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Follow tips to avoid unplanned admissions
Consider these suggestions when examining the risk of outpatient surgery patients having unplanned admissions:
• Look at the risk factors.
In a study recently published in The Archives of Surgery, researchers developed an outpatient surgery admission index from independent predictors of immediate hospital admission using the following point values:
— 65 years or older (1 point);
— operating time longer than 120 minutes (1 point);
— cardiac diagnoses (1 point);
— peripheral vascular disease (1 point);
— cerebrovascular disease (1 point);
— malignancy (1 point);
— seropositive findings for human immunodeficiency virus (1 point);
— regional (1 point) or general (2 points) anesthesia.1
Patients with at least a score of 4 or higher were more than 30 times more likely to require hospitalization than those with a score of zero or 1. The researchers labeled their system an "outpatient surgery admission index," and they say it provides an evidence-based guide to assist providers and facilities identify patients at higher risk of immediate hospital admission.
The researchers note that there was a low absolute rate of hospitalization and a number of false-positive findings that "require this model to be a supplement to clinical judgment, suggesting cases where a higher level of evidence concerning the safety of ambulatory surgery is appropriate."1 They also said that there was no data regarding the patients' presurgical condition or whether admissions were planned.
"All we did was predict who would be admitted," says Lee A. Fleisher, MD, lead author and Dripps professor and chair of anesthesiology at the University of Pennsylvania School of Medicine in Philadelphia. Some of risk factors may not connect to complications, Fleisher says.
The issue of who should have outpatient surgery has grown as providers increasingly take patients with American Society of Anesthesiologists (ASA) scores beyond the 1s and 2s of yesteryear, he says. "Now, anybody can have ambulatory surgery," Fleisher says.
The question is that if a patient has a 3% chance of being admitted, is the facility prepared for that 1 in 30 chance, he says. "That's really the decision that patients and surgeons need to make," Fleisher says.
Kathy Bryant, president of the Federated Ambulatory Surgery Association (FASA), says that clearly it makes sense for physicians to look at these risk factors to see if it would help guide them. "While I don't agree with some conclusions, physicians and anesthesiologists should look at these to the extent they are meaningful and define risk factors better than what we have."
• Proper matching of patients and facilities.
Outpatient surgery and ambulatory surgery centers are a good thing, Fleisher says. "The issue is that some patients, although the vast majority scheduled gets to go home, some may not and need to be admitted," he says. For patients who have higher probability of being admitted after ambulatory surgery, providers should consider doing those cases in a hospital-based system where "we can easily admit them," Fleisher says. Each facility has its advantages and limitations, he maintains. Outpatient surgery providers need to make sure they match of the facility and patient characteristics, he says. "What we're trying to say is, let's make sure, when there is a higher probability of admission, that we match the right patient with the right facility, given patient characteristics, surgical characteristics, and facility characteristics," Fleisher says.
William P. Schecter, MD, FACS, chair of the American College of Surgeons Committee on Perioperative Care and professor of clinical surgery at the University of California, San Francisco, and chief of surgery at San Francisco General Hospital, says, "All components of the health care system must work in concert to achieve safety and optimal outcome."