Impact of Comprehensive Preoperative Assessments on Gynecological Ambulatory Surgery Outcomes in a Chinese Hospital

Introduction

China has a large population. According to the results of the country’s seventh national population census [1], China had a population of around 1.41 billion by the end of 2020. A large population can cause an increase in the number of patients and the number of surgeries. The results of Wu et al [2] have shown that the duration of hospital stays of patients undergoing laparoscopic surgery after admission is about 1 week. If there is a shortage of hospital beds, patients may have to wait several weeks or months to be admitted. To alleviate the difficulty of hospitalization and to control the average length of hospital stay, healthcare institutions need to reform and implement process reengineering. Ambulatory surgery is strongly advocated in China and other countries. It is also known as same-day surgery or a surgery not requiring hospitalization. In 2003, the International Association of Ambulatory Surgery recommended to define ambulatory surgery as follows: patient completes admission, surgery, and discharge within 1 working day (within 24 h after admission), excluding outpatient surgeries conducted in clinics or hospitals [3]. Ambulatory surgery is characterized by a small burden to patients, low nosocomial infection rate, fast turnover of beds, and short average length of stay.

With the rise and development of ambulatory surgery, the amount of surgeries in hospitals is increasing. Patients undergoing ambulatory surgery may have comorbidities, which can bring risks to patients if they receive surgeries without condition optimization. Therefore, preoperative assessments for each surgery are indispensable. Previous studies pointed out that abnormal preoperative examination results, incorrect delivery of preoperative instructions to patients, incorrect execution of preoperative instructions, and patients’ fear of surgery are the most common reasons leading to cancellation of ambulatory surgery [4]. The issue of how to solve these problems by optimizing the process is an urgent problem for ambulatory surgery.

Preoperative assessments being completed before hospitalization have become common in Western countries, and there are corresponding guidelines for perioperative control of different comorbidities [5,6]. Some departments in some hospitals in China have tried to complete preoperative assessments before hospitalization, such as implementing comprehensive geriatric assessment before surgery and making perioperative and post-discharge treatment plans for patients according to the results of comprehensive geriatric assessment. The results of Wang et al [7] show that preoperative comprehensive geriatric assessment can significantly reduce the post-discharge readmission and outpatient visits in the 3 to 6 months after percutaneous coronary intervention in elderly patients with coronary disease.

This study aimed to investigate the implementation of outpatient comprehensive preoperative assessments, jointly performed by a gynecological surgeon, anesthesiologist, and nurse, 1 week prior to ambulatory surgery in a grade A tertiary hospital in China. Assessments were done in order to improve the efficiency of ambulatory surgery and patient experience and to ensure patient safety.

Material and Methods

ETHICS APPROVAL:

Ethics approval of this study was obtained from the Medical Research Ethics Committee of the authors’ institution (2024 Medical Scientific Research for Ethical Approval No. 126).

GENERAL INFORMATION:

Convenience sampling was conducted in this study. Patients undergoing gynecologic minimally invasive surgery who received outpatient comprehensive preoperative assessment and ambulatory surgical procedures during November 2021 to December 2021 were classified into the intervention group. Patients undergoing gynecologic minimally invasive surgery who received routine medical procedures during the same period were classified into the control group. The surgeons for both groups were the same.

The inclusion criteria of the patients in the 2 groups were as follows: (1) 18–65 years old; and (2) gynecological patient undergoing laparoscopic or hysteroscopic surgery under general anesthesia.

The exclusion criteria were as follows: Patients with malignant gynecological tumors were excluded from this study. Removal criteria: (1) patients who switched to laparotomy; and (2) patients with intraoperative/postoperative diagnosis of malignant tumor.

When data was extracted from the hospital information system, the 2 groups of patients were matched for age, education level, and marital status. The age difference between the 2 groups was not more than 5 years, and each group contained patients from every level of education level. The difference in the number of patients with the same level of education level between the 2 groups was not higher than 10%. The difference in marital status between the 2 groups was also not higher than 10%.

