY IN OBSTETRICS AND GYNECOLOGY
In obstetrics and gynecology, physicians use magnifying laparoscopes to view women's reproductive organs and perform a variety of procedures with very small instruments similar to those used for orthopedics and ophthalmology. Pennsylvania Hospital gynecologists tried many new techniques when they were first proposed by researchers. For example, laparoscopic tubal ligations were first performed in the late 1960s. This is a permanent sterilization method for women, now one of the most common procedures done in ambulatory surgery settings. As a result, hundreds of women each year undergo the procedure and recuperate at home, often returning to work just a few days later. Once again, the small incision, in contrast to the longer ones previously required, means there is less trauma and easier and quicker healing.
Percutaneous umbilical blood sampling (PUBS) is a significant new tool used to determine the health of a fetus in high-risk pregnancy. The test involves the use of ultrasound to guide a needle directly into the mother's abdomen through the uterine wall to the umbilical cord where a blood sample is taken from the fetal umbilical blood vessel. Using PUBS, doctors can administer medication, monitor medication levels that reach the fetus, and perform fetal blood transfusions. The procedure is performed on an outpatient basis with local anesthesia and little or no maternal-fetal sedation. It provides the physician with much more information about the development and genetic makeup of the fetus, thereby allowing better and earlier treatment of the unborn baby.
Technology also aids couples who are infertile. In vitro fertilization/gamete intrafallopian transfer (IVF/GIFT) procedures involve fertilizing an egg in the laboratory and implanting the embryo into the uterus. With the help of ultrasound and small instruments, there is just one small incision in the abdomen, and the operation is done under local anesthesia. The patients can watch the procedure on a television screen and even make a videotape for themselves.
LASERS IN OUTPATIENT SURGERY
The past 10 years have seen a dramatic increase in the use of lasers in surgery. Because the laser produces light of uniform wavelength in a focused, powerfully intense beam, it is useful to
surgeons working on a small area of tissue. The energy of the laser beam is absorbed by the tissue, causing a localized temperature increase, resulting in vaporization and tissue removal. The laser makes a clean, precise cut and instantly cauterizes the wound, so that little or no bleeding occurs.
The laser minimizes the formation of scar tissue and is self-sterilizing, so the risk of postoperative infection is much less than that associated with conventional surgery. Swelling is minimal, and healing is rapid.
When lasers were first being manufactured for surgical uses, Pennsylvania Hospital's chief of urology encouraged vendors to provide him with equipment that he could use to find clinical applications in urology. The doctor was able quickly to refine procedures and increase the number of ways in which lasers could be used. For example, lasers have made removal of cancerous tumors in the bladder much safer because the beam can be so precisely controlled that there is no longer risk of damaging the bladder wall, which was a serious complication when the old method of electrocautery was used.
In gynecologic oncology many patients with preinvasive cancer of the cervix are treated with lasers. In the recent past, these women would have had surgery under general anesthesia and a hospital stay of one to three days. The costs would have been high, and because a large part of the cervix had to be removed, the procedure could result in infertility. Today gynecologists vaporize specific layers of cells from the surface of the cervix instead of excising a section of it. These treatments can be done without anesthesia in the physician's office. The cost is considerably less, as is the discomfort, and healing is much more rapid. With laser surgery, there is less damage to normal structure because the physician can meticulously limit the area of destruction. There also is less blood loss and less scarring. For gynecologic patients, this helps to preserve childbearing capacity.
In addition to surgery, other medical uses for lasers have also been developed. Since 1982 a pulmonary disease specialist at Pennsylvania Hospital has been using lasers successfully to open the airway passages of people suffering from lung cancer and other bronchial obstructions. In 1987 he and the chief of radiation oncology began to follow the clearing of the obstructions with the temporary implantation of a wire laden with radioactive material. This procedure, known as pulmonary brachytherapy, allows the radiation to be delivered in close proximity to the tumor over a shorter period of time—approximately 12 hours instead of the
two-week course of normal radiation treatments. Again, the result is decreased damage to healthy tissue as well as a shorter hospital stay. Because of their extensive experience in the development of the uses of lasers, Pennsylvania Hospital physicians are also active in educating other doctors in the use of lasers.
