AMBULATORY SURGERY CENTERS A C OMPREHENSIVE REVIEW€¦ · Ambulatory surgery centers also commonly provide pain management procedures, including epidural and facet joint injections

AMBULATORY SURGERY CENTERS: A COMPREHENSIVE REVIEW

1965

1965AMBULATORY SURGERY CENTERS:

A COMPREHENSIVE REVIEW

STUDY GUIDE

DisclaimerAORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products orservices. Although all commercial products in this course are expected to conform to professional medical/nursing standards,inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or ofthe claims made by the manufacturers.

No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability,negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions,or ideas contained in the material herein. Because of rapid advances in the health care sciences in particular, independentverification of diagnoses, medication dosages, and individualized care and treatment should be made. The material containedherein is not intended to be a substitute for the exercise of professional medical or nursing judgment.

The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN,INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDINGBUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRDPARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE.

This publication may be photocopied for noncommercial purposes of scientific use or educational advancement. The followingcredit line must appear on the front page of the photocopied document:

Reprinted with permission from The Association of periOperative Registered Nurses, Inc.

Copyright 2013 “AMBULATORY SURGERY CENTERS: A COMPREHENSIVE REVIEW.”

All rights reserved by AORN, Inc.2170 South Parker Road, Suite 400,

Denver, CO 80231-5711(800) 755-2676www.aorn.org

Video produced by Cine-Med, Inc.127 Main Street North, Woodbury, CT 06798

Tel (203) 263-0006 Fax (203) 263-4839www.cine-med.com

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PURPOSE/GOAL/OBJECTIVES.....................................................................................................4 INTRODUCTION.............................................................................................................................5TRENDS IN AMBULATORY SURGICAL NURSING...................................................................5TYPES OF AMBULATORY SURGERY PROCEDURES ..............................................................6PERIOPERATIVE NURSES IN AMBULATORY SETTINGS .......................................................7

Perioperative staffing in ASCs.................................................................................................7Preoperative nurse ...................................................................................................................7Circulating nurse......................................................................................................................8Registered nurse first assistant ................................................................................................8Postanesthesia care unit nurse .................................................................................................8

INFECTION CONTROL IN AMBULATORY SURGERY CENTERS (ASCs)..............................9BENCHMARKING ..........................................................................................................................9SUMMARY.....................................................................................................................................10REFERENCES ................................................................................................................................11 POST TEST.....................................................................................................................................12 POST TEST ANSWERS .................................................................................................................14


Ambulatory Surgery Centers: A Comprehensive Review

TABLE OF CONTENTS

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PURPOSE/GOALThe purpose of this study guide and accompanying video is to review the role of ambulatory surgery centers (ASCs), theirdifferences from inpatient care, and the role of the ASC perioperative nurse, an important part of the United States health caresystem.

OBJECTIVESAfter viewing the video and completing the study guide, the participant will be able to:

• Describe the role of ASCs in the United States health care system. • Compare and contrast ASCs with inpatient surgery units and facilities.• Discuss roles and responsibilities of perioperative nurses in ASCs.• Describe best practices for clinical nursing care in the ambulatory surgical setting.

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INTRODUCTION

Ambulatory surgery is a complex and growing trend in UShealth care that is of special interest and relevance toperioperative nurses. In contrast to inpatient surgery facilitiesand organizations, ambulatory surgery centers (ASCs) offersame-day surgery to patients admitted to the ASC for less than24 hours. By design, ASCs are fast-paced with rapid caseturnover, but they are also patient-centered and require clinicalteam members to excel at patient assessment and to be highlyskilled, flexible, team-oriented, and effective leaders withexcellent communication skills and a commitment to safety.The expansion of ASCs in the United States createsopportunities for perioperative nurses to work in a variety ofroles such as preoperative nurses, RN circulators, firstassistants, and in postanesthesia care.

