Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2 No. 4 (Dec. 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Unanticipated Care After Discharge from Ambulatory Surgical Facilities O f the PA-PSRS reports in which patients required hospital-level care within hours or days of treat- ment at an ambulatory surgical facility (ASF), approxi- immediately after a procedure may have caused, or at least increased the risk of, bleeding. We do not know whether the patient resumed taking aspirin with or mately 12% suggest that activities at discharge and against advice given at discharge. during post-discharge follow-up may have contributed to the events. In a random sample of 100 of these Managing Care Postdischarge cases, nine required hospital admission and three Discharge instructions are given to the patient to were treated in the emergency department. bridge the care from the ASF to the home, to help ensure the continuation of symptom relief and patient Discharging a patient from an ASF is the culmination monitoring, and to indicate when the doctor should be of services delivered but not the end of clinical re- notified and/or when follow-up care is needed. Typi- sponsibility. Unlike postoperative discharge from a cally, these instructions include a list of prescribed hospital, ASF discharge occurs within hours of the medications, diet and activity restrictions, side effects surgical procedure; therefore, an abbreviated time is related to surgery and anesthesia, with emphasis on available to perform patient assessment and provide symptoms of complications related to the specific sur- discharge instructions. During this observation period, gical intervention. Treatments, procedures, and fol- heightened sensitivity on the part of the clinician helps low-up tests are usually outlined in the instructions, as to identify and address any physiologic changes from are postoperative appointments.1 the patient’s preoperative state that would deem dis- charge unsafe. Additionally, the instructions given to PA-PSRS reports indicate that patients seek postdis- the patient or caregiver—including information regard- charge medical intervention for a variety of reasons, ing how and when to contact the physician or when to but bleeding and pain are mentioned most frequently. seek emergent care—help to ensure a safe postop- A few reports also describe complaints of nausea/ erative period. vomiting or urinary retention. In several reports, de- lays in seeking medical attention have occurred. Follow-Up Care Timely access to care may be related to patient com- Once discharged home, the patient is dependent on pliance with discharge instructions; to a patient’s un- the discharge instructions to know what to expect dur- derstanding of postoperative expectations; or to a ing recovery. The patient’s decision to seek follow-up patient’s convenient access to care. care is based on his or her understanding and toler- ance of the perceived acceptable postoperative ex- Delays in seeking additional medical care may involve pectations. Sometimes, the patient’s tolerance is be- patients who experience bleeding or potential organ yond what one should be expected to endure. In perforations, as the following cases indicate: other situations, a change in condition may be unin- tentionally provoked. Patient with a history of ulcerative colitis had routine colonoscopy. During the procedure, two Patient called the surgeon and complained of polypectomies and several biopsies were per- severe pain. The office encouraged him to take formed. Discharge to home without problems or his pain medication. When this did not work, he complaints. Patient called the doctor’s office six went to the ED. Patient was found to have uri- days later with a complaint of bloody stool; this nary retention; a Foley catheter was placed. Medicated for pain with IM medication and dis- This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. charged to home. 4—Dec. 2005. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI & ISMP under contract to the Authority as Patient discharged to home stable. Forty-eight part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). hours later, notified doctor of bleeding. Had Copyright 2005 by the Patient Safety Authority. This publication may be re- resumed taking ASA. Admitted to hospital for printed and distributed without restriction, provided it is printed or distributed in bleeding. its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. In the first case, it appears that assessment of the location of the patient’s pain may have been inade- To see other articles or issues of the Advisory, visit our web site at quate. In the second case, aspirin (ASA) resumption www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2 No. 4 (Dec. 2005) Unanticipated Care After Discharge from Ambulatory Surgical Facility (Continued) was the first bowel movement since the proce- transition when a change in pain management occurs dure. Patient was admitted, received a unit of from postanesthesia to oral analgesia in home care.3,5 PRBCs, and was discharged in 48 hours. A speedy discharge with