Ambulatory Surgical Setting Research Articles

Effect of music tempo on operating room preparation time.

Most operating rooms around the world play music, both during the surgeries and in between cases. We investigated whether music tempo (fast or slow) can affect the operating room preparation time in between surgeries (turnover time) in an ambulatory outpatient surgical centre setting. We compiled two playlists, one with fast upbeat tempo and the other with slow relaxing tempo. Each of the playlists was played throughout the workday in the operating room for one week with the same surgeon and nursing staff. The turnover times for each case were analysed. Inclusion criteria were standard cataract extraction with intraocular lens implant surgery. Exclusion criteria were any external reasons causing delays in the turnover time (such as anaesthesia team break time, computer system down, etc.). The turnover time from 32 cases in the slow group and 26 cases in the fast group were compared with Student's t test. The turnover time was significantly faster in the fast group versus the slow group (17.0 ± 0.60 vs. 20.1 ± 0.96, p < 0.03). Our study demonstrated that fast music tempo in the operating room can significantly reduce turnover time. This improved efficiency could potentially lead to significant cost savings in the healthcare sector.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Navigation and Intraoperative Monitoring: 49. Novel technology for C-arm based pedicle navigation

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Navigation and Intraoperative Monitoring: 49. Novel technology for C-arm based pedicle navigation

Early readmission and reoperation characteristics of ambulatory hypospadias repair

Hypospadias is a common birth defect. It is present in about 34.2 in 10,000 live births in North America. However, few studies have evaluated the immediate reoperation and readmission rates following elective repair. This study aimed to define the rates of readmission and reoperation following elective hypospadias repair, to improve pre-operative counseling on risks of the procedure. The Pediatric Health Information System (PHIS) was interrogated from 2004 to 2015 for all elective hypospadias repairs (ICD-9-CM code 58.45) performed in the ambulatory surgical setting. The following were then determined: age at initial operation, insurance status, race, presence or absence of readmission or reoperation within 30 days, presence of repeat hypospadias repair (same ICD-9 code), and presence or absence of another urethral operation (ICD-9 CM code 58.XX, excluding 58.45). Mixed effects logistic regression were then performed with dependent variables of 30-day repeat encounter, 30-day emergency department (ED) visit, 30-day readmission, or 30-day reoperation; and independent variables of age, race, ethnicity, and insurance status. The study identified 45,264 hypospadias repairs during 2004-2015 performed in 43 hospitals. Within 30 days of the procedures, 2826 (6.2%) had additional encounters in the ED at the same facilities, and 546 (1.2%) had readmissions. A total of 105 (0.2%) underwent second anesthetic within the first 30 days. With regards to a 30-day repeat encounter, odds of repeat encounter were significantly increased in patients aged <5 years, Black and Asian patients, and those with Medicaid. Of the 4882 repeat encounters, 954 (19.5%) had discharge ICD-9 codes related to the penis, or to postoperative complications in general. This study described the epidemiology of clinical events occurring at the same tertiary children's hospital within the first 30 days following more than 45,000 hypospadias repairs. Limitations included a cohort generated from a single set of ICD-9 codes. Elective hypospadias repair had a low rate of readmission (1.2%) and reoperation (0.2%) within the first 30 days. Patients aged <5 years, of non-white race, Hispanic ethnicity, and on Medicaid had significantly higher odds of 30-day repeat encounters.

Sleep, Snoring, and Surgery: OSA Screening Matters

This study was aimed to identify potential obstructive sleep apnea (OSA) in ambulatory surgical patients and create perianesthesia nursing protocols using a reliable and validated screening tool. Descriptive survey. A nurse-initiated OSA survey was conducted in 1,118 preoperative ambulatory patients using the STOP-Bang Questionnaire to identify patients at risk for OSA. The findings resulted in the development of protocols, patient education, and interventions. Ambulatory surgical patients were not routinely assessed for OSA before this study. The study verified that 10% of patients scheduled for ambulatory elective surgery had undiagnosed OSA and, because of the OSA identification, 16% of all scheduled surgeries were canceled. There were no unnecessary hospitalizations after the nurse-initiated OSA protocol. The STOP-Bang Questionnaire is a useful tool for screening patients with risks of OSA in the ambulatory surgical setting. This study supports using nursing best practices and safe patient care.

Updates in Pediatric Regional Anesthesia and Its Role in the Treatment of Acute Pain in the Ambulatory Setting.

