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Heo KY, Bonsu JM, Khawaja S, Karzon A, Rajan PV, Barber LA, Yoon ST. Database analysis comparing incidence and complication rates between inpatient and outpatient laminotomies for lumbar disc herniation. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100328. [PMID: 38966040 PMCID: PMC11222817 DOI: 10.1016/j.xnsj.2024.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 07/06/2024]
Abstract
Background Lumbar disc herniation (LDH) is a common condition that can be characterized with disabling pain. While most patients recover without surgery, some still require operative intervention. The epidemiology and trends of laminotomy for LDH have not been recently studied, and current practice patterns might be different from historical norms. This study aimed to investigate the trends of inpatient and outpatient laminotomies for LDH and compare complication rates between these two sites of service. Methods A large, national database was utilized to identify patients > 8 years old who underwent a laminotomy for LDH between 2009 and 2019. Two cohorts were created based on site of surgery: inpatient versus outpatient. The outpatient cohort was defined as patients who had a length of stay less than 1 day without any associated hospitalization. Epidemiologic analyses for these cohorts were performed by demographics. Patients in both groups were then 1:1 propensity-score matched based on age, sex, insurance type, geographic region, and comorbidities. Ninety-day postoperative complications were compared between cohorts utilizing multivariate logistic regressions. Results The average incidence of laminotomy for LDH was 13.0 per 10,000 persons-years. Although the national trend in incidence had not changed from 2009 to 2019, the proportion of outpatient laminotomies significantly increased in this time period (p=.02). Outpatient laminotomies were more common among younger and healthier patients. Patients with inpatient laminotomies had significantly higher rates of surgical site infections (odds ratio [OR] 1.61, p<.001), venous thromboembolism (VTE) (OR 1.96, p<.001), hematoma (OR 1.71, p<.001), urinary tract infections (OR 1.41, p<.001), and acute kidney injuries (OR 1.75, p=.001), even when controlling for selected confounders. Conclusions Our study demonstrated an increasing trend in the performance of laminotomy for LDH toward the outpatient setting. Even when controlling for certain confounders, patients requiring inpatient procedures had higher rates of postoperative complications. This study highlights the importance of carefully evaluating the advantages and disadvantages of performing these procedures in an outpatient versus inpatient setting.
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Affiliation(s)
- Kevin Y. Heo
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Janice M. Bonsu
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Sameer Khawaja
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Anthony Karzon
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Prashant V. Rajan
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Lauren A. Barber
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Sangwook Tim Yoon
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
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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 PMCID: PMC11331359 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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Hui LT, St Pierre D, Miller RS. Frail Patients Undergoing Optimization Before Surgery: Preliminary Results. J Am Coll Surg 2024; 238:577-586. [PMID: 38205921 DOI: 10.1097/xcs.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND It is estimated that 10% or more of patients older than 65 years are affected by frailty, a mental and physical state of vulnerability to adverse surgical outcomes. Frailty can be assessed using the Edmonton Frailty Scale: a reliable and convenient multidimensional assessment before surgery. The correlation between frailty score, presurgical optimization, and surgical outcomes was investigated in this preliminary pilot study. STUDY DESIGN A retrospective study was performed on patients referred to the surgical optimization clinic and assessed for frailty from September 2020 to May 2023. Patients received presurgical optimization for reasons including diabetes, smoking cessation, prehabilitation and nutrition, and/or cardiopulmonary issues. Outcomes were evaluated whether they proceeded to surgery, were referred to the High-Risk Surgical Committee, surgical case canceled, or not scheduled. For those who proceeded to surgery, infection rates, complications, and 30-day emergency department (ED) and readmission rates were evaluated. RESULTS Of 143 unique patients, 138 (men = 61, women = 77) were evaluated for this study. The average Edmonton frailty score for patients who proceeded to surgery was 7.013 (n = 78) vs 9.389 with cancelation and 9.600 for not scheduled or not optimized for surgery. Postoperative infection rates were <3%. However, 30-day ED and readmission rate was 21% (16 of 78). CONCLUSIONS Patients with lower average Edmonton frailty scores were more likely to proceed to surgery, whereas those with higher average Edmonton frailty scores were more likely to have surgery canceled or delayed. Frail patients cleared for surgery were found to have a high 30-day ED and readmission rate.
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Affiliation(s)
- Lauren T Hui
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Hui)
| | - Diane St Pierre
- Department of Surgery, John Peter Smith Health Network, Fort Worth, TX (St Pierre, Miller)
| | - Richard S Miller
- Department of Surgery, John Peter Smith Health Network, Fort Worth, TX (St Pierre, Miller)
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4
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Gurunathan U, Roe A, Milligan C, Hay K, Ravichandran G, Chawla G. Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study. Anesth Analg 2024; 138:763-774. [PMID: 38236756 DOI: 10.1213/ane.0000000000006728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population. METHODS Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives). RESULTS Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives ( P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives ( P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension ( P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1-7.1 and OR, 7.7; 95% CI, 3.7-14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group ( P < .001). CONCLUSIONS Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.
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Affiliation(s)
- Usha Gurunathan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Adrian Roe
- Department of Urology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Caitlin Milligan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Karen Hay
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Gowri Ravichandran
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Gunjan Chawla
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
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Glowka L, Tanella A, Hyman JB. Quality indicators and outcomes in ambulatory surgery. Curr Opin Anaesthesiol 2023; 36:624-629. [PMID: 37871296 DOI: 10.1097/aco.0000000000001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW Quality indicators are used to monitor the quality and safety of care in ambulatory surgery, a specialty in which major morbidity and mortality remain low. As the demand for safe and cost-effective ambulatory surgical care continues to increase, quality indicators and metrics are becoming critical tools used to provide optimal care for these patients. RECENT FINDINGS Quality indicators are tools used by both regulatory agencies and surgical centers to improve safety and quality of ambulatory surgical and anesthetic care. These metrics are also being used to develop value-based payment models that focus on efficient, safe, and effective patient care. Patient reported outcome measures are a growing method of collecting data on the satisfaction and postoperative recovery period for ambulatory surgical patients. Monitoring of perioperative efficiency and utilization using quality metrics are important to the financial health of ambulatory surgical centers. SUMMARY Quality indicators will continue to play a growing role in the monitoring of quality and safety in ambulatory surgery, especially with the trend towards value-based reimbursement models and efficient, cost-effective surgical care. Additionally, quality indicators are useful tools to monitor postoperative patient outcomes and recovery pathways and the efficiency of operating room utilization and scheduling.
