Ambulatory Surgery Facilities Research Articles

The pros and cons of sharing an office-based ambulatory surgery facility

Sharing your office-based ambulatory surgery facility may generate additional revenue, but your equipment will be subject to additional wear and tear, your office procedures may be compromised, and your liability may increase. The author discusses the pros and cons of “renting” your OR.

Development of an appropriate list of surgical procedures of a specified maximum anesthetic complexity to be performed at a new ambulatory surgery facility.

A common but difficult task for a hospital when it decides to open a freestanding ambulatory surgery facility is how to decide which surgical procedures should be done at the new facility. This is necessary in order to determine how many operating rooms to plan for the new facility and which ancillary services are needed on-site. In this case study, we describe a novel methodology that we used to develop a comprehensive list of procedures to be done at a new ambulatory facility. The level of anesthetic complexity of a procedure was defined by its number of ASA Relative Value Guide basic units. Broad categories of procedures (e.g., eye surgery) were defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification. We identified 22 categories that are of a type that every procedure in the category has no more than seven basic units. In addition, by analyzing all procedures that the hospital being studied actually performed on an ambulatory basis, we identified six other categories of procedures that were of a type that all procedures eligible for surgery at the new facility had seven or fewer basic units. We describe a novel method to develop a comprehensive list of procedures that have a prespecified maximum level of anesthetic complexity to be performed at a new ambulatory surgery facility.

A practical guide to achieving AAAASF accreditation.

As time goes on, more professional societies and individual states are mandating stricter standards for office surgical facilities to ensure quality of care. As the nurse is often the person who coordinates accreditation efforts within the facility, he or she needs to be "savvy" regarding the implementation and maintenance of these standards. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) criteria are discussed with strategies and rationale for implementation.

Does functional ability in the postoperative period differ between remifentanil- and fentanyl-based anesthesia?

Study Objectives: To compare patients’ functional ability in the 24-hour postoperative period following a remifentanil compared to a hypnotic-fentanyl-treated anesthesia regimen using a 24-Hour Functional Ability Questionnaire. Design: Prospective, 1:1 single-blind, randomized, controlled effectiveness study. Setting: Multicenter study including 156 hospitals and ambulatory surgery facilities. Patients: 2438 patients (1496 outpatients and 942 inpatients) 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness of ≥30 minutes. Interventions: Patients were randomized to receive either intravenous remifentanil (0.5 μg/kg/min for induction and intubation; with the infusion rate decreased to 0.25 μg/kg/min after intubation) or fentanyl (administered according to anesthesiologists’ usual practice) as the opioid during surgery. Concomitant hypnotic drugs were propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given in the remifentanil patients and at the discretion of the anesthesiologists in the fentanyl patients. Measurements: A validated set of measurements of functional ability, rather than more traditional clinical psychological methods, to compare the recovery of patients from remifentanil- and fentanyl-treated anesthetic regimens up to 24 hours after surgery. Main Results: Remifentanil was statistically superior to fentanyl for the four functional assessments evaluated: walking without dizziness, thinking clearly, concentration, and communicating effectively. These differences reflect events occurring within the first 24 hours after anesthesia and surgery. Conclusions: A remifentanil-treated anesthetic demonstrated earlier return to some functions than a fentanyl-treated technique. Although functional assessment is a field that is still in its infancy, a questionnaire to assess functional ability during the 24 hours after anesthesia may provide more practical information about anesthetic recovery than previously used, traditional psychomotor evaluations.

Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of surgical patients

Study Objective: To compare the responses to, and hemodynamics associated with surgical stress, recovery profiles, and anesthesiologists’ satisfaction following balanced general anesthesia using either remifentanil or fentanyl in a large-scale population. Design: Prospective, 1:1 single blind, randomized, controlled effectiveness study in which patients received either remifentanil or fentanyl in combination with a hypnotic-based anesthesia regimen of either isoflurane or propofol. Setting: Multicenter study including 156 hospitals and ambulatory surgery facilities. Patients: 2,438 patients (1,496 outpatients and 942 inpatients), 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness ≥30 minutes. Interventions: Patients were randomized to receive either intravenous (IV) remifentanil (0.5 μg/kg/min for induction and intubation, with the infusion rate decreased to 0.25 μg/kg/min after intubation) or IV fentanyl (administered according to anesthesiologists’ usual practice) as the opioid during surgery. Concomitant hypnotic drugs were either propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given to the remifentanil patients and, at the anesthesiologists’ discretion, in the fentanyl patients. Measurements: Vital signs, adverse events, and emergence profiles were assessed and recorded. Recovery profile was assessed by recording time spent in the postanesthesia care unit and step-down recovery unit, number and timing of adverse events, timing and dosage of rescue medications, and time to eligibility for discharge (to home or to hospital room). Anesthesiologists’ satisfaction with the anesthetic regimen was assessed at the end of surgery. Main Results: Remifentanil-treated patients exhibited lower systolic and diastolic blood pressures (by 10–15 mmHg) and lower heart rates (by 10–15 bpm) intraoperatively compared to the fentanyl-treated patients. This difference promptly disappeared on emergence. Remifentanil-treated patients responded to verbal command, left the operating room, and (for outpatients) were discharged home sooner than fentanyl-treated patients. Anesthesiologists rated the predictability of response to intraoperative titration, assessment of hemodynamic profiles, and the quality of anesthesia higher in the remifentanil-treated patients. Conclusions: This study confirms previous observations on the hemodynamic properties associated with remifentanil and extends these to a wider context than previously reported. These characteristics provide clinicians with an alternative in opioid-based anesthesia.

