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Willer BL, Petkus H, Manupipatpong K, Tram N, Nafiu OO, Tobias JD, Mpody C. Association of Obstructive Sleep Apnea With Unanticipated Admission Following Nonotolaryngologic Pediatric Ambulatory Surgery. Anesth Analg 2024; 139:590-597. [PMID: 37307227 DOI: 10.1213/ane.0000000000006593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Approximately 2% of ambulatory pediatric surgeries require unanticipated postoperative admission, causing parental dissatisfaction and suboptimal use of hospital resources. Obstructive sleep apnea (OSA) occurs in nearly 8% of children and is known to increase the risk of perioperative adverse events in children undergoing otolaryngologic procedures (eg, tonsillectomy). However, whether OSA is also a risk for unanticipated admission after nonotolaryngologic surgery is unknown. The objectives of this study were to determine the association of OSA with unanticipated admission after pediatric nonotolaryngologic ambulatory surgery and to explore trends in the prevalence of OSA in children undergoing nonotolaryngologic ambulatory surgery. METHODS We used the Pediatric Health Information System (PHIS) Database to evaluate a retrospective cohort of children (<18 years) undergoing nonotolaryngologic surgery scheduled as ambulatory or observation status from January 1, 2010, to August 31, 2022. We used International Classification of Diseases codes to identify patients with OSA. The primary outcome was unanticipated postoperative admission lasting ≥1 day. Using logistic regression models, we estimated the odds ratio (OR) and 95% confidence intervals (CIs) for unanticipated admission comparing patients with and without OSA. We then estimated trends in the prevalence of OSA during the study period using the Cochran-Armitage test. RESULTS A total of 855,832 children <18 years underwent nonotolaryngologic surgery as ambulatory or observation status during the study period. Of these, 39,427 (4.6%) required unanticipated admission for ≥1 day, and OSA was present in 6359 (0.7%) of these patients. Among children with OSA, 9.4% required unanticipated admission, compared to 5.0% among those without. The odds of children with OSA requiring unanticipated admission were more than twice that in children without OSA (adjusted OR, 2.27; 95% CI, 1.89-2.71; P < .001). The prevalence of OSA among children undergoing nonotolaryngologic surgery as ambulatory or observation status increased from 0.4% to 1.7% between 2010 and 2022 ( P trends < .001). CONCLUSIONS Children with OSA were significantly more likely to require unanticipated admission after a nonotolaryngologic surgery scheduled as ambulatory or observation status than those without OSA. These findings can inform patient selection for ambulatory surgery with the goal of decreasing unanticipated admissions, increasing patient safety and satisfaction, and optimizing health care resources related to unanticipated admission.
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Affiliation(s)
- Brittany L Willer
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Holly Petkus
- Heritage College of Osteopathic Medicine-Athens Campus and Ohio University, Athens, Ohio
| | - Katherine Manupipatpong
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Nguyen Tram
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Christian Mpody
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Shah S, Qureshi F, Stanley S, Bennett-Guerrero E. Unplanned hospital admissions within 24 h after 53,185 surgical procedures at a U.S. ambulatory surgery center. Perioper Med (Lond) 2024; 13:88. [PMID: 39138487 PMCID: PMC11323584 DOI: 10.1186/s13741-024-00447-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Unplanned admission after surgery at an ambulatory surgery center (ASC) is an established measure of the quality of care and can affect the patient's experience. Previous studies on this topic are generally dated, focused on a single specialty, or studied 30-day admissions after ambulatory surgery. Few studies have reported admission within 24 h after surgery at an ASC which is a different but important measure of the quality of anesthetic and surgical care. Understanding admissions within 24 h of surgery can identify opportunities for improvement immediately after surgery. Therefore, our study was designed to assess the incidence and risk factors for unplanned hospital admissions within 24 h after surgery performed at a hospital ASC. METHODS After Institutional Review Board approval, a retrospective analysis was performed on all adult patients who underwent surgery at a US ASC between January 1, 2016, and December 31, 2022. Data were obtained from the hospital's electronic medical record. The study sample was divided into two groups: those with an unplanned hospital admission within 24 h after surgery and those without an unplanned hospital admission. To evaluate risk factors for unplanned hospital admissions, univariate analyses with p value < 0.05 were utilized to identify significant patient variables related to hospital admissions. These variables were further adjusted using a multivariable Firth logistic regression. Descriptive statistics were used to explore the number of patients in different variable categories. RESULTS Overall, 53,185 cases were identified for the 7-year period. The incidence of unplanned hospital admission over this period was 0.09% (95% CI 0.07-0.1122%; ranging from 0.05 to 0.12% per year. In the multivariable model, surgery duration (OR 1.010, 95% CI 1.007-1.012, p value < 0.0001), peripheral vascular disease (OR 14.489, 95% CI 4.862-43.174, p value < 0.0001), and deep venous thrombosis (OR 5.527, 95% CI 1.909-16.001, p value = 0.0016) were significantly associated with unplanned hospital admission. CONCLUSION The overall incidence of unplanned hospital admission after surgery at a large tertiary care ambulatory surgery center is very low. This admission rate can also serve as a reference point for future studies and quality improvement initiatives.
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Affiliation(s)
- Syed Shah
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, USA
| | - Faiza Qureshi
- Patient Care Services, Stony Brook Eastern Long Island Hospital, Stony Brook, USA.
| | - Samuel Stanley
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, USA
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Simon NB, McCready TM, Serafin J, Assel M, Jewell E, Mehta M, Vickers AJ, Barnett KM. Transfers and anesthesia-related postoperative outcomes after 3361 same-day cancer surgeries at a freestanding surgery center: An observational retrospective study. J Surg Oncol 2024; 129:1442-1448. [PMID: 38685751 DOI: 10.1002/jso.27643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Expanding outpatient surgery to the increasing number of procedures and patient populations warrants continuous evaluation of postoperative outcomes to ensure the best care and safety. We describe adverse postoperative outcomes and transfer rates related to anesthesia in a large sample of patients who underwent same-day cancer surgery at a freestanding ambulatory surgery center. METHODS Between January 2017 and June 2021, 3361 cancer surgeries, including breast and plastic, head and neck, gynecology, and urology, were performed. The surgeries were indicated for diagnosis, staging, and/or treatment. We report the incidence of transfers and adverse postoperative outcomes related to anesthesia. RESULTS Breast and plastic surgeries were the most common (1771, 53%), followed by urology (1052, 31%), gynecology (410, 12%), and head and neck surgeries (128, 4%). Based on patients' first procedure, comorbidity levels were highest for urology (75% American Society of Anesthesiologists physical status score 3, 1.7% score 4) and lowest for breast surgeries (31% score 3, 0.2% score 4). Most gynecology surgeries used general anesthesia (97.6%), whereas breast surgeries used the least (38%). A total of seven patients (0.2%; 95% CI: 0.08%-0.4%) were immediately transferred to an outside hospital; four due to anesthesia-related reasons. Only 7 (0.2%) patients needed additional postoperative care related to anesthesia-related adverse events, specifically cardiac events (4), difficult intubations (2), desaturation (1), and agitation, nausea, and headache (1). CONCLUSIONS The incidence of anesthesia-related adverse postoperative outcomes is low in cancer patients undergoing outpatient surgeries at our freestanding ambulatory surgery center. This suggests that carefully selected cancer patients, including patients with metastatic cancer, can undergo anesthesia for same-day surgery, making cancer care accessible locally and reducing stress associated with travel for treatment. More research investigating complication rates related to surgery and to cancer disease trajectory are needed to establish a complete evaluation of safety for outpatient cancer surgery.
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Affiliation(s)
| | - Taylor M McCready
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - Joanna Serafin
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Melissa Assel
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Jewell
- Memorial Sloan Kettering Cancer Center, Middletown, New Jersey, USA
| | - Meghana Mehta
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Kara M Barnett
- Memorial Sloan Kettering Cancer Center, Middletown, New Jersey, USA
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Hidalgo NJ, Guillaumes S, Llompart-Coll MM, González-Atienza P, Bachero I, Momblán D, Vidal Ó. Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study. Langenbecks Arch Surg 2024; 409:165. [PMID: 38801551 PMCID: PMC11129998 DOI: 10.1007/s00423-024-03358-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 05/22/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission. METHODS A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission. RESULTS A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission. CONCLUSIONS Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.