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Affiliation(s)
- Lena Glowka
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA
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Rajan N. The emerging landscape of ambulatory surgery and anesthesia. Curr Opin Anaesthesiol 2023; 36:609-610. [PMID: 37871295 DOI: 10.1097/aco.0000000000001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Niraja Rajan
- Penn State Health Hershey Medical Center, Hershey, PA, USA
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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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8
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Alder C, Bronsert MR, Meguid RA, Stuart CM, Dyas AR, Colborn KL, Henderson WG. Preoperative risk factors and postoperative complications associated with mortality after outpatient surgery in a broad surgical population: an analysis of 2.8 million ACS-NSQIP patients. Surgery 2023; 174:631-637. [PMID: 37290998 DOI: 10.1016/j.surg.2023.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/02/2023] [Accepted: 04/27/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Thirty-day mortality after outpatient surgery is unexpected and undesired. We investigated preoperative risk factors, operative variables, and postoperative complications associated with 30-day death after outpatient surgery. METHODS Using the 2005 to 2018 American College of Surgeons National Surgical Quality Improvement Program database, we evaluated 30-day mortality rate trends over time after outpatient operations. We analyzed associations between 37 preoperative variables, operation time, hospital length of stay, and 9 postoperative complications with mortality rate using χ2 analyses for categorical data and tests for continuous data. We used forward selection logistic regression models to determine the best predictors of mortality preoperatively and postoperatively. We also separately analyzed mortality by age group. RESULTS A total of 2,822,789 patients were included. The 30-day mortality rate did not change significantly over time (P = .34, Cochran-Armitage trend test), remaining steady at around 0.06%. The most significant preoperative predictors of mortality included the patient having disseminated cancer, decreased functional health status, increased American Society of Anesthesiology Physical Status classification, increased age, and ascites, accounting for 95.8% (0.837/0.874) of the full model c-index. The most significant postoperative complications associated with increased risk of mortality included having cardiac (26.95% yes vs 0.04% no), pulmonary (10.25% vs 0.04%), stroke (9.22% vs 0.06%), and renal (9.33% vs 0.06%) complications. Postoperative complications conferred a greater risk for mortality than preoperative variables. Mortality risk increased incrementally with age, particularly past age 80. CONCLUSION The operative mortality rate after outpatient surgery has not changed over time. Patients over 80 years with disseminated cancer, decreased functional health status, or increased ASA class should generally be considered for inpatient surgery. However, there might be some circumstances where outpatient surgery could be considered.
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Affiliation(s)
- Catherine Alder
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Department of Surgery, 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
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, 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.
| | - Christina M Stuart
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Kathryn L Colborn
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Department of Surgery, 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
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9
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Christou N, Di Maria S, Mirallié E, Noullet S, Mathonnet M, Menegaux F. Ambulatory thyroidectomy. Recommendations of the Association francophone de chirurgie endocrinienne (AFCE), with the Société française d'endocrinologie (SFE) and the Société française de médecine nucléaire (SFMN). J Visc Surg 2023:S1878-7886(23)00072-3. [PMID: 37211444 DOI: 10.1016/j.jviscsurg.2023.04.007] [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: 05/23/2023]
Abstract
Before ambulatory thyroidectomy is proposed, the patient and his family and/or friends will need to be informed by the surgeon of the specificity of this procedure, the normal postoperative effects of a thyroidectomy, and potential complications. Also known as outpatient thyroid surgery, it can only be proposed by an experienced surgeon supported by an adequately trained medical and paramedical team. The healthcare establishment must be in possession of all the resources needed in ambulatory management, with continuity of care guaranteed 24h/24 7d/7 in the event of possible emergency rehospitalization. In all cases, contact the day after the operation between the healthcare facility and the patient is imperative. Ambulatory management can be proposed for lobo-isthmectomy or isthmectomy, possibly involving lymph node dissection. It is also possible for secondary totalization of thyroidectomy (following lobectomy). On the other hand, indications for single-stage total thyroidectomy must be limited and ensure proximity between the patient's home and a healthcare structure with a platform adapted to the pathology necessitating surgical intervention (non-plunging euthyroid goiter). A precise clinical pathway must be set out, including pre-, peri- and postoperative protocols having been formalized for surgery (hemostasis procedures) and for anesthesia (prevention of pain, of vomiting and of hypertension). We recommend at least 6hours of postoperative surveillance in outpatient care. When outpatient treatment is not possible or not recommended, hospitalization stay after thyroidectomy can be limited to 24hours, except in the event of postoperative complications, or a need for effectively dosed anticoagulant treatment.
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Affiliation(s)
- Niki Christou
- Digestive, Endocrine and General Surgery Department, University Hospital Center of Limoges, Limoges, France.
| | - Sophie Di Maria
- Department of Anesthesia-Resuscitation, University Hospital Center of Pitié-Salpêtrière, AP-HP, Sorbonne University, Paris, France
| | - Eric Mirallié
- Cancer, Digestive and Endocrine Surgery Department, Institut des Maladies de l'Appareil Digestif, University Hospital Center of Nantes, Nantes, France
| | - Séverine Noullet
- Department of General, Visceral and Endocrine Surgery, University Hospital Center of Pitié-Salpêtrière, AP-HP, Sorbonne University, Paris, France
| | - Muriel Mathonnet
- Digestive, Endocrine and General Surgery Department, University Hospital Center of Limoges, Limoges, France
| | - Fabrice Menegaux
- Department of General, Visceral and Endocrine Surgery, University Hospital Center of Pitié-Salpêtrière, AP-HP, Sorbonne University, Paris, France
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Niebuhr H, Köckerling F, Fortelny R, Hoffmann H, Conze J, Holzheimer RG, Koch A, Köhler G, Krones C, Kukleta J, Kuthe A, Lammers B, Lorenz R, Mayer F, Pöllath M, Reinpold W, Schwab R, Stechemesser B, Weyhe D, Wiese M, Zarras K, Meyer HJ. [Inguinal hernia operations-Always outpatient?]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:230-236. [PMID: 36786812 PMCID: PMC9950173 DOI: 10.1007/s00104-023-01818-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 06/17/2023]
Abstract
Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.
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Affiliation(s)
- H Niebuhr
- Hamburger Hernien Centrum, Eppendorfer Baum 8, 20249, Hamburg, Deutschland.
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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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Menegaux F, Baud G, Chereau N, Christou N, Deguelte S, Frey S, Guérin C, Marciniak C, Paladino NC, Brunaud L, Caiazzo R, Donatini G, Gaujoux S, Goudet P, Hartl D, Lifante JC, Mathonnet M, Mirallié E, Najah H, Sebag F, Trésallet C, Pattou F. SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Surgical treatment. ANNALES D'ENDOCRINOLOGIE 2022; 83:415-422. [PMID: 36309207 DOI: 10.1016/j.ando.2022.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French-speaking Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the surgical management of thyroid nodules.
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Affiliation(s)
- Fabrice Menegaux
- Service de Chirurgie Générale, Viscérale et Endocrinienne, GH Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France.