The purpose of this review is to summarize the latest advances in pediatric regional anesthesia with special emphasis on its role in the ambulatory surgical setting. Undertreated pain in children following ambulatory surgery is not a rare occurrence and it is associated with increased morbidity and significant psychosocial harm. Use of regional anesthesia as part of the anesthetic approach in the ambulatory setting is safe when performed on children under general anesthesia and inclusion of certain adjuncts improves block outcomes. Ultrasonographic visualization during blockade improves safety and prolongs duration. Ambulatory continuous nerve blocks in older children are safe, efficacious, and associated with high patient and caregiver satisfaction rates. In the ever-growing field of pediatric same-day surgery, safe and efficient flow through the perioperative period necessitates use of a multimodal approach, of which regional anesthesia is but one important component. Perioperative complications are minimized with less opioid use, and yet appropriate pain management must be ensured. Pediatric regional anesthesia has been shown to be exceedingly safe under general anesthesia. Findings demonstrate that advances in ultrasound technology have contributed to safer and longer-lasting analgesia. It facilitates the development of new methods by which regional anesthesia can improve postoperative analgesia in children upon discharge and beyond.

The impact of critical event checklists on medical management and teamwork during simulated crises in a surgical daycare facility.

Although the incidence of major adverse events in surgical daycare centres is low, these critical events may not be managed optimally due to the absence of resources that exist in larger hospitals. We aimed to study the impact of operating theatre critical event checklists on medical management and teamwork during whole-team operating theatre crisis simulations staged in a surgical daycare facility. We studied 56 simulation encounters (without and with a checklist available) divided between an initial session and then a retention session several months later. Medical management and teamwork were quantified via percentage adherence to key processes and the Team Emergency Assessment Measure, respectively. In the initial session, medical management was not improved by the presence of a checklist (56% without checklist vs. 62% with checklist; p = 0.50). In the retention session, teams performed significantly worse without the checklists (36% without checklist vs. 60% with checklist; p = 0.04). We did not observe a change in non-technical skills in the presence of a checklist in either the initial or retention sessions (68% without checklist vs. 69% with checklist (p = 0.94) and 69% without checklist vs. 65% with checklist (p = 0.36), respectively). Critical events checklists do not improve medical management or teamwork during simulated operating theatre crises in an ambulatory surgical daycare setting.

Postoperative Instructions Preoperatively—Evaluating the Effectiveness of a Teaching Model on Patient Satisfaction Regarding Instructions for Home Care

Patients in the ambulatory setting often receive home care instructions, primarily in the postoperative phase. Patient's retention and understanding of these instructions is one determinant of postoperative outcomes. This article highlights how we designed and implemented a teaching strategy to better prepare patients for discharge from an ambulatory surgical setting. Our methods included developing a day of surgery plan for teaching patients their discharge instructions upon arrival, creating on-line teaching videos, and revising post discharge pain medication instructions. We used our patient satisfaction surveys to differentiate patients who were taught home care instructions in the preoperative phase day of surgery compared to those who received instructions in the postoperative phase. Our results indicate that doing home care instructions before surgery is the optimal time for patient teaching.

Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting.

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

Examining the Relationship Among Ambulatory Surgical Settings Work Environment, Nurses' Characteristics, and Medication Errors Reporting.

To describe work environment characteristics (leadership style and safety climate) of ambulatory surgical settings and to examine the relationship between work environment and nurses' willingness to report medication errors in ambulatory surgical settings. Descriptive correlational design using survey methodology. The sample of this study consisted of 40 unit-based registered nurses, working as full time, part time, or as needed in four ambulatory surgical settings affiliated with one health care system located in Northeast Ohio. The results of two separate regression analyses, one with three nurse manager's leadership styles and another with five safety climate dimensions as independent variables, explained 44% and 50%, respectively, on variance of nurses' willingness to report medication errors. To increase nurses' willingness to report medication errors, ambulatory surgical settings administrators should invest in nurse manager leadership training programs and focus on enhancing safety climate aspects, particularly errors feedback and organizational learning.

Timely Patient Discharge From the Ambulatory Surgical Setting

Timely Patient Discharge From the Ambulatory Surgical Setting

Preventing Venous Thromboembolism in the Ambulatory Surgical Setting

AORN JournalVolume 101, Issue 5 p. 567-570 Column Preventing Venous Thromboembolism in the Ambulatory Surgical Setting Lynn Razzano MSN, RN, ONCC, Lynn Razzano MSN, RN, ONCCSearch for more papers by this author Lynn Razzano MSN, RN, ONCC, Lynn Razzano MSN, RN, ONCCSearch for more papers by this author First published: 01 May 2015 https://doi.org/10.1016/j.aorn.2015.02.011 Editor's note: Impad is a trademark of Novamedix Distribution Limited, Nicosia, Cyprus. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume101, Issue5Infection PreventionMay 2015Pages 567-570 RelatedInformation

A dose-finding study of sufentanil sublingual microtablets for the management of postoperative bunionectomy pain.