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Affiliation(s)
- Nils Jimmy Hidalgo
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic Barcelona, C. de Villarroel, 170, Barcelona, 08036, Spain.
| | - Salvador Guillaumes
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic Barcelona, C. de Villarroel, 170, Barcelona, 08036, Spain
| | - M Magdalena Llompart-Coll
- Department of General and Digestive Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic Barcelona, Barcelona, Spain
| | - Paula González-Atienza
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic Barcelona, C. de Villarroel, 170, Barcelona, 08036, Spain
| | - Irene Bachero
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic Barcelona, C. de Villarroel, 170, Barcelona, 08036, Spain
| | - Dulce Momblán
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic Barcelona, C. de Villarroel, 170, Barcelona, 08036, Spain
| | - Óscar Vidal
- Department of General and Digestive Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic Barcelona, Barcelona, Spain
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Rupp S, Ahrens E, Rudolph MI, Azimaraghi O, Schaefer MS, Fassbender P, Himes CP, Anand P, Mirhaji P, Smith R, Freda J, Eikermann M, Wongtangman K. Development and validation of an instrument to predict prolonged length of stay in the postanesthesia care unit following ambulatory surgery. Can J Anaesth 2023; 70:1939-1949. [PMID: 37957439 DOI: 10.1007/s12630-023-02604-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/12/2023] [Accepted: 04/28/2023] [Indexed: 11/15/2023] Open
Abstract
PURPOSE We sought to develop and validate an Anticipated Surveillance Requirement Prediction Instrument (ASRI) for prediction of prolonged postanesthesia care unit length of stay (PACU-LOS, more than four hours) after ambulatory surgery. METHODS We analyzed hospital registry data from patients who received anesthesia care in ambulatory surgery centres (ASCs) of university-affiliated hospital networks in New York, USA (development and internal validation cohort [n = 183,711]) and Massachusetts, USA (validation cohort [n = 148,105]). We used stepwise backwards elimination to create ASRI. RESULTS The model showed discriminatory ability in the development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI], 0.82 to 0.83), 0.82 (95% CI, 0.81 to 0.83), and 0.80 (95% CI, 0.79 to 0.80), respectively. In cases started in the afternoon, ASRI scores ≥ 43 had a total predicted risk for PACU stay past 8 p.m. of 32% (95% CI, 31.1 to 33.3) vs 8% (95% CI, 7.9 to 8.5) compared with low score values (P-for-interaction < 0.001), which translated to a higher direct PACU cost of care of USD 207 (95% CI, 194 to 2,019; model estimate, 1.68; 95% CI, 1.64 to 1.73; P < 0.001) The effects of using the ASRI score on PACU use efficiency were greater in a free-standing ASC with no limitations on PACU bed availability. CONCLUSION We developed and validated a preoperative prediction tool for prolonged PACU-LOS after ambulatory surgery that can be used to guide scheduling in ambulatory surgery to optimize PACU use during normal work hours, particularly in settings without limitation of PACU bed availability.
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Affiliation(s)
- Samuel Rupp
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- School of Medicine, Technical University of Munich, Munich, Germany
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- School of Medicine, Philipps-University Marburg, Marburg, Germany
| | - Maira I Rudolph
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology and Intensive Care Medicine, Cologne University Hospital, Cologne, Germany
| | - Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology, Operative Intensive Care Medicine, Pain- and Palliative Care Medicine, Marien Hospital Herne, Ruhr-University Bochum University Hospital, Herne, Germany
| | - Carina P Himes
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Preeti Anand
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Parsa Mirhaji
- Center for Health Data Innovations, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard Smith
- Department of Otorhinolaryngology - Head & Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jeffrey Freda
- Surgical Services, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
- Department of Anesthesiology and Intensive Care Medicine, Duisburg-Essen University Hospital, Essen, Germany.
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Ardon AE, Nimma S, Nin OC. Twenty-three-hour stays in the ambulatory surgical center: benefits, pathways and protocols. Curr Opin Anaesthesiol 2023; 36:617-623. [PMID: 37615495 DOI: 10.1097/aco.0000000000001306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
PURPOSE OF REVIEW To summarize recent evidence that discusses the clinical, financial, and logistical implications of a 23 h stay postsurgical stay unit in an ambulatory surgical center (ASC). RECENT FINDINGS Twenty-three-hour stays in ambulatory surgery centers are safe, but proper patient selection and optimization are key to maintaining a high level of safety. The financial implications of overnight stays in ASCs rely heavily on payment structures and comparative costs at hospital-based outpatient surgery centers. The establishment of pathways and protocols for clinical care are key to the success of a 23 h stay at an ASC. SUMMARY A concurrent concern with the recent increase in outpatient surgery and medical complexity of cases performed in an ambulatory surgical center (ASC) is the possibility that patients may need overnight stay. Further, whether certain patients would benefit from anticipated 23 h observation rather than same-day discharge is an emerging topic. Overnight stays in ASCs may have financial advantages and decrease the risk of unanticipated admission with proper patient selection. The use of protocols and established pathways is key to the success of this model.
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Affiliation(s)
- Alberto E Ardon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville
| | - Sindhuja Nimma
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville
| | - Olga C Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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Bronheim RS, Shu HT, Jami M, Hsu NN, Aiyer AA. Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications? FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231205306. [PMID: 37886622 PMCID: PMC10599117 DOI: 10.1177/24730114231205306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Background Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. Methods We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Results Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94). Conclusion The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Rachel S. Bronheim
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Henry T. Shu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Meghana Jami
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Nigel N. Hsu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Amiethab A. Aiyer
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Eerdekens GJ, Van Beersel D, Rex S, Gewillig M, Schrijvers A, Al Tmimi L. The patient with congenital heart disease in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:421-436. [PMID: 37938087 DOI: 10.1016/j.bpa.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022]
Abstract
The number of patients with congenital heart disease (CHD) undergoing ambulatory surgery is increasing. Deciding whether a CHD patient is suitable for an ambulatory procedure is still challenging. Several factors must be considered, including the type of planned procedure, the complexity of the underlying pathology, the American Society of Anesthesiologists' Physical Status classification of the patient, and other patient-specific factors, including comorbidity, chronic complications of CHD, medication, coagulation disorders, and issues related to the presence of a pacemaker (PM) or cardioverter-defibrillator. Numerous studies reported higher perioperative mortality and morbidity rates in surgical patients with CHD than non-CHD patients. However, most of these studies were conducted in a cohort of hospitalized patients and may not reflect the ambulatory setting. The current review aims to provide the anesthesiologist with an overview and practical recommendations on selecting and managing a CHD patient scheduled for an ambulatory procedure.
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Affiliation(s)
- Gert-Jan Eerdekens
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Dieter Van Beersel
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven - University of Leuven, B-3000, Leuven, Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, B-3000, Leuven, Belgium; Department of Pediatric Cardiology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - An Schrijvers
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Layth Al Tmimi
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven - University of Leuven, B-3000, Leuven, Belgium.
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Rodriguez LV, Bloomstone JA. Benchmarking outcomes for day surgery. Best Pract Res Clin Anaesthesiol 2023; 37:331-342. [PMID: 37938080 DOI: 10.1016/j.bpa.2023.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023]
Abstract
In comparison to large acute care centers, Ambulatory Surgery Centers (ASCs) provide patient-centered, fast, efficient, effective, high-value, high-quality, reliable, and safe care. For these reasons, ASCs are often preferred working venues for perioperative staff and desirable partners for surgeons, proceduralists, and anesthesiologists. Given today's many headwinds, including inflation, downward rate pressures, increasing regulation, and near constant supply chain issues, not to mention increasing patient and procedural complexity, exemplary clinical and operational management is of paramount importance and requires frequent measurement and benchmarking. Benchmarking is critical to performance assessment and is vital for assessing existing processes and new pathways and protocols, and remains the best way to identify areas for improvement. This chapter provides the reader with an overview of key ASC-related performance indicators, what they mean, and how best to measure and compare them to local, regional, and national benchmarks.
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Affiliation(s)
- Leopoldo Vicente Rodriguez
- American Society of Anesthesiologists (ASA) Committee on Ambulatory Surgical Care (CASC); ASA Committee on Performance & Outcome Measures (CPOM); Society for Ambulatory Anesthesia (SAMBA); UCHealth Longs Peak Hospital, Longmont, CO, USA; Boulder Community Health, Foothills Hospital, Boulder, CO, USA; Nova Southeastern University, Ft Lauderdale, FL, USA; Boulder Valley Anesthesiology PLLC, P.O. Box 21147, Boulder, CO 80308-4147, USA.
| | - Joshua Aaron Bloomstone
- SVP Clinical Innovation & Practice Transformation, Envision Healthcare, USA; University of Arizona, USA; University College London, UK; Outcomes Research Consortium, Cleveland, OH, USA; 13017 N10th Avenue, Phoenix, AZ 85029, USA.
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10
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de Pablos-Rodríguez P, Suárez Novo JF, Castells Esteve M, Bonet Puntí X, Picola Brau N, Abella Serra A, López Picazo E, Cabrera Coma A, Sánchez Allueva A, Vigués Julià F. Preliminary results of the implementation of robotic radical prostatectomy in a major ambulatory surgery regimen. Actas Urol Esp 2023; 47:288-295. [PMID: 37272321 DOI: 10.1016/j.acuroe.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To report our initial experience with robotic radical prostatectomy as an outpatient procedure. MATERIAL AND METHODS Retrospective analysis of patients who underwent RRP as MAS (Major Ambulatory Surgery) at our center between March 2021 and May 2022. We collected baseline patient characteristics, intraoperative outcomes and postoperative data (need for unplanned medical care and complications at one month after surgery). Oncologic characteristics at disease diagnosis (PSA, staging, ISUP, MRI) and postoperative pathologic outcomes were collected. RESULTS We identified a total of 35 patients with an average age of 60,8 ± 6,88 years and a BMI of 27 ± 2,9 Kg/m2. All patients had a low anesthetic risk and 25.71% had undergone previous abdominal surgery. The surgical time was 151,66 ± 42,15 min and the average blood loss was 301,2 ± 184,38 mL. Two patients (5.7%) were admitted for one night and 7 patients (20%) consulted the emergency department in the following month, of which 3 (8.57%) were readmitted. We recorded one intraoperative complication, seven mild postoperative complications (Clavien I-II) and one severe complication (Clavien IIIb). The severe complication occurred on the eighth postoperative day and was not related to the procedure being ambulatory. CONCLUSION The absence of serious complications in the immediate postoperative period supports RRP in MAS as a safe technique for selected patients.