SAMPLE SIZE:

G*Power (Version 3.1.9.6; Franz Faul, Universität Kiel, Germany) was used to calculate the sample size. Assuming a power of 0.99, an α of 0.05, and an effect size of 0.50 for patient experience based on a preliminary test, the minimum sample size of 300 patients was required for each group. In fact, a total of 666 patients were included in this study. Of them, 330 patients were in the intervention group, and 336 patients were in the control group.

WORK PROCEDURES OF THE OUTPATIENT COMPREHENSIVE PREOPERATIVE ASSESSMENT UNIT:

The patients made an appointment with the outpatient comprehensive preoperative assessment unit, then the patients’ leucorrhea was sampled on the day of the visit. If a patient received normal results in leucorrhea testing, a gynecological surgeon assessed the results of various tests, including routine blood test, coagulation test, leucorrhea test, biochemical test, chest X-ray, blood type, and bright scan ultrasonography. They also reviewed the medical history and wrote outpatient medical records. Next, a specialist nurse conducted a nursing assessment, including basic patient information, psychological assessment, nutritional assessment, thrombus assessment, preoperative patient education, and instructions on admission procedures. Afterward, an anesthesiologist conducted an anesthesia assessment, including medical history assessment (whether the patient had anesthesia contraindications, complications, and history of anesthesia). The anesthesiologist then performed an electrocardiogram, confirmed the surgical method, wrote anesthesia medical records, and signed the informed consent letter for anesthesia. Finally, the gynecological surgeon conducted the final review and instructed the patient to make an appointment with the admission center for ambulatory surgery. The patient was admitted to the Ambulatory Surgery Department on the morning of the scheduled surgery or the afternoon of the day before surgery. The work procedures of the outpatient comprehensive preoperative assessment unit are shown in Figure 1.

MANAGEMENT OF THE OUTPATIENT COMPREHENSIVE PREOPERATIVE ASSESSMENT UNIT:

A total of 3 consultation rooms, for the gynecological surgeon, specialist nurse, and anesthesiologist, were set up adjacent to each other, and closed-loop management was conducted. The order of the patient’s visit was as follows: gynecological surgeon, specialist nurse, anesthesiologist, and then they returned to the surgeon’s consultation room if necessary. The patient’s preoperative health information was sent to the surgeon, the appointment scheduling center (admission center), and the Ambulatory Surgery Department in advance through the hospital information system.

In our study, every gynecological surgeon was an attending physician, and every anesthesiologist was an attending anesthesiologist. Every specialist nurse was a supervising nurse and possessed at least 5 years of work experience in the gynecological ward.

The preoperative patient health education contained the following information: admission instructions, workflow of the ambulatory surgery, perioperative period of gynecological surgery, thrombosis prevention, and early recovery of gastrointestinal function after surgery. Partial information included in the intraoperative and postoperative patient health education was introduced before surgery.

PICKER PATIENT EXPERIENCE QUESTIONNAIRE: The Picker Patient Experience Questionnaire (PPE-15), designed by Jenkinson et al in 2002 to evaluate patient experience, has been used worldwide for a long time [8]. Studies by Wang et al [9] confirmed that this questionnaire could also be widely used in research on patient experience evaluation in China. This questionnaire is divided into 6 components and contains 15 items. Each item has 3 or 4 answer options. The maximum overall patient experience score is 55. The higher the overall score was, the better the patient experience. Cronbach’s alpha coefficient of this questionnaire was 0.820.

PREOPERATIVE PATIENT HEALTH EDUCATION EFFECT QUESTIONNAIRE:

We self-designed a preoperative patient health education effect questionnaire. This questionnaire contains 9 items and was used to investigate the patients’ level of mastery, degree of helpfulness and satisfaction of health education on the admission process, material preparation, personal physical preparation, and family support. Cronbach’s alpha coefficient of this questionnaire was 0.890. A 5-point Likert scale was used, with a maximum scale score of 45. The higher the scale score was, the better the effect of preoperative patient health education.

