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Who Says You Can't Go Home?

Conquest - Spring 2009

By Julie Penne

It’s 7 a.m. and the pre-op areas of the Mays Clinic and Main Building are beehives of activity.

Mays Clinic pre-op area

Though separated by Holcombe Boulevard, the pre-surgery areas on the north and south sides of the M. D. Anderson campus are virtually indistinguishable as teams of nurses, anesthesiologists, certified registered nurse anesthetists and nursing assistants hustle to prepare patients for the day’s surgeries and procedures.

At 5 p.m., however, the scenes are quite different.

In the 30 operating rooms of the Main Building, where some of the most complex cancer surgeries in the world are performed, multi-team operations may continue into the evening, and patients in the post-anesthesia recovery unit wait to be transferred to either a room in the hospital or the intensive care unit.

In the Mays Clinic, all six operating rooms are empty, cleaned, stocked with supplies and ready for the next day, while a handful of patients in the 18-bed post-anesthesia care unit (PACU) wait to be given the green light to go home and recover in their own beds.

Often referred to as day or outpatient surgery, the operating rooms at the Mays Clinic are used for procedures and surgeries that require less time, are less complex and typically let patients return home within 24 hours.

Patient satisfaction key measurement

Taking the shorter procedures out of the Main Building and designating an outpatient surgical area streamlines surgery scheduling and allows surgical teams to develop their own rhythm for preparing and recovering patients, says Carla Willis, director of nursing for the Mays Clinic OR.

“Teams in the two surgical areas work quite differently, setting and responding to the pace of the day’s schedule, the needs of patients and the fact that our ultimate goal is getting patients home within 24 hours,” she says.

Since opening the outpatient surgical unit in 2005, shortly after the Mays Clinic began welcoming patients, an average of 4,000 procedures and surgeries per year have been performed. A maximum of 35 to 40 procedures are done daily with the average length about 90 minutes.

“Early in my career as an anesthesiologist, surgical outcomes often were measured solely by the patient’s survival,” says Thomas Feeley, M.D., head of the Division of Anesthesiology and Critical Care and vice president for medical operations. “Today, anesthesia and surgery are much safer, and patient satisfaction is a key measurement. It means a great deal to patients to leave the hospital free from pain and discomfort, recover at home and get back to work quickly.”

The most common procedures performed in the Mays Clinic include mastectomy and lumpectomy (without major reconstruction or lymph node removal), non-invasive ablation of tumors in the prostate, bladder procedures, implantation of pain devices and some reconstructive and plastic surgery, and other procedures where a long hospital stay is not necessary.

The issue of sending patients home less than a day following surgery has been debated nationally for more than a decade, but Frederick Ames, M.D., clinical professor in the Department of Surgical Oncology and a breast surgeon at M. D. Anderson since 1977, has been an advocate for reduced stays since beginning his career here. Today, he operates almost exclusively at the Mays Clinic.

“The real payoff of the Mays OR is the great feedback you get from patients in follow-up visits. They want to have their surgeries, go home to their own beds and then quickly move on to their next chapters in life or treatment,” Ames says.

Research leads to less pain, fewer side effects

Farzin Goravanchi, D.O. (left), associate
professor, and Spencer Kee, M.D.,
assistant professor, both in the
Department of Anesthesiology and
Perioperative Medicine, confer in the
PACU between surgical cases.

Each week, only about 15 to 20 patients are kept overnight for observation by a nursing team in the Mays Post-Anesthesia Care Unit (PACU) until they are cleared to go home.
Rarely are patients admitted to the hospital after their outpatient procedures, says John Frenzel, M.D., associate professor in the Department of Anesthesiology and Perioperative Medicine, who launched the unit and who now oversees a research program that is both collaborative, yet unique, to the patient population it serves.

Frenzel and his colleagues admit that while anesthesiology is a vital service at M. D. Anderson and every hospital, it typically has not been a hotbed for research. However, the team of anesthesiologists — three of whom have been in the Mays Clinic OR since it was established — is driven by observations in their daily practice to make the patient experience even better through research.

In the last three years, they have published and presented on three primary topics — the paravertebral block used to alleviate the surgical pain associated with mastectomy, reduction in post-operative nausea and vomiting, and patient identification through bar coding — and continue to work with colleagues to determine if new practices can be adapted to the Main Building OR.

Paravertebral block

Patients are sedated when given the
paravertebral block immediately prior to

Brought to M. D. Anderson in 2005 by Farzin Goravanchi, D.O., associate professor in the Department of Anesthesiology and Perioperative Medicine, the paravertebral block is an injection of local anesthetic into a number of locations on the nerves of the spine to block the pain of some surgeries for up to three days. With pain as one of the primary reasons patients stay in the hospital, the option of the block is offered to those who are having lumpectomy, mastectomy (of one or two breasts) and some cases of lymph node dissection and reconstruction.

