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 1-2 paragraph response for each scenario, and determine the following:
- Does the patient’s medical history pose a potential risk for complications prior/post surgery? Explain your reasoning.
- 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. |
Expert Solution Preview
Introduction: The move from inpatient to outpatient care has increased with the advancements in technology and reimbursement patterns. In this scenario, we will evaluate the risks associated with ambulatory care and the potential complications for patients undergoing surgery.
Case Scenario 1: Mr. Rogers has a preexisting medical condition of gout and complains of an ache in his right foot during his pre-operative examination. The nurse notes that his ankle is reddened, slightly swollen, and warm to the touch. Based on his medical history and current health status, Mr. Rogers may be at risk for surgical complications as gout is a chronic condition that can affect joints. Surgery may increase inflammation, leading to more serious joint problems. Hence, Mr. Rogers should be evaluated and treated outside of the ambulatory care setting to avoid potential complications.
Case Scenario 2: Mr. Sanders has a preexisting medical condition of coronary heart disease and hypertension and has been newly diagnosed with diabetes. He presents with severe symptoms such as vomiting, mental confusion, and high blood glucose levels. Based on his medical history and current health status, Mr. Sanders may be at an increased risk for postoperative complications as his diabetes is poorly controlled. Surgery can cause stress and a potential increase in blood glucose levels, leading to further complications. Therefore, Mr. Sanders should be evaluated and treated outside of the ambulatory care setting to stabilize his medical condition before surgery.
Case Scenario 3: Mrs. Miller has a preexisting medical condition of heart failure, GERD, and presents with acute pancreatitis symptoms, including vomiting, nausea, and abdominal pain. Her white blood cell count is also elevated. Based on her medical history and current health status, Mrs. Miller may be at risk for surgical complications due to her underlying medical conditions. Surgery can cause stress on her heart and lead to further complications in her respiratory and digestive systems. Therefore, Mrs. Miller should be evaluated and treated outside of the ambulatory care setting to stabilize her medical condition before surgery.