Last Updated: 09/15/2021
Prepared by: Catherine Tobin, MD, FASA and Kara Barnett MD, FASA
Safety of Same-day Discharge in High-risk Patients Undergoing Ambulatory General Surgery
George Pang, MD; Michelle Kwong, BHSc; Christopher M. Schlachta, MDCM; Nawar A. Alkhamesi, MD, PhD; Jeffrey D. Hawel, MD; and Ahmad I. Elnahas, MD, MSc
J Surg Res; July 2021; 263:71-77
PMID: 33639372 DOI: 10.1016/j.jss.2021.01.024
Retrospective study using data from National Surgical Quality Improvement Program (NSQIP) comparing overnight stay versus same day discharge in “high risk” patients undergoing ambulatory surgery.
What this article Tells Us?
- Overall mortality and morbidity is low in both groups. It is acceptable to discharge sicker patients on the same day when indicated.
- Overnight stay did not appear to lower the complication risks.
- Risk factors for complications are renal failure, disseminated cancer, ascites, older patients, diabetes, CHF, and nondependent functional status, and bleeding disorder.
Patient Selection in Outpatient Surgery
Tripti Kataria, MD; Thomas W. Cutter, MD, MEd; Jeffrey L. Apfelbaum
Clin Plastic Surg; July 2013; 40(3):371–382
PMID: 23830745 DOI: 10.1016/j.cps.2013.04.004
What this article Tells Us?
- There are no set recommendations on patient selection for outpatient surgery.
- One must follow general guidelines. More work in this area is needed.
- Patient selection is a complex issue that requires algorithms to be developed that include patient comorbidities, location of procedure, who is doing the procedure, who is doing the anaesthesia, and type of anesthesia.
Patient Selection for Day Case-eligible Surgery Identifying Those at High Risk for Major Complications
Michael R. Mathis, MD; Norah N. Naughton, MD, MBA; Amy M. Shanks, MS; Robert E. Freundlich, MD, MS; Christopher J. Pannucci, MD, MS; YiJia Chu, MD; Jason Haus, MD; Michelle Morris, MS; Sachin Kheterpal, MD, MBA
Anesthesiology; December 2013; 119(6):1310-1321
PMID: 24108100 DOI: 10.1097/ALN.0000000000000005
Data from American College of Surgeons’ National Surgical Quality Improvement Program was used to see if risk factors for morbidity and mortality in ambulatory surgery could be found since clear outcomes are lacking.
What this article Tells Us?
- When the surgical complexity was controlled, risk factors for increased morbidity and mortality were: COPD, HTN, Previous stent or cardiac surgery, history of CVA or TIA, and longer surgeries were identified.
Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study
Amanda Whippey, MD; Greg Kostandoff, BMBS; James Paul, MD; Jinhui Ma, MSc; Lehana Thabane, PhD; P Heung Kan Ma, MD
Can J Anesth; April 19 2013; 60(7):675–683
PMID: 23606232 DOI: 10.1007/s12630-013-9935-5
Retrospective study of 3 Canadian hospitals ambulatory surgeries in adult patients looking at unanticipated admissions and did not include emergency surgeries.
What this article Tells Us?
- MAC cases as compared to general were less likely to have an unexpected admission.
- Smokers had a decreased risk of admission.
- Cases longer (1- 3 hours), patient age over 40, BMI over 30, higher ASA scores had higher unplanned admissions.
Preoperative Evaluation for Ambulatory Anesthesia What, When, and How?
Obianuju Okocha, MD; Rebecca M. Gerlach, MD; BobbieJean Sweitzer, MD
Anesthesiol Clin; March 22 2019; 37(2):195–213
PMID: 31047124 DOI: 10.1016/j.anclin.2019.01.014
What this article Tells Us?
- Routine testing does not improve outcomes.
- “Same day anesthesia pre- op” workups are common.
- Cataract surgery is super low risk despite patients being elderly with health problems.
- Patients with cardiac pacemakers, and ICDS, on dialysis, and complex pain syndromes benefit from perioperative planning on coordination ahead of time.
- American College of Cardiology/American Heart Association (ACC/AHA) guidelines for cardiac evaluation in non cardiac surgery from 2014 are still an excellent resource.