M. D. Anderson is one of only a small number of cancer centers in the nation that routinely offers paravertebral block to patients, Goravanchi says. He estimates that about 2,100 M. D. Anderson patients have been given the block prior to their surgeries.

“It’s great to offer this to patients, but it is not appropriate for everyone,” he says. “However, for the patients who get the paravertebral block, we see a dramatic reduction in the pain medication they take after surgery, thus eliminating the many side effects that come with that. Plus, patients are often less anxious going into surgery because they know they will wake up virtually pain-free and go home that way.”

According to Goravanchi, early research suggests that paravertebral block also may inhibit recurrence in some breast cancer patients. The study, which was not done at M. D. Anderson, shows some "encouraging data" and warrants additional study about the blocking mechanisms and their effect on the cancer process, he says.

Post-surgery nausea and vomiting

John Frenzel, M.D., associate professor
in the Department of Anesthesiology and
Perioperative Medicine, helped open the
Mays OR in 2005 and is one of six
anesthesiologists who care for patients

According to Frenzel, nausea and vomiting after surgery is the number one reason for keeping patients overnight following an outpatient surgery. However, giving the right mix and amounts of anti-nausea medications to the patient during the procedure can dramatically cut the number of patients suffering from this complication. It also is a common occurrence among patients having surgery in the Main Building, because of the nature and types of surgeries performed.

Two studies have led to decreases in post-operative nausea and vomiting among M. D. Anderson patients who have surgery on either side of the street.

In one study, researchers identified the top four risk factors for post-operative nausea and vomiting, characteristics that are discussed at each patient’s pre-operative assessment. Once high-risk patients are identified, they are given a combination of drugs at specific times during their surgery to decrease the chance of discomfort when they come out of their anesthesia. The study found that three established and less costly drugs were more effective than the same three combined with an expensive drug.

Spencer Kee, M.D., assistant professor in the Department of Anesthesiology and Perioperative Medicine and a member of the research team, says, “We were very pleased to zero in on what we can do to make our patients more comfortable and get them home earlier. Plus, we shared this information with our colleagues in the Main Building OR so they could examine the problem as it pertains to their patients.”

As a way of sharing the research and motivating their colleagues to assess and evaluate their practices, the research team developed an educational and communications program that measured instances of post-nausea and vomiting among patients.

The result of the collaboration and study findings is a decrease in post-operative nausea and vomiting. This is a quality improvement initiative in the Main Building OR and remains a high priority at Mays Clinic.

Bar coding to verify patient identification

Launched and under way in the Mays Clinic OR and soon to arrive in the Main Building ORs, bar coding to verify patient information is a safety net to ensure that every member of the surgical team has timely access to vital and accurate patient information.

Through an interface with M. D. Anderson’s patient records and anesthesiology’s database, the system provides an encyclopedia of patient information to decrease the possibility of error. Such information includes name and medical record number, but, more important, any allergies, the surgery that is scheduled for the day and specifics of the procedure.

Both surgical areas now have multiple points at which the information is verified verbally. While that verbal identification will still be done, the bar coding and patient information system will take over after a patient is sedated or anesthetized.

According to Joseph Ruiz, M.D., assistant professor in the Department of Anesthesiology and Perioperative Medicine, the new technology is a “tremendous boost to ensuring that our patients are in not only the best medical hands but also in the safest environment.

“Medicine and surgery are becoming more and more sophisticated, but at the root of everything we do is patient safety. This tool will be a terrific addition to the processes we already have in place,” he says.

Note: This is the first of a two-part series on surgical innovations at M. D. Anderson. To learn what is new on the surgical floor of the Main Building, watch for the second part in the fall 2009 issue of Conquest.

Paravertebral Block: ‘An Added Level of Comfort’

By Bayan Raji

JoAnna Burton was diagnosed with cancer in the right breast in October 2007. By November, she had decided to undergo a prophylactic bilateral mastectomy, the removal of both breasts.

The method is generally a preventive measure for patients considered at high risk of developing cancer in the opposite breast. At-risk patients may have a family history of breast cancer or test positive for the cancer gene mutation, BRCA1 or BRCA2.

When doctors recommended that Burton have the paravertebral block in addition to general anesthesia, she agreed and became one of a large number of women who have had the procedure at M. D. Anderson.

The purpose of the block is to give patients relief from pain for days after the procedure, to cut down on their need for pain medication and avoid the side effects of narcotics.

For Burton, the PV block helped her recover from the trauma of surgery sooner.

“I barely remember the doctor performing it,” she says. “There’s really nothing different to the patient, except an added level of comfort.”

The block also allows patients to recuperate at home. Burton’s hospital stay was short and so was her recovery. While she experienced some soreness, she was back at the gym about four weeks later doing weight training.

© 2015 The University of Texas MD Anderson Cancer Center