timely recovery can be pro- jected if pain is well managed.1,3 In the following Patient reported to emergency room with com- case, the patient initially may have had satisfactory plaints of abdominal pain three days post- relief postdischarge, but discomfort became unman- colonoscopy with hot biopsy polypectomy. Di- ageable: agnostic studies revealed free air in bowel. Per- foration confirmed and colon resection per- Patient had right-wrist fusion done and met crite- formed. ria for discharge three hours after procedure. On the afternoon of the following day the patient Discharge instructions can emphasize specific infor- was admitted to the hospital for pain relief per mation on the risks related to the procedure, such as physician’s office. bleeding, abdominal distention without flatus, or lack of bowel movement, and can instruct patients who Accrediting organizations such as the Joint Commis- experience these complications to contact the physi- sion on Accreditation of Healthcare Organizations cian. Consider defining the time parameters related to emphasize improved management of patients’ pain the specific surgical procedure so that the patient and as the “right thing to do.”6 One article indicated that caregiver have clear directions regarding when to standardizing pain management, staff education, and contact the physician and what to communicate. standing orders improved pain management in the ambulatory setting.7 Preventive analgesia is sug- Postoperative Bleeding gested using a multimodal, synergistic approach with In a study at the SUNY Health Science Center at a nonsteroidal anti-inflammatory drug (NSAID), Brooklyn, bleeding was found to be the primary rea- opioid, and local anesthetic.3,8 Critical to analgesia son for patients to seek emergency department care selection is the concomitant communication of side after a procedure in an ASF. The study suggested effects. Patients may choose less-than-adequate pain that patients be better informed about when bleeding relief over analgesic side effects. It may be productive is expected and that they receive instructions outlin- to explore this trade-off with the patient in an effort to ing what to do when bleeding occurs.2 Although identify the optimal pain-relief regimen with tolerable some postoperative bleeding is to be expected, the side effects,5 with the understanding that it is better to amount of incisional bleeding can be clarified. It is maintain control of pain than try to regain it after it has important that the patient know how to apply pressure been lost. to the wound and to change or reinforce dressings, as well as when to contact the physician.3 Bleeding, al- Format of Discharge Instructions though high on the list of reasons for seeking follow- Most ASFs have developed standardized forms cov- up care, has remained low in volume, considering the ering the various discharge needs of the postopera- high volume of surgical interventions at ASFs.3,4 tive patient. These forms typically include reminders to the clinician to cover essential information, but total Postoperative Pain Management reliance on standardized forms can be problematic, Pain after ambulatory surgery can be managed at as the following case indicates: home, but only when expectations of pain levels and anticipated relief from analgesia are clearly communi- Patient resumed Coumadin post-op tonsillec- cated.3 Patient education often addresses what de- tomy and developed bleeding requiring admis- gree of pain to expect. Pain or discomfort is best dis- sion to the hospital and return to the OR for cussed when an objective system of monitoring is cauterizing of bleeding site. Dr. signed stan- used, similar to what is applied at the ASF postopera- dard discharge instruction sheet indicating tively. For example, if a verbal numeric rating scale of patient to resume medication unless otherwise 1 to 10 is employed to assess pain in the postanes- indicated. thesia care unit, the patient can be instructed to use this scale when communicating with the physician. A patient’s presurgical medications are usually re- Additionally, when informing patients of anticipated sumed postoperatively, only after physician review of postoperative pain and time frames for analgesia, each medication and any related risks associated with applying the same pain scale will help to eliminate the surgical procedure. PA-PSRS reports indicate that ambiguity. when patients fail to follow instructions and continue to take coumadin and ASA/NSAIDs postoperative Objective parameters for measuring pain postopera- bleeding requiring emergent follow-up care may oc- tively are particularly important and allow for a smooth Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2 No. 4 (Dec. 2005) Unanticipated Care After Discharge from Ambulatory Surgical Facility (Continued) cur. Patient education can obviate the risk of bleeding • Managing care beyond the ASF by providing associated with these drugs.9 well-defined, objective criteria for seeking fol- low-up care or physician contact. In response to the case reported above, this facility changed its medication documentation