SURGICAL PATIENT SAFETY AND EFFICIENCY LOG SHEET:

The surgical patient safety and efficiency log sheet was used to obtain data concerning whether complications (anesthetic complications and surgical complications) occurred, length of hospital stay, and incidences of delayed surgery and surgery cancellation.

INPATIENT SATISFACTION QUESTIONNAIRE:

We self-designed an inpatient satisfaction questionnaire that contained 10 items. It was used to evaluate healthcare staff’s service attitude, clinical skills, privacy protection, timeliness of problem solving, and instructions on illness/medication. The reliability and validity of this questionnaire were good. Cronbach’s alpha coefficient was 0.933. Each item had 4 answer options. The maximum score of the questionnaire was 40. The higher the score was, the higher level of patient satisfaction during hospitalization.

DATA COLLECTION:

The questionnaire to measure the effect of the outpatient comprehensive preoperative assessment was distributed to the 2 groups of patients through the patient center’s WeChat official public account. The surgical patient safety and efficiency log sheet was filled in by the professionally trained staff of the Ambulatory Surgery Department and the general wards. The inpatient satisfaction questionnaire was completed by patients from the Ambulatory Surgery Department and general wards on the day of discharge.

STATISTICAL ANALYSIS:

IBM SPSS Statistics 23.0 was used for data analysis. The measurement data were in line with normal distribution and were described by x±s. Comparison between groups was performed using the t test. The enumeration data were presented by frequency and percentage. The interaction between variables was analyzed by a generalized linear model. The chi-square test was performed with the number of cases of complications, surgery appointment withdrawal, surgery cancellation, and delayed surgery. A Fisher’s exact test was performed when the number of the cases was less than 5. Statistically significant difference was identified by P<0.05.

Results

GENERAL PATIENT INFORMATION:

General patient information between the 2 groups were compared. No statistically significant differences were identified in age, education level, marital status, place of residence, household monthly income per person, type of health insurance, and preoperative diagnosis between the 2 groups (P>0.05; Table 1).

PATIENT EXPERIENCE: The score for information transmission and patient education of the intervention group was 8.73±1.07 higher than that of the control group (8.44±1.26), with a statistically significant difference (P<0.05; Table 2).

LEVEL OF MASTERY OF PREOPERATIVE PATIENT HEALTH EDUCATION KNOWLEDGE: The score for the level of mastery of preoperative patient health education knowledge of the intervention group was higher than that of the control group, with a statistically significant difference (P<0.05; Table 3).

CORRELATION BETWEEN OUTPATIENT EXPERIENCE AND AWARENESS OF PREOPERATIVE HEALTH EDUCATION: In our study, outpatient experience was positively correlated with awareness of preoperative patient health education (r=0.525, P<0.01). Among them, information transmission and patient education, emotional support, respect for patient preferences, involvement of family and friends, and continuity of healthcare services were all positively correlated with awareness of preoperative patient health education (P<0.01), while no correlations were found between physical comfort and awareness of preoperative patient health education (P>0.05; Table 4).

INCIDENCES OF SURGERY APPOINTMENT WITHDRAWAL, DELAYED SURGERY AND SURGERY CANCELLATION: Surgery appointment withdrawal refers to outpatient appointment withdrawal due to a patient’s personal reasons. Delayed surgery refers to the delayed surgery due to the patient’s condition (the delayed surgery for the intervention group refers to delayed admission to hospital; the delayed surgery for the control group refers to delayed surgery after admission). Surgery cancellation means that the surgery could not be performed as scheduled due to various reasons after the patient was admitted to the hospital. A statistically significant difference was identified in the number of delayed surgery cases between the 2 groups (P<0.05). No statistically significant differences were identified in the number of cases of surgery appointment withdrawal and surgery cancellation between the 2 groups (P>0.05; Table 5).