| | - Gregory Baud
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
| | - Nathalie Chereau
- Service de Chirurgie Générale, Viscérale et Endocrinienne, GH Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | - Niki Christou
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Limoges, France
| | - Sophie Deguelte
- Service de Chirurgie Digestive et Endocrinienne, Hôpital Robert-Debré, Université de Champagne Ardennes, Reims, France
| | - Samuel Frey
- Service de Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, Université de Nantes, Nantes, France
| | - Carole Guérin
- Service de chirurgie Générale, Endocrinienne et Métabolique, CHU La Conception, AP-HM, Aix Marseille Université, Marseille, France
| | - Camille Marciniak
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
| | - Nunzia Cinzia Paladino
- Service de chirurgie Générale, Endocrinienne et Métabolique, CHU La Conception, AP-HM, Aix Marseille Université, Marseille, France
| | - Laurent Brunaud
- Département de Chirurgie Viscérale, Métabolique et Cancérologique, Université de Lorraine, CHRU Nancy, Hôpital Brabois Adultes, Vandœuvre les Nancy, France
| | - Robert Caiazzo
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
| | - Gianluca Donatini
- Service de Chirurgie Viscérale et Endocrinienne, CHU-Poitiers, Poitiers Université, Poitiers, France
| | - Sebastien Gaujoux
- Service de Chirurgie Générale, Viscérale et Endocrinienne, GH Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | - Pierre Goudet
- Département de Chirurgie Générale et Endocrinienne, CHU de Dijon, Université de Bourgogne, Dijon, France
| | - Dana Hartl
- Département d'Anesthésie, de Chirurgie et de Radiologie Interventionnelle, Unité de Chirurgie Thyroïdienne, Institut Gustave Roussy, Villejuif, France
| | - Jean-Christophe Lifante
- Service de Chirurgie Endocrinienne, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Muriel Mathonnet
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Limoges, France
| | - Eric Mirallié
- Service de Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, Université de Nantes, Nantes, France
| | - Haythem Najah
- Service de Chirurgie Digestive et Endocrinienne, Hôpital Haut Lévêque, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frederic Sebag
- Service de chirurgie Générale, Endocrinienne et Métabolique, CHU La Conception, AP-HM, Aix Marseille Université, Marseille, France
| | - Christophe Trésallet
- Service de Chirurgie Digestive, Bariatrique et Endocrinienne, HU Paris Seine-Saint-Denis, AP-HP, Hôpital Avicenne, Bobigny, France
| | - Francois Pattou
- Service de Chirurgie Générale et Endocrinienne, CHRU de Lille, Université de Lille, Lille, France
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Medical disease and ambulatory surgery, new insights in patient selection based on medical disease. Curr Opin Anaesthesiol 2022; 35:385-391. [PMID: 35671030 DOI: 10.1097/aco.0000000000001132] [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
PURPOSE OF REVIEW Improvements in perioperative care contributed to enlarge the eligibility criteria for day case surgery and more and more patients with comorbidities may be concerned. However, underlying medical diseases may influence postoperative outcomes, and therefore, must be considered when selecting patients to undergo ambulatory surgery. RECENT FINDINGS To limit postoperative complications, rigid patient selection criteria are often applied in ambulatory surgery. In practice, however, most of these criteria predict the occurrence of treatable perioperative adverse events but not the need for unanticipated admission or readmission. SUMMARY The underlying medical diseases should not be considered as sole criteria but they should rather be regarded as a dynamic process, which includes the surgical procedure as well as the experience and expertise of the perioperative setting.
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Stone AB, Wu CL, Liu J. Postoperative Day 0 Discharge Is Not Equivalent to Ambulatory Surgery. Anesth Analg 2022; 134:e35-e36. [PMID: 35595700 DOI: 10.1213/ane.0000000000005985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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Xu F, Wheaton AG, Liu Y, Greenlund KJ. Major ambulatory surgery among US adults with inflammatory bowel disease, 2017. PLoS One 2022; 17:e0264372. [PMID: 35202440 PMCID: PMC8870533 DOI: 10.1371/journal.pone.0264372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/09/2022] [Indexed: 01/13/2023] Open
Abstract
Background Patients with inflammatory bowel disease (IBD) have higher health services use than those without IBD. We investigated patient and hospital characteristics of major ambulatory surgery encounters for Crohn’s disease (CD) or ulcerative colitis (UC) vs non-IBD patients. Methods We conducted a cross-sectional study using 2017 Nationwide Ambulatory Surgery Sample. Major ambulatory surgery encounters among patients aged ≥18 years with CD (n = 20,635) or UC (n = 9,894) were compared to 9.4 million encounters among non-IBD patients. Weighted percentages of patient characteristics (age, sex, median household income, primary payers, patient location, selected comorbidities, discharge destination, type of surgeries) and hospital-related characteristics (hospital size, ownership, location and teaching status, region) were compared by IBD status (CD, UC, and no IBD). Linear regression was used to estimate mean total charges, controlling for these characteristics. Results Compared with non-IBD patients, IBD patients were more likely to have private insurance, reside in urban areas and higher income zip codes, and undergo surgeries in hospitals that were private not-for-profit, urban teaching, and in the Northeast. Gastrointestinal surgeries were more common among IBD patients. Some comorbidities associated with increased risk of surgical complications were more prevalent among IBD patients. Total charges were 9% lower for CD patients aged <65 years (Median: $16,462 vs $18,106) and 6% higher for UC patients aged ≥65 years (Median: $16,909 vs $15,218) compared to their non-IBD patient counterparts. Conclusions Differences in characteristics of major ambulatory surgery encounters by IBD status may identify opportunities for efficient resource allocation and positive surgical outcomes among IBD patients.
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Affiliation(s)
- Fang Xu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- * E-mail:
| | - Anne G. Wheaton
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Yong Liu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Kurt J. Greenlund
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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Bash LD, Black W, Turzhitsky V, Urman RD. Neuromuscular Blockade and Reversal Practice Variability in the Outpatient Setting: Insights From US Utilization Patterns. Anesth Analg 2021; 133:1437-1450. [PMID: 34784330 DOI: 10.1213/ane.0000000000005657] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Neuromuscular blockade (NMB) is a critical part of many surgical procedures. Data on practice patterns of NMB agents (NMBAs) and NMB reversal in recent years in the US ambulatory surgical care setting are limited. METHODS This retrospective analysis of US adult outpatients was conducted using the Premier Healthcare Database. We describe anesthesia practice trends in NMB management and assess the association of patient, procedural, and site characteristics with NMB reversal approach using multivariable logistic regression. RESULTS Approximately 5.2 million outpatient surgical encounters involving NMB and 4.6 million involving rocuronium or vecuronium between January 2014 and June 2019 were included. Following the introduction of sugammadex to US clinical practice (~2016), there was an increased use of rocuronium or vecuronium and a decrease in succinylcholine alone. Before 2016, NMB was pharmacologically reversed with neostigmine in approximately two-thirds of outpatient encounters. Over time, active reversal increased; by 2019, 42.3% and 36.0% of encounters were reversed by neostigmine and sugammadex, respectively, with 21.7% undergoing spontaneous recovery. Choice of NMBA (rocuronium or vecuronium alone), time since 2016, obesity, peripheral vascular disease, and procedures on the digestive, ocular, and female genital systems (vs musculoskeletal procedures) were independently and positively associated with pharmacologic reversal (versus spontaneous reversal). Conversely, advanced age; Western geography; and cardiovascular, endocrine, hemic/lymphatic, respiratory, and ear, nose, and throat procedures were independently and negatively associated with pharmacologic reversal of NMB.Among pharmacologic reversals, time since 2016 was positively and independently associated with sugammadex compared with neostigmine (odds ratios [ORs], ranged from 1.8 in 2017 to 3.2, P < .0001 in 2019). Those administered rocuronium or vecuronium without succinylcholine, with increased age and history of certain comorbidities, and those undergoing ocular or respiratory procedures (compared with musculoskeletal) were positively associated with reversal with sugammadex and endocrine procedure negatively and independently associated with reversal with sugammadex. There was variability in the association of several factors with NMB reversal choices by geographic region, particularly in patients' race, ethnicity, and size of affiliated hospital. CONCLUSIONS Overall, active pharmacological reversal of NMB increased in US adult outpatients following the introduction of sugammadex, although there remains significant practice variability. The multifactorial relationship between patient-, procedural-, and environmental-level characteristics and NMB management is rapidly evolving. Additional research on how these anesthesia practice patterns may be impacted by the shift to the ambulatory care setting and how they may impact patient outcomes and health disparities is warranted.
