Outpatient Surgery?
There’s an App for That
 John Semple
The hospital of the future, as Surgeon-in-Chief John
Semple (see also http://www.surgicalspotlight.ca/Article.aspx?ver=Fall_2007 ) describes the new Women’s College
Hospital, opened June 13, 2013, marking a “milestone
in the Province’s plan to shift health care out of hospitals
and into home and community settings. This new state
of the art facility has no in-patient beds and is designed
to streamline patient care to totally ambulatory.
“Currently, 70% of all surgical cases in North America
are done on an outpatient basis. Complex cases, such as
TRAM flaps (transversus rectus abdominis myocutaneous
flaps) a common form of breast reconstruction, are
listed in the CIHI database as having an average length
of stay up to 6.2 days. At Women’s College Hospital we
are sending these patients home in just 18 hours. We
know, however, that these patients may find self-care at
home somewhat daunting, so we have designed a smartphone
technology platform which allows us to monitor
the patient’s quality of recovery while they are at home.”
The patient-centered innovations that John and his
colleagues at QoC Health Inc (Quality of Care) have
developed will be a great advance in postoperative home
monitoring. “The quality of recovery is quantified using a
modified QoR 40 scale which is adapted for a touch screen
interface. Patients make daily entries, e.g. the volume in
their surgical drainage and their level of pain, quantified
on a Likert visual analogue scale. The data is then relayed
to an encrypted and secure cloud server and made available
for viewing by the surgeon on a tablet in dashboard
format. During this past year we performed a pilot at
Women’s College Hospital where Samsung supplied the
devices and Rogers supplied the airtime free of charge. In
this study, 30 breast reconstructions and 30 ACL (anterior
cruciate ligament) orthopaedic reconstructions were carefully
evaluated. There was an unexpected finding of the
study. After we reviewed the daily pictures that the patient
took, we realized that we have never seen the surgical site
quite like this before. Even when patients were in hospital
we were never able to look at the appearance of the wound
in sequence and compare it this accurately to yesterday’s
picture. The continuity is far superior to human memory.
Another unexpected finding was that we could eliminate
some of the patients’ early post op visits to the clinic.
Patients who live in Owen Sound do not need to travel
to Toronto just to have us look at the wound if we can
observe remotely that they are doing well. This opens up
slots in the clinic schedule for new patients to be seen and
shortens wait times.
“A patient whose wound site looked slightly pinker
than yesterday was found to have stopped her antibiotics.
She was advised to go back on, and her wound
regained its normal colour. The first 30 days at home are
part of our surgical domain. Patients are pleased with
the system and Samsung, who gave the telephones for
the study, was also pleased. None of the phones were
lost and none were misused. The patients felt cared for.
Abnormal values are flagged in the telephone system, so
they go to the top of my patient list to review each day.”
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John and his colleagues are writing this experience up
for publication. They have given presentations at numerous
conferences, at the Hospital for Sick Children and at
General Surgery Inter-hospital Rounds. They are exploring
the suitability of this application for other types of
surgical procedures including thyroid cancer surgery. As
part of an initiative with the Change Foundation at the
Northhumberland Hills Hospital, near Cobourg, they
are adapting the technology for overseeing the transition
of elderly patients from the hospital to their homes.
 Women’s College Hospital's new building
“We feel that this technology may be of value to
NSQUIP (American College of Surgeons National
Surgical Quality Improvement Program). NSQUIP
gathers patient recovery data after the first 30 days post
op, whereas we gather up to 500 points of data on each
patient during that same period of time.
“Overall patients found the smartphone interface
easy to use and reported high satisfaction in post pilot
interviews. Surgeons and other care providers found
the data easy to access and useful for understanding
patient recovery. Cost and efficiency benefits were identified
although the accurate assessment of savings in the
application of innovation in Canadian Health Care is
complex. This study allowed us to extrapolate the cost
benefits based on obvious parameters such as reduced
length of stay, fewer follow up visits, and reductions in
readmission rates. The use of smart phone technology
for monitoring the quality of recovery in post-operative
patients at home is a feasible concept. The technology
platform supports the ambulatory model with expedited
discharge but allows for continuous monitoring and a
high degree of patient satisfaction. The enthusiasm for
outpatient surgery is very high and the new building is
an ideal setting for advancing the practice of ambulatory
surgery at the University of Toronto.
“Anesthesiologist Pam Morgan at Women’s College
is very active in the Simulation and Checklist research
area. She recently received a SIM 1 Innovation Grant,
looking at the use of the simulation lab and checklists
to cope with catastrophic events in the operating room (1).
The majority of our anesthesia is provided through the
UHN Anesthesia Program, under Gerry O’Leary and
his colleagues.”
M.M.
(1) Arriaga, AF, Bader, AM, Wong JM, Lipsitz SR, Berry WR,
Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink
DS, Gawande AA. Simulation-Based Trial of Surgical-Crisis
Checklists, N Engl J Med: 368:246-53, 2013.
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