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Affiliation(s)
- P de Pablos-Rodríguez
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain; Escuela de Doctorado de la Universidad de Las Palmas de Gran Canaria (ULPGC), Las Palmas de Gran Canaria, Spain.
| | - J F Suárez Novo
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - M Castells Esteve
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - X Bonet Puntí
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - N Picola Brau
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - A Abella Serra
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - E López Picazo
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - A Cabrera Coma
- Servicio de Anestesiología y Reanimación, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - A Sánchez Allueva
- Servicio de Anestesiología y Reanimación, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - F Vigués Julià
- Servicio de Urología, Hospital Universitari de Bellvitge, Barcelona, Spain
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11
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Madsen HJ, Henderson WG, Dyas AR, Bronsert MR, Colborn KL, Lambert-Kerzner A, Meguid RA. Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations. World J Surg 2023; 47:627-639. [PMID: 36380104 DOI: 10.1007/s00268-022-06819-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Operations performed outpatient offer several benefits. The prevalence of outpatient operations is growing. Consequently, the proportion of patients with multiple comorbidities undergoing outpatient surgery is increasing. We compared 30-day mortality and overall morbidity between outpatient and inpatient elective operations. METHODS Using the 2005-2018 ACS-NSQIP database, we evaluated trends in percent of hospital outpatient operations performed over time, and the percent of operations done outpatient versus inpatient by CPT code. Patient characteristics were compared for outpatient versus inpatient operations. We compared unadjusted and risk-adjusted 30-day mortality and morbidity for inpatient and outpatient operations. RESULTS A total of 6,494,298 patients were included. The proportion of outpatient operations increased over time, from 37.8% in 2005 to 48.2% in 2018. We analyzed the 50 most frequent operations performed outpatient versus inpatient 25-75% of the time (n = 1,743,097). Patients having outpatient operations were younger (51.6 vs 54.6 years), female (70.3% vs 67.3%), had fewer comorbidities, and lower ASA class (I-II, 69.3% vs. 59.9%). On both unadjusted and risk-adjusted analysis, 30-day mortality and overall morbidity were less likely in outpatient versus inpatient operations. CONCLUSION In this large multi-specialty analysis, we found that patients undergoing outpatient surgery had lower risk of 30-day morbidity and mortality than those undergoing the same inpatient operation. Patients having outpatient surgery were generally healthier, suggesting careful patient selection occurred even with increasing outpatient operation frequency. Patients and providers can feel reassured that outpatient operations are a safe, reasonable option for selected patients.
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Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA. .,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.
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12
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de Pablos-Rodríguez P, Suárez Novo J, Castells Esteve M, Bonet Puntí X, Picola Brau N, Abella Serra A, López Picazo E, Cabrera Coma A, Sánchez Allueva A, Vigués Julià F. Resultados preliminares de la implementación de la prostatectomía radical robótica en régimen de cirugía mayor ambulatoria. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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13
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Total Joint Arthroplasty at a Novel “Hyperspecialty” Ambulatory Surgical Center With Extended Care Suites is as Safe as Inpatient Arthroplasty. Arthroplast Today 2022; 16:242-246.e1. [PMID: 36092129 PMCID: PMC9458896 DOI: 10.1016/j.artd.2022.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/26/2022] [Accepted: 05/06/2022] [Indexed: 11/20/2022] Open
Abstract
Background New “hyperspecialty” ambulatory surgical centers (HASCs) have been introduced to deliver safe and cost-efficient care, allowing patients to spend additional nights in an extended care suite before discharge. This study compared the 90-day complications and readmissions of total joint arthroplasty (TJA) at an HASC and inpatient TJA at a tertiary hospital. Methods We retrospectively reviewed 1365 primary, unilateral, TJAs (658 total hip arthroplasty, 707 total knee arthroplasty) performed at 4 HASCs in 2017-2021. Following their outpatient procedure, patients were discharged to an extended care suite staffed full-time by nurses and physical therapists. These patients were matched 1:1 with 1365 inpatient TJAs (628 total hip arthroplasty, 737 total knee arthroplasty) based on demographics, joint, and American Society of Anesthesiologists (ASA) score. Ninety-day complications and readmissions were compared. Results The mean age was 60.0 ± 9.8 years and 59.4 ± 8.1 years in the inpatient and outpatient groups, respectively (P = .106). There was no difference in ASA≥3 patients (16.4% vs 17.7%; P = .387) and operative time (86.9 ± 31.8 vs 88.7 ± 27.9 minutes; P = .118). Five patients (0.4%) in the outpatient group were transferred to an acute hospital. When comparing 90-day outcomes between the inpatient and outpatient groups, there was no difference in pulmonary embolism (0.1% vs 0.0%; P = .317), mechanical complications (0.3% vs 0.7%; P = .165), periprosthetic joint infections (0.5% vs 1.1%; P = .092), or readmissions (1.2% vs 1.5%; P = .513). A subgroup analysis of ASA≥3 patients yielded similar findings. Conclusions Patients undergoing outpatient TJA at a novel HASC had similar complication and readmission rates as those undergoing TJA at a tertiary hospital. Based on these data, such facilities seem appropriate for the care of outpatient TJA patients with ASA<4.
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14
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Dyas AR, Henderson WG, Madsen HJ, Bronsert MR, Colborn KL, Lambert-Kerzner A, McIntyre RC, Meguid RA. Development and validation of a prediction model for conversion of outpatient to inpatient surgery. Surgery 2022; 172:249-256. [PMID: 35216822 DOI: 10.1016/j.surg.2022.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/05/2022] [Accepted: 01/16/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Unplanned hospital admission after intended outpatient surgery is an undesirable outcome. We aimed to develop a prediction model that estimates a patient's risk of conversion from outpatient surgery to inpatient hospitalization. METHODS This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database, 2005 to 2018. Conversion from outpatient to inpatient surgery was defined as having outpatient surgery and >1 day hospital stay. The Surgical Risk Preoperative Assessment System was developed using multiple logistic regression on a training dataset (2005-2016) and compared to a model using the 26 relevant variables in the American College of Surgeons National Surgical Quality Improvement Program. The Surgical Risk Preoperative Assessment System was validated using a testing dataset (2017-2018). Performance statistics and Hosmer-Lemeshow plots were compared. Two high-risk definitions were compared: (1) the maximum Youden index, and (2) the cohort above the tenth decile of risk on the Hosmer-Lemeshow plot. The sensitivities, specificities, positive predictive values, negative predictive values, and accuracies were compared. RESULTS In all, 2,822,379 patients were included; 3.6% of patients unexpectedly converted to inpatient. The 6-variable Surgical Risk Preoperative Assessment System model performed comparably to the 26-variable American College of Surgeons National Surgical Quality Improvement Program model (c-indices = 0.818 vs. 0.823; Brier scores = 0.0308 vs 0.0306, respectively). The Surgical Risk Preoperative Assessment System performed well on internal validation (c-index = 0.818, Brier score = 0.0341). The tenth decile of risk definition had higher specificity, positive predictive values, and accuracy than the maximum Youden index definition, while having lower sensitivity. CONCLUSION The Surgical Risk Preoperative Assessment System accurately predicted a patient's risk of unplanned outpatient-to-inpatient conversion. Patients at higher risk should be considered for inpatient surgery, while lower risk patients could safely undergo operations at ambulatory surgery centers.
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Affiliation(s)
- Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO.
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Helen J Madsen
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO. https://twitter.com/ColbornKathryn
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Robert C McIntyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO. https://twitter.com/MeguidRobert
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15
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Siebert D, Giraudet G, Collinet P, Gonzalez Estevez M, Cosson M, Rubod C. Risk factors for immediate failure of outpatient surgery in gynecologic surgery. Int J Gynaecol Obstet 2022; 159:592-599. [PMID: 35426951 DOI: 10.1002/ijgo.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To describe the risk factors for immediate failure of gynecologic outpatient surgery. The secondary objective was to describe the risk factors for rehospitalization within 30 days after surgery. METHODS This is a single-center retrospective cohort study conducted on all patients operated on in outpatient surgery in gynecology at the Lille University Hospital. The primary outcome was defined as any unanticipated admission to the inpatient postoperative care unit on the day of the operation. The secondary outcome was defined as any rehospitalization within 30 days following the intervention. Our statistical analysis included 916 patients operated on between January and July 2019. RESULTS In our study, 84 patients (9.2%) had an immediate failure of outpatient surgery. The most frequent etiologies were surgical (58.3%). In multivariate analysis with logistic regression, the following variables were associated with an increased risk of immediate failure of outpatient surgery: urogynecologic surgery (P < 0.001), complex laparoscopy (P = 0.004), endometriosis surgery (P < 0.001), and a duration of intervention longer than 1 hour (P < 0.001). CONCLUSION We find an increased risk of immediate failure of gynecologic outpatient surgery depending on the type of surgery as well as for surgeries lasting more than 1 hour.