INCIDENCE OF COMPLICATIONS: The chi-square test was performed to investigate the incidence of surgical and anesthetic complications between the 2 groups. Fisher’s exact test was performed with the number of cases of ≤5. No statistical significant differences were identified in the number of cases of complications between the 2 groups (P>0.05; Table 6).

PATIENT SATISFACTION DURING HOSPITALIZATION: A t test was performed to investigate the scores for patient satisfaction during hospitalization between the 2 groups. No statistically significant differences were identified (P>0.05; Table 7).

LENGTH OF HOSPITAL STAY: A t test was performed to analyze the length of hospital stay between the 2 groups. The length of hospital stay of the control group was longer than that of the intervention group. A statistically significant difference of P<0.05 was identified (Table 7).

Discussion

THE OUTPATIENT COMPREHENSIVE PREOPERATIVE ASSESSMENT UNIT COULD HELP STRENGTHEN DOCTOR-PATIENT COMMUNICATION:

In this study, the score for information transmission and patient education of the intervention group was higher than that of the control group, and a statistically significant difference was identified. The information transmission and patient education component contained 3 items: surgeon’s answers to questions, nurse’s answers to questions, and whether the responses of different healthcare staff were unanimous. Our study showed that the establishment of the outpatient comprehensive preoperative assessment unit could promote doctor-patient communication and improve the accuracy and consistency of information transmission. Under healthcare reform, any careless communication between healthcare staff and patients is very likely to cause doctor-patient disputes, especially in patients undergoing ambulatory surgery. This not only harms patients and their families, but also brings stress to healthcare staff to a certain extent and can also bring negative effects to the hospital [10]. Therefore, it is necessary to establish an outpatient comprehensive preoperative assessment unit for patients undergoing gynecological ambulatory surgery. Liu C et al [11] suggested establishing an ambulatory surgery assessment center in hospitals, to complete a surgeon’s preoperative assessment at the ambulatory surgery assessment center. Liu X et al [12] suggested that the surgeon’s and anesthesiologist’s assessment of the ambulatory surgery patient should be conducted before surgery. In our study, preoperative assessment by the surgeon, specialist nurse, and anesthesiologist was moved to the outpatient comprehensive preoperative assessment unit. Although patients needed to receive a lot of information during the outpatient treatment, the number of repeated visits of patients to the hospital could be reduced. This was convenient for healthcare staff to conduct a comprehensive preoperative assessment with patients and to reduce the risk of surgery cancellation. Our study also showed that the overall score for patient experience at the outpatient comprehensive preoperative assessment unit was not lower than that of the gynecological surgeon’s other outpatient unit. This indicates that the outpatient comprehensive preoperative assessment unit for gynecological ambulatory surgery can be accepted by patients.

AN OUTPATIENT COMPREHENSIVE PREOPERATIVE ASSESSMENT UNIT COULD HELP IMPROVE GYNECOLOGICAL SURGICAL PATIENTS’ LEVEL OF MASTERY OF PREOPERATIVE HEALTH EDUCATION KNOWLEDGE:

Our study showed that the score for the mastery of preoperative health knowledge in the intervention group was higher than that of the control group. A statistically significant difference was identified. Because an outpatient preoperative assessment by a gynecological specialist nurse was added to the outpatient comprehensive preoperative assessment in our study, this, combined with the surgeon assessment, helped patients receive professional preoperative health education before surgery and to get ready for surgery. In our study, the level of mastery of preoperative health knowledge was positively correlated with outpatient experience, possibly because the addition of an outpatient preoperative assessment by a specialist nurse improved the effect of healthcare staff’s comprehensive preoperative assessment and health education to patients. The results of Lozada et al [13] show that preoperative health education can reduce patients’ psychological stress, relieve their bad emotions, and encourage them to better cooperate with the anesthesiologist and surgeon. A nurse-led preoperative assessment can reduce incidence of surgery cancellation, shorten the length of hospital stay, relieve patients’ anxiety, improve patients’ degree of preoperative preparation and awareness of postoperative needs, and improve patients’ satisfaction [14]. Therefore, an outpatient comprehensive preoperative assessment, including outpatient assessment by a specialist nurse, can effectively improve patients’ level of mastery of preoperative health knowledge and reduce patients’ psychological stress.