DIAGNOSTIC TECHNOLOGY IN RADIOLOGY AND PATHOLOGY
Magnetic resonance imaging (MRI), a radiologic technique that provides a multidimensional picture of the entire body or of a specific area in question, aids the surgeon in determining the plan for an operation because it can view parts of the body that would not have been accessible until surgery. This visualization minimizes invasiveness and saves time on the operating table. The application of this important diagnostic tool illustrates the use of new technology in the patient care setting. Although research-oriented institutions developed the technique, other hospitals, like Pennsylvania Hospital, adapted its use to enhance patient care and increase efficiency.
Pathologists also play an important role in determining the appropriateness of treatment and surgery. When a tumor is correctly and accurately classified, a patient can receive the optimal therapy. New technologies for analyzing tissues on the cellular level have contributed to the efficiency of patient care.
For example, diagnosis of tumors of the breast can now be done on an outpatient basis because of fine needle aspiration and the technology to study very small biopsies. Surgeons can take the biopsies under local anesthesia in the Short Procedure Unit, and the women often avoid inpatient surgery altogether if laboratory examination shows that the tumor is benign. Before this technique was developed, a much larger specimen was surgically removed from a women's breast, resulting in more trauma and scarring for the same diagnostic result.
Pathologists also are able now to make diagnoses with smaller amounts of tissue. Immunocytochemistry uses specific antibodies to identify cells in small biopsies. These methods are more precise than conventional methods and can be used with much smaller samples of tissue. With electron microscopy, cells are magnified up to 100,000 times, in contrast to the normal microscope magnification of 1,000 times.
Flow cytometry is a technique that uses antibodies to diagnose tumors or disease in blood samples. In this technique, antibodies
are stained with a fluorescent dye, mixed with the blood cells, and then analyzed with a flow cytometer, which measures fluorescence emission from each cell that passes through it. It shows the relationship between the blood sample cells and the tagged antibodies as they flow through it in a fluid stream. The presence of the antibodies is then plotted on a graph by a profile analyzer as the stream runs through the cytometer, giving the lab immediate illustration of the antibody count. Once again, the results enable better diagnosis of the pathology of the cells and help to determine the most appropriate care for the patient.
WHERE TECHNOLOGY WILL LEAD
In the 237-year history of Pennsylvania Hospital, technological change has been fostered and encouraged because of the hospital's fundamental mission of providing the best possible patient care. Pennsylvania Hospital is not a research institution, but one dedicated to providing the most advanced clinical care. Many of the physicians are innovators in the application of research results in the clinical setting.
In the first years of the nineteenth century, the hospital's ability to perform its mission was advanced dramatically with its building of a surgical amphitheater unique in the Western Hemisphere. At a time when most cities did not yet have hospitals, Pennsylvania Hospital surgeons were removing gall stones, improving amputation methods, and educating a new generation of physicians who watched from the rows of benches encircling the operating theater. This positive attitude toward technological advancements and medical education continues today.
The past 10 years have seen revolutionary changes in the health care system coming about because of the redefinition of medical insurance and payment systems. This has forced researchers to develop new technology to treat patients in a less costly manner. The results have been seen in more outpatient surgery, more efficient inpatient surgery, and more effective methods of diagnosis and treatment of disease. One of the practical effects of this change is that more patients in the hospital are more acutely ill. Whereas a nurse previously took care of a mix of patients—some preoperatively, some after minor surgery, and others more seriously ill—now virtually all hospitalized patients need close attention.
As new technology has led to reduced lengths of stay and more outpatient procedures, it has not reduced the inflationary cost of
health care. After all, new technology is expensive. Pacemakers, for example, have been refined greatly in the past 10 years and are now smaller and more efficient. The cost of the research and development affects the price of the pacemaker but also results in better prognosis for the patient. It is highly likely that as health care costs continue to rise, even more new technologies will develop, and the rate of change will continue through the 1990s.