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Affiliation(s)
- David Siebert
- Lille University Hospital, Gynecologic Surgery Department, Lille, France
| | - Géraldine Giraudet
- Lille University Hospital, Gynecologic Surgery Department, Lille, France
| | - Pierre Collinet
- Lille University Hospital, Gynecologic Surgery Department, Lille, France.,Lille University Hospital, Faculty of Medicine, Lille, France
| | - Max Gonzalez Estevez
- Lille University Hospital, Anesthesia in Gynecology and Obstetrics Department, Lille, France
| | - Michel Cosson
- Lille University Hospital, Gynecologic Surgery Department, Lille, France.,Lille University Hospital, Faculty of Medicine, Lille, France
| | - Chrystèle Rubod
- Lille University Hospital, Gynecologic Surgery Department, Lille, France.,Lille University Hospital, Faculty of Medicine, Lille, France
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16
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Huda A, Alharthi A, Mohammed A, Jamil M, Mehboob A. Evaluation of risk factors for unanticipated hospital admission following ambulatory surgery – An observational study. Saudi J Anaesth 2022; 16:419-422. [DOI: 10.4103/sja.sja_420_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/04/2022] Open
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17
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Rajan N, Rosero EB, Joshi GP. Patient Selection for Adult Ambulatory Surgery: A Narrative Review. Anesth Analg 2021; 133:1415-1430. [PMID: 34784328 DOI: 10.1213/ane.0000000000005605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.
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Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
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18
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Tseng CC, Gao J, Barinsky GL, Grube JG, Fang CH, Eloy JA, Hsueh WD. Inpatient Sinus Surgery Patient Morbidity and Outcomes: A National Analysis. Laryngoscope 2021; 132:1523-1529. [PMID: 34581441 DOI: 10.1002/lary.29881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/25/2021] [Accepted: 09/13/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the morbidity and mortality of patients undergoing endoscopic sinus surgery (ESS) in the inpatient setting. STUDY DESIGN Retrospective database review. METHODS The Nationwide Inpatient Sample was queried for all ESS between 2008 and 2014. Using All Patients Refined Diagnosis Related Groups (APR-DRG) codes, cases with APR-DRG codes under Major Diagnostic Category 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat) were designated as patients with primary otolaryngology diagnoses undergoing ESS (ORL), and all other codes were designated as patients with non-otolaryngology pathologies as their primary reason for admission but undergoing ESS (non-ORL). A univariate analysis and a logistic regression were used to compare patient demographics, comorbidities, disease severity, and mortality. RESULTS There were 8,305 ORL patients and 6,342 non-ORL patients. ORL patients were more likely to be elective admissions (61.3% vs. 48.5%, P < .001), have a deviated nasal septum (17.9% vs. 12.3%, P < .001), nasal polyps (15.8% vs. 5.0%, P < .001), obstructive sleep apnea (10.7% vs. 5.2%, P < .001), and pulmonary disease (15.9% vs. 10.5%, P < .001). Non-ORL patients had a higher likelihood of in-hospital mortality (odds ratio [OR] 6.22, 95% confidence interval [CI] 3.29-11.78, P < .001), length of stay in the highest quartile (OR 2.43, 95% CI 2.16-2.74, P < .001), and a higher proportion had APR-DRG subclasses indicating extreme severity of illness (19.3% vs. 4.3%, P < .001) or extreme risk of mortality (12.5% vs. 2.0%, P < .001). CONCLUSION Patients undergoing ESS in the inpatient setting have a higher than expected mortality rate which can be associated with a non-otolaryngology pathology as the primary reason for their admission. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Christopher C Tseng
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jeff Gao
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Gregory L Barinsky
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jordon G Grube
- Department of Otolaryngology, Albany Medical Center, Albany, New York, U.S.A
| | - Christina H Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Jean A Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center, RWJBarnabas Health, Livingston, New Jersey, U.S.A
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
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19
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Pang G, Kwong M, Schlachta CM, Alkhamesi NA, Hawel JD, Elnahas AI. Safety of Same-day Discharge in High-risk Patients Undergoing Ambulatory General Surgery. J Surg Res 2021; 263:71-77. [PMID: 33639372 DOI: 10.1016/j.jss.2021.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Same-day surgery is an increasingly utilized and cost-effective strategy to manage common surgical conditions. However, many institutions limit ambulatory surgical services to only healthy individuals. There is also a paucity of data on the safety of same-day discharge among high-risk patients. This study aims to determine whether same-day discharge is associated with higher major morbidity and readmission rates compared with overnight stay in high-risk general surgery patients. METHODS This is a retrospective cohort using the data from the National Surgical Quality Improvement Program from 2005 to 2017. Patients with an American Society of Anesthesiologists class ≥3 undergoing general surgical procedures amenable to same-day discharge were identified. Primary and secondary outcomes were major morbidity and readmission at 30 d. A multivariable logistic regression model using mixed effects was used to adjust for the effect of same-day discharge. RESULTS Of 191,050 cases, 137,175 patients (72%) were discharged on the same day. At 30 d, major morbidity was 1.0%, readmission 2.2%, and mortality <0.1%. Adjusted odds ratio of same-day discharge was 0.59 (95% confidence interval 0.54-0.64; P < 0.001) for major morbidity and 0.75 (95% confidence interval 0.71-0.80; P < 0.001) for readmission. Significant risk factors for morbidity and readmission included nonindependent functional status, ascites, renal failure, and disseminated cancer. CONCLUSIONS Major morbidity and readmission rates are low among this large sample of high-risk general surgery patients undergoing common ambulatory procedures. Same-day discharge was not associated with increased adverse events and could be considered in most high-risk patients after uncomplicated surgery.
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Affiliation(s)
- George Pang
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, Ontario, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Michelle Kwong
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, Ontario, Canada
| | - Christopher M Schlachta
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, Ontario, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nawar A Alkhamesi
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, Ontario, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jeffrey D Hawel
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, Ontario, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ahmad I Elnahas
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, Ontario, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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20
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Cabaton J, Thy M, Sciard D, De Paulis D, Beaussier M. Unplanned admission after ambulatory anaesthesia in France: analysis of a database of 36,584 patients. Anaesth Crit Care Pain Med 2020; 40:100794. [PMID: 33359372 DOI: 10.1016/j.accpm.2020.100794] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Unplanned admission (UA) after ambulatory procedures is an unexpected event that has organisational and financial impacts. This study was undertaken to determine the current rate of UA in France and to evaluate the factors associated with the occurrence of this event. METHOD This is a retrospective analysis of a database of 36,584 patients issued from a private hospital in France. This study received an IRB approval. All of the patients that received ambulatory anaesthesia between April 2015 and June 2017 were included in this database. RESULTS The overall rate of UA was 1.8% (95%CI: 1.3-2.3]. Hospitalisation after endoscopic procedures (gastrointestinal endoscopy and bronchial fibroscopy) was 1.1% (95%CI: 0.3-1.9), whereas it was 2.5% (95%CI: 1.8-3.2) after surgical procedures (p < 0.01). Organisational concerns, medical reason and surgical complications accounted respectively for one third of the hospitalisations. Pain was liable in 13% of cases, whereas PONV, residual sedation and urinary retention accounted respectively for 6.9%, 2.8% and 2.6% of cases. In a multivariate analysis, age > 60 years, ASA status > 2, general anaesthesia and the type of the procedures were identified risk factors. CONCLUSIONS In this large cohort of ambulatory patients, the rate of UA remains significant. This is probably related, at least partly, to more invasive procedures scheduled in ambulatory setting. However, organisational problems occurred still frequently. Some factors appear to be easily improvable by appropriate preoperative information, better operating theatre scheduling and better analgesic strategy.
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Affiliation(s)
- Julien Cabaton
- Department of Anaesthesiology, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Michael Thy
- Department of Anaesthesiology, Institut Mutualiste Montsouris, Paris, France
| | - Didier Sciard
- Department of Anaesthesiology, Institut Mutualiste Montsouris, Paris, France
| | - Damien De Paulis
- Department of Anaesthesiology, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Marc Beaussier
- Department of Anaesthesiology, Institut Mutualiste Montsouris, Paris, France.