AN OUTPATIENT COMPREHENSIVE PREOPERATIVE ASSESSMENT COULD ENSURE SURGICAL SAFETY:

Our study showed that no statistically significant differences were identified in the number of cases of surgical complications and anesthetic complications between the 2 groups. This indicates that surgical safety of patients undergoing gynecological ambulatory surgery after an outpatient comprehensive preoperative assessment was not reduced, compared with that of routine surgical procedures, and that the safety of gynecological patients undergoing ambulatory surgery can be effectively guaranteed. Previous studies [5,14] have shown that an outpatient preoperative assessment by a surgeon, nurse, and anesthesiologist prior to admission can help comprehensively collect patient information and reduce the incidence of surgery cancellation on the day of surgery, thereby helping to ensure patient safety. Although an outpatient comprehensive preoperative assessment contains various content, and the patient’s visit schedule is tight, it is highly efficient for patients because various examinations and communication can be completed within a short time period and the patient can know the visit schedule in time. For healthcare staff, an outpatient comprehensive preoperative assessment unit is helpful for them to comprehensively assess patient information and promptly adjust treatment plans, thereby reducing the lengths of visits and improving healthcare efficiency while ensuring surgical safety. Therefore, establishing an outpatient comprehensive preoperative assessment unit for gynecological ambulatory surgery can effectively guarantee surgical safety.

AN OUTPATIENT COMPREHENSIVE PREOPERATIVE ASSESSMENT UNIT COULD HELP REDUCE HEALTHCARE COSTS:

This study showed that a statistically significant difference was identified in the number of delayed surgery cases between the 2 groups. The main reasons for delayed surgery in the intervention group were as follows: a failed preoperative leptoorrhea test, patient being in menstrual period, patient having a cold, or patient having high blood pressure. When an ambulatory surgery patient visited the outpatient comprehensive preoperative assessment unit, if they did not meet the requirements of ambulatory surgery, they were not admitted to the hospital until they did. However, if patients in the control group encountered the above-mentioned reasons, they might be allowed for admission due to the surgeon’s consideration of the reasons why they failed to meet the requirements of surgery, their willingness for admission, and the distance between their home to the hospital. They would undergo surgery after meeting the requirements of surgery following observation and treatment. Therefore, the number of delayed surgery cases in the intervention group was larger than that of the control group, and the length of hospital stay in the control group was longer than that of the intervention group.

Ambulatory surgery allows patients to spend less time in the hospital; therefore, it is regarded as an effective means to improve the efficiency of healthcare services and reduce healthcare costs [15,16]. The guidelines of quality and safety management of ambulatory surgery in China requires hospitals to establish a structure-process-outcome-based management mechanism [17], including standardized procedures, appointments, and assessments of pre-admission, in-hospital, and eventual discharge. The hospital in our study implemented the outpatient comprehensive preoperative assessment (including appointment and pre-admission assessment) in the management of gynecological ambulatory surgery and established a set of standardized work procedures and management mode. This reduced the length of hospital stay by 2.58 days and reduced the time of care by family members, thereby reducing overall healthcare costs.

AN OUTPATIENT COMPREHENSIVE PREOPERATIVE ASSESSMENT UNIT COULD IMPROVE PATIENT SATISFACTION DURING HOSPITALIZATION:

In our study, no statistically significant differences were found in patient satisfaction during hospitalization between the 2 groups. This indicates that the management mode of ambulatory surgery in the hospital in our study did not affect patient satisfaction during hospitalization. Patients received comprehensive assessment and communication from a surgeon, nurse, and anesthesiologist at the outpatient comprehensive preoperative assessment unit; therefore, they understood the procedures of ambulatory surgery and preparation for admission. This can help patients to make a psychological construction and preparation. Healthcare staff introducing surgeon information, admission procedures, and estimated length of hospital stay during their preoperative health education can relieve patients’ anxiety, shorten the length of hospital stay, and reduce hospitalization costs, thereby significantly improving patient satisfaction during hospitalization [18].