The High Risk Patient for Ambulatory Surgery
Niraja Rajan
Curr Opin Anesthesiol; December 2020; 33(6):724–731
PMID: 33093300 DOI: 10.1097/ACO.0000000000000919
What this article Tells Us?
- Article has guidelines, risk stratification, optimization, and tips to help anesthesiologist with high risk patients in ambulatory. Role of anesthesiologist is important in perioperative workup.
- Prehabilitation, Pre op phone call about NPO guidelines, medications to take etc. when possible is helpful for cases.
- Pre op testing in ASA 1,2s and cataracts is not needed and does not decrease complications.
- Pre op testing only indicated if medical optimization could be done or it would change perioperative management.
High-risk Surgical Procedures and Semi-emergent Surgical Procedures for Ambulatory Surgery
Mark A Skues
Curr Opin Anesthesiol; December 2020; 33(6):718–723
PMID: 33002955 DOI:10.1097/ACO.0000000000000918
Review of hysterectomy, joint replacement, thyroidectomy, and spinal procedures, and semi-urgent and non-elective surgeries in ambulatory surgery.
What this article Tells Us?
- Multimodal analgesia, PONV guidelines, and post-operative follow-up are important parts of ambulatory management in complex cases.
- More complex cases can be considered for ambulatory operating rooms.
Improving outcomes in ambulatory anesthesia by identifying high risk patients
Mike T Walsh
Curr Opin Anesthesiol; December 2018; 31(6):659–666
PMID: 30325340 DOI: 10.1097/ACO.0000000000000653
What this article tells us?
- Screening high risk patients for ambulatory can help optimize their conditions prior to surgery and aid in post-operative care.
- Age, obesity, frailty, higher ASA status, OSA are risk factors for complications.
Non-Operating Room Anesthesia: Patient Selection and Special Considerations
Timothy Wong, Paige L Georgiadis, Richard D Urman, Mitchell H Tsai
Local Reg Anesth; January 8 2020; 13:1–9
PMID: 32021414 DOI: 10.2147/LRA.S181458
What this article tells us?
- Endoscopy, interventional pulmonology, interventional radiology, interventional cardiology, MRI, Pediatrics, IVF Retrieval are specifically covered in this review.
- NORA locations have sicker patients, higher radiation exposure to anesthesia providers, and higher complications. Anesthesia providers should become more familiar with the unique environment to lower risks.
- Pre-op, intra-op, post-op/ discharge have special considerations in NORA locations.
Preoperative Assessment and Optimization of Cognitive Dysfunction and Frailty in the Ambulatory Surgery Patient
Karina Charipova; Ivan Urtis; Omar Viswanath; Richard D Urman
Curr Opin Anaesthesiol; December 2020; 33(6):732-739
PMID: 32769745 DOI: 10.1097/ACO.0000000000000901
What this article tells us?
- Screen elderly patients (>65 years old) for preoperative neurocognitive decline and frailty to guide treatment decision making.
Older Adults and Unanticipated Hospital Admission within 30 Days of Ambulatory Surgery: An Analysis of 53,667 Ambulatory Surgical Procedures.
Gildasio S De Oliveira Jr., MD; Jane L Holl, MD, MPH; Lee Ann Lindquist,MD, MBA; Nicholas J Hackett, BA; John Y S Kim, MD; Robert J McCarthy, PharmD
J Am Geriatr Soc; August 2015; 63(8):1679-1685
PMID: 26200608 DOI: 10.1111/jgs.13537
What this article tells us?
- There were rates of 2.5% of unplanned hospital admission and 2% morbidity within 30 days of ambulatory surgery.
- The following characteristics were associated with an increased risk of unplanned admission: age (≥ 70 years), renal failure, chronic obstructive pulmonary disease, current cancer treatment, diabetes mellitus, and history of amputation or revascularization.
- Most common reasons for admission include wound problems, infections, bleeding, and pain.
A Novel Index of Elevated Risk of Inpatient Hospital Admission Immediately Following Outpatient Surgery.
Lee A Fleisher, MD; L Reuven Pasternak, MD, MBA, MPH; Alan Lyles, ScD, MPH
Arch Surg; March 1 2007; 142(3):263-268
PMID: 17372051 DOI: 10.1001/archsurg.142.3.263
What this article tells us?