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Affiliation(s)
- Lori D Bash
- From the Center for Observational and Real-World Evidence (CORE), Merck & Co, Inc, Kenilworth, New Jersey
| | - Wynona Black
- Center for Observational and Real-World Evidence (CORE), Merck & Co, Inc, Boston, Massachusetts
| | - Vladimir Turzhitsky
- Center for Observational and Real-World Evidence (CORE), Merck & Co, Inc, Boston, Massachusetts
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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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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Chaturvedi R, Patel K, Burton BN, Gabriel RA. Geriatric Patients Undergoing Outpatient Surgery in the United States: A Retrospective Cohort Analysis on the Rates of Hospital Admission and Complications. Cureus 2021; 13:e20607. [PMID: 35103183 PMCID: PMC8782635 DOI: 10.7759/cureus.20607] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION This study is a retrospective cohort analysis that describes key clinical outcomes in elderly individuals who undergo outpatient surgical procedures. In particular, we report same-day admission, 30-day mortality, 30-day complications, and 30-day readmission rates for three separate age groups undergoing frequent outpatient, general surgical procedures. METHODS Patients ≥18 years old who underwent the 10 most common outpatient surgical procedures in the National Surgical Quality Improvement Program database from 2017 to 2019 and who underwent general anesthesia were included in the study. The primary outcome of interest was hospital admission, defined as hospital length of stay >0 days. Secondary outcomes of interest included 30-day readmission, 30-day mortality, and 30-day postoperative complications. The primary exposure variable of interest was age, which was divided into <65 years of age (reference cohort), 65-79 years of age, and ≥80 years of age. For univariate analysis, to measure differences in the outcomes and patient characteristics, we used chi-squared tests. Our primary method of analysis was multivariable logistic regression. RESULTS Those who were ≥80 and 65-79 years of age compared to <65 years of age had higher odds of same-day admission, 30-day mortality, composite postoperative complications, and readmission. Patients who were ≥80 years old had higher odds of same-day admission for laparoscopic cholecystectomy, partial mastectomy, laparoscopic inguinal hernia repair, inguinal hernia repair, umbilical hernia repair, laparoscopic removal of adnexal structures, and lumbar laminotomy. CONCLUSION Increasing age, particularly greater than 80 years or older and 65-79 years of age group, is associated with an increased rate of same-day hospital admissions and complications after ambulatory surgery.
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Affiliation(s)
- Rahul Chaturvedi
- Anesthesiology, University of California San Diego School of Medicine, La Jolla, USA
| | - Kruti Patel
- Anesthesiology, University of California San Diego School of Medicine, La Jolla, USA
| | - Brittany N Burton
- Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, USA
| | - Rodney A Gabriel
- Anesthesiology, University of California San Diego School of Medicine, La Jolla, USA
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Kadoor AS, Patel K, Burton BN, Gabriel RA. Class 3 obesity is not associated with same-day admission in obese patients undergoing parathyroidectomy. J Clin Anesth 2021; 75:110472. [PMID: 34332495 DOI: 10.1016/j.jclinane.2021.110472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
IMPORTANCE Rising rates of obesity and outpatient performance of parathyroidectomies are making it increasingly crucial to investigate the association of obesity with post-operative complications. OBJECTIVE To determine whether Class 3 obesity is associated with increased same-day admission compared to lower obesity classes following outpatient parathyroidectomy. DESIGN Retrospective cohort study. SETTING Outpatient surgery. PATIENTS 12,973 patients ≥18 years old who underwent outpatient parathyroidectomy between 2014 and 2016, per the American College of Surgeons National Surgical Quality Improvement Program registry. INTERVENTIONS Primary exposure variable: body mass index (BMI), with patients assigned to one of six cohorts. MEASUREMENTS Primary outcome measure: same-day admission. Secondary outcome measure: 30-day readmission. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). MAIN RESULTS There was a final sample size of 12,973 adult patients who underwent parathyroidectomy from 2014 to 2016. The admission rate for BMI ≥30 and < 40 kg/m2 (reference cohort) was 42.6%. The admission rates for Class 3 obesity categories were 46.2%, 56.2%, and 52.6% for those in the BMI range of ≥40 kg/m2 and < 50 kg/m2, ≥50 kg/m2 and < 60 kg/m2, and ≥ 60 kg/m2, respectively. On multivariable logistic regression, there were no difference in the odds of 30-day hospital admission or readmission rate with any of the BMI cohorts when compared to the reference group. CONCLUSIONS There is no significant difference in rates of same-day admission or 30-day readmission between any Class 3 (BMI ≥40 kg/m2) obesity cohort and the Class 1 and 2 (BMI ≥30 and < 40 kg/m2) reference cohort following outpatient parathyroidectomy. This corroborates the notion that BMI classes cannot be used in a vacuum to determine eligibility for outpatient parathyroidectomy - a concept that can guide safe and cost-effective institutional practices.
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Affiliation(s)
- Adarsh S Kadoor
- School of Medicine, University of California, San Diego (9500 Gilman Dr), La Jolla, CA 92093, USA).
| | - Kruti Patel
- Department of Anesthesiology, Division of Perioperative Informatics, University of California, San Diego (9500 Gilman Dr), La Jolla, CA 92093, USA.
| | - Brittany N Burton
- Department of Anesthesiology, University of California, Los Angeles (405 Hilgard Avenue), Los Angeles, CA 90095, USA.
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Perioperative Informatics, University of California, San Diego (9500 Gilman Dr), La Jolla, CA 92093, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego (9500 Gilman Dr), La Jolla, CA 92093, USA.
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Jenkins NW, Parrish JM, Nolte MT, Jadczak CN, Mohan S, Geoghegan CE, Hrynewycz NM, Podnar J, Buvanendran A, Singh K. Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting. Int J Spine Surg 2021; 15:219-227. [PMID: 33900978 DOI: 10.14444/8030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol. METHODS A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered. RESULTS A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day. CONCLUSION In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.
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Affiliation(s)
- Nathaniel W Jenkins
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - James M Parrish
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Michael T Nolte
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Caroline N Jadczak
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Shruthi Mohan
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Cara E Geoghegan
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Jeffrey Podnar
- Department of Anesthesiology, Midwest Anesthesia Partners LLC, Park Ridge, Illinois
| | | | - Kern Singh
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
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Singh T, Lee J, Zahurak M, Bae HJ, Habtu T, Hobbs R, Le Y, Burdette EC, Song DY. Superior Postimplant Dosimetry Achieved Using Dynamic Intraoperative Dosimetry for Permanent Prostate Brachytherapy. Pract Radiat Oncol 2021; 11:264-271. [PMID: 33722782 DOI: 10.1016/j.prro.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Low-dose-rate brachytherapy is a highly effective treatment modality for prostate carcinoma, but postimplant dosimetry quality is essential and correlated with likelihood of treatment success. Registered ultrasound and fluoroscopy (iRUF) can facilitate real-time intraoperative monitoring and plan adaptation, with the aim of attaining superior dosimetric outcomes. The purpose of this research was to compare clinical postimplant dosimetric results of iRUF-guided brachytherapy against brachytherapy using standard ultrasound-guided intraoperative dosimetry methods. METHODS AND MATERIALS We analyzed postimplant dosimetry in 292 patients treated with Pd-103 between January 2007 and December 2018. All patients had postimplant dosimetry measured on day 0 to 1 using fused magnetic resonance/computed tomography assessment. Fifty-two patients were treated in 2 prospective clinical trials using iRUF intraoperative dosimetry, including 6 patients in a pilot study and 46 treated in a phase 2 study. Postimplant dosimetry in iRUF-treated patients was compared with dosimetry from 240 patients treated using standard (real-time ultrasound) intraoperative seed tracking. RESULTS For every parameter measuring dose coverage to the prostate, iRUF patients had significantly higher values, irrespective of adjustment for year of treatment. In adjusted analyses, parameters of dose to urethra and rectum were not significantly higher among iRUF-treated patients. CONCLUSIONS Use of iRUF intraoperative dosimetry was associated with improved postimplant dose coverage in prostate, without associated increases in doses to urethra or rectum.