This study guide reviews essential concepts and practicesrelated to ambulatory surgery as it is currently practiced in theUnited States. Learners are expected to understand theexpanding role of ASCs within the US health care system aswell as the major differences between ASCs and inpatientsurgery organizations and facilities. In addition, the guidereviews the diverse roles and responsibilities of perioperativenurses in ASCs and best practices for clinical nursing care inthe ambulatory surgical setting.

TRENDS IN AMBULATORY SURGICALNURSINGAs recently as the 1970s, nearly all surgeries in the UnitedStates were performed in hospitals. But since the early 1980s,ambulatory surgery (also known as same-day surgery) hasexpanded markedly and currently, more than two-thirds of allsurgical procedures in the United States are performed inASCs, which by definition and licensure do not admit patientsfor more than 24 hours.1

Several factors underlie the rapid expansion of ambulatory

surgery in the United States. These include the rise in healthcare costs, which in the 1980s motivated the Centers forMedicare & Medicaid Services (CMS) to cover proceduresperformed in ASCs; improvements in medical technologiessuch as minimally invasive procedures that have enabledfaster patient recovery times; and advances in short-actinganesthetic agents and analgesia medication for painmanagement, which also enables patients to recover faster andto better manage their pain after discharge.

Recent statistics underscore the continued expansion ofambulatory surgical care. During 2004-2009, Medicare-certified ASCs increased by 28%, according to data from theMedicare Payment Advisory Commission.2 This growth stemsin part from the fact that in 2008, CMS substantially increasedthe number of surgical procedures covered under its ASCpayment system. Although the rate of growth has slowedsomewhat since then, statistics from the Medicare PaymentAdvisory Commission show that in 2011, 5,344 Medicare-certified ASCs provided outpatient surgery services to 3.4million Medicare beneficiaries.3 This represents a 54% growthsince 2001.

Under the current health system, CMS reimburses ASCs afraction of what inpatient surgical facilities receive for thesame procedure.4 Because of this, health care experts havehypothesized that the continued flux of surgeries toambulatory care settings could ultimately reduce health carespending, particularly because the growth of ASCs generallyhas not coincided with an increase in the rate of surgicalprocedures in the general population.4

For example, an analysis of 2000-2009 Medicarereimbursement data evaluated the effect of the increase inASCs on total Medicare procedure volume during 2000-2009.4 The study quantified the increase in ASCs as well asCMS procedure volume for four common outpatient surgeries:cataract surgery, upper gastrointestinal procedures,colonoscopy, and arthroscopy. The results showed a sustainedincrease in ASC operation rooms per 100,000 populationduring 2000-2009.4 However, each additional ASC per100,000 population was associated with only a 1.8% increasein outpatient colonoscopies and there was no significantassociated increase in the other procedures.4 Data reported byCMS in 2013 show that the average number of ASC servicesper fee-for-service beneficiary increased 5.7% during 2006-2010, but increased only 1.9% during 2010-2011.3

TYPES OF AMBULATORY SURGERYPROCEDURESAnalyses of Medicare reimbursement data also indicate that

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an increasing variety of surgeries and other invasiveprocedures are being performed in ASCs.3,4 These include avariety of ophthalmic, orthopedic, soft tissue, and plasticsurgeries, such as:

• cataract extraction with lens insertion,• upper gastrointestinal endoscopy with or without

biopsy,• diagnostic colonoscopy,• colonoscopy and biopsy,• post cataract laser surgery,• lesion removal colonoscopy,• pain management procedures including epidural and

facet joint injections, • cystoscopy,• paravertebral nerve ablation,• upper eyelid revision,• complex cataract surgery,• cervical and thoracic spinal injections,• hernia surgery,• arthroscopic orthopedic procedures (eg, excision of

semilunar cartilage of the knee),• myringotomy, • and cholecystectomy and common bile duct

exploration.A 2013 analysis by Koenig found that in 2009, ASCsperformed 61% of cataract and lens insertion procedures, 41%of colonoscopies, 36% of upper gastrointestinal procedures,and 32% of arthroscopies of the temporomandibular joint andthe knee, shoulder, hip, wrist, and elbow.4

