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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.”

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.

building photo
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.”


(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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