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Affiliation(s)
- Tanmay Singh
- Departments of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Junghoon Lee
- Departments of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marianna Zahurak
- Departments of Oncology, Biostatistics and Bioinformatics Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hee Joon Bae
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tamey Habtu
- Merit Health Leadership Academy, Baltimore, Maryland
| | - Robert Hobbs
- Departments of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yi Le
- Department of Radiation Oncology, Indiana University, Bloomington, Indiana
| | | | - Daniel Y Song
- Departments of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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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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The Association Between BMI and Mortality in Surgical Patients. World J Surg 2021; 45:1390-1399. [PMID: 33481082 DOI: 10.1007/s00268-021-05961-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND While obesity is commonly associated with increased morbidity and mortality, in patients with chronic diseases, it has have been associated with a better prognosis, a phenomenon known as the 'obesity paradox'. OBJECTIVE We investigated the relationship between mortality, length of hospital stay (LOHS), and body mass index (BMI) in patients hospitalized to general surgical wards. METHODS We extracted data of patients admitted to the hospital between January 2011 and December 2017. BMI was classified according to the following categories: underweight (< 18.5), normal weight (18.5-24.9), overweight (25-29.9), obesity (30-34.9) and severe obesity (≥ 35). Main outcomes were mortality at 30-day mortality and at the end-of-follow-up mortality), as well as LOHS. RESULTS A total of 27,639 patients (mean age 55 ± 20 years; 48% males; 19% had diabetes) were included in the study. Median LOHS was longer in patients with diabetes vs. those without diabetes (4.0 vs 3.0 days, respectively), with longest LOHS among underweight patients. A 30-day mortality was 2% of those without (371/22,297) and 3% of those with diabetes (173/5,342). In patients with diabetes, 30-day mortality risk showed a step-wise decrease with increased BMI: 10% for underweight, 6% for normal weight, 3% for overweight, 2% for obese and only 1% for severely obese patients. In patients without diabetes, 30-day mortality was found to be 6% for underweight, 3% for normal weight and 1% across the overweight and obese categories. Mortality rate at the end-of-follow-up was 9% of patients without diabetes and 18% of those with diabetes (adjusted OR = 1.3, 95% CI, 1.2-1.5). In patients with diabetes, mortality risk showed an inverse association with respect to BMI: 52% for underweight, 29% for normal weight, 17% for overweight, 14% for obesity and 7% for severely obese patients, with similar trend in patients without diabetes. CONCLUSIONS The results support the 'obesity paradox' in the general surgical patients as those with and without diabetes admitted to surgical wards, BMI had an inverse association with short- and long-term mortality.
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Yan L, Rong F, Gao M, Chen G, Su Y, Xing L, Xu M. Complications and feasibility analysis of ambulatory surgery for gynecological diseases in China. Medicine (Baltimore) 2021; 100:e23995. [PMID: 33429761 PMCID: PMC7793318 DOI: 10.1097/md.0000000000023995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022] Open
Abstract
The Chinese government is attaching great importance to the development of ambulatory surgery in order to optimize the healthcare system in China. The study aims to examine the complications and quality indicators of patients who underwent gynecological ambulatory surgery at a tertiary hospital in China.This was a retrospective study of patients who underwent ambulatory surgery between July and September 2019 at the Department of Gynecology of the First Affiliated Hospital of Shandong First Medical University. The patients were followed by phone at 30 days after discharge. The postoperative complications, mortality, unplanned re-operation, delayed discharge, unplanned re-hospitalization, and patient satisfaction were collected. The patients who underwent conventional hysteroscopic resection of uterine lesions during the same period were collected as controls for the economics analysis.A total of 392 patients who underwent ambulatory gynecological surgery were included. Fifteen patients had postoperative complications, and the total complication rate was 3.8% (15/392). Eight (8/392, 2.0%) patients had delayed discharge. There were no unplanned re-operations and deaths. There were two (2/392, 0.5%) cases of unplanned re-hospitalization. At 30 days after discharge, two patients were dissatisfied, and 390 cases were satisfied, for an overall satisfaction rate of 99.5%. Compared with conventional hysteroscopic resection of uterine lesions, ambulatory hysteroscopic surgery had a shorter hospital stay and lower total costs (P < .05) but similar surgery-related costs.Ambulatory gynecological surgery is feasible in China, with an acceptable complication profile and obvious economic and social benefits. Nevertheless, hospital management shall be reinforced.
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Affiliation(s)
- Li Yan
- Department of Obstetrics and Gynecology
| | | | | | | | | | | | - Min Xu
- Administrative Department, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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Melton MS, Li YJ, Pollard R, Chen Z, Hunting J, Hopkins T, Buhrman W, Taicher B, Aronson S, Stafford-Smith M, Raghunathan K. Unplanned hospital admission after ambulatory surgery: a retrospective, single cohort study. Can J Anaesth 2021. [PMID: 33058058 DOI: 10.1007/s12630-020-01822-1/tables/3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
PURPOSE We estimated the rate of unplanned hospital and intensive care unit (ICU) admissions following ambulatory surgery centre (ASC) procedures, and identified factors associated with their occurrence. METHODS This retrospective cohort included adult patients who underwent ASC procedures within a large community practice from January 2010 to December 2014. Patients were categorized into two groups: unplanned postoperative hospital/ICU admission within 24 hr of procedure or uneventful discharge. Demographics, comorbidities, anesthesia type, procedure type, procedure group, and ASC facility were assessed. RESULTS Of the 211,389 patients included, there were 211,147 uneventful discharges (99.89%) and 242 unplanned hospital admissions (0.11%), of which 75 were ICU admissions (0.04%). The multivariable logistic regression model for hospital admission showed an increased risk associated with age > 50 yr (odds ratio [OR], 1.53); American Society of Anesthesiologists (ASA) physical status (III vs II: OR, 1.45; IV vs II: OR, 1.88), comorbidity (chronic obstructive pulmonary disease: OR, 2.63; diabetes mellitus: OR, 1.62; transient ischemic attack: OR, 2.48) procedure (respiratory: OR, 2.92; digestive: OR, 2.66; musculoskeletal system: OR, 2.53), anesthetic management (general anesthesia [GA] and peripheral nerve block vs GA: OR, 1.79), and ASC facility (189BB: OR, 2.29; 30E9A: OR, 7.41; and BD21F: OR, 1.69). The multivariable logistic regression model for ICU admission showed increased risk of unplanned ICU admission associated with ASA physical status (ASA III vs II: OR, 3.0; ASA IV vs II: OR, 8.52), procedure (musculoskeletal system: OR, 2.45), and ASC facility (00E6C: OR, 3.14; 189BB: OR, 2.77; 30E9A: OR, 2.59; and BD21F: OR, 3.71). CONCLUSION While a small percentage of adult patients who underwent ASC procedures required unplanned hospital admission (0.07%), approximately one-third of these admissions were to the ICU (0.04%). Facility was at least as strong a predictor of hospital admission as the patient- and/or procedure-specific variables.
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Affiliation(s)
- M Stephen Melton
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA.