Ambulatory surgery centers also commonly provide painmanagement procedures, including epidural and facet jointinjections for persons who suffer from chronic, refractorypain. And surgical teams at specialized ASCs also areincreasingly handling more complex cases, such as total jointreplacements and bariatric procedures.5

THE ROLE OF PERIOPERATIVE NURSES INTHE AMBULATORY SETTINGPerioperative nurses in ASCs have a wide range ofresponsibilities that can sometimes exceed those of theircolleagues in inpatient surgery units. This difference stemsfrom the fact that ASCs typically lack specialized departmentsin areas such as infection control and quality improvement.During a single day, a perioperative nurse at an ASC might

compound medications for a patient’s surgery, perform hand-washing surveillance, and help lead a meeting on qualityimprovement projects within the facility – this in addition toperforming preoperative patient preparations, intraoperativecirculating duties for a surgical case, and/or providingpostanesthesia care.

Perioperative nurses in ASCs are tasked with the challengeand responsibility of ensuring optimal patient care andoutcomes while keeping up with the fast pace of proceduresand rapid case turnover. Redundancies in patient safetymeasures such as repeated verification of correct patient,correct side or site, correct surgery, and correct physician arefollowed just as they are for inpatient surgery. Every day,perioperative nurses in ASCs assess and manage multiplecases for same-day discharge while also juggling a widevariety of duties such as preparing preoperative medications;performing a time out and fire risk assessment in the ORbefore the start of the case; assessing patients for risk of deepvenous thrombosis and providing prophylactic interventionwhen necessary; educating patients and families by use ofdetailed discharge instructions; and ensuring that cleaning,sterilization, use of personal protective equipment (PPE), andpatient safety practices all meet the ASC’s policies as well asthose of accreditation organizations and local, state, andfederal rules and regulations.

Perioperative staffing in ambulatory surgery centersEffective administration is crucial in ambulatory as well asinpatient surgery. AORN recommends that ASCs developpolicies and procedures to address topics such as staffing,supplies and equipment, preadmission patient assessment andevaluation, anesthesia evaluation, preoperative patientteaching, preoperative nursing assessments and their relateddocumentation, best practices for the prevention of surgicalsite infections and other postoperative infections,postanesthesia care, and monitoring of clinical outcomes.6,7

Adequate staffing is fundamental to providing optimal patientcare and establishing a safe, well-managed work environment.Ambulatory surgery centers should develop staffing plans thatensure an adequate number and mix of personnel to meet theneeds of patients.6,7 All personnel in ASCs should be qualifiedand competent based on experience as well as state licensingrequirements, accreditation and professional standards, andprocedure-specific training.6 All staff should undergo acomprehensive orientation and their competencies should betracked and documented.6,7 Furthermore, staff should betrained in advanced cardiac life support (ACLS), and pediatricadvanced life support (PALS), if the center provides pediatriccare.7. This includes the use of all emergency equipment foradults and children.

Federal regulations specify that to receive CMSreimbursement, ASCs must direct and staff nursing servicesto ensure that the nursing needs of all patients are met,delineate patient care responsibilities for all nursing servicepersonnel, and provide nursing services that meet recognizedstandards of practice.8 State regulations of ASC staffingrequirements vary and should be consulted on a state-by-statebasis.

The organizational structure of ASCs varies considerablybased on the center’s size and types of surgeries or otherinvasive procedures performed. Therefore, the roles andresponsibilities of perioperative nurses in ASCs also vary.General responsibilities of preoperative nurses, RNcirculators, first assistants, and postanesthesia care unit(PACU) nurses in ASCs are described here.

Preoperative nursePreoperative nurses in ASCs review laboratory work andimaging results before patients are admitted, prepare thepatient’s chart, perform the preoperative assessment, prepareand compound medications as needed, and assist theanesthesia professional as he or she administers and monitorspreoperative analgesia and sedation.