Possibly due to the small number of cases in our study, the level of patient satisfaction during hospitalization in the intervention group was not significantly higher than that of the control group. However, no statistically significant differences were identified in the level of patient satisfaction during hospitalization between the 2 groups, suggesting that an outpatient comprehensive preoperative assessment for gynecological ambulatory surgery can help improve patient satisfaction during hospitalization.

THE RESULTS OF THIS STUDY ARE BASICALLY CONSISTENT WITH THOSE OF THE STUDIES BY FOREIGN RESEARCHERS:

The establishment of the outpatient comprehensive preoperative assessment unit for gynecological ambulatory surgery in our study is the first in southwestern China. Compared with the results of Yen et al [19], the management mode of the outpatient comprehensive preoperative assessment unit in our study was more mature and suitable to be implemented in southwestern China. Yen et al [19] suggested that the optimal model for outpatient preoperative assessment can depend on the characteristics of the hospital, such as the type of specialty care provided, geographic and socioeconomic differences in the population served by the hospital, patient expectations, and whether the facility is for private or academic practice. This means that it is difficult to compare the effectiveness of different preoperative assessment systems in correctly educating patients and reducing complications. A study by Tulloch et al [20] in 2018 found that preoperative assessment could reduce the anxiety level of patients. This is consistent with the results of our study. It is necessary to improve the information provided to patients before surgery and to identify the patients who need additional preoperative support. In our study, psychological screening of patients was conducted by specialist nurses in the comprehensive preoperative assessment unit. Information of patients with abnormal screening results was delivered to the ambulatory surgery ward for personalized services. The results of an observational study on surgeons’ satisfaction to anesthetic services in an anesthetic preoperative evaluation clinic in South Korea [21] show that quality improvement of healthcare service in an anesthesia preoperative evaluation clinic can affect patient perception. In our study, satisfaction surveys and quality control were conducted in the outpatient comprehensive preoperative assessment unit to continuously improve the quality of healthcare service and patient satisfaction. A study by Kageyama et al [22] from Japan highlighted the significance of the preoperative assessment unit and the preoperative patient health education, which was consistent with the results of our study. In our study, nurses in the ambulatory surgery ward re-evaluated the patients according to the results of the outpatient comprehensive preoperative assessments after receiving the patients and then gave patients personalized guidance, thereby improving patient satisfaction.

LIMITATIONS:

This study has some limitations. First, the samples in this study were collected from a single center, lacking data from other approaches and hospitals. This might limit the universality of the results. Second, the sample size of this study was not large, thus increasing the possibility of uncertainty of some results. Third, this was a retrospective study. Supplementary information might not have been obtained during data collection or some information might not have been further verified. Fourth, a blinded method could not be used in this study; therefore, bias of the results can exist. Fifth, this study involved efficient implementation of gynecological ambulatory surgery in a large hospital in a city with a large population and advocated introducing partial content of intraoperative and postoperative patient health education before surgery. However, this has not been implemented in small hospitals with fewer resources or in rural areas. This is a shortcoming of the research method. Similar research will be conducted in other hospitals to improve the quality of healthcare services and to explore the possibilities of implementation of ambulatory surgery in different levels of healthcare institutions in China.

Conclusions

An outpatient comprehensive preoperative assessment unit for gynecological ambulatory surgery can improve patients’ experience, patients’ level of mastery of preoperative health knowledge, and the quality of preoperative assessment of gynecological surgery patients. It can ensure surgical safety, shorten the length of a hospital stay, reduce healthcare costs and time of care by family members, improve healthcare staff’s work efficiency, and optimize healthcare resource allocation, thereby improving patient satisfaction and social and economic benefits.