Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study

Purpose

The primary objectives of this historical case-control study were to evaluate the incidence of and reasons and risk factors for adult unanticipated admissions in three tertiary care Canadian hospitals following ambulatory surgery.

Methods

A random sample of 200 patients requiring admission (cases) and 200 patients not requiring admission (controls) was taken from 20,657 ambulatory procedures was identified and compared. The following variables were included: demographics, reason for admission, type of anesthesia, surgical procedure, length of procedure, American Society of Anesthesiologists’ (ASA) classification, surgical completion time, pre-anesthesia clinic, medical history, medications (classes), and perioperative complications. Multiple logistic regression analysis was used to assess factors associated with unanticipated admissions.

Results

The incidence of unanticipated admission following ambulatory surgery was 2.67%. The most common reasons for admission were surgical (40%), anesthetic (20%), and medical (19%). The following factors were found to be associated with an increased risk of unanticipated admission: length of surgery of one to three hours (odds ratio [OR] 16.70; 95% confidence interval [CI] 4.10 to 67.99) and length of surgery more than three hours (OR 4.26; 95% CI 2.40 to 7.55); ASA class III (OR 4.60; 95% CI 1.81 to 11.68); ASA class IV (OR 6.51; 95% CI 1.66 to 25.59); advanced age (> 80 yr) (OR 5.41; 95% CI 1.54 to 19.01); and body mass index (BMI) of 30-35 (OR 2.81; 95% CI 1.31 to 6.04). Current smoking status was found to be associated with a decreased likelihood of unanticipated admission (OR 0.44; 95% CI 0.23 to 0.83), as was monitored anesthesia care when compared with general anesthesia (OR 0.17; 95% CI 0.04 to 0.68) and plastic (OR 0.18; 95% CI 0.07 to 0.50), orthopedic (OR 0.16; 95% CI 0.08 to 0.33), and dental/ear-nose-throat surgery (OR 0.32; 95% CI 0.13 to 0.83) when compared with general surgery. Other comorbid conditions did not impact unanticipated admission.

Conclusion

Unanticipated admission after ambulatory surgery occurs mainly due to surgical, anesthetic, and medical complications. Length of surgery more than one hour, high ASA class, advanced age, and increased BMI were all predictors. No specific comorbid illness was associated with an increased likelihood of unanticipated admission. These findings support continued use of the ASA classification as a marker of patient perioperative risk rather than attributing risk to a specific disease process.     

Unanticipated admissions following ambulatory surgery

The principal causes of unanticipated admission to the ambulatory surgery unit at Viladecans Hospital between October 1990 and January 1997 were analyzed. Of 7006 patients who underwent outpatient surgery in our facility, 108 were admitted (1.54%). The mean age was 38 years and 93.5% were American Society of Anesthesiologists' (ASA) physical status classification I and II. The principal reasons for admission were surgical complications 42.5% (46); anaesthetic complications 15.7% (17); uncontrollable pain 13% (14); infections 8.3% (9); protracted vomiting 7.4% (8); and coexisting medical problems 6.4% (7). The percentage of admissions in our facility is comparable to that of other ambulatory surgery units. Haemorrhage and pain were the principal causes of admission, vomiting was not common, and we address the role of infection, which has been overlooked as a reason for admission in other published series, perhaps due to the fact that it occurs after discharge.     

Cancellations in ambulatory day surgery: Ten years observational study

Background

Reasons for cancellation of booked procedures in ambulatory surgery need a detailed analysis in order to introduce corrective measures to lessen them.

Methods

Cancellations occurring the day before operation without patient replacement and procedures cancelled on the day of operation in 10 500 patients scheduled to be operated on in a multidisciplinary ambulatory surgery unit were analysed. Data were obtained from the incident register sheets and the database of the unit.

Results

A total of 424 patients were cancelled (4%). Reasons for cancellation were: acute medical conditions in 23.3% of cases, personal decision of the patient to refuse programming in 22.2%, non-attendance in 2.1%, failure to follow pre-operative guidance in 23.3% and unavailability of resources in 29%. These causes were preventable or possibly preventable in 57.1% of cases, difficult to prevent in 29% and not preventable in 13.9%.

Conclusion

More than half the cases of cancellation could be prevented. A rapid response of surgical departments to substitute patients, campaigns to increase the awareness of the population about the cost of health services and the implementation of pre-operative assessment guidelines must be considered.     

A postanaesthetic discharge scoring system for home readiness after ambulatory surgery

The assessment of a patient's home readiness is an important element in ambulatory surgery. No objective scoring system exists which systematically determines home readiness. A new postanaesthetic discharge scoring system (PADSS) has been designed and evaluated for reliability and validity against the existing clinical discharge criteria (CDC) in the ambulatory surgery unit of the hospital. Two hundred and forty-seven ambulatory surgery patients undergoing general anaesthesia were studied. Overall, there was a close correlation between the end of anaesthesia to the time patients were fit for discharge using either the PADSS or the CDC (Pearson's correlation coefficient r = 0.89). The internal consistency reliability of the PADSS ( = 0.65) was superior to that of the CDC ( = 0.14). The interobserver reliability coefficients of the PADSS at 1.0 and 1.5 h post surgery was also superior to the CDC for the dilatation and curettage patients. We have validated the PADSS against the CDC and found it to have superior measurement scaling and diagnostic properties.     