to prevent • Discussing pain management expectations, similar events from occurring to other patients. Now, trade-offs, and alternatives with the patient. anticoagulants are flagged on routine preoperative • Addressing incisional bleeding, dressings, review with a “med alert” sticker to help ensure that pressure dressings and when to contact the clinicians recognize and are attentive to the risks as- physician for further intervention. sociated with this type of medication. • Reviewing preoperative medications and post- Patient Compliance with Discharge Instructions operative resumption of medications, with spe- Traditionally, patients sign discharge instructions that cial attention to anticoagulants. indicate comprehension and represent an informal agreement that the recommendations will be followed. • Reinforcing the risks related to specific instruc- However, two telephone surveys of postoperative tions, such as driving within 24 hours post- patients indicate that patients are not always compli- operatively or lacking a supportive caregiver. ant, especially with limitations on driving and recom- • A comprehensive discharge checklist. mendations to avoid alcohol and to have a caregiver available.10,11 The best method to ensure patient com- Notes pliance has not been proven. 1. Marley R, Swanson J, Patient care after discharge from the am- bulatory surgical center. Journal of PeriAnesthesia Nursing. 2001 Sample Discharge Record Dec;16(6):399-417. 2. Twersky, R, Fishman D, Homel P. What happens after dis- A sample comprehensive discharge record can be charge? Return hospital visits after ambulatory surgery. Anesthesia found in the Association of periOperative Registered Analog. 1997 Feb, 84(2):319-24. Nurses (AORN) Ambulatory Surgery Principles and 3. Reiling R. McKellar D. Outpatient surgery. ACS Surgery. Med- Practices. This sample form lists pertinent criteria, scape [online] 2004 [cited 2005 June 17]. Available from Internet: including the following issues mentioned in PA-PSRS http://www.medscape.com/viewarticle/505418_print. 4. Vaghadia H, Scheepers L, Merrrick PM. Readmission for bleed- reports:12 ing after outpatient surgery. Candian Journal Anaesthesia. 1998 • ASA or ASA product resumption Nov:45(11):1079-83. 5. Gan, TJ, Lubarsky, DA, Flood, EM et al. Patient preferences for • Doctor notification in the following instances: acute pain treatment. British Journal of Anaesthesia. 2004 Mar; 92 - Elevated temperature over 100˚F (5): 681-8. - Ineffective pain management 6. Improving the quality of pain management through measurement - Nausea/vomiting or excessive bleeding and action. Joint Commission on Accreditation of Healthcare Or- ganizations and National Pharmaceutical Council, Inc. [online] - Inability to urinate by [specify time] 2003 [cited 2005 Aug 1]. http://www.jcaho.org/news+room/ - No bowel movement after 24 hours health+care+issues/pain_mono_jc.pdf. 7. Woodley KS, Case study in brief improving ambulatory surgical In addition, the article “Patient Care after Discharge pain management. Joint Commission Journal on Quality and from the Ambulatory Surgical Center” addresses the Safety. 2004 Jan;30(1):36-41,1. general discharge needs of the surgical patient and 8. Redmond M, Florence B, Glass PS. Effective analgesic modali- details various surgical complications, risks, and sug- ties for ambulatory patients. Anesthesiology Clinics North America. gested methods of symptom management.1 2003 Jun;21(2);329-46. 9. Greenburg AG, Greenburg JP, et al Hospital admission following ambulatory surgery. American Journal of Surgery. 1996 Jul;172 Conclusions (1):21-3. An American Journal of Surgery article states that 10. Correa R, Menezes RB et al, Compliance with postoperative “unplanned admission following ambulatory surgery is instructions: a telephone survey of 750 day surgery patients. An- relatively rare but could reflect overall quality in terms aesthesia. 2001 May;56(5):481-4. of the system, physician, and patient.”9 With the vol- 11. Cheng CJ, Smith I, et al A multicentre telephone survey of com- pliance with postoperative instructions. Anaesthesia. 2002 Aug:57 ume of ambulatory surgical services growing expo- (8):805-11. nentially, providing safe care beyond the walls of the 12. Ambulatory surgery: principles and practice: standards and ASF is everyone’s goal.13 Comprehensive discharge recommended practices for ambulatory surgery, Vinson, NJ, ed. instructions include critical information for the patient Association of Perioperative Registered Nurses. Denver, CO: and caregiver and provide for both optimal patient AORN, 2003 140-141. 13. Fleisher, L. Ambulatory surgery centers proliferate. Physician’s outcomes and staff satisfaction in delivering quality News Digest. [online] 2005 [cited 2005 Aug 1]. http:// care. www.physiciansnews.com/cover/705.html. Consider whether your facility’s discharge protocol addresses the following elements: ©2005 Pennsylvania Patient Safety Authority Page 3 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2 No. 4 (Dec. 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 4 ©2005 Pennsylvania Patient Safety Authority