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | | | - Zhengxi Chen
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - John Hunting
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Thomas Hopkins
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - William Buhrman
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Brad Taicher
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Solomon Aronson
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
- CAPER Unit, Duke Anesthesiology, Durham, NC, USA
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Melton MS, Li YJ, Pollard R, Chen Z, Hunting J, Hopkins T, Buhrman W, Taicher B, Aronson S, Stafford-Smith M, Raghunathan K. Unplanned hospital admission after ambulatory surgery: a retrospective, single cohort study. Can J Anaesth 2021; 68:30-41. [PMID: 33058058 DOI: 10.1007/s12630-020-01822-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE We estimated the rate of unplanned hospital and intensive care unit (ICU) admissions following ambulatory surgery centre (ASC) procedures, and identified factors associated with their occurrence. METHODS This retrospective cohort included adult patients who underwent ASC procedures within a large community practice from January 2010 to December 2014. Patients were categorized into two groups: unplanned postoperative hospital/ICU admission within 24 hr of procedure or uneventful discharge. Demographics, comorbidities, anesthesia type, procedure type, procedure group, and ASC facility were assessed. RESULTS Of the 211,389 patients included, there were 211,147 uneventful discharges (99.89%) and 242 unplanned hospital admissions (0.11%), of which 75 were ICU admissions (0.04%). The multivariable logistic regression model for hospital admission showed an increased risk associated with age > 50 yr (odds ratio [OR], 1.53); American Society of Anesthesiologists (ASA) physical status (III vs II: OR, 1.45; IV vs II: OR, 1.88), comorbidity (chronic obstructive pulmonary disease: OR, 2.63; diabetes mellitus: OR, 1.62; transient ischemic attack: OR, 2.48) procedure (respiratory: OR, 2.92; digestive: OR, 2.66; musculoskeletal system: OR, 2.53), anesthetic management (general anesthesia [GA] and peripheral nerve block vs GA: OR, 1.79), and ASC facility (189BB: OR, 2.29; 30E9A: OR, 7.41; and BD21F: OR, 1.69). The multivariable logistic regression model for ICU admission showed increased risk of unplanned ICU admission associated with ASA physical status (ASA III vs II: OR, 3.0; ASA IV vs II: OR, 8.52), procedure (musculoskeletal system: OR, 2.45), and ASC facility (00E6C: OR, 3.14; 189BB: OR, 2.77; 30E9A: OR, 2.59; and BD21F: OR, 3.71). CONCLUSION While a small percentage of adult patients who underwent ASC procedures required unplanned hospital admission (0.07%), approximately one-third of these admissions were to the ICU (0.04%). Facility was at least as strong a predictor of hospital admission as the patient- and/or procedure-specific variables.
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Affiliation(s)
- M Stephen Melton
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA.
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | | | - Zhengxi Chen
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - John Hunting
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Thomas Hopkins
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - William Buhrman
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Brad Taicher
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Solomon Aronson
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, DUMC, Box #3094, Stop# 4, Durham, NC, 27110, USA
- CAPER Unit, Duke Anesthesiology, Durham, NC, USA
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Janeway MG, Sanchez SE, Chen Q, Nofal MR, Wang N, Rosen A, Dechert TA. Association of Race, Health Insurance Status, and Household Income With Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States. JAMA Surg 2020; 155:1123-1131. [PMID: 32902630 PMCID: PMC7489412 DOI: 10.1001/jamasurg.2020.3318] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/17/2020] [Indexed: 12/27/2022]
Abstract
Importance The receipt of surgery in freestanding ambulatory surgery centers (ASCs) is often less costly compared with surgery in hospital-based outpatient departments. Although increasing numbers of surgical procedures are now being performed in freestanding ASCs, questions remain regarding the existence of disparities among patients receiving care at ASCs. Objective To examine the association of patient race, health insurance status, and household income with the location (ASC vs hospital-based outpatient department) of ambulatory surgery. Design, Setting, and Participants This cohort study used data from the State Ambulatory Surgery and Services Databases of the Healthcare Cost and Utilization Project to perform a secondary analysis of patients who received ambulatory surgery in New York and Florida between 2011 and 2013. Patients aged 18 to 89 years who underwent 12 different types of ambulatory surgical procedures were included. Data were analyzed from December 2018 to June 2019. Main Outcomes and Measures Receipt of surgery at a freestanding ASC and 30-day unplanned hospital visits after ambulatory surgery. Results A total of 5.6 million patients in New York (57.4% female; 68.9% aged ≥50 years; and 62.5% White) and 7.5 million patients in Florida (57.3% female; 77.4% aged ≥50 years; 74.3% White) who received ambulatory surgery were included in the analysis. After adjusting for age, comorbidities, health insurance status, household income, location of surgery, and type of surgical procedure, the likelihood of receiving ambulatory surgery at a freestanding ASC was significantly lower among Black patients (adjusted odds ratio [aOR], 0.82; 95% CI, 0.81-0.83; P < .001) and Hispanic patients (aOR, 0.78; 95% CI, 0.77-0.79; P < .001) compared with White patients in New York. This likelihood was also lower among Black patients (aOR, 0.65; 95% CI, 0.65-0.66; P < .001) compared with White patients in Florida. Public health insurance coverage was associated with a significantly lower likelihood of receiving ambulatory surgery at freestanding ASCs in both New York and Florida, particularly among patients with Medicaid (in New York, aOR, 0.22; 95% CI, 0.22-0.22; P < .001; in Florida, aOR, 0.40; 95% CI, 0.40-0.41; P < .001) and Medicare (in New York, aOR, 0.46; 95% CI, 0.46-0.46; P < .001; in Florida, aOR, 0.67; 95% CI, 0.66-0.67; P < .001). Conclusions and Relevance Differences in the use of freestanding ASCs were found among Black patients and patients with public health insurance. Further exploration of the factors underlying these differences will be important to ensure that all populations have access to the increasing number of freestanding ASCs.
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Affiliation(s)
- Megan G. Janeway
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sabrina E. Sanchez
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Qi Chen
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
| | - Maia R. Nofal
- Boston University School of Medicine, Boston, Massachusetts
| | - Na Wang
- Boston University School of Public Health, Boston, Massachusetts
| | - Amy Rosen
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
| | - Tracey A. Dechert
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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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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Blood pressure management and perioperative myocardial injury. Int Anesthesiol Clin 2020; 59:36-44. [PMID: 33060430 DOI: 10.1097/aia.0000000000000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Malonek D, Dekel BZ, Haran G, Reens-Carmel R, Groisman GM, Hallak M, Bruchim I. Rapid intraoperative diagnosis of gynecological cancer by ATR-FTIR spectroscopy of fresh tissue biopsy. JOURNAL OF BIOPHOTONICS 2020; 13:e202000114. [PMID: 32463546 DOI: 10.1002/jbio.202000114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 06/11/2023]
Abstract
A rapid and reliable intraoperative diagnostic technique to support clinical decisions was developed using Fourier-transform infrared (FTIR) spectroscopy. Twenty-six fresh tissue samples were collected intraoperatively from patients undergoing gynecological surgeries. Frozen section (FS) histopathology aimed to discriminate between malignant and benign tumors was performed, and attenuated total reflection (ATR) FTIR spectra were collected from these samples. Digital dehydration and principal component analysis and linear discriminant analysis (PCA-LDA) models were developed to classify samples into malignant and benign groups. Two validation schemes were employed: k-fold and "leave one out." FTIR absorption spectrum of a fresh tissue sample was obtained in less than 5 minutes. The fingerprint spectral region of malignant tumors was consistently different from that of benign tumors. The PCA-LDA discrimination model correctly classified the samples into malignant and benign groups with accuracies of 96% and 93% for the k-fold and "leave one out" validation schemes, respectively. We showed that a simple tissue preparation followed by ATR-FTIR spectroscopy provides accurate means for very rapid tumor classification into malignant and benign gynecological tumors. With further development, the proposed method has high potential to be used as an adjunct to the intraoperative FS histopathology technique.
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Affiliation(s)
- Dov Malonek
- Ruppin Academic Center, Department of Electrical and Computer Engineering, Emek-Hefer, Israel
| | - Ben-Zion Dekel
- Ruppin Academic Center, Department of Electrical and Computer Engineering, Emek-Hefer, Israel
| | - Gabi Haran
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Technion Israel Institute of Technology, Haifa, Israel
| | - Renat Reens-Carmel
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Technion Israel Institute of Technology, Haifa, Israel
| | - Gabriel M Groisman
- Department of Pathology, Hillel Yaffe Medical Center, Hadera, Israel
- Technion Israel Institute of Technology, Haifa, Israel
| | - Mordechai Hallak
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Technion Israel Institute of Technology, Haifa, Israel
| | - Ilan Bruchim
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Technion Israel Institute of Technology, Haifa, Israel
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Terminology, communication, and information systems in nonoperating room anaesthesia in the COVID-19 era. Curr Opin Anaesthesiol 2020; 33:548-553. [DOI: 10.1097/aco.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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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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Operative Time as an Independent and Modifiable Risk Factor for Short-Term Complications After Knee Arthroscopy. Arthroscopy 2019; 35:2089-2098. [PMID: 31227396 DOI: 10.1016/j.arthro.2019.01.059] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE To determine whether operative time is an independent risk factor for 30-day complications after arthroscopic surgical procedures on the knee. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2005 and 2016 for all arthroscopic knee procedures including lateral release, loose body removal, synovectomy, chondroplasty, microfracture, and meniscectomy. Cases with concomitant procedures were excluded. Correlations between operative time and adverse events were controlled for variables such as age, sex, body mass index, patient comorbidities, and procedure using a multivariate Poisson regression with robust error variance. RESULTS A total of 78,864 procedures met our inclusion and exclusion criteria. The mean age of patients was 51.0 ± 14.3 years; mean operative time, 31.2 ± 18.1 minutes; and mean body mass index, 31.0 ± 7.8. Arthroscopic lateral release (coefficient, 5.8; 95% confidence interval [CI], 4.8-6.8; P < .001), removal of loose bodies (coefficient, 4.2; 95% CI, 3.2-5.3; P < .001), synovectomy (coefficient, 1.8; 95% CI, 1.2-2.3; P < .001), and microfracture (coefficient, 6.5; 95% CI, 5.8-7.2; P < .001) had significantly greater durations of surgery in comparison with meniscectomy. The overall rate of adverse events was 1.24%. After we adjusted for demographic characteristics and the procedure, a 15-minute increase in operative duration was associated with an increased risk of transfusion (relative risk [RR], 1.5; 95% CI, 1.3-1.8; P < .001), death (RR, 1.6; 95% CI, 1.2-2.1; P = .005), dehiscence (RR, 1.6; 95% CI, 1.2-2.2; P = .002), surgical-site infection (RR, 1.3; 95% CI, 1.2-1.3; P = .001), sepsis (RR, 1.3; 95% CI, 1.2-1.4; P < .001), readmission (RR, 1.1; 95% CI, 1.1-1.2; P < .001), and extended length of stay (RR, 1.4; 95% CI, 1.3-1.4; P < .001). CONCLUSIONS Marginal increases in operative time are associated with an increased risk of adverse events such as surgical-site infection, sepsis, extended length of stay, and readmission. Efforts should be made to maximize surgical efficiency. LEVEL OF EVIDENCE Level IV, retrospective database study.
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Abstract
Chronic pain is extremely prevalent in older adults and is associated with significant morbidity, including limited mobility, social isolation, and depressed mood. Pain is defined by a biopsychosocial model highlighting the importance of a multidisciplinary approach to treatment, including multimodal medications, selected interventions, physical therapy and rehabilitation, and psychological treatments. In this narrative review, the authors highlight the use of these approaches in older adults with specific attention paid to considerations unique to aging, including alterations in drug metabolism, avoidance of polypharmacy, and physiologic changes predisposing to painful conditions.
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Abstract
Outpatient surgery has become a national policy priority set by health care authorities (targets for more than 70% of outpatient procedures by 2022), making ambulatory hospitalization the new standard of care. This practice introduces new risks along the patient's course. Even though these risks are low and although the literature and data from insurance databases is reassuring, the risks in outpatient surgery remain poorly understood. Risks can be organizational in view of the many stages of the patient journey that must be formalized-medical, anesthetic or surgical-in view of planned discharge the same evening as the procedure, and medico-legal because of the importance of the discharge authorization and the information provided to the patient. A risk management approach (a priori or a posteriori) has become a mandatory part of a policy of continuous quality improvement and safety of care. The coordination of all the team members (surgeon, anesthesiologist, nursing and administrative staff and the patient's accompanying person) as well as the patient's active participation are essential to minimize risks and prevent complications.
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Jaensson M, Dahlberg K, Nilsson U. Factors influencing day surgery patients' quality of postoperative recovery and satisfaction with recovery: a narrative review. Perioper Med (Lond) 2019; 8:3. [PMID: 31139359 PMCID: PMC6530125 DOI: 10.1186/s13741-019-0115-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
The aim of healthcare services is to provide a high quality of care. One way to ensure that this aim has been fulfilled is to assess patients' satisfaction with their care. Although satisfaction is a complex concept, it is an important outcome in perioperative care. The objective of this paper is to discuss and reflect on factors that can affect patients' quality of postoperative recovery and satisfaction with recovery after day surgery. Involving patients in shared decision-making (SDM) and providing sufficient preoperative and postoperative information can improve their satisfaction. It is important to assess whether patients experience poor recovery, which can be both distressing and dissatisfying. We suggest that patients' age, sex, mental health status, and health literacy (HL) skills should be assessed preoperatively, since these factors seem to have a negative impact on patients' postoperative recovery. Identifying factors that have a negative impact on patients' quality of postoperative recovery and satisfaction with recovery after day surgery will assist healthcare professionals in supporting vulnerable patients, such as those with limited HL and poor mental health. Treating patients with respect and dignity and providing SDM can increase their quality of postoperative recovery and satisfaction with recovery.
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Affiliation(s)
- Maria Jaensson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, 70182 Örebro, Sweden
| | - Karuna Dahlberg
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, 70182 Örebro, Sweden
| | - Ulrica Nilsson
- Division of Nursing, Department of Neurobiology, Care Sciences, and Society, Karolinska Institute and Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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Guertin M, Heard J, Del Rosario T. Ambulatory Surgery Center Medical Director: Visionary Leader. Anesthesiol Clin 2019; 37:389-400. [PMID: 31047137 DOI: 10.1016/j.anclin.2019.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The ambulatory surgery center medical director is a physician leader who recognizes the need to develop a culture that encourages communication and empowerment of employees and professional staff, leading to engagement that optimize care through patient selection, safety and satisfaction requires vision and guidance from the medical director and is central to success of the ASC. Innovative thinking further improves patient care and long-term success by leveraging advances in technology and sustainable practices.
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Affiliation(s)
- Michael Guertin
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Jameson Crane Sports Medicine Institute, 2835 Fred Taylor Drive, Office 2214, Columbus, OH 43202, USA.
| | - Jarrett Heard
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, N410 Doan Hall, Columbus, OH 43210, USA
| | - Timothy Del Rosario
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, N410 Doan Hall, Columbus, OH 43210, USA
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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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Aya AGM, Pouchain PH, Thomas H, Ripart J, Cuvillon P. Incidence of postoperative delirium in elderly ambulatory patients: A prospective evaluation using the FAM-CAM instrument. J Clin Anesth 2018; 53:35-38. [PMID: 30292069 DOI: 10.1016/j.jclinane.2018.09.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 09/07/2018] [Accepted: 09/29/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND While the incidence of postoperative delirium is high in aged hospitalized patients undergoing major surgery, little is known concerning patients undergoing ambulatory surgery. OBJECTIVE To determine the incidence of postoperative delirium in aged patients after hospital discharge from an ambulatory surgery unit. DESIGN Prospective observational study. PATIENTS Elderly patients (≥75 years) scheduled for a surgical procedure on an ambulatory basis. INTERVENTIONS Filling of the Family Confusion Assessment Method (FAM-CAM) questionnaire (11 items) during a phone interview of family caregivers on two separate occasions: five to three days before surgery, and three to five days after surgery. MAIN OUTCOME MEASURES The detection of acute onset and fluctuating course inattention, disorganized thinking, altered level of consciousness, disorientation, perceptual disturbances, and psychomotor agitation from the observations of family caregivers. RESULTS Signs of delirium appeared de novo in 2 of 141 patients (incidence 1.4%) in the postoperative period: a 80-years old man who was disoriented and had incoherent and illogical speech on postoperative day 1 of resection of a cephalic cutaneous melanoma under local anesthesia and sedation (midazolam, sufentanil, and propofol), and a 83-years old woman with a pre-existing mental confusion, who experienced visual and hearing hallucinations and had inappropriate behaviour on postoperative day 2 of cataract surgery performed under episcleral block. Both patients returned to their preoperative states within a few days. CONCLUSIONS Using the FAM-CAM instrument for the detection of postoperative delirium in ambulatory patients, the study showed that the incidence of cognitive changes in the ambulatory setting is very low. Among several putative factors, the lightness of the surgical procedure, the wide use of regional anesthesia, and the short hospital stay may be contributing factors to this result. The findings of this study need to be confirmed in a larger sample of patients.
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Affiliation(s)
- Antoine G M Aya
- New Bonnefon Clinic, Alès, France; Nîmes University Hospital, Nîmes, France.
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Theissen A, Fuz F, Bouregba M, Autran M, Beaussier M. A ten-year analysis of the reasons for death following ambulatory surgery: Nine closed claims declared to the SHAM insurance. Anaesth Crit Care Pain Med 2018; 37:447-451. [DOI: 10.1016/j.accpm.2018.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 02/27/2018] [Accepted: 03/01/2018] [Indexed: 12/29/2022]
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Domino KB. Reducing patient harm after ambulatory surgery: Lessons from malpractice claims. Anaesth Crit Care Pain Med 2018; 37:409-410. [PMID: 30236475 DOI: 10.1016/j.accpm.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Karen B Domino
- Department of anesthesiology and pain medicine, university of Washington school of medicine, 98195 Seattle, WA, USA.
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Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res 2018; 229:134-144. [PMID: 29936980 DOI: 10.1016/j.jss.2018.03.022] [Citation(s) in RCA: 412] [Impact Index Per Article: 68.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/27/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of this study was to systematically synthesize the large volume of literature reporting on the association between operative duration and complications across various surgical specialties and procedure types. METHODS An electronic search of PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from January 2005 to January 2015 was conducted. Sixty-six observational studies met the inclusion criteria. RESULTS Pooled analyses showed that the likelihood of complications increased significantly with prolonged operative duration, approximately doubling with operative time thresholds exceeding 2 or more hours. Meta-analyses also demonstrated a 14% increase in the likelihood of complications for every 30 min of additional operating time. CONCLUSIONS Prolonged operative time is associated with an increase in the risk of complications. Given the adverse consequences of complications, decreased operative times should be a universal goal for surgeons, hospitals, and policy-makers. Future study is recommended on the evaluation of interventions targeted to reducing operating time.
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Ghabra H, Smith SA. Anesthesia for Urological Procedures. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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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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Abstract
PURPOSE OF REVIEW Ambulatory surgery has grown in recent decades in volume and represents a significant number of anesthetics delivered throughout the USA. Preoperative anesthetic assessment in the ambulatory setting has become important because patients with numerous complex comorbidities are now commonplace in this arena. Disease states involving the lungs, the heart, the kidneys, and subpopulations including those who are obese and the elderly commonly receive anesthetics in an ambulatory setting. RECENT FINDINGS This review presents key aspects of current thinking with regard to preoperative assessment and considerations for different critical disease states and subpopulations that are now being managed under ambulatory surgery. Same day surgery centers require patient safety, and expectations are high for patient satisfaction. Advancements in surgical and anesthetic technique have allowed for more complex patients to partake in ambulatory surgery. Anesthesiologists must be familiar with guidelines, state-of-the-art pain management, and standards of preoperative patient evaluation to accurately stratify patient risk and to advocate for patient safety.
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Ramachandran SK, Pandit J, Devine S, Thompson A, Shanks A. Postoperative Respiratory Complications in Patients at Risk for Obstructive Sleep Apnea: A Single-Institution Cohort Study. Anesth Analg 2017. [PMID: 28622177 DOI: 10.1213/ane.0000000000002132] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a prevalent condition that is associated with early postoperative respiratory complications (PRCs). As the majority of patients with OSA are undiagnosed, preoperative screening remains the most efficient method to identify suspected OSA. METHODS This retrospective study was performed on patients undergoing anesthesia in a single academic medical center. We assigned OSA risk class retrospectively to all patients in the study by using the Perioperative Sleep Apnea Prediction (PSAP) score. We evaluated the relationship between PSAP categories and early postoperative invasive airway placement after adjusting for several preoperative and intraoperative factors (including surgical risk) previously associated with PRC occurrence. RESULTS A total of 108,479 patients were included in the final analysis with an incidence of PRC was 0.3% (n = 280). High PSAP score was associated with postoperative intubation (adjusted odds ratio, 2.3; 95% confidence interval, 1.5-3.7). Several risk factors reflecting anesthetic agents, neuromuscular blocking agents, and opioids were also independently associated with early PRC. CONCLUSIONS We report that suspected OSA based on the PSAP score is independently associated with increased risk of early PRC. Specific anesthetic agents are independently associated with early PRC, pointing to the potential for examining risk modification through these exposures in future studies.
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Affiliation(s)
- Satya Krishna Ramachandran
- From the *Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School at Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts; †Nuffield Department of Anaesthesia, University of Oxford, Oxford, United Kingdom; and ‡Center for Observational & Real World Evidence, Merck, Sharpe and Dohme, Whitehouse Station, New Jersey
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De Oliveira GS, McCarthy RJ, Davignon K, Chen H, Panaro H, Cioffi WG. Predictors of 30-Day Pulmonary Complications after Outpatient Surgery: Relative Importance of Body Mass Index Weight Classifications in Risk Assessment. J Am Coll Surg 2017; 225:312-323.e7. [DOI: 10.1016/j.jamcollsurg.2017.04.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/04/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
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Abbott T, Pearse R, Archbold R, Wragg A, Kam E, Ahmad T, Khan A, Niebrzegowska E, Rodseth R, Devereaux P, Ackland G. Association between preoperative pulse pressure and perioperative myocardial injury: an international observational cohort study of patients undergoing non-cardiac surgery. Br J Anaesth 2017; 119:78-86. [DOI: 10.1093/bja/aex165] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 01/23/2023] Open
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