加速康复外科在日间病房内镜逆行胰胆管造影治疗胆总管结石中的应用

目的探讨加速康复外科（ERAS）在日间病房内镜逆行胰胆管造影（ERCP）治疗胆总管结石（CBDS）中的安全性、有效性。 方法回顾性分析2015年4月至2018年4月新疆医科大学第一附属医院肝胆包虫科接受ERCP术治疗的CBDS患者211例。其中在2015年4月至2016年3月间接受传统治疗的患者85例，设为传统治疗组；2016年4月至2018年4月间接受ERAS日间治疗的126例，设为ERAS日间组。分析比较两组患者围手术期及随访情况。 结果ERAS日间组患者的首次进食时间、下床活动时间显著早于传统治疗组（P<0.05），平均术后住院时间、医疗费用、口渴/饥饿感、术后恶心呕吐（PONV）发生率、腹胀腹痛发生率及术后3、12 h血清淀粉酶水平明显低于传统治疗组（P<0.05）；ERAS日间组患者满意度评分为（96.66±3.39）分，显著高于传统治疗组的（90.25±4.87）分（t=10.54，P<0.05），术后疼痛评分显著低于传统治疗组（z=-5.12，P<0.05）。两组患者无一例30 d内再入院，术后并发症发生率、白细胞计数比较，差异无统计学意义。 结论在ERAS模式下行日间ERCP治疗CBDS是安全可行的，可加快患者康复，减轻术后疼痛，提高患者满意度。     

加速康复外科理念在日间腹腔镜腹股沟疝修补术中的应用

目的分析和评价加速康复外科理念(ERAS)下日间腹腔镜经腹腔腹膜前腹股沟疝修补术(TAPP)与传统理念下行TAPP的临床疗效。方法回顾性分析2017年6月至2019年2月收治的接受TAPP术式的99例患者的临床资料,其中在日间病房接受ERAS理念管理的TAPP患者为ERAS组(57例),在普通病房接受传统围手术期管理的TAPP患者为传统组(42例),应用SPSS21.0统计学软件进行数据分析,两组患者术中术后相关指标、疼痛评分、满意度评分等计量资料用(x±s)表示,采用独立t检验;患者并发症发生率等计数资料采用检验,P<0.05表示差异有统计学意义。结果99例患者均成功完成手术达到临床治愈。ERAS组在术后6 h、12 h疼痛评分,术后胃肠道通气时间,首次下床活动时间、患者满意度、住院时间[(34.7±3.9)vs.(72.3±9.8)h]、住院费用[(1.6±0.1)vs.(1.8±0.1)万元]等方面均优于传统组(P<0.05);术后并发症方面,ERAS组恶心呕吐发生率低于传统组(P<0.05)。结论基于ERAS理念下的日间模式行TAPP是安全、可行的。具有手术创伤小,术后恢复快、住院时间短等诸多优势。     

Evolution of outcomes of robotic bariatric surgery: first report based on MBSAQIP database

BackgroundRobotic surgery is increasingly being used in bariatric surgery; however, the benefits of robotic surgery in bariatrics remain controversial.ObjectivesThe objective of this study was to compare the outcomes of robotic bariatric surgery with laparoscopic surgery over a 3-year period between 2015 and 2017 using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.SettingUniversity Hospital, United States.MethodsUsing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the years 2015 to 2017, we included patients who underwent primary robotic or laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Patients were divided into either robotic or laparoscopic groups. Primary outcomes included serious adverse events, organ space infection (OSI), readmissions, reoperations, and interventions at 30 days. Secondary outcomes included operation length and hospital stay. We performed propensity score matching based on clinically relevant preoperative variables to create balanced groups before analysis. We analyzed our data using separate Cochran-Mantel-Haenszel tests with year as the stratification variable and conducted subgroup analyses for robotic patients only using separate t tests for proportions, with P < .05 denoting statistical significance.ResultsOf the 315,647 patients available for comparison in the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files, there were 41,364 matched in the final data set. Using the Cochran-Mantel-Haenszel test, we found a significant association between year of performance and outcomes for OSI, 30 day-readmission, and intervention. The incidence of OSI after laparoscopic and robotic cases was .3% and .4%, respectively, in 2015 versus .2% and .3%, respectively, in 2017 (P = .04, odds ratio = 1.49). Thirty-day readmission for robotic cases was 5.2% in 2015 and 4.0% in 2017 (P < .05, odds ratio = 1.16). The incidence of 30-day intervention for robotic cases also dropped from 2.2% in 2015 to 1.3% in 2017 (P < .05, odds ratio = 1.37). Using a Student’s t test, there was also a statistically significant decrease in serious adverse events in the robotic group between 2015 and 2017 (incidence of serious adverse events in 2015 was 5.2% versus 3.7% in 2017, P < .05). Rate of 30-day reoperation for the robotic group did change over time but was comparable to the laparoscopic group (1.4% versus 1.3%).ConclusionsOur study showed between 2015 and 2017 the outcomes of robotic bariatric surgery have improved as evidenced by the significant decrease in the rate of OSI, readmissions, and interventions at 30 days.     

