Master Class

Payment changes drive hysteroscopy to the office


 

Preparing the office

Physicians in Europe have been performing in-office hysteroscopy for years. But in the United States, it is a newer concept, with most gynecologic surgeons having been taught to perform surgical procedures in the operating room. Undoubtedly, our unfamiliarity with in-office surgery has played a role in the slow uptake of hysteroscopy in our practices.

In-office set up needed for hysteroscopy Courtesy Dr. Amy Garcia

A dedicated exam room, with stirrups attached to the table, a movable light, and video equipment are the basic needs for doing operative procedures in the office.

It requires a culture change. Performing surgery while the patient is awake forces us to be more alert to issues such as the room temperature, the lighting, and the noises that a patient may hear. All of these factors can affect a patient’s anxiety level. We need to train ourselves to be acutely aware of the surroundings and to incorporate a “vocal local” approach – a form of nonpharmacologic pain management that involves speaking directly and reassuringly with the patient in order to reduce anxiety and avoid/distract from pain.

Open communication about everything the patient will see hear and feel before, during and after the procedure is important. Focusing on these details can improve your patient’s experience and your professional relationship with her.

In an earlier edition of Master Class, I addressed instrumentation and technique, elements of pain control and anesthesia, and the value of a vaginoscopic approach to hysteroscopy. Vaginoscopy avoids the use of a vaginal speculum or cervical tenaculum, and is so tolerable to many patients that I use minimal premedication and only rarely use any local anesthetic and/or sedation, even for biopsies and polypectomies.

Preparing your practice for hysteroscopy is a multifaceted process involving not only the purchase and/or rental of equipment but also compliance with guidelines, regulatory considerations, patient rights, hospital transfer arrangements, and other issues. ACOG’s Report of the Presidential Task Force on Patient Safety in the Office Setting is a valuable resource for getting started. The report discusses anesthesia levels and the benefits and risks of a contract anesthesiologist, for instance, as well as the role of and processes for credentialing, privileging, and accreditation.

Checklists and drills are important for ensuring a safe practice, and the report discusses each of these elements and provides templates and examples. A sample “Office Surgical Safety Checklist” to be used for each procedure, for instance, has sections with preoperative steps (before anesthesia/analgesia, and before incision), intraoperative steps, postoperative steps, and discharge steps. Similar in format to checklists used in the aviation industry, each step has a box to be checked off to verify completion.

Mock drills help ensure that staff are knowledgeable about their roles and coordinated in their response to potential complications, such as vasovagal episodes, respiratory arrest caused by laryngospasm, and local anesthetic toxicity reactions. And, while not the focus of drills, we also must be prepared to manage cervical strictures and stenosis, cervical laceration, uterine perforation, and other complications.

Outpatient surgery guidelines from organizations such as the American College of Surgeons, the Joint Commission, state regulatory agencies, and professional liability insurers, can also be useful resources. With the use of ACOG’s report and other such resources, the set-up and the transition to in-office hysteroscopy need not be daunting. For most gynecologic surgeons, it will all feel comfortable after only a few procedures.

Dr. Cholkeri-Singh is with the University of Illinois at Chicago, and is director of gynecologic surgical education and associate director of minimally invasive gynecology at Advocate Lutheran General Hospital in Park Ridge, Ill. She is in private practice in Chicago. She is a consultant for Hologic, Bayer HealthCare, Olympus, Caldera Medical, Karl Storz, Medtronic, DYSIS Medical, and Channel Medsystems.

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