- Immediate outpatient surgery admission rate of 0.6% with an index developed and included the following point values: (1) ≥ 65 years, (1) operating time > 120 minutes, (1) cardiac diagnoses, (1) peripheral vascular disease, (1) cerebrovascular disease, (1) malignancy, (1) seropositive for human immunodeficiency virus, (1) regional anesthesia and (2) general anesthesia.
- Odds ratio of hospitalization relative to those with 0-1 points included: score =2: 9.5, Score 3: 20.6 and score ≥4: 32.
Ambulatory Surgery Adult Patient Selection Criteria – A Survey of Canadian Anesthesiologists
Zeev Friedman; Frances Chung; David T Wong; Canadian Anesthesiologists’ Society
Can J Anaesth; May 2004; 51(5):437-443
PMID: 15128628 DOI: 10.1007/BF03018305
What this article tells us?
- 75% of the anesthesiologists surveyed found the follow comorbidities would still allow the patient to proceed with ambulatory surgery: ASA III, low grade angina pectoris, prior myocardial infarction > 60 months ago, low grade congestive heart failure, asymptomatic valvular disease, sleep apnea and monitored anesthesia care or regional anesthesia without narcotics, morbid obesity (BMI=35-44) without cardiovascular or respiratory comorbidities, insulin dependent diabetes mellites, and malignant hyperthermia susceptible.
- 75% felt the following comorbidities were not appropriate for ambulatory anesthesia locations: ASA IV patients, high grade angina pectoris (symptoms with daily activities or present at rest), prior myocardial infarction within 6 months, high grade congestive heart failure (symptoms at rest), sleep apnea with general anesthesia and postoperative narcotics, morbid obesity (BMI ≥ 45) with cardiovascular or respiratory comorbidities, and no patient escort.
Patient Selection in Outpatient Surgery.
Tripti Kataria, MD; Thomas W Cutter, MD, MEd; Jeffrey L Apfelbaum, MD
Clin Plast Surg; July 2013; 40(3):371-382
PMID: 23830745 DOI: 10.1016/j.cps.2013.04.004
What this article tells us?
- To determine if a patient is appropriate for the surgery in the outpatient setting, assess patient comorbidities, surgical procedure, who the surgeon/proceduralist is, anesthetic need, anesthetic provider available and the type of surgical setting.
Unplanned Hospital Admission After Ambulatory Surgery: A Retrospective, Single Cohort Study
M Stephen Melton, MD; Yi-Ju Li, PhD; Richard Pollard; MD; Zhengxi Chen; John Hunting; Thomas Hopkins, MD; William Buhrman, MD; Brad Taicher, DO; Solomon Aronson, MD; Mark Stafford-Smith, MD; Karthik Raghunathan, MBBS, MPH
Can J Anaesth; January 2021; 68(1):30-41
PMID: 33058058 DOI: 10.1007/s12630-020-01822-1
What this article tells us?
- The rate of unplanned hospital admission after ambulatory surgery was 0.7% with the following factors increasing this risk: > 50 years, ASA III or IV vs II, chronic obstructive pulmonary disease, diabetes mellitus, transient ischemic attack, specific procedures (respiratory, digestive, or musculoskeletal), general anesthesia with peripheral nerve block vs general anesthesia, and ambulatory surgery center facility.
- ICU admission rate was 0.4% with the following factors increasing this risk: ASA III or IV vs. II, musculoskeletal procedure and ambulatory surgery center.
- Reduced risk of unplanned hospital and/or ICU admission with monitored anesthesia care vs general anesthesia.
Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration.
Hillary J Mull, PhD, MPP; Amy K Rosen, PhD; William J O’Brien, MS; Nathalie McIntosh, PhD; Aaron Legler, MPH; Mary T Hawn, MD, MPH; Kamal M F Itani, MD; Steven D Pizer, PhD
Health Serv Res; October 2018; 53(5):3855-3880
PMID: 29363106 DOI: 10.1111/1475-6773.12826
What this article tells us?
- Rate of hospital admission within 7 days after VA outpatient surgery was 16% but varied by procedure surgical specialty as listed: general surgery 14%, urology 28%, orthopedics 6%, ear nose and throat 26%, and podiatry 5%.