The preoperative assessment is an especially critical nursingpractice in ASCs because it helps verify that patients meetadmission criteria as defined by the surgery center, and thatthey are able to recover safely at home after same-daydischarge.9 Because patients who have same-day surgery aredischarged when stable, but while the recovery phase isongoing, patients must be able to safely continue anuneventful recovery at home.9 Patients for whom suchrecovery is unlikely or questionable are not good candidatesfor same-day surgery. The ideal candidate would have nomajor medical co-morbidities, will not be rendered immobile

by surgery for an extended period of time, and will haveavailable assistance at home, as needed, during the recoveryperiod.9

Preadmission nursing activities in ASCs should includeassessments for the following6

• baseline physical status;• allergies and/or sensitivities;• signs of abuse or neglect in persons who are

particularly vulnerable (eg, children, the elderly);• cultural, emotional, and socioeconomic status;• pain;• medication history, including nonprescription

medications, illicit drugs, herbal therapies, andsupplements;

• anesthetic history, including personal and family-related;

• results of relevant imaging studies and examinations;• discharge planning;• physical factors that could require additional

equipment or supplies, including after discharge (eg,crutches);

• preoperative teaching of the patient and his or her careprovider;

• any other relevant preoperative testing (eg, cardiacclearance or pregnancy test);

• informed consent forms, advance directives, andhistory and physical for completeness and timelinessbased on regulatory requirements; and


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• documentation and communication of all informationaccording to the ASC’s policy.

RN CirculatorLike their counterparts in inpatient surgery settings, RNcirculators in ASCs help ensure that procedures go smoothly,safely, and according to plan by performing duties such as:

• preparing the OR and so that all necessary equipmentis available and functioning properly before thepatient’s arrival to the room,

• monitoring for breaks in sterile technique duringsurgery,

• actively participating in the time-out,• performing and recording accurate sponge and sharps

counts at the appropriate times, and• serving as the patient’s advocate.

Most states have enacted legislation regulating the duties andrequired qualifications of RN circulators, and these laws varysomewhat from state to state.10

Registered Nurse First AssistantThe duties of first assistants in ASCs generally resemble thoseperformed in inpatient surgical settings. During surgery, theregistered nurse first assistant (RNFA) assists with the surgicalprocedure, practices at the direction of the surgeon, and doesnot concurrently perform the duties of a scrub nurse.11

Whether in an ASC or an inpatient setting, the position ofRNFA is an expanded role in perioperative nursingaccompanied by strong knowledge, judgment, and skills inperioperative nursing.11 The RNFA is a registered nurse withadditional training who displays cognitive, psychomotor, andaffective behaviors that are appropriate to determine and meetthe needs of perioperative patients.11

The scope of practice of RNFAs is regulated in all 50 states.Registered nurse first assistants must meet minimumqualifications that include certification in perioperativenursing, successful completion of an RNFA program thatmeets AORN standards, and compliance with applicablestatutes, regulations, and institutional policies. In addition, asof January 1, 2020, all practicing RNFAs will be required topossess a bachelor’s degree.

PACU nursePostanesthesia care unit nurses in ASCs are responsible formonitoring patients as they recover after surgery. Many PACUnurses have a critical care background. Postanesthesia care isespecially important in ambulatory settings because patientsmust be carefully assessed to ensure that they are ready for

discharge and can safely continue recovering at home.

Ambulatory surgery centers should use recommended staffingguidelines from the American Society of PeriAnesthesiaNurses (ASPAN)12 to calculate postanesthesia staffing needs.7ASPAN provides recommended staffing ratios forpostanesthesia care based on patient acuity and phase ofrecovery. However, ASPAN emphasizes that institutionsshould tailor their own staffing ratios based on factors thatinclude patient safety; the number and complexity of cases;the extent of required nursing interventions (eg, average timefor patient preparation and the number of medicationstypically required); and specific processes of surgical units orfacilities, such as blending levels of care.12

AORN recommends that ASCs develop written dischargepolicies and procedures in accordance with the standards orgeneral guidelines of accrediting organizations and anesthesiaand postanesthesia provider associations.7 Before beingdischarged after same-day surgery, the patient should meet thefollowing criteria10,13

• stable vital signs , including a total Aldrete score of 8-10 for activity, respiration, circulation, consciousness,and oxygen saturation;10

• well-controlled pain and no active bleeding;• be oriented, taking oral fluids without nausea or

vomiting, and able to void and empty bladder;• have a responsible adult available to drive the patient

home• have received written discharge instructions, including

a phone number to call with questions or concerns;and

• have been instructed on what to do if he or shesuspects a true medical emergency.

