Emergency Response in the Ambulatory Surgery Center

Original Research: Is Your Outpatient Office Prepared to Manage an Opioid Overdose?

BACKGROUND

Outpatient facilities, such as family and adult practice offices, psychiatric offices, and substance use treatment centers, should be equipped to manage medical emergencies and facilitate hospital transfers. Clinics that treat patients with opioid use disorder must be especially prepared to address respiratory arrest due to opioid overdose.

PURPOSE

The objective of this integrative review was to identify emergency response initiatives already investigated or developed that could be adapted to address opioid-related medical emergencies in the outpatient adult treatment setting.

METHODS

Initial and updated literature searches were conducted using MEDLINE and PubMed. These searches yielded 207 and 60 articles of interest, respectively, and a total of 6 and 18 were selected for retrieval. Of these, 5 and 8, for a total of 13, met the inclusion criteria.

RESULTS

We found few publications in the mental health literature to inform or guide outpatient practitioners in preparing their offices for emergencies. This integrative review draws from all areas of the medical literature to identify emergency response strategies that have been developed for outpatient settings. We identified 4 major themes in office emergency preparedness: simulation training, response team organization, equipment readiness, and emergency action protocols.

CONCLUSION

These 4 themes can provide guidance for improving readiness in medical offices, and in ambulatory mental health and substance use clinics. Researchers will need to develop emergency response algorithms that address these themes and assess patient outcomes.

Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers

BACKGROUND

As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs.

METHODS

Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim.

RESULTS

Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002).

CONCLUSIONS

This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.

Emergency preparedness in the central sterile supply department: a multicenter cross-sectional survey

OBJECTIVE

To investigate the current situation of emergency preparation and emergency drill in the CSSD, and analyze its influence on the nurses' emergency attitude and ability.

METHODS

This study employed a multicenter stratified sampling method, conducted from January to June 2023 using the online survey, participants completed the general data, emergency preparedness and drill questionnaire, public health emergency response questionnaire and emergency capacity scale. An independent samples t test or Kruskal-Wallis test was used to analyse differences in nurses' emergency capacity and attitudes.

RESULTS

The data from 15 provinces 55 hospitals in China. Overall, 77.58% of participants' institutions set up emergency management teams, 85.45% have an emergency plan and revise it regularly. 92.12% store emergency supplies. All survey staff participated in the emergency drill, which predominantly consisted of individual drills (51.52%), with 90.30% being real combat drills, 49.09% of participants engaging in drills every quarter, and 91.52% of the drill's participants exceeding 50%. The respondents' emergency attitude score was (29.346 ± 6.029), their emergency ability score was (63.594 ± 10.413), and those with rescue experience showed a more positive attitude (Z = -2.316, P = 0.021). Different titles, education levels, rescue experience and the frequency of emergency drill affected the emergency rescue ability of the respondents (P < 0.05).

CONCLUSIONS

Most medical institutions establish emergency management systems and plans, yet the content lacks geographical specificity.The duration and participation of emergency drills are high, but the effectiveness of the drills needs to be further improved, and the response capacity and attitudes of CSSD nurses are low. It is recommended that agencies develop comprehensive and targeted contingency plans to strengthen the inspection and evaluation of team strength, equipment and safeguards against the contingency plans, so as to ensure that the measures mandated by the contingency plans can be implemented promptly after the emergency response is initiated.

Single Incision Midurethral Sling Site of Care: Office-based Ambulatory Surgical Unit versus Hosptial-based Ambulatory Surgical Unit Setting

STUDY OBJECTIVE

To compare the economic difference in terms of overall costs between two Ambulatory Surgical Unit (ASU) settings in which a midurethral single incision sling (MSIS) can be performed.

DESIGN

A retrospective cohort study was carried out, examining the implanting of an MSIS performed at two different ASU settings by a single surgeon. Total cost was determined by assessing differences in charges and subsequent reimbursement associated with the procedure at each ASU setting. Time was measured using an EMR system for tracking both patient entry/exit from the facility as well as intraoperative time. Adverse events commonly associated with the procedure and patient-reported unanticipated adverse events were collected. A validated Surgical Satisfaction Questionnaire was administered postoperatively.

SETTING

University Health Network Teaching Hospital.

PATIENTS

A total of 125 women with stress urinary incontinence.

INTERVENTION

MSIS.