Constructing an office-based ambulatory surgery facility

In planning an ambulatory surgery facility, do not waste space on hallways, large consultation rooms, and oversized waiting rooms. Furthermore, for a single practitioner, 2 treatment rooms are adequate. Take all the extra space you can generate and allocate it for spare storage, an adequately sized operating room, and a very large recovery room. The author provides practical suggestions to facilitate the construction of a well-functioning ambulatory surgery facility, strongly advising surgeons to “be involved.” ( Aesthetic Surg J 2001;21:279-280.)

HIPAA--hip, hip, hurray for confidentiality.

Leigh Anderson, MA, BS, RN,is Administrator of The Centre for Plastic Surgery, San Bernadino, California. She is a surveyor (site inspections) for American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF), and co-founder ofAccreditationHQ.

The changing rules for office-based surgery

Edward S. Truppman, MD, Aventura, FL , is a past president of the American Association for Accreditation of Ambulatory Surgery Facilities. Twenty years ago, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) was established as a voluntary accreditation organization. The specialty of plastic surgery recognized the need for quality assurance and peer review of surgery performed in the office setting. To seek such review voluntarily was unheard of in 1980, which made the creation of AAAASF a profound tribute to the specialty's dedication to excellence. Among the states that took action to make accreditation mandatory, California and Florida led the way. The various office surgery rules developed by these states were applied to most surgical specialties in which intravenous sedation or general anesthesia is used. Under these rules, the surgeon must maintain complete documentation of each surgical procedure, including anesthesia records, informed consent as to surgical risks, and information on the anesthesia provider. Limits have been set on lipoplasty volumes and the maximum amount of lidocaine (per kg) to be injected. The facility must be registered with the Department of Health, and the surgeon must report any serious adverse incidents within 15 days of …

Cost effectiveness of an office-based ambulatory surgery facility

Cost effectiveness of an office-based ambulatory surgery facility

Comparison of Pain, Motility, and Preoperative Sedation in Cataract Phacoemulsification Patients Receiving Peribulbar or Sub-Tenon's Anesthesia

The authors hoped to reduce the need for preoperative sedation and intravenous pain medication during cataract surgery by converting from peribulbar anesthesia to sub-Tenon's anesthesia. A consecutive series of 2453 cataract patients' charts were reviewed. Each patient had previously watched a videotape explaining the anesthetic method to be used. Requests for preoperative sedation were compared between patients who received peribulbar or sub-Tenon's anesthesia. A sample of 200 charts of nonsedated patients were reviewed to compare intraoperative pain and motility. Intraoperative freedom from pain was reported by 91% of the peribulbar patients and 99% of the sub-Tenon's patients. Preoperative sedation was reduced from 26% of the peribulbar patients to 6.7% of the sub-Tenon's patients. Sub-Tenon's anesthesia provided excellent intraoperative pain relief and reduced the need for preoperative sedation, making it a satisfactory anesthetic technique for patients undergoing cataract phacoemulsification in an ambulatory surgery facility.

Organizing and Managing an Efficient Ambulatory Surgery Facility

Organizing and Managing an Efficient Ambulatory Surgery Facility

An introduction to ambulatory surgery facility acceditation

"Managing Your OR" focuses on various aspects of aesthetic surgery in the ambulatory surgical setting.

Patient Safety in Accredited Office Surgical Facilities

The medical profession is besieged by concerns about cost containment. This in turn has focused attention on the use of ambulatory surgical facilities. However, the costs of hospital outpatient surgery programs usually prevent them from being competitive when compared with the costs of using office surgical facilities. To address the question of patient safety in office surgical facilities, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) sent a questionnaire to its accredited facilities. Two-hundred and forty-one (57.7 percent) of the 418 accredited facilities returned the anonymous questionnaires, a very high response rate. Or interest are the following findings: 400,675 operative procedures were reported during a 5-year period. Significant complications (hematoma, hypertensive episode, wound infection, sepsis, hypotension) were infrequent, occurring in 1 in every 213 cases. Return to the operating room within 24 hours and preventive hospitalization were less frequent. A death occurred in 1 in 57,000 cases (0.0017 percent). The overall risk is comparable in an accredited office (plastic surgical facility) and in a free-standing or hospital ambulatory surgical facility. This study documents an excellent safety record for plastic surgery done in accredited office surgical facilities by board-certified plastic surgeons.