AORN also recommends that ASCs develop written policiesand procedures for completing discharge follow-up withpatients and that this follow-up include assessment of ongoingpain and efficacy of prescribed analgesia.7


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In addition, AORN recommends that staffing plans for ASCPACUs meet national and state guidelines and regulations forsafe postanesthesia nursing care.7 As of 2013, federalregulations stipulated that to receive reimbursement fromCMS, a physician or anesthesia professional must evaluateeach patient for proper anesthesia recovery before dischargefrom the ASC.8

Competency requirements for PACU staff also should meetstate licensure guidelines and conform to appropriateaccreditation and professional standards. Clinical personnelin ASCs should be trained in the use of all emergencyequipment. Most ASCs require all nursing staff and anesthesiaproviders to be trained in advanced cardiac life support(ACLS) and pediatric advanced life support (PALS), if theASC serves pediatric patients.

INFECTION CONTROL IN AMBULATORYSURGERYInfection control is a vital part of safe patient care. Onedifference between infection control in ambulatory andinpatient surgery is that effective surveillance for surgical siteinfections (SSIs) in ASCs cannot rely on routine hospital-based surveillance methods. State health departments typicallyregulate several aspects of ASCs and inpatient surgeryfacilities. These areas include licensing, the scope of practicefor nurses and other licensed health care providers, andreporting of health care-associated infections. Types of SSIsand other health care-associated infections that ASCs andinpatient facilities must report by law vary from state to state.For example, in Colorado, SSIs must be reported inassociation with hip and knee replacements, hernia repairs,abdominal and vaginal hysterectomies, procedures involvingthe breast or colon, and cardiac procedures.14

The Centers for Disease Control and Prevention (CDC) andCMS jointly implemented an Infection Control SurveyorWorksheet for use as part of their Conditions for Coverage.16

The worksheet is used during CMS site visit surveys andfollows nationally recognized infection control guidelines, asdefined by the Association for Professionals in InfectionControl and Epidemiology (APIC), AORN, and the CDC.During a CMS site visit, the CMS reviewer typically performsa tracer that follows one patient from admission to discharge.CMS now requires all states to use the infection control audittool and case tracer method when inspecting ASCs.16 Anydeficiencies that are found and not properly addressed andcorrected, can jeopardize the center’s participation in CMS.16

Device reprocessing is a common practice in both inpatientsurgery units and ASCs.9 This practice has been a source of

debate because of concerns that reprocessing surgical devicescould lead to breaks in infection control.9 Three acceptableoptions for handling single-use medical and surgical devicesare to dispose of them after one use, reprocess them followingstrict US Food and Drug Administration and manufacturer’sguidelines, or contract with an outside reprocessing specialtycompany to collect, reprocess, and reship the product to thefacility.10

BENCHMARKING IN AMBULATORYSURGERY

Simply defined, benchmarking means comparing one’s ownperformance to that of others in a same or similarenvironment. Benchmarking is a core quality improvementarea for health care organizations that, when usedappropriately, can help improve health care practice andperformance.17 For ASCs, benchmarking is emerging as aparticularly important area in support of quality improvement,and perioperative nurses in ASCs typically play a central rolein benchmarking activities.

