FACILITY DESIGN AND SAFETY
Ambulatory surgical facilities need to be well designed to ensure
efficient delivery of surgical services at the lowest possible cost. In the late
1960s, it was proposed that a facility for performance of minor surgical procedures
under general anesthesia did not need to be affiliated with a hospital. The first
freestanding outpatient surgical facility was built and managed by an anesthesiologist,
Wallace Reed, in Phoenix, Arizona, to provide surgical care to patients whose operations
were deemed too demanding for a surgeon's office, yet did not require overnight hospitalization.
[22]
Since that time, outpatient surgical facilities
have continued to grow and evolve.[23]
Today, these
facilities are found in a wide variety of different settings around the world that
reflect their association with other health care facilities. A prototypical ambulatory
surgical unit can have four basic designs[24]
:
- Hospital integrated: Ambulatory surgical
patients are managed in the same surgery facility as inpatients. Outpatients may
have separate preoperative preparation and second-stage recovery areas.
- Hospital based: A separate ambulatory
surgical facility within a hospital handles only outpatients.
- Freestanding: These surgical and diagnostic
facilities may be associated with hospitals but are housed in separate buildings
that share no space or patient care functions. Preoperative evaluation, surgical
care, and recovery occur within this unit.
- Office based: These operating or diagnostic
suites (or both) are managed in conjunction with physicians' offices for the convenience
of patients and health care providers.
Figure 68-1
Essential components related to patient flow in an ambulatory
surgery facility. (Redrawn with modification from Snyder DS, Pasternak LR:
Facility design and procedural safety. In White
PF [ed]: Ambulatory Anesthesia and Surgery. London, WB Saunders, 1997, p 61.)
Many specific requirements must be considered when planning an
ambulatory surgical facility. Patient volume, types of patients (e.g., children),
types of diagnostic and therapeutic procedures, organizational structure, and radiologic
and laboratory testing procedures must all be considered during the initial planning
of a new facility. To be optimally efficient, it is recommended that all the outpatient
services be organized in one dedicated area. Designs that place the waiting room,
preoperative evaluation area, preanesthesia room, operating suites, and recovery
areas in close proximity have many advantages.[25]
Surgeons and anesthesiologists are able to visit the patient and family before and
after the operation without losing time in transit. Patient transportation time
is reduced to a minimum, and extra personnel are unnecessary because the circulating
nurse (or anesthesiologist) can transport the patient to and from the operating room
( Fig. 68-1
). In many office-based
facilities, the patients walk in and walk out of the operating room.
Quality assurance and total quality improvement are helpful in
maintaining high standards for outpatient care and ensuring patient safety. Quality
standards are set and enforced either by government regulation, through a licensing
process, or by accreditation by private organizations such as the Accreditation Association
for Ambulatory Health Care (AAAHC). The AAAHC is an independent accreditation organization
whose principal activities are to develop standards, conduct surveys, and confer
accreditation on ambulatory health care providers. In the United States and Canada,
hospital-based ambulatory surgical facilities receive accreditation through the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO), which is the primary
accreditation agency for hospitals. As a result of heightened public and practitioner
concern over the safety and quality of office-based surgical procedures, the AAAHC
has established new quality standards for office-based and so-called mobile or itinerant
anesthesia organizations.[26]
It has been recommended
that all facilities where surgery is performed, as well as the practitioner, be accredited
to ensure patient safety.[27]
The American Society of Anesthesiologists (ASA) also provides
guidelines for ambulatory surgical facilities. The availability of personnel and
equipment for unexpected emergencies or a delayed return to the operating room is
essential. In-service training of all staff members regarding skills that are infrequently
required should be given regularly, including advanced cardiac life support, drills
for airway complications, emergency tracheotomy, and treatment of malignant hyperthermia
(MH).[24]
Depending on the size and range of surgical
services, a formal cardiac arrest team may be needed, and all facilities in which
anesthesia is administered require a portable crash cart and suction device. General
support services for routine laboratory tests, an electrocardiography (ECG) machine,
and access to a blood supply should be available. Ready access to an MH kit is also
required for any location where general anesthesia is performed.
As ambulatory surgery continues to expand, dedicated outpatient
facilities will be developed in a variety of settings (e.g., medical centers, surgical
clinics, diagnostic centers, physicians' offices, and even shopping malls). Anesthesiologists
need to be involved in the initial planning and organization of these facilities
to ensure safe, efficient, and economic patient care.