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21
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Lamblin G, Courtieu C, Bensouda-Miguet C, Panel L, Moret S, Chabert P, Chene G, Nohuz E. Outpatient vaginal surgery for pelvic organ prolapse: a prospective feasibility study. ACTA ACUST UNITED AC 2020; 72:19-24. [PMID: 32153159 DOI: 10.23736/s0026-4784.20.04510-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In the light of recent progress in pelvic organ prolapse surgery, the modalities of hospital admission need reconsidering. This work aims to assess success rate of outpatient (ambulatory) vaginal mesh surgery for genital prolapse. METHODS A prospective observational study was conducted between January 2015 and July 2017, including all patients presenting with POP-Q stage ≥3 anterior and/or apical prolapse. RESULTS Sixty-nine of the 89 eligible patients were treated on an ambulatory basis (group A); 20 required overnight admission (group B): i.e., ambulatory success rate, 77.5%. Mean operative time was 44.9±2.5 min in group A and 62±6.5 min in group B. Reasons for ineligibility for ambulatory management comprised organizational issues at home (10.5%) and excessive home-to-hospital distance (5.7%). The postoperative urinary retention rate was 4.5%. Rates for successful cystocele correction (POP-Q <2) at 2 months were similar in the two groups: 94.2% in group A and 94.4% in group B (P=ns). Mean satisfaction score was 8.6±0.3/10. CONCLUSIONS Outpatient anterior vaginal mesh surgery for prolapse is safe and effective. The current medical-economic context favors ambulatory management. Patient selection, prior information and continuity of care seem primordial.
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Affiliation(s)
- Géry Lamblin
- Department of Gynecological Surgery and Urogynecology, Femme Mere Enfant University Hospital (HFME), Hospices Civils de Lyon, Lyon, France
| | - Christophe Courtieu
- Department of Gynecological Surgery, Beau Soleil Clinic, Montpellier, France
| | - Chloé Bensouda-Miguet
- Department of Gynecological Surgery and Urogynecology, Femme Mere Enfant University Hospital (HFME), Hospices Civils de Lyon, Lyon, France
| | - Laure Panel
- Department of Gynecological Surgery, Beau Soleil Clinic, Montpellier, France
| | - Stéphanie Moret
- Department of Gynecological Surgery and Urogynecology, Femme Mere Enfant University Hospital (HFME), Hospices Civils de Lyon, Lyon, France
| | - Philippe Chabert
- Department of Gynecological Surgery and Urogynecology, Femme Mere Enfant University Hospital (HFME), Hospices Civils de Lyon, Lyon, France
| | - Gautier Chene
- Department of Gynecological Surgery and Urogynecology, Femme Mere Enfant University Hospital (HFME), Hospices Civils de Lyon, Lyon, France
| | - Erdogan Nohuz
- Department of Gynecological Surgery and Urogynecology, Femme Mere Enfant University Hospital (HFME), Hospices Civils de Lyon, Lyon, France -
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Mihailescu SD, Maréchal I, Thillard D, Gillibert A, Compère V. Socioenvironmental criteria and postoperative complications in ambulatory surgery in a French university hospital: a prospective cross-sectional observational study. BMJ Open 2020; 10:e036795. [PMID: 33247006 PMCID: PMC7703412 DOI: 10.1136/bmjopen-2020-036795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Ambulatory surgery lowers hospitalisation costs, shortens the time to return to work but requires caution regarding socioenvironmental risk factors for complications and rehospitalisation. METHODS This was a single-centre prospective cross-sectional observational study conducted in a university hospital centrein January 2017. The primary objective was to assess the rate of conversion from ambulatory surgery to conventional hospitalisation or emergency department visit within 30 days following discharge from ambulatory unit. Secondary objectives were to describe the socioenvironmental characteristics of outpatients and to identify risk factors for severe postoperative complications. RESULTS 598 outpatients were included. The most represented surgical specialties were ophthalmology (23.5%), gynaecology (19%) and orthopaedics (17.7%). Patients' mean age was 50.8 years (SD, 19.8) and the male/female sex ratio was 0.68. There were 22 (3.68%, 95% CI 2.32% to 5.52%) severe complications, including 11 (1.84%, 95% CI 0.92% to 3.27%) conversions to conventional hospitalisation and 11 (1.84%) conversions to emergency department visit, 3 of which led to readmission. Regarding socioenvironmental characteristics, 116 outpatients (19.7%) lived alone but were not isolated and 15 (2.6%) lived alone and were socially isolated. Following ambulatory surgery, 9 outpatients (1.6%) returned home on foot, 20 (3.4%) by public transportation and 8 (1.4%) drove home; 133 outpatients (13.7%) were alone the first night following surgery. Severe complication rates were not significantly different according to socioenvironmental subgroups. CONCLUSION In our study, the prevalence of severe complications was low, conforming to the literature. The study was underpowered to estimate the effect of socioenvironmental variables.
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Affiliation(s)
- Sorina-Dana Mihailescu
- Rouen University Hospital, Unit for the Prevention of Care-Associated Risks, Rouen, France
| | - Isabelle Maréchal
- Rouen University Hospital, Unit for the Prevention of Care-Associated Risks, Rouen, France
| | - Denis Thillard
- Rouen University Hospital, Unit for the Prevention of Care-Associated Risks, Rouen, France
| | - André Gillibert
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Vincent Compère
- Department of Anesthesia and Intensive Care, Normandie Univ, UNIROUEN, Inserm U 982, Rouen University Hospital, Rouen, France
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Abstract
PURPOSE OF REVIEW This article describes the processes for identifying high-risk patients at the time of ambulatory procedure scheduling, enabling the implementation of multidisciplinary collaborative pathways for prehabilitation and optimization, allowing for risk mitigation and improvement in outcomes. This review is particularly relevant because of the current proliferation of ambulatory surgery with more complex procedures being performed on an outpatient basis on patients who may be American Society of Anesthesiologists Physical Status 3 or greater. RECENT FINDINGS Increased longevity and rising prevalence of obesity have resulted in patients with a wide variety of comorbidities presenting for complex ambulatory procedures with the expectation of rapid recovery and same-day discharge to home. Recent literature highlights the importance of patient preparation, value-based healthcare, patient outcomes, and the role of anesthesiologists as perioperative physicians. SUMMARY The focus of this article is on general principles and establishment of best practices based on current evidence and a brief description of anesthetic management of specific comorbidities. This review will provide guidance to the practicing anesthesiologist on identifying, stratifying, optimizing, and managing high-risk patients in the ambulatory setting.
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Peuchot J, Allard E, Dureuil B, Veber B, Compère V. Efficiency of Text Message Contact on Medical Safety in Outpatient Surgery: Retrospective Study. JMIR Mhealth Uhealth 2020; 8:e14346. [PMID: 32909948 PMCID: PMC7516679 DOI: 10.2196/14346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 10/24/2019] [Accepted: 05/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Establishing pre- and postoperative contact with patients is part of successful medical management in outpatient surgery. In France, this is mostly done via telephone. Automated information with short message service (SMS) reminders might be an interesting alternative to increase the rate of compliance with preoperative instructions, but no study has shown the safety of this approach. OBJECTIVE The objective of this study was to evaluate the impact of pre- and postoperative automated information with SMS reminders on medical safety in outpatient surgery. METHODS We conducted a retrospective, single-center, nonrandomized, controlled study with a before-after design. All adult patients who had outpatient surgery between September 2016 and December 2017 in our university hospital center were included. Before April 2017, patients were contacted by telephone by an outpatient surgery nurse. After April 2017, patients were contacted by SMS reminder. All patients were contacted the day before and the day after surgery. Patients contacted by SMS reminder were also contacted on day 7 after surgery. The primary end point was the conversion rate to full-time hospitalization. Secondary end points were hospitalization causes (anesthetic, surgical, organizational) and hospitalization costs. RESULTS A total of 4388 patients were included, 2160 before and 2228 after the introduction of SMS reminders. The conversion rate to full-time hospitalization was 34/4388 (0.77%) with a difference between SMS group (8/2228, 0.36%) and telephone group (26/2160, 1.20%). The cost of SMS reminders was estimated as half that of telephone calls. CONCLUSIONS In this work, we report a decrease in the rate of conversion to full-time hospitalization with the use of pre- and postoperative SMS reminders. This new approach could represent a safe and cost-effective method in an outpatient surgery setting.
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Affiliation(s)
- Jeremy Peuchot
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | | | - Bertrand Dureuil
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | - Benoit Veber
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | - Vincent Compère
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France.,Day Surgery Unit, Rouen University Hospital, France.,Normandie University, Institut National de la Santé et de la Recherche Médicale Unité 982, Rouen, France
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25
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Joshi GP, Vetter TR. Unanticipated Hospital Admission After Ambulatory Surgery: The Devil Is in the Details. Anesth Analg 2020; 131:494-496. [DOI: 10.1213/ane.0000000000004947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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26
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Reeves JJ, Mannix E, Burton BN, Gabriel RA, Waterman RS. Functional status as a marker of need for hospital admission following outpatient hernia repair. J Perioper Pract 2020; 31:175-180. [PMID: 32609068 DOI: 10.1177/1750458920925346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The careful selection of patients for hernia repair in ambulatory surgery centres is critical to prevent unanticipated inpatient admissions. The aim of this study was to evaluate risk factors associated with inpatient admission. METHODS A multivariable logistic regression was performed utilising the ACS NSQIP database from 2007 to 2016. The primary outcome was same-day hospital discharge. The primary exposure variable was preoperative functional status. Additional covariates included sex, obesity, age, smoking status, steroid use, dyspnoea, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, hypertension, bleeding disorder, dialysis-dependence and American Society of Anesthesiologists classification score. RESULTS A total of 194,822 patients underwent hernia repair in the outpatient setting; 8705 (4.5%) required hospital admission. The variables with the most significantly increased odds for hospital admission were partially dependent and totally dependent preoperative functional status. CONCLUSION A non-independent baseline functional status is the strongest predictor of need for admission following outpatient hernia repair.
