With sicker patients undergoing ever-more complex surgical procedures, the post-discharge period deserves increased attention. Recovery has shifted from the hospital to the home, and caregiving has shifted from health care workers to non-medical family or friends. Optimized post-discharge analgesia and nausea prevention are more important than ever, as are fall and venous thromboembolism prevention and overall patient quality of recovery and satisfaction.
Novel methods of post-discharge follow-up and care
The use of technology to facilitate patient care has expanded rapidly due to disruption of the traditional health care landscape during the pandemic. Telemedicine can provide patient-centered care in the post-discharge period if the barriers, including access to technology, privacy regulations, and provider compensation, are overcome. The pandemic has certainly accelerated the timeline for overcoming some of these barriers, paving the way for virtual patient follow-up and support after ambulatory surgery (Curr Opin Anaesthesiol 2021;34:672-7).
“Post-discharge monitoring should be tailored to the specific procedure, for example, bleeding assessment with gynecologic procedures, venous thromboembolism in high-risk orthopedic procedures, and screening for post-dural puncture headache in patients with incidental durotomy during spine surgery.”
Daily patient-reported outcomes via electronic survey after ambulatory cancer surgery with nursing follow-up for clinical alerts have been associated with decreased urgent care utilization (JAMA Surg 2021;156:740-6). The additional intervention of real-time automated feedback about expected symptom severity reduced nursing phone call utilization and hastened a reduction in anxiety scores postoperatively (Ann Surg 2021;274:441-8).
Even more involved virtual post-discharge care with remote automated monitoring to obtain vital signs, daily symptom surveys, and virtual nurse visits with tablet computers demonstrated promise in decreasing acute care visits after urgent surgery with discharge within 24 hours (CMAJ Open 2021;9:E142-8). Pain control was superior with virtual post-discharge care, with increased use of analgesics as prescribed and reductions in moderate to severe pain.
Post-discharge monitoring should be tailored to the specific procedure, for example, bleeding assessment with gynecologic procedures, venous thromboembolism in high-risk orthopedic procedures, and screening for post-dural puncture headache in patients with incidental durotomy during spine surgery (Surgery 2021;169:240-7; Int J Spine Surg 2019;13:386-91).
It must be recognized with any innovation that it is important to consider health care disparities and to ensure that novel tools are inclusive, patient-centered, and do not contribute to further disparities in the vulnerable post-discharge period.
Post-discharge pain control has implications for short-term discomfort and effective rehabilitation, and early postoperative pain is also linked to persistent post-surgical pain. In addition to use of preoperative or intraoperative non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), local-regional anesthesia should also be administered (Best Pract Res Clin Anaesthesiol 2019;33:259-67).
Post-discharge analgesia has traditionally been managed with prescriptions for oral opioids. Acetaminophen and NSAIDs (in the absence of significant renal impairment, pregnancy, or coagulation disorder) are safe and effective, with an associated decrease in post-discharge opioid consumption (J Am Coll Surg 2021;232:765-90). Patients and their caregivers should be encouraged to utilize around-the-clock acetaminophen and NSAIDs, and to reserve prescription opioid tablets for pain not controlled with non-opioid analgesics. The number of opioid tablets prescribed should be thoughtfully considered and tailored to the particular patient and surgical procedure to minimize unused opioids (asamonitor.pub/3ufcn0t). Oxycodone tablets are recommended in place of opioid-acetaminophen combination tablets to optimize use of stand-alone acetaminophen.
Post-discharge nausea and vomiting (PDNV)
Multimodal prophylaxis should be prescribed in patients at elevated risk for PDNV (Curr Opin Anaesthesiol 2021;34:695-702). Options include orally disintegrating ondansetron tablets or the long-acting 5-HT3 receptor antagonist palonosetron. Neurokinin-1 receptor antagonists are also long-acting and are effective in antiemesis, but not in reducing nausea. A pre-induction dose of the atypical antipsychotic olanzapine demonstrated effectiveness in reducing nausea and vomiting in the 24 hours after discharge from ambulatory surgery (Anesthesiology 2020;132:1419-28).
Post-discharge fall prevention
A prospective observational study of older adults undergoing hip arthroplasty found that more than 40% sustained falls in the 12-month post-discharge period, with a significant proportion leading to injury and even fracture (J Gerontol A Biol Sci Med Sci 2021;76:1814-20). This was despite the cohort having good functional mobility preoperatively. The same authors found a similar incidence of falls after knee arthroplasty (Am J Phys Med Rehabil July 2021). The authors concluded that post-discharge rehabilitation programs should emphasize fall prevention and that further research is needed to evaluate fall-specific interventions for the post-discharge period. Education of caregivers on fall prevention demonstrates promise (J Geriatr Phys Ther 2020;43:128-36).
Venous thromboembolism (VTE)
VTE prevention has been a major focus of quality improvement in inpatient surgery. As higher-risk patients undergo more complex ambulatory surgery, it is imperative to expand VTE risk assessment and prophylaxis to the outpatient setting. A cohort study using American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) data from 2005-2009 found a 30-day incidence of VTE of 0.15% among 173,501 ambulatory surgical patients (Ann Surg 2012;255:1093-9). Among a high-risk subset (taking into account venous surgery, age, OR time, BMI, cancer, arthroscopic surgery, and pregnancy), the rates of VTE were 1.18%, which is similar to inpatient surgery (Ann Surg 2010;251:344-50). The authors note that several other recognized risk factors (e.g., history of VTE, known thrombophilia, oral contraceptives, tamoxifen use, inflammatory bowel disease) are not captured in the NSQIP database but may also be associated with VTE in the ambulatory surgical population. A study that linked hospital databases with primary care databases from 1997-2012 in the United Kingdom found that post-discharge VTE independently predicted 90-day mortality (OR=4.03, 95% CI, 2.95-5.51, p<0.001) (PLoS One 2015;10:e0145759). As the subset of higher-risk ambulatory surgery patients continues to grow in number, increased focus must be placed on protocols for VTE risk assessment as well as initiation and compliance with post-discharge chemoprophylaxis in the highest-risk patients.
“In order to get a more holistic understanding of our patients’ recovery after ambulatory surgery, increased focus is being placed on assessing patient-centered outcomes for research and quality-improvement initiatives.”
In order to get a more holistic understanding of our patients’ recovery after ambulatory surgery, increased focus is being placed on assessing patient-centered outcomes for research and quality-improvement initiatives (Curr Opin Anaesthesiol 2021;34:667-71). Early quality of recovery can be assessed using the validated QoR-40 survey, which covers physical comfort, emotional state, independence, and psychological support, or the shorter QoR or QoR-15 versions (Br J Anaesth 2018;120:705-11). Patient satisfaction after ambulatory surgery can be evaluated with the modified Bauer questionnaire, which evaluates anesthesia-related discomfort and satisfaction with anesthesia care (Br J Anaesth 2019;123:664-70). Long-term quality of life after ambulatory surgery can be assessed with the EuroQol 5, which includes mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (Qual Life Res 2011;20:1727-36).
In summary, as ambulatory surgery continues to grow, novel approaches to post-discharge follow-up utilizing technology are vital. Additionally, comprehensive plans for post-discharge analgesia, nausea prevention, fall prevention, and VTE prophylaxis are paramount. Determining our success as anesthesiologists providing ambulatory care will depend upon assessing early quality of recovery, patient satisfaction, and long-term quality of life.