Low Rates of Adverse Events Following Ambulatory Outpatient Total Hip Arthroplasty at a Free-Standing Surgery Center

Background

We proposed to determine the complication and hospital admission rates for patients with total hip arthroplasty (THA) done by a single surgeon in a stand-alone ambulatory surgical center with same-day discharge. Given the recent emphasis on bundled payments for a 90-day episode of care, this same time frame after surgery was chosen to determine patient outcomes.

机器人辅助神经鞘瘤切除日间手术一例报道

神经鞘瘤是一种常见的后纵隔占位性病变,通常发生于脊神经根,具有一定的恶变可能性。临床上对于后纵隔占位性病变,若无禁忌证,均应考虑外科治疗。手术方式根据肿瘤的大小和位置分为开胸手术以及胸腔镜手术。尽管后纵隔肿瘤切除术通常被认为是一种安全的、低风险的手术,但患者术后仍需要住院观察。随着手术机器人技术的开发,机器人辅助手术可以保护周围组织减少术后出血的可能性,以达到日间手术的标准。本文介绍了一例接受机器人辅助后纵隔肿瘤切除日间手术的患者,手术效果满意,患者在24h内顺利出院。     

Resident continuity of care experience: a casualty of ambulatory surgery and current patient admission practices

BACKGROUND: The purpose of this study was to define and assess the impact of changes in health care delivery on the current continuity of care experience of surgical residents. METHODS: This 4-week, prospective cohort study included all patients who underwent a general surgical procedure at the University of British Columbia if a resident was present at the operation. The residents' perioperative involvement in each patient's care was recorded. RESULTS: Of the 592 eligible cases, 74.8% were elective same-day admissions, 5.4% elective previously admitted patients, and 19.8% emergencies. The overall rate of assessment was 27% preoperatively, 84% postoperatively on the ward, and <1% in oupatient clinic postdischarge. Elective cases were associated with significantly lower rates of preoperative assessment compared with emergency cases (15% versus 74%, P < .001). CONCLUSIONS: Changes in health care delivery have outpaced changes in the structure of surgical education, resulting in suboptimal continuity of care experiences for trainees. Residency programs must adapt their curricula to include adequate ambulatory experience.     

Compliance with postoperative instructions: a telephone survey of 750 day surgery patients

Patients undergoing day surgical procedures are given postoperative instructions not to drink alcohol, drive vehicles or make important decisions for 24 h. They are also advised to have a responsible adult stay with them at home overnight. Seven hundred and fifty patients were telephoned at 24 h postoperatively to determine their compliance with these instructions. Four per cent of patients drove vehicles, 1.8% consumed alcohol, while one patient made an important decision. A higher proportion of patients (5%) drove after general anaesthesia than regional anaesthesia or intravenous sedation (2.4%). The percentage of patients consuming alcohol was similar in both groups (1.8% vs. 1.9%). Four per cent of patients had no one staying with them overnight despite being accompanied out of the hospital. Patient compliance with instructions to not drink alcohol, drive or make important decisions may be improved by physician reinforcement of instructions and patient education.     

日间手术及加速康复外科用于胸腔镜胸交感神经切除术的探索及实践

目的探索日间手术及加速康复外科(enhanced recovery after surgery, ERAS)胸交感神经切除术应用的安全性、可行性。 方法回顾性分析2016年1月至2020年12月期间,深圳市第三人民医院胸外科657例接受胸交感神经切除术的原发性多汗症(primary hyperhidrosis, PHH)患者资料,其中男273例、女384例,年龄14~43岁、平均(24±5)岁,分为日间组及过夜组。分析两组的住院时间、手术时间、并发症、满意度、术后代偿性出汗、手术预约取消率、非计划再次手术、非计划再次住院等指标。 结果两组手术时间、麻醉时间、手术有效、代偿性出汗发生、非计划再次手术、非计划再次住院等,差异无统计学意义(P>0.05)。相比过夜组,日间组住院时间短[(9.6±1.1)h比(24.8±6.6)h, P<0.05],术后恶心和呕吐少(7例比23例,P<0.05),手术预约取消率高(15例比0例,P<0.05),患者满意度高[90分(90分,95分)比85分(80分,90分)]。 结论日间手术及ERAS理念可安全应用于胸腔镜胸交感神经切除术。     

减重代谢手术对心脑血管不良事件的影响

肥胖是诱发心脑血管不良事件的重要原因之一,减重代谢手术是近年来新兴的被证实可安全、有效减轻患者体重,并改善肥胖相关合并症如2型糖尿病、高血压、代谢综合征等的一种方式。有研究发现减重代谢手术可改善心脑血管不良事件危险因素,如炎症、高血压、血脂异常等,但减重代谢手术可否显著降低肥胖患者心脑血管不良事件尚不明确。本文通过回顾相关文献报道,了解减重代谢手术对肥胖患者心脑血管不良事件的影响,进一步阐明减重代谢手术的疗效及应用价值。