Use of analgesics during propofol sedation: A comparison of ketorolac, dezocine, and fentanyl

Study Objective: To evaluate the comparative efficacy and side effect profile of ketorolac 60 mg, dezocine 6 mg, and fentanyl 100 μg when used as analgesic supplements to a propofol infusion during monitored anesthesia care (MAC). Design: Randomized, double-blind, placebo-controlled study. Setting: Ambulatory surgery facility at a university medical center. Patients: 80 outpatients undergoing breast biopsy or inguinal herniorraphy procedures under MAC. Interventions: All patients received midazolam 2 mg intravenously (IV) followed by 1 ml of the study medication containing either dezocine 3 mg IV, ketorolac 30 mg IV, fentanyl 50 μg IV, or normal saline. A propofol infusion was initiated at 75 μg/kg/min and then varied to maintain a stable level of sedation ( i.e., Observer Assessment of Alertness/Sedation scale score of 3). An additional 1 ml of the same study medication was administered IV 2 to 3 minutes prior to infiltration of the local anesthetic solution. During the operation, supplemental (rescue) medication consisted of fentanyl 25 μgIV, bolus injections in all four treatment groups. Measurements and Main Results: Propofol infusion and supplemental fentanyl dosage requirements, oxygen saturation values, respiratory rates, recovery times, and postoperative side effects were recorded. Visual analog scales were used to assess sedation, anxiety, pain, and nausea preoperatively (baseline), upon entry into the postanesthesia care unit, and at 30-minute intervals until discharge. The fentanyl and dezocine groups required lower average infusion rates of propofol to maintain a stable level of sedation than the control (saline) group. The saline and ketorolac groups required rescue analgesic medication more frequently and/or larger supplemental dosages of fentanyl than the two opioid analgesic treatment groups. Compared with the three analgesic treatment groups, postoperative pain scores were only marginally higher in the control group. Ketorolac-treated patients had consistently (but not significantly) shorter recovery times to oral intake, ambulation, and discharge than those in the dezocine or fentanyl groups. No postoperative nausea, vomiting, or pruritis was reported in the ketorolac group. Conclusion: Compared with ketorolac 60 mg, fentanyl 100 μg and dezocine 6 mg produced a greater decrease in the propofol sedation requirement during MAC. However, the use of ketorolac in combination with propofol for MAC was associated with an improved recovery profile.

Ambulatory surgery facilities: definition and identification.

Senior Vice President Center for Health Policy Studies Columbia, Maryland The research on which this article is based was supported in part by the National Center for Health Statistics under Contract No. 282-86-0103.

Vasectomy and Its Reversal

Techniques, results, complications, and medicolegal aspects of vasectomy are discussed in this article. Emphasis is placed on techniques that prevent spontaneous recanalization of the ends of the vas deferens after vasectomy. Factors that affect the reversibility of vasectomy are discussed. New microsurgical techniques of vasectomy reversal are described, and results of these new techniques are compared with results of nonmicrosurgical techniques of vasectomy reversal. Indications for bypass vasoepididymostomy during vasectomy reversal procedures, as well as techniques for performing vasoepididymostomy, are discussed.

Dissociative anesthesia in ambulatory plastic surgery: a 10-year experience.

The author describes extensive use of diazepam (Valium) with ketamine as a safe and efficacious technique of dissociative local anesthesia in an ambulatory plastic surgery facility. He finds these agents helpful in rhinoplasty, facial surgery, and breast augmentations as well as all other aesthetic and most reconstructive procedures.

Orthopedic Patients in an Ambulatory Surgery Facility

There is no doubt that ambulatory surgical intervention is here to stay. The advantages afforded the patient are substantial. Orthopedic procedures that previously required one to two nights of hospitalization are now routinely performed on an outpatient basis. This is a result of an increase in the use of arthroscopic surgery and an awareness of the importance of preoperative preparation and postoperative follow-up of the patient. Given the usual localized nature of orthopedic problems, the usual pre-existing good health of the orthopedic patient, and his or her desire to return to normal functioning as soon as possible, the scope of what can be accomplished on an ambulatory surgical basis is just beginning to be realized.

Planning and designing ambulatory surgery facilities for hospitals.

Planning and designing ambulatory surgery facilities for hospitals.