Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions

Patients' experiences of day surgery and recovery: A meta-ethnography

AIM

To explore and synthesise findings from qualitative studies on adult patients' experiences of day surgery and the processes of recovery.

BACKGROUND

There has been a shift in the practice of elective surgery, from inpatient to ambulatory treatment. Accordingly, more patients are undergoing day surgery and expected to care for themselves at home. To our knowledge, an updated metasynthesis on patients' experiences of day surgery across diverse contexts and continents is lacking.

DESIGN

Meta-ethnography.

METHODS

MEDLINE, EMBASE and CINAHL were systematically searched for qualitative research in English published between 2006 and 2023. Noblit and Hare's meta-ethnographic approach guided the synthesis of findings from 12 qualitative studies, and the eMERGe Reporting Guidance was used in the writing of this article.

RESULTS

Four themes were revealed: (1) requests for tailored information, (2) challenges of recognising and understanding postoperative symptoms, (3) being dependent on continuous professional and personal support and (4) calling for individual adaptation.

CONCLUSION

Our meta-ethnography indicates there is a need to improve information provision to better prepare patients for the processes of day surgery and recovery and promote their self-care abilities. Our findings highlight the importance of ensuring adequate levels of individualised care and support throughout the treatment process.

RELEVANCE TO CLINICAL PRACTICE

To improve quality of care in day surgery practice, implementation of interventions to enhance information provision and promote self-care during recovery at home may be considered. Pre-admission appointments that incorporate provision of tailored information and assessment of the patients' individual needs of care and support, home conditions and access to assistance from family/friends can be recommended.

Association between postoperative opioid use and outpatient surgical adverse events

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.

Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration

OBJECTIVE

Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers.

DATA SOURCES

Veterans Health Administration's Corporate Data Warehouse.

STUDY DESIGN

Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE.

PRINCIPAL FINDINGS

Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent.

CONCLUSIONS

The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.

Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration

OBJECTIVE

To examine factors associated with 0- to 7-day admission after outpatient surgery in high-volume specialties: general surgery, orthopedics, urology, ear/nose/throat, and podiatry.

STUDY DESIGN

We calculated rates and assessed diagnosis codes for 0- to 7-day admission after outpatient surgery for Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VA) dually enrolled patients age 65 and older. We also estimated separate multilevel logistic regression models to compare patient, procedure, and facility characteristics associated with postoperative admission.

DATA COLLECTION

2011-2013 surgical encounter data from the VA Corporate Data Warehouse; geographic data from the Area Health Resources File; CMS enrollment and hospital admission data.

PRINCIPAL FINDINGS

Among 63,585 outpatient surgeries in 124 facilities, 0- to 7-day admission rates ranged from 5 percent (podiatry) to 28 percent (urology); nearly 66 percent of the admissions occurred on the day of surgery. Only 97 admissions were detected in the CMS data (1 percent). Surgical complications were diagnosed in 4 percent of admissions. Procedure complexity, measured by relative value units or anesthesia risk score, was associated with admission across all specialties.

CONCLUSION

As many as 20 percent of VA outpatient surgeries result in an admission. Complex procedures are more likely to be followed by admission, but more evidence is required to determine how many of these reflect potential safety or quality problems.