The migration of hysteroscopy from the operating room to an ambulatory setting

Summary

The relocation of appropriate gynecologic procedures, such as diagnostic and operative hysteroscopy, from the operating room to an ambulatory setting meets all 3 arms of Kissick’s “Iron Triangle”: providing quality care with improved access without an associated increase in cost to the system.

Contemporary surgical practice across many specialties has seen a steady migration away from the operating room to the ambulatory setting. This patient-centred trend has increased access, lowered cost, and increased the quality of care for certain procedures, optimizing the “Iron Triangle” of health care proposed by Kissick in 1994.¹

The gynecologic literature confirms that ambulatory hysteroscopy is safe and highly effective, with a high rate of patient satisfaction and acceptability.² In select centres across Canada, the benefits of ambulatory gynecology have been shown by the successful widespread implementation of gynecologic procedures, including hysteroscopy, endometrial ablation, polypectomy, and myomectomy, under conscious sedation.^3–5 Despite this, an ongoing hesitancy to shift gynecologic procedures from the operating room to ambulatory centres persists. This hesitancy can be a result of institutional inertia and individual surgeons or departments lacking the time and administrative knowledge to overcome this inertia.

The Canadian Society for the Advancement of Gynecologic Excellence (CanSAGE) believes that all gynecologic patients should have access to these procedures in ambulatory care settings. The move from the operating room setting to an ambulatory one for some gynecologic cases, such as diagnostic and operative hysteroscopy, is positive in all 3 aspects of the Iron Triangle, which will be examined in more detail.

The authors of this statement were selected by the CanSAGE Board of Directors to represent operative hysteroscopists across Canada. The completed statement was circulated to the CanSAGE membership with an invitation for comments, and consensus was determined by vote.

Access

One of the most important issues facing patients and surgeons in Canada is access to the operating room and equipment required to provide surgical care. The operating room has been the traditional site for gynecologic procedures and remains so in many centres across the country. Operating rooms are typically bound by rigid protocols, long case turnover and patient transit times, anesthesia induction, and longer recovery times before discharge.

By contrast, an ambulatory gynecology suite can complete cases with nurse- or physician-administered procedural analgesia. The equipment needed for simple hysteroscopy is minimal, decreasing set-up and take-down times, accelerating room cleaning, and allowing for a higher volume of cases to be done daily. These factors combined allow for near doubling of the number of diagnostic or operative hysteroscopic procedures completed in an ambulatory care setting, as compared with a traditional operating room in the same amount of time. This also ensures adequate time to teach the necessary skills to residents and fellows.

As an auxiliary benefit, any case moved from the operating room setting will improve access for those requiring the operating room for a procedure.

Cost

Development of any new program will result in one-time capital costs if renovations of a new space or additional equipment are needed. Once these costs are assumed, there are considerable savings to be had for each procedure completed.³ The cost-effectiveness of ambulatory hysteroscopic procedures is a direct result of reduced staffing needs, including physicians and residents, nurses, anesthesiologists, and cleaning staff. In the ambulatory setting, a single nurse is required for administration of intravenous sedation; another nurse assists with direct patient care, including positioning and equipment set-up; and a third nurse is responsible for intake, preparation, and recovery of patients. This flow of nursing staff ensures high efficiency and rapid turnover. A single member of the cleaning staff is required because of the minimal equipment used and minimal room disruption. A single physician, the gynecologist, is involved. The result is a cost-effective system with the lower cost per case allowing for higher patient volumes, reducing wait times and delays to diagnosis in some cases.²

Quality

Quality of care provided in the ambulatory setting is non-inferior to care received in an operating room. This is supported by prospective literature indicating that procedures performed in an ambulatory care setting are safe and highly effective, and have a high rate of patient satisfaction and acceptability.² Higher patient volumes and a familiar staff environment allow for adaptability in the care provided should unexpected complexity be encountered, allowing for the “see and treat” approach, without delays in having to proceed to the operating room.

The ambulatory environment allows for patient interaction and involvement, if desired. Patient control in the desired degree of sedation is maintained. The intimidation of the operating room and associated protocols is lessened, adding patient-centred care to the equation. The patient benefits from relatively rapid access to diagnosis and treatment in addition to a comfortable procedure, allowing a rapid return to daily life.

Engagement

The first step in creating a successful ambulatory clinic for gynecologic procedures is to ensure that hospital administrators and operating room managers understand the safety, efficiency, and quality of the procedures delivered in these settings. Engaging the decision-makers via a tour of existing facilities and reviewing supporting local, national, and international data are critical. Patient advocacy with testimonies from populations traditionally underserved are powerful tools to highlight the deficiencies existing in gynecologic care. Approaching local hospital foundations is an additional avenue for funding for the creation of an ambulatory clinic and covering the upfront costs, in addition to creating awareness of the existing inequities in health care, particularly as they pertain to gynecologic health and access.

Finally, it is important to ensure that administrators are aware that an ambulatory clinic, while reducing costs for the gynecologic procedures, does not reduce overall costs to the system. What it does allow is the creation of time for cases that require access to the operating room to be done in a more timely manner, improving access for all.

The disparity across Canada in providing access to ambulatory gynecologic procedures remains. This is not limited to smaller centres, as barriers exist in large urban areas owing to administrative and surgeon resistance to change. Concerns over initial capital costs without recognition of the long-term savings to the system persist. Whatever the reasons, as the national society of minimally invasive gynecologic surgeons focused on the advancement of excellence in gynecologic care, CanSAGE calls on our colleagues to demand that patients have access to ambulatory gynecologic procedures when appropriate. Health ministries and hospital administrations should be willing participants to ensure that gynecologic health care has the same access to minor surgical care in an ambulatory setting as colonoscopy, gastroscopy, or hernia repair.