MEASUREMENT AND MAIN RESULTS

Between January 2016 until August 2020, 125 women underwent an MSIS procedure. The total office-based ASU (O-ASU) charges averaged $4564.00 (reimbursement of $2642.07). The total hospital-based ASU (H-ASU) charges averaged $40 136 (reimbursement of $9000), as well as an anesthesia average charge of $800 (reimbursement of $500). The average O-ASU total patient encounter time was 53.76 minutes versus 344.702 minutes for the H-ASU. There was no difference between commonly associated or unanticipated adverse events nor global patient satisfaction.

CONCLUSIONS

Based on overall cost, total encounter time, and global patient satisfaction, a certified O-ASU is an optimal site of care for MSIS for surgical management of female stress urinary incontinence.

Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers?

With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.

Office-based Plastic Surgery-Evidence-based Clinical and Administrative Guidelines

Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.

American Society of Anesthesiologists Physical Status Classification as a reliable predictor of postoperative medical complications and mortality following ambulatory surgery: an analysis of 2,089,830 ACS-NSQIP outpatient cases

BACKGROUND

Seventy percent of surgical procedures are currently performed in the outpatient setting. Although the American Society of Anesthesiologists (ASA) Physical Classification ability to predict risk has been evaluated for in-patient surgeries, an evaluation in outpatient surgeries has yet to be performed. The major goal of the current study is to determine if the ASA classification is an independent predictor for morbidity and mortality for outpatient surgeries.

METHODS

The 2005 through 2016 NSQIP Participant Use Data Files were queried to extract all patients scheduled for outpatient surgery. ASA PS class was the primary independent variable of interest. The primary outcome was 30-day medical complications, defined as having one or more of the following postoperative outcomes: (1) deep vein thrombosis, (2) pulmonary embolism, (3) reintubation, (4) failure to wean from ventilator, (5) renal insufficiency, (6) renal failure, (7) stroke, (8) cardiac arrest, (9) myocardial infarction, (10) pneumonia, (11) urinary tract infection, (12) systemic sepsis or septic shock. Mortality was also evaluated as a separate outcome.

RESULTS

A total of 2,089,830 cases were included in the study. 24,777 (1.19%) patients had medical complications and 1,701 (0.08%) died within 30 days. ASA PS IV patients had a much greater chance of dying when compared to healthy patients, OR (95%CI) of 89 (55 to 143), P < 0.001. Nonetheless, over 30,000 ASA PS IV patients had surgery in the outpatient setting. Multivariable analysis demonstrated a stepwise independent association between ASA PS class and medical complications (C statistic = 0.70), mortality (C statistic = 0.74) and readmissions (C statistic = 0.67). Risk stratifying ability was maintained across surgical procedures and anesthesia techniques.

CONCLUSIONS

ASA PS class is a simple risk stratification tool for surgeries in the outpatient setting. Patients with higher ASA PS classes subsequently developed medical complications or mortality at a greater frequency than patients with lower ASA PS class after outpatient surgery. Our results suggest that the ambulatory setting may not be able to match the needs of high-risk patients.

[Outpatient Surgery in German ENT]

Currently there is an intense discussion ongoing to enhance and expand outpatient surgery in the ENT in Germany, which is the intention by several politicians. The goal is to achieve a frequency of outpatient surgery comparable to an international level.To achieve this goal, acceptance of outpatient interventions by both, surgeons and patients is required, particularly in regard of equal quality standards and patient safety requirements.In the following review the organization, outcome, quality management and strategies for different ENT outpatient surgery worldwide is analyzed. Basically, outpatient surgery is organized in different ways: office-based-procedures in local anesthesia, procedures in ambulatory surgery center settings as standalone facilities or in connection with and adjacent to a hospital with possible inpatient treatment. Contact and resident times of the patients in the outpatient surgery centers differ between some hours through 23 hours. A deliberated and careful selection of patients which are suitable for outpatient procedures is required and should address comorbidities, medications, social circumstances, health literacy of the patient and its relatives, and distance from home to the hospital. A careful and strict quality management is mandatory which comprises the entire process from patient selection through patient entry, surgery, discharge and postoperative care in a multidisciplinary setting.Zur besseren Lesbarkeit des Textes wird bei geschlechterbezogenen Bezeichnungen die männliche Form benutzt. Es sind jedoch in gleicher Rangfolge auch das jeweilige weibliche Geschlecht oder andere Geschlechtsausprägungen gemeint.