Benchmarking at ASCs is required for reimbursement byCMS, and is also a requirement of accreditation organizations.The Accreditation Association for Ambulatory Health Carehas conducted benchmarking studies of procedures such ascataract extraction with lens insertion, colonoscopy, knee andshoulder arthroscopies, low back injections for painmanagement, and provision of surgical and proceduralservices.18 Examples of data benchmarked in these studiesinclude indications for procedures, procedure times,intraoperative complications, and information from patientsatisfaction surveys. Participation in benchmarking studieshelps ASCs meet accreditation standards.18

External benchmarking consists of monitoring quality-relateddata within a health care organization and comparing it withsimilar data from other facilities or groups. Examples ofexternal benchmarking activities include assessing patient fallrates and comparing them to national data; monitoring and


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evaluating surgical outcomes by specialty and comparingthem to nationally established benchmarks; and monitoringrates of hospital admissions and direct transfers afterambulatory surgery and comparing them to national averages.

Private corporations typically work with ASCs and otherhealth care organizations to provide benchmarking servicesand standards in support of CMS and licensing oraccreditations requirements. Participating facilities submit de-identified (ie, Health Insurance Portability and AccountabilityAct-compliant) data on outcomes such as surgical siteinfection rates or average time that patients remain in thePACU. Individual member facilities can compare theirperformance with averages that the benchmarking companycalculates for all member facilities. Reports are typicallygenerated on a monthly, quarterly, and annual basis. An ASCmight use quarter-to-quarter data to identify and, whennecessary, respond to trends such as a decrease in surgical siteinfections or an increase in the percentage of patients reportingnot well-controlled pain in the PACU.

Analysis of patient satisfaction scores is another form ofbenchmarking. Press Ganey provides benchmarking servicesfor numerous health care organizations in the United Statesby annually processing a database of more than 9.5 millionbenchmarking surveys every year and providing benchmarkreports to same-type organizations.19 Patient satisfactionsurveys are included in the company’s benchmarking tools.In one study at a health care network in Pennsylvania, nursingleaders used Press Ganey benchmarking tools to develop aquality improvement initiative in response to low patientsatisfaction scores related to ASC services. Nursing managersand clinical educators educated perioperative nurses on theuse of Press Ganey reports. Analyses of patient satisfactionsurveys indicated that after the benchmarking and qualityimprovement initiative, patients reported small increases insatisfaction regarding two identified areas of concern:information about delays (4%) and the cosmetic appeal of theASC (0.2%).

Internal benchmarking means collecting and analyzingobjective data or patient satisfaction scores within the ASC toassess progress in meeting standards and goals over time. Forexample, executive staff might measure, analyze, and sharesurgery times internally so that physicians and surgical teammembers can compare their average time in surgery to otherteams and evaluate ways to decrease surgery times, if needed(http://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/3-internal-benchmarks-to-share-with-surgery-center-physicians.html). Other examples of internalbenchmarking at ASCs include assessing quarterly rates of

cases that must be referred to hospitals because ofcomplications or unplanned returns to the OR.20 Monitoringcomplications such as this can help ASCs identify and respondto potential problem areas and improve patient care.

SUMMARYAmbulatory surgery is a robust and expanding area of surgicalcare in the United States that offers a variety of opportunitiesfor perioperative nurses. Ambulatory surgery centers providea patient- and family-centered model of care that results inquality patient outcomes. Perioperative nurses in ASCs mustbe highly efficient and able to work in a fast-pacedenvironment while maintaining standards of excellence inpatient safety, comfort, and education. The range ofresponsibilities for an ambulatory surgical nurse may be morebroad than their colleagues in acute care facilities and tosucceed, need strong skills in patient assessment, criticalthinking, and communication. They also must be flexible,comfortable in leadership roles, and team-oriented.Perioperative nurses in ASCs often play central roles in qualityimprovement and benchmarking activities in addition to theirday-to-day tasks.


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REFERENCES1. Neuman DG. The changing geography of outpatient procedures. LDI Issue Brief. 2011;16(5):1-4.2. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Medicare Payment

Advisory Commission: Washington, DC, 2011. Available at:http://www.medpac.gov/documents/Mar11_EntireReport.pdf

3. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Washington, DC,2013.Available at: http://www.medpac.gov/documents/Mar13_entirereport.pdf Accessed March 10, 2013.

4. Koenig L, Gu Q. Growth of ambulatory surgical centers, surgery volume, and savings to medicare. Am JGastroenterol. 2013;108(1):10-15.

5. Berger RA, Sanders SA, Thill ES, Sporer SM, Della Valle C. Newer anesthesia and rehabilitation protocols enableoutpatient hip replacement in selected patients. Clin Orthop Relat Res. 2009;467(6):1424-1430.

6. AORN Guidance statement: preoperative patient care in the ambulatory surgery setting. In: Standards,Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2005:179-184.

7. AORN Guidance Statement: postoperative patient care in the ambulatory surgery setting. In: Standards,Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2005: 179-184.

8. Rothrock JC. Alexander’s Care of the Patient in Surgery. 14th ed. St. Louis, Missouri; Mosby, 2011: AmbulatoryConsiderations, Chapters 1 and 2.

9. Ambulatory Surgical Services. 42 CFR 416.US Government Printing Office. http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f4638a147b703da1c62a30cffb011271&ty=HTML&h=L&n=42y3.0.1.1.3&r=PART. Accessed September 17, 2013.

10. AORN Comments to CMS Regarding ASC Quality Reporting Program August 29, 2011. AORN, Inc.http://www.aorn.org/Advocacy/Issues_and_Initiatives/ASC_Policy_News_and_Updates.aspx Accessed May 10,2013.

11. Position statement on RN First Assistants. AORN, Inc.http://www.aorn.org/Clinical_Practice/Position_Statements/Position_Statements.aspx. Accessed May 10, 2013.

12. Practice recommendation I: patient classification/staffing recommendations. American Society of PeriAnesthesiaNurses. http://www.aspan.org/Portals/6/docs/ClinicalPractice/Pt_Classification_Staffing_2012-14.pdf. AccessedSeptember 17, 2013.

13. D’Arcy Y, Nevius KS. Decrease recovery time with proper pain management. Nurs Manage. 2008;39(11):26-32.14. Surgical Site Infections. Colorado Department of Public Health and Environment.

http://www.colorado.gov/cs/Satellite/CDPHE-HF/CBON/1251616700373.Accessed September 17, 2013.15. Exhibit 351: Infection Control Surveyor Worksheet. Centers for Medicare and Medicaid Services.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf.AccessedSeptember 17, 2013.

16. Infection Control Assessment of Ambulatory Surgical Centers. The Centers for Disease Control and Prevention.http://www.cdc.gov/injectionsafety/pubs-IC-Assessment-Ambulatory-Surgical-Centers.html. Accessed September17, 2013.

17. Copp NA. Benchmarking in ambulatory surgery. AORN J. 2002;76(4):643-647.18. Benchmarking Studies. Accreditation Association for Ambulatory Health Care, Inc.

https://iweb.aaahc.org/eweb/dynamicpage.aspx?site=aaahc_site&webcode=iqi_studies.Accessed September 17,2013.

19. Farber J. Measuring and improving ambulatory surgery patients’ satisfaction. AORN J. 2010;92(3):313-321.20. Antonacci A, Lam S, Lavarias V, Homel P, Eavey RD. Benchmarking surgical incident reports using a database

and a triage system to reduce adverse outcomes. Arch Surg. 2008;143(12):1192-1197


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1. Ambulatory surgery has expanded markedly sincethe early 1980s. Which of the following is NOT areason for the increase in ASCs and procedures?a. the rise in health care costs motivated the

Centers for Medicare & Medicaid Services tocover procedures performed in ASCs

b. Americans are healthier on average and fewerneed intensive surgeries with overnight stays

c. medical technologies and minimally invasiveprocedures have improved, enabling fasterrecovery times

d. short-acting anesthetics and analgesiamedications for pain management haveimproved, so patients often can be dischargedthe same day to continue recovering at home

2. Choose the FALSE statement.a. Infection control practices, such as high-level

disinfection of medical equipment, is lessimportant in ASCs because patients arehealthier.

b. Ambulatory surgery centers are increasinglyhandling complex procedures, such as bariatricsurgeries.

c. Ambulatory surgery centers are required toperform benchmarking by accrediting bodies,and by the Centers for Medicare & MedicaidService for reimbursement.

d. Perioperative nurses in ASCs often play acentral role in benchmarking or qualityimprovement activities.

3. State health departments typically regulate all of thefollowing aspects of ambulatory surgery centersEXCEPTa. the types of procedures that can be performedb. the scope of practice for RN circulators in the

perioperative settingc. reporting of health care-associated infectionsd. licensing requirements

4. Which of the following procedures is NOTcommonly performed in ambulatory surgerycenters?a. upper gastrointestinal endoscopy and biopsyb. myringotomyc. excision of semilunar cartilage of the kneed. cholecystectomy and common duct exploratione. all of the above are commonly performed in

ambulatory surgery centers

5. Preoperative assessment helps determine if patientsare suitable candidates for outpatient orthopedicsurgery. Based on the information provided, whichof the following patients is the BEST candidate fororthopedic surgery in an ASC? a. a patient whose mobility will be significantly

limited for a substantial time after surgeryb. a patient with multiple medical co-morbiditiesc. a patient who needs a total hip replacement, is

otherwise healthy, and has a short-term homecare assistant

d. a patient who lives alone and will not have helpavailable after surgery

6. Which of the following is NOT a commonresponsibility of a circulating nurse in an ASC?a. setting up the OR and making sure equipment

is functioning properlyb. monitoring for breaks in sterile techniquec. counting sponges and instrumentsd. consulting with and assisting the

anesthesiologist before surgerye. tracking and recording lost blood and urine


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POST-TESTAMBULATORY SURGERY CENTERS:

A COMPREHENSIVE REVIEW

Multiple choice assessment. Select the response that best answers each question.

7. Which of the following is NOT a commonresponsibility of a preoperative nurse in an ASC? a. serving as first assistant during surgeryb. preparing the patient’s chart and obtaining

imaging and laboratory resultsc. preparing (compounding) the patient’s

prophylactic antibiotics and other medicationsd. checking the patient’s vital signs and health

status and confirming correct side, patient,procedure, and doctor

e. setting up the preoperative room and changingthe bedding

8. Select the TRUE statement.a. to keep up with the case load in the fast-paced

environment of ASCs, surgery and anesthesiateams can skip performing Time Outs and firerisk assessments

b. preoperative nurses in ambulatory surgerycenters usually do not review surgical consentforms or assess patients for risk of deep venousthrombosis

c. detailed instructions for recovery andconvalescence are especially important inambulatory surgery because this phase is notcomplete when patients are discharged

d. cleaning, sterilization, use of PPE, and patientsafety practices are adjusted in ambulatorysurgery centers to meet the rapid pace of work

9. Before discharge from an ASC, a patient shouldmeet all the following criteria EXCEPT:a. has stable vital signs, no respiratory depression,

and little or no nausea, pain, or bleedingb. is oriented, taking oral fluids, and able to voidc. is able to drive homed. has received written discharge instructions,

including a phone number to call for help ifneeded

10. Which of the following is NOT an example of abenchmarking activity that should be performed inASCs?a. assessing patient burn rates and comparing

them to national datab. monitoring and evaluating surgical outcomes,

and comparing them to nationally establishedbenchmarks

c. monitoring rates of hospital admissions anddirect transfers and comparing them to nationalaverages

d. monitoring patient falls and comparing thefacility’s rate exceeds that of other ASCs

e. all of the above are benchmarking activities thatshould be performed in ASCs


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1.b2.a3.a4.e5.c6.d7.a8.b9.c10.e

POST-TEST ANSWERS


Documents

AMBULATORY SURGERY CENTERS A C OMPREHENSIVE REVIEW€¦ · Ambulatory surgery centers also commonly provide pain management procedures, including epidural and facet joint injections