Sufentanil sublingual microtablets (SSMs) at a dose of 15 µg per tablet have been studied for postoperative patient-controlled analgesia with a 20-minute lockout via a bedside handheld system over 2 days to 3 days of use. For more short-term (<24 hours) management of acute moderate-to-severe pain, such as in the ambulatory surgical setting, a single, higher-strength SSM dose administered via a health care provider would be of benefit as it would require less frequent administration and avoid the setup of a drug delivery system. This study was a two-center, randomized, double-blind, placebo-controlled trial for 12 hours in patients 18 years to 80 years of age who were undergoing bunionectomy alone or with hammertoe repair. Patients were randomly assigned at a 2:2:1 ratio to treatment with SSM 20 µg, SSM 30 µg, or placebo. The primary endpoint was time-weighted summed pain intensity difference to baseline over 12 hours (SPID12). Patients had to have a pain intensity score of 4 or higher just before initial microtablet dosing. Additional doses were administered when requested by the patient, with a minimum redosing interval of 1 hour. One hundred patients were randomized and received study drug. The SSM 30 µg was superior in the treatment of postbunionectomy surgical pain compared with placebo as demonstrated by the SPID12 score (6.53 vs. -7.12, respectively; p = 0.003) as well as all other secondary efficacy end points. The SSM 20-µg dosage strength was not superior to placebo for primary or secondary efficacy measures. Adverse events were similar among the three groups with the exception of nausea, vomiting, and somnolence, which demonstrated a dose-dependent increase in occurrence. The SSM 30 µg may be an effective, noninvasive alternative to health care provider-administered intravenous, intramuscular, or oral opioids for the management of moderate-to-severe acute pain. Therapeutic study, level I.

Scheduling elective surgeries with sequence-dependent setup times to multiple operating rooms using constraint programming

The problem studied in this paper is to schedule elective surgeries (in contrast to urgent surgeries) to multiple operating rooms (ORs) in ambulatory surgical settings. We focus on three aspects of the daily scheduling decisions, including the number of ORs to open, the allocation of surgery-to-OR, and the sequence of surgeries in each OR. All the surgeries to be scheduled are known in advance, which is a common assumption for elective surgery scheduling problems. The surgeries belong to different types, and each OR can only allow certain types of surgeries to be performed. Before a surgery starts, some setup work needs to be done, such as sterilization and preparing required equipment. The setup times are assumed sequence-dependent, and both setup times and surgery durations are deterministic. The fixed costs of running the ORs are high; while sometimes overtime costs, which are even higher than the fixed costs, may occur when the surgeries cannot be done within the normal operating period of the ORs. We build a Mixed Integer Nonlinear Programming (MINLP) model and a Constraint Programming (CP) model to solve this problem. The performance of these two models is tested on numerical examples, and the results show that the CP model is more efficient than the MINLP model in terms of the computational time and solution quality. We also examine the sensitivity of the solutions to the variation of surgery durations, and the analysis shows that the total costs do not change much when the variations of surgery durations are small.

Effect of site selection on pain of intravenous cannula insertion: A prospective randomised study.

Background and Aim:Pain on intravenous (IV) cannulation continues to cause considerable anxiety among the patients visiting the hospital for elective surgery. Often, it is the only unpleasant experience, especially in ambulatory surgical settings. Although, anecdotal evidence suggests that antecubital fossa (ACF) might be less painful site for venous cannulation, no scientific study exists to validate the same.Methods:In this prospective randomised study, effect of site selection on pain of venous cannulation was studied. Fifty-five consecutive adults, scheduled to undergo elective surgery, were randomly allocated to get IV cannulation first on ACF (28 patients) or on dorsum of hand (DOH) (27 patients) followed by cannulation on the contralateral arm on the alternative site (DOH or ACF). Five patients were excluded due to multiple cannulation attempts. Pain scores on cannulation related to both sites were recorded and compared.Results:Non-parametric data and frequency data analysis, using the Wilcoxon signed rank test or the Chi-square test as appropriate, showed that ACF approach was significantly less painful in comparison to the DOH when using a 20-gauge cannula for venous cannulation (P < 0.05).Conclusion:We recommend that in the absence of any contraindications, ACF should be the cannulation site of choice. However, considerations like increased chance of kinking and obstruction might preclude such practice.