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Affiliation(s)
- J Jeffery Reeves
- Department of Surgery, University of California, San Diego, CA, USA
| | - Emily Mannix
- San Diego School of Medicine, University of California, La Jolla, CA, USA
| | - Brittany N Burton
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA.,Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
| | - Ruth S Waterman
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
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Uzumcugil F, Ankay Yilbas A, Akca B, Ozkaragoz DB, Adiloğlu S, Tuz HH, Kanbak M. Overnight hospital stay and/or extended recovery period may allow long-duration oral and maxillofacial surgeries in the operating room of a dental hospital in an outpatient setting: a single-center experience. J Korean Assoc Oral Maxillofac Surg 2020; 46:125-132. [PMID: 32364352 PMCID: PMC7222620 DOI: 10.5125/jkaoms.2020.46.2.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 12/18/2022] Open
Abstract
Objectives The requirement for overnight hospital stay should be considered preoperatively according to patient-related factors, type of surgery, and anesthetic management plan. In this study, we aimed to define the major factors that influence consideration of overnight hospital stay in patients undergoing oral and maxillofacial (OMF) surgery in an operating room (OR) of a dental hospital in an outpatient setting. Materials and Methods The records of patients who underwent oral procedures under general anesthesia between 2014-2017 were reviewed. Results A total of 821 patients underwent oral procedures under general anesthesia; 631 of them underwent OMF surgery in the OR of a dental hospital, and 174 of these patients were hospitalized for overnight stay. There was no significant difference in the number of patients with comorbidities between the outpatient and hospitalized patient groups (P=0.389). The duration of surgery was longer in the hospitalized patient group (105.25±57.48 vs 189.62±82.03 minutes; P<0.001). Double-jaw (n=15; 310.00±54.21 minutes) and iliac crest grafting surgeries (n=59; 211.86±61.02 minutes) had the longest durations. Patients who underwent iliac crest grafting had the highest rates of hospitalization (79%). The overall recovery period was longer in outpatients (119.40±41.60 vs 149.83±52.04; P<0.001). Conclusion Duration of surgery was the main determinant in considering whether a patient required overnight hospital stay. However, patients with an American Society of Anesthesiology physical status score <3 may be scheduled for OMF surgery in the OR of a dental hospital in an outpatient setting regardless of duration of surgery if overnight hospital stay is planned or an extended recovery period is provided until patients meet the discharge criteria.
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Affiliation(s)
- Filiz Uzumcugil
- Department of Anesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey
| | - Aysun Ankay Yilbas
- Department of Anesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey
| | - Basak Akca
- Department of Anesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey
| | - Demet Basak Ozkaragoz
- Department of Anesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey
| | - Selen Adiloğlu
- Department of Oral and Maxillofacial Surgery, Hacettepe University Faculty of Dentistry, Ankara, Turkey
| | - Hıfzı Hakan Tuz
- Department of Oral and Maxillofacial Surgery, Hacettepe University Faculty of Dentistry, Ankara, Turkey
| | - Meral Kanbak
- Department of Anesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey
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Obesity and unanticipated hospital admission following outpatient laparoscopic cholecystectomy. Surg Endosc 2020; 35:1348-1354. [DOI: 10.1007/s00464-020-07514-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022]
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Ruohoaho UM, Toroi P, Hirvonen J, Aaltomaa S, Kokki H, Kokki M. Implementation of a 23-h surgery model in a tertiary care hospital: a safe and feasible model with high patient satisfaction. BJS Open 2020; 4:391-399. [PMID: 32109004 PMCID: PMC7260407 DOI: 10.1002/bjs5.50267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/01/2020] [Accepted: 01/19/2020] [Indexed: 02/03/2023] Open
Abstract
Background The 23‐h surgery model consists of elective operative care with an overnight hospital stay for patients unsuitable for day case surgery. The aim of this study was to assess the success of the 23‐h surgery model. Methods This was a prospective follow‐up study of patients undergoing surgery with the planned 23‐h model in a tertiary‐care university hospital during a 12‐month period 2 years after the model was implemented. Patients were interviewed 2 weeks after surgery, and the hospital operative database and patient records were searched. The primary outcome was the success of the process, defined as discharge before 10.00 hours on the first morning after surgery. Secondary outcomes were 30‐day readmission and reoperation rates, adverse events, and patient satisfaction with the process. Results Between May 2017 and May 2018, 993 adult patients underwent surgery with the 23‐h model, of whom 937 adhered to the model as planned (success rate 94·4 per cent). Gynaecological, gastrointestinal and orthopaedic surgery were the three most common surgical specialties. The surgical process was changed to an in‐hospital model for 45 patients (4·5 per cent), and 11 (1·1 per cent) were discharged on the day of surgery. The readmission rate was 1·9 per cent (19 of 993), and five patients (0·5 per cent) had a reoperation within 30 days of surgery. Fifty‐nine adverse events were noted in 53 patients (5·3 per cent), most commonly infection. Patient satisfaction was a median of 6–7 (maximum 7) points for various aspects of the model. Conclusion The success rate and patient satisfaction for the 23‐h surgery model was
high.
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Affiliation(s)
- U-M Ruohoaho
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | - P Toroi
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | - J Hirvonen
- Controller Unit, Kuopio University Hospital, Kuopio, Finland
| | - S Aaltomaa
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - H Kokki
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - M Kokki
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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Perioperative Risks Are Similar for Normal versus Selected High-Body Mass Index Patients Undergoing Outpatient Hand and Elbow Surgery. Plast Reconstr Surg 2020; 144:836e-840e. [PMID: 31688759 DOI: 10.1097/prs.0000000000006152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many ambulatory surgery centers use body mass index as a screening tool to make admissions decisions because of complication risks associated with high-body mass index patients. The objective of this investigation was to evaluate perioperative complications in a cohort of high-body mass index patients undergoing hand and elbow surgery at an ambulatory surgery center. The authors' hypothesis was that anesthesia-related complications for this cohort would be similar to those of a normal-body mass index group. METHODS The authors retrospectively reviewed data from all hand and elbow procedures performed on patients with a high body mass index (>40 kg/m). One hundred eighty-nine high-body mass index patients and 189 normal-body mass index patients were included in the analysis. RESULTS The average weight-based dosage of propofol was similar in both groups but was lower in the high-body mass index group for midazolam and fentanyl. Two high-body mass index patients had oxygen desaturations in the postanesthesia care unit. No patients developed complications related to anesthesia. In the high-body mass index group, one patient developed hypotension in the postanesthesia care unit, was admitted to the emergency room for monitoring, but was discharged the following morning. CONCLUSIONS Outpatient hand surgical care of high-body mass index patients can be performed safely. Body mass index alone should not be considered as an absolute contraindication for surgery. Careful patient selection, evaluation of comorbidities, and close involvement of the anesthesia and medical teams are critical. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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31
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The association of body mass index with same-day hospital admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy: A national registry analysis. J Clin Anesth 2020; 59:26-31. [DOI: 10.1016/j.jclinane.2019.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/08/2019] [Accepted: 06/02/2019] [Indexed: 11/19/2022]
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery.
Methods
We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators.
Results
We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups.
Conclusions
In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant.
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Recovery and discharge criteria after ambulatory anesthesia: can we improve them? Curr Opin Anaesthesiol 2019; 32:698-702. [DOI: 10.1097/aco.0000000000000784] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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34
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Mudumbai SC, Pershing S, Bowe T, Kamal RN, Sears ED, Finlay AK, Eisenberg D, Hawn MT, Weng Y, Trickey AW, Mariano ER, Harris AHS. Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC Health Serv Res 2019; 19:859. [PMID: 31752856 PMCID: PMC6868867 DOI: 10.1186/s12913-019-4640-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/15/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes. METHODS Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator. RESULTS Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.
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Affiliation(s)
- Seshadri C Mudumbai
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94402, USA. .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA. .,Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.
| | - Suzann Pershing
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Ophthalmology, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Thomas Bowe
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA
| | - Robin N Kamal
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Orthopaedic Surgery, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Erika D Sears
- Department of Surgery, Section of Plastic Surgery at the University of Michigan, 2101 Taubman Center 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA
| | - Dan Eisenberg
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Mary T Hawn
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Yingjie Weng
- Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Amber W Trickey
- Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94402, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Alex H S Harris
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
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Rodriguez LV. Anesthesia for Ambulatory and Office-Based Ear, Nose, and Throat Surgery. Otolaryngol Clin North Am 2019; 52:1157-1167. [PMID: 31551126 DOI: 10.1016/j.otc.2019.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
With today's technological advances in outpatient surgery, anesthetic technique does not differ significantly between inpatient and outpatient settings. It is important to decide which setting is most appropriate for the patient based on the surgeon's ability, the patient's comorbidities, the facility resources, and the staff who will provide care for the patient. Matching all of the above can lead to good outcomes, less complications, and a good patient experience.
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Affiliation(s)
- Leopoldo V Rodriguez
- Society for Ambulatory Anesthesiology (SAMBA); ASA Committee on Ambulatory Surgical Care; Surgery Center of Aventura, Aventura, FL, USA; Envision Physician Services, 7700 West Sunrise Boulevard, Plantation, FL 33322, USA.
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Van Caelenberg E, De Regge M, Eeckloo K, Coppens M. Analysis of failed discharge after ambulatory surgery: unanticipated admission. Acta Chir Belg 2019; 119:139-145. [PMID: 29848193 DOI: 10.1080/00015458.2018.1477488] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Advantages of ambulatory surgery are lost when patients need an unplanned admission. This retrospective cohort study investigated reasons for failed discharge and unanticipated admission of adult patients after day surgery. METHODS Ambulatory patients (n = 145) requiring unanticipated admission were compared to patients (n = 4980) not requiring admission and timely discharged from a total of 5156 ambulatory surgical procedures. Demographic data, organisational data, reason for admission, type of anesthesia, surgical discipline, length of procedure, ASA classification, surgical completion time and severity of illness score were collected from both groups. Reason for admission was classified according to four subtypes. Logistic regression analysis was used. RESULTS Incidence of unanticipated admission following day care surgery was 2.89%. The reasons for admission were mainly organisational issues (45.52%), time of completion surgery in the afternoon between 12 pm and 3 pm (OR 1.73; 95% CI 1.05-2.86) and surgery that ends after 3 pm (OR 6.52; 95% CI 4.11-10.34). Surgical factors associated with unanticipated admission (38.62%) were length of surgery of one to three hours (OR 2.05; 95% CI 1.27-3.29), length of surgery more than three hours (OR 8.31; 95% CI 3.56-19.40). Additionally, anaesthetic (10.34%) and medical (5.52%) reasons were found, e.g. ASA class II (OR 1.61; 95% CI 1.06-2.44), ASA class III (OR 2.19; 95% CI 1.10-4.34); moderate severity of illness score (OR 1.72; 95% CI 1.03-2.88) and major of severity of illness score (OR 7.85; 95% CI 2.31-26.62). CONCLUSIONS Unanticipated admissions following day surgery occur mainly due to social/organisational and surgical reasons. However, medical and anaesthetic reasons also explain 15.86% of the unanticipated admissions.
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Affiliation(s)
| | - Melissa De Regge
- Strategic Policy Cell, Ghent University Hospital, Ghent, Belgium
- Department of Innovation, Entrepreneurship, and Service Management, Faculty of Economics and Business Administration, Ghent University, Ghent, Belgium
| | - Kristof Eeckloo
- Strategic Policy Cell, Ghent University Hospital, Ghent, Belgium
- Department of Public health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Marc Coppens
- Ambulatory Surgery Centre, Ghent University Hospital, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Anesthesiology and Perioperative Medicine, Ghent University, Ghent, Belgium
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Suitability of outpatient or ambulatory extended recovery cancer surgeries for obese patients. J Clin Anesth 2019; 58:111-116. [PMID: 31154282 DOI: 10.1016/j.jclinane.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/25/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE An increasing number of overweight and obese patients are presenting for ambulatory surgical procedures and may be at risk of complications including longer surgeries, longer length of stay (LOS), and possible increase in unanticipated return visits or hospital admissions. DESIGN Observational study using prospectively-collected data. SETTING Freestanding and hospital-based ambulatory surgery facilities. PATIENTS AND INTERVENTIONS 13,957 patients underwent ambulatory cancer surgery procedures at the Josie Robertson Surgery Center (JRSC) since opening in 2016, and 4591 patients eligible for ambulatory surgery at JRSC underwent surgery at the main hospital during the same timeframe. MEASUREMENTS We assessed whether BMI was associated with increased operative time, post-operative LOS, hospital transfer after surgery, or hospital readmission or urgent care center visits within 30 days. Using multivariable logistic regression, we assessed whether BMI was associated with decision to do surgery at JRSC controlling for age, ASA score and surgical service. MAIN RESULTS While higher BMI was associated with a higher rate of transfer out of JRSC (p = 0.014), the difference in rate was small (mean risk 0.8% for BMI 25 vs 1.3% for BMI 40, difference in risk 0.52%, 95% CI 0.05%, 1.0%). We found no evidence that higher BMI increased the risk of urgent care visits or readmissions within 30 days or outpatient LOS (p = 0.7 for all). There was a statistically but not clinically significant difference in operative time for outpatient procedures (p = <0.0001), with a mean operative time of 59 vs 63 min for BMI 25 vs 40. Ambulatory extended recovery patients with higher BMI had shorter operative times (p < 0.0001). Patients with higher BMI were not significantly less likely to undergo surgery at JRSC (84% vs 83% vs 82% probability of treatment at JRSC for BMI 25, BMI 40 or BMI 50, respectively, p = 0.089). CONCLUSIONS Ambulatory cancer surgeries can be performed safely among clinically eligible patients. Patients with BMI up to 50 or more can be treated safely in an ambulatory setting if they otherwise meet eligibility criteria.
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Dasinger EA, Branch-Elliman W, Pizer SD, Abdulkerim H, Rosen AK, Charns MP, Hawn MT, Itani KMF, Mull HJ. Association between postoperative opioid use and outpatient surgical adverse events. Am J Surg 2019; 217:605-612. [PMID: 30639132 DOI: 10.1016/j.amjsurg.2018.12.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Opioid-related adverse drug events are common following inpatient surgical procedures. Little is known about opioid prescribing after outpatient surgical procedures and if opioid use is associated with short term risks of outpatient surgical adverse events (AEs). METHODS VA Corporate Data Warehouse was used to identify opioid use within 48 h for FY2012-14 chart-reviewed cases from a larger VA study of AEs in outpatient surgeries. We estimated a multilevel logistic regression model to determine the effect of opioid exposure on risk of AEs between 2 and 30 days postoperatively. RESULTS Of the 1730 outpatient surgical cases, 628 (36%) had postoperative opioid use and 12% had an AE. Opioid use following outpatient surgery was not significantly associated with higher surgical AE rates after controlling for relevant covariates (OR = 1.1 95% CI 0.79-1.54). Only procedure RVUs were associated with higher odds of postoperative AEs. CONCLUSIONS Postoperative opioid use following outpatient surgery is not a significant driver of postoperative AEs.
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Affiliation(s)
- Elise A Dasinger
- VA Quality Scholars Program, Birmingham VA Medical Center, Birmingham, AL, United States.
| | - Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Medicine, VA Boston Healthcare System, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Steven D Pizer
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, MA, United States; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Hassen Abdulkerim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States
| | - Martin P Charns
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Mary T Hawn
- Palo Alto VA Medical Center, Palo Alto, CA, United States; Stanford University School of Medicine, Stanford, CA, United States
| | - Kamal M F Itani
- Harvard Medical School, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States; Department of Surgery, VA Boston Healthcare System, Boston, MA, United States
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States
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Improving outcomes in ambulatory anesthesia by identifying high risk patients. Curr Opin Anaesthesiol 2018; 31:659-666. [DOI: 10.1097/aco.0000000000000653] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Lee JW. Considerations in treating obese patients in office-based anesthesia. Minerva Anestesiol 2018; 84:1318-1322. [DOI: 10.23736/s0375-9393.18.12670-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Van Orden K, Farber A, Schermerhorn ML, Goodney PP, Kalish JA, Jones DW, Rybin D, Siracuse JJ. Local anesthesia for percutaneous endovascular abdominal aortic aneurysm repair is associated with fewer pulmonary complications. J Vasc Surg 2018; 68:1023-1029.e2. [DOI: 10.1016/j.jvs.2017.12.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/15/2017] [Indexed: 12/17/2022]
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Surve A, Cottam D, Zaveri H, Cottam A, Belnap L, Richards C, Medlin W, Duncan T, Tuggle K, Zorak A, Umbach T, Apel M, Billing P, Billing J, Landerholm R, Stewart K, Kaufman J, Harris E, Williams M, Hart C, Johnson W, Lee C, Lee C, DeBarros J, Orris M, Schniederjan B, Neichoy B, Dhorepatil A, Cottam S, Horsley B. Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies. Surg Obes Relat Dis 2018; 14:1442-1447. [DOI: 10.1016/j.soard.2018.05.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 12/12/2022]
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Yuki K, Koutsogiannaki S, Lee S, DiNardo JA. Unanticipated hospital admission in pediatric patients with congenital heart disease undergoing ambulatory noncardiac surgical procedures. Paediatr Anaesth 2018; 28:607-611. [PMID: 29777565 DOI: 10.1111/pan.13388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND An increasing number of surgical and nonsurgical procedures are being performed on an ambulatory basis in children. Analysis of a large group of pediatric patients with congenital heart disease undergoing ambulatory procedures has not been undertaken. AIMS The objective of this study was to characterize the profile of children with congenital heart disease who underwent noncardiac procedures on an ambulatory basis at our institution, to determine the incidence of adverse cardiovascular and respiratory adverse events, and to determine the risk factors for unscheduled hospital admission. METHODS This is a retrospective study of children with congenital heart disease who underwent noncardiac procedures on an ambulatory basis in a single center. Using the electronic preoperative anesthesia evaluation form, we identified 3010 patients with congenital heart disease who underwent noncardiac procedures of which 1028 (34.1%) were scheduled to occur on an ambulatory basis. Demographic, echocardiographic and functional status data, cardiovascular and respiratory adverse events, and reasons for postprocedure admission were recorded. Univariable analysis was conducted. RESULTS The unplanned hospital admission was 2.7% and univariable analysis demonstrated that performance of an echocardiogram within 6 mo of the procedure and procedures performed in radiology were associated with postoperative admission. Cardiovascular adverse event incidence was 3.9%. Respiratory adverse event incidence was 1.8%. CONCLUSION Ambulatory, noncomplex procedures can be performed in pediatric patients with congenital heart disease and good functional status with a relatively low unanticipated hospital admission rate.
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Affiliation(s)
- Koichi Yuki
- Department of Anaesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, MA, USA
| | - Sophia Koutsogiannaki
- Department of Anaesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, MA, USA
| | - Sandra Lee
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, MA, USA
| | - James A DiNardo
- Department of Anaesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, MA, USA
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Kingery MT, Cuff GE, Hutzler LH, Popovic J, Davidovitch RI, Bosco JA. Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur. J Arthroplasty 2018; 33:6-9. [PMID: 28870744 DOI: 10.1016/j.arth.2017.07.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/13/2017] [Accepted: 07/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.
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Affiliation(s)
- Matthew T Kingery
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Germaine E Cuff
- Department of Anesthesiology, NYU Langone Medical Center, Perioperative Care and Pain Medicine, New York, New York
| | - Lorraine H Hutzler
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Jovan Popovic
- Department of Anesthesiology, NYU Langone Medical Center, Perioperative Care and Pain Medicine, New York, New York
| | - Roy I Davidovitch
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
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Teunkens A, Vanhaecht K, Vermeulen K, Fieuws S, Van de Velde M, Rex S, Bruyneel L. Measuring satisfaction and anesthesia related outcomes in a surgical day care centre: A three-year single-centre observational study. J Clin Anesth 2017; 43:15-23. [PMID: 28964960 DOI: 10.1016/j.jclinane.2017.09.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/01/2017] [Accepted: 09/24/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To evaluate patient satisfaction and patient reported anaesthesia related outcome parameters after outpatient surgery. DESIGN A three-year (2013-2016) observational study. SETTING A surgical day care centre embedded in a tertiary care, university hospital. PATIENTS Adult Dutch-speaking patients who underwent surgery under general or regional anaesthesia on an outpatient basis (n=5424). INTERVENTIONS A questionnaire was developed to evaluate patients' satisfaction with care during their hospitalisation in the surgical day centre, as well as to assess their reports of anaesthesia related outcomes. MEASUREMENTS Various aspects of care were measured, including care by nurses, care by doctors, organisational and safety items. Variation in satisfaction and surgery and anaesthesia related outcomes as a function of different categories (gender, age, education, type of anaesthesia, discipline and era) were also investigated. MAIN RESULTS Confirmatory factor analysis showed an excellent fit to the hypothesized factors of the survey. Satisfaction scores were very high for different aspects of care, resulting in 98% of patients being (very) satisfied (59.1% very satisfied, 38.9% satisfied). Male (p=0.0003), higher educated (p<0.0001) and older patients (p<0.0001) were more likely to be very satisfied. Postoperative nausea and vomiting (PONV) were frequent (nausea: 13.9%, vomiting: 3.3%), and more present in female than in male patients (p<0.0001). Pain scores at the PACU differed among disciplines (p<0.0001) were higher in female patients compared to male patients (3.41% versus 2.54%, p<0.0001) and after general anaesthesia compared to regional anaesthesia (3.25% versus 0.39%, p<0.0001) and decreased with higher age (p=0.0001) and education level (p=0.0033). CONCLUSIONS Whereas satisfaction with all aspects of care is generally high, the results regarding pain and PONV should inspire quality improvement initiatives. The questionnaire developed in this study can be a vehicle to assess and improve the quality of care in surgical day care centres.
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Affiliation(s)
- An Teunkens
- Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
| | - Kristien Vermeulen
- Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Steffen Fieuws
- I-Biostat, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
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Mortuaire G, Theis D, Fackeure R, Chevalier D, Gengler I. Cost-effectiveness assessment in outpatient sinonasal surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2017; 135:11-15. [PMID: 28927846 DOI: 10.1016/j.anorl.2017.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS To assess the cost-effectiveness of outpatient sinonasal surgery in terms of clinical efficacy and control of expenses. METHODS A retrospective study was conducted from January 2014 to January 2016. Patients scheduled for outpatient sinonasal surgery were systematically included. Clinical data were extracted from surgical and anesthesiology computer files. The cost accounting methods applied in our institution were used to evaluate logistic and technical costs. The standardized hospital fees rating system based on hospital stay and severity in diagnosis-related groups (Groupes homogènes de séjours: GHS) was used to estimate institutional revenue. RESULTS Over 2years, 927 outpatient surgical procedures were performed. The crossover rate to conventional hospital admission was 2.9%. In a day-1 telephone interview, 85% of patients were very satisfied with the procedure. All outpatient cases showed significantly lower costs than estimated for conventional management with overnight admission, while hospital revenue did not differ between the two. CONCLUSION This study confirmed the efficacy of outpatient surgery in this indication. Lower costs could allow savings for the health system by readjusting the rating for the procedure. More precise assessment of cost-effectiveness will require more fine-grained studies based on micro costing at hospital level and assessment of impact on conventional surgical activity and post-discharge community care.
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Affiliation(s)
- G Mortuaire
- Service d'ORL de chirurgie cervico-faciale, hôpital Huriez, CHRU de Lille, 59000 Lille, France; Inserm U995, Lille Inflammation Research International Center, université de Lille, Lille, France.
| | - D Theis
- Département d'information médicale, université de Lille, Lille, France
| | - R Fackeure
- Département d'anesthésie, université de Lille, Lille, France
| | - D Chevalier
- Service d'ORL de chirurgie cervico-faciale, hôpital Huriez, CHRU de Lille, 59000 Lille, France
| | - I Gengler
- Service d'ORL de chirurgie cervico-faciale, hôpital Huriez, CHRU de Lille, 59000 Lille, France; Inserm U995, Lille Inflammation Research International Center, université de Lille, Lille, France
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Rosero EB, Joshi GP. Hospital readmission after ambulatory laparoscopic cholecystectomy: incidence and predictors. J Surg Res 2017; 219:108-115. [PMID: 29078868 DOI: 10.1016/j.jss.2017.05.071] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/22/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy. MATERIALS AND METHODS The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions. RESULTS A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions. CONCLUSIONS This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Arnal Velasco D, Romero García E, Martínez Palli G, Muñoz Corsini L, Rey Martínez M, Postigo Morales S. [Patient safety recommendations for out of operating room procedure sedation]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2017; 32:155-165. [PMID: 27641104 DOI: 10.1016/j.cali.2016.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 07/18/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. METHOD We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. RESULTS The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. CONCLUSION We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare.
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Affiliation(s)
- D Arnal Velasco
- Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
| | - E Romero García
- Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Hospital Universitario La Fe, Valencia, España
| | - G Martínez Palli
- Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Hospital Clínic y Centro de Investigaciones IDIBAPS, Barcelona, España
| | - L Muñoz Corsini
- Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Hospital Universitario de Guadalajara, Guadalajara, España
| | - M Rey Martínez
- Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Hospital Povisa, Vigo, Pontevedra, España
| | - S Postigo Morales
- Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Hospital de Galdakao, Usansolo, Bizkaia, España
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Abstract
PURPOSE OF REVIEW Given the growing number of ambulatory surgeries being performed and the variability in postoperative pain requirements, early discharge, and inconsistent follow-up, ambulatory surgery presents a unique challenge for this patient population and warrants the presence of an ambulatory pain specialist to evaluate a patient preoperatively and postoperatively to optimize patient safety and satisfaction. This article explores the crucial role that a dedicated pain physician would have in the ambulatory surgery setting. RECENT FINDINGS The prevalence of chronic pain, opioid use, and substance abuse is growing in this country, while ambulatory and same-day surgery have also experienced considerable growth. Inevitably, more patients with challenging chronic pain or substance abuse are having ambulatory surgery. Increased BMI, advanced age, more comorbidities warranting a higher ASA physical status classification, and longer surgeries are now all components of ambulatory surgery that contribute to increased risk too. Certain surgeries including breast surgery, inguinal hernia repair, and thoracotomy are at higher risk for the conversion of acute to chronic pain, and an ambulatory pain specialist would be beneficial for added focus on these patients. Multimodal pain control with non-opioids and regional anesthesia adjuvants are beneficial, while emphasis on a patient's functional capacity may be more useful than quantifying the severity of pain. Despite the best efforts of patients' primary care providers or surgeons, patients often are discharged with more chronic opioid therapy than they presented with, and an ambulatory pain specialist can help manage the complications and prevent further escalation of this opioid epidemic. An onsite anesthesiologist with interest in pain management in each ambulatory surgery center administering anesthesia and available onsite to deal with immediate preoperative, intraoperative, and recovery room would be ideal to curb and manage complication from uncontrolled pain and related pain issues.
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