Incidence, Predictions, and Causes of Unplanned 30-Day Hospital Admission After Ambulatory Procedures.
Bijan Teja, MD; Dana Raub, Cand Med; Sabine Friedrich, MD; Paul Rostin, Cand Med; Maria D Patrocínio, MD; Jeffrey C. Schneider, MD; Changyu Shen, PhD; Gabriel A. Brat, MD; Timothy T Houle, PhD; Robert W Yeh, MD, MSc; Matthias Eikermann, MD, PhD
Anesth Analg; August 2020; 131(2):497-507
PMID: 32427660 DOI: 10.1213/ANE.0000000000004852
What this article tells us?
- Instrument developed to predict unplanned 30-day hospital admission after ambulatory anesthesia procedures included the following point values: (2) chronic pulmonary disease, (2) diabetes mellitus), (2) peripheral vascular disease, (3) liver disease, (4) congestive heart failure, (4) depression, (4) anemia, (5) moderate or severe renal failure, (6) drug abuse, (8) malignancy, or the following types of surgeries: (14) emergency procedure, (1) male genital system, (2) eye and ocular adnexa, (4) female genital, (5) integumentary system, (5) maternity care or delivery, (7) musculoskeletal system, (10) endocrine system, (10) hemic and lymphatic system, (14) digestive system, (14) nervous system, (14) urinary system, (16) respiratory system, (18) mediastinal and diaphragm, (18) vascular system.
- Overall readmission rate of 2% with lowest readmission rate of 0.5% if ≤ 4 points to rate of 8.7% if ≥ 24 points.
- Most common reasons for admission include issues related to malignancy, nonsurgical site infection and surgical complications.
Complex Cancer Surgery in the Outpatient Setting: The Josie Robertson Surgery Center.
Hanae Tokita, MD; Rebecca Twersky, MD, MPH; Vincent Laudone, MD; Marcia Levine, MSN, RN, NE-BC; Daniel Stein, MD, PhD; Peter Scardino, MD; Brett Simon, MD, PhD
Anesth Analg; September 2020; 131(3):699-707
PMID: 32224721 DOI: 10.1213/ANE.0000000000004754
What this article tells us?
- Facility patient selection criteria (eg. BMI > 45, presence of AICD, end stage renal disease on hemodialysis) adjusted to serve as red flags rather than rigid exclusion criteria.
Last Updated: 01/04/2022
Prepared by: Niraja Rajan, MD, SAMBA-F
Patient Selection for Adult Ambulatory Surgery: A Narrative Review
Niraja Rajan, MD, SAMBA-F, Eric B Rosero, MD, Girish Joshi, MB, BS, MD, FFARCSI, SAMBA-F
Anesth Analg. 2021;133(6):1415-1430.
PMID: 34784328 DOI: 10.1213/ANE.0000000000005605
What this article tells us?
- Anesthesiologists who practice at ambulatory surgery centers need to have clearly defined patient selection criteria allowing for safe and efficient care of medically complex patients undergoing extensive surgical procedures with the expectation of discharge to home on the day of surgery.
- Patient selection is not a “one size fit all.” Determining suitability of a patient for surgery as an outpatient is a dynamic process, involving the complex interplay of several factors such as surgical procedure, patient characteristics, expected anesthetic technique (eg, sedation/analgesia, local/ regional anesthesia, or general anesthesia), type of ambulatory setting (ie, short-stay [23-hour stay] facilities, hospital-based ambulatory center, freestanding ambulatory surgery center [ASC], and office-based surgery) and social factors, such as availability of transportation and a responsible individual to take care of the patient at home.
- The majority of comorbid conditions do not preclude ambulatory surgery, provided they are optimized and stable. Severe comorbid conditions with the potential for perioperative instability should not be cared for in the outpatient setting. These include conditions listed in the ASA PS 4 classification.
- It is advisable to develop procedure-specific exclusion criteria for patients that are not candidates for ambulatory surgery. Developing and implementing protocols (or clinical pathways) for patient selection and prehabilitation would further enhance patient safety and efficiency. A pragmatic question to ask is: Will postoperative hospitalization influence patient care or perioperative outcome? If no improvement would be achieved, then the patient should undergo the procedure on an ambulatory basis.