Fasciotomy and Surgical Tenotomy for Recalcitrant Lateral Elbow Tendinopathy

Background: The optimal choice for intervention for recalcitrant lateral elbow tendinopathy remains unclear as various treatment modalities have documented comparable results in the literature. Purpose: To explore the safety, tolerability, and early efficacy of a new minimally invasive mode of treatment that delivers focused, calibrated ultrasonic energy, effectively microresecting the pathological tendon and removing only pathological tissue. Study Design: Case series; Level of evidence, 4. Methods: Seven male and 13 female patients aged 33 to 65 years averaging 12.5 months (range, 4-48) of failed nonoperative therapy underwent the ultrasonic microresection procedure in an outpatient clinic setting. The procedure involved a sterile, ultrasound-guided percutaneous microresection with a proprietary device (TX1) performed through a stab incision under local anesthesia. The duration of the procedure and complications of the device or procedure were assessed. Outcome parameters included patient satisfaction; visual analog scale (VAS) pain scores; Disabilities of the Arm, Shoulder and Hand (DASH) scores at 1, 3, 6, and 12 months; and ultrasound assessment at 3 and 6 months. Results: The median duration for the sterile confirmatory ultrasound examination (phase 1) was 88.5 seconds (range, 39-211; SD, ±47.6), the median duration of the procedure proper (phase 2) was 10.1 minutes (range, 4.1-19.4; SD, ±3.7), and the median energy time (duration the TX1 device was activated) was 32.5 seconds (range, 18-58; SD, ±11.0). No complications were encountered. A significant improvement in VAS score (from 5.5 to 3.3; P < .001) occurred by 1 week, and significant improvements in both DASH-Compulsory (from 21.7 to 11.3; P = .001) and DASH-Work (from 25.0 to 6.3; P = .012) scores occurred by 1 month. The VAS scores further improved at 3, 6, and 12 months (from 2.0 to 1.0 to 0.50; P = .003 and .023). The DASH-Compulsory score improved significantly from 3 to 6 months (from 8.6 to 4.6; P = .003), and both the DASH-Compulsory and DASH-Work scores were sustained by 12 months. Sonographically reduced tendon thickness (19 patients), resolved or reduced hypervascularity (17 patients), and reduced hypoechoic area (18 patients) occurred by 6 months. Nineteen of the 20 patients (95%) expressed satisfaction with the procedure, with 9 patients being very satisfied with their overall experience at 6 months after the procedure, 10 patients somewhat satisfied, and 1 patient neutral. Conclusion: Ultrasonic microresection of diseased tissue with the TX1 device provides a focally directed, safe, specific, minimally invasive, and well-tolerated treatment for recalcitrant lateral elbow tendinopathy in an office-based or ambulatory surgical setting with good evidence of some level of efficacy in 19 of 20 patients (95%) that is sustained for at least 1 year.

Anticoagulation Management in the Ambulatory Surgical Setting

Many people receiving maintenance anticoagulation therapy require surgery each year in ambulatory surgery centers. National safety organizations focus attention toward improving anticoagulation management, and the American College of Chest Physicians has established guidelines for appropriate anticoagulation management to balance the risk of thromboembolism when warfarin is discontinued with the risk of bleeding when anticoagulation therapy is maintained. The guidelines recommend that patients at high or moderate risk for thromboembolism should be bridged with subcutaneous low-molecular-weight heparin or IV unfractionated heparin with the interruption of warfarin, and low-risk patients may require subcutaneous low-molecular-weight heparin or no bridging with the interruption of warfarin. The guidelines recommend the continuation of warfarin for patients who are undergoing minor dermatologic or dental procedures or cataract removal. The literature reveals, however, that there is not adequate adherence to these recommendations and guidelines. Management of anticoagulation therapy by a nurse practitioner may improve compliance and safety in ambulatory surgery centers.

Transitioning the Older Adult in the Ambulatory Care Setting

Transitions between care settings are periods of vulnerability for patients. This is especially true for older adults, for whom comorbidities and functional impairments can increase the complexity of care and the need for multiple caregivers can compromise safety. Poor care transitions can result in costly hospital admissions. For this reason, leading health care organizations have initiated programs to improve the quality of transitions; however, to date, the ambulatory surgical setting has not been a focus of these initiatives. The ambulatory setting serves an increasingly complex patient population and provides the majority of elective surgeries, and adapting some of the transition tools that have been tested in other settings will benefit health care providers and patients in the ambulatory setting. Identifying periods of transition and risk, implementing electronic health records across all phases of patient care, and using evidence-based tools at each transitional stage can optimize the quality and safety of patient care.

Adverse events of conscious sedation in ambulatory spine procedures

Interventional spine procedures are commonly performed in the ambulatory surgical setting, often using conscious sedation. The rate of adverse events with conscious sedation has not been previously assessed in the interventional spine procedure setting. The goal of this study was to determine the rate of adverse events when using conscious sedation in the ambulatory interventional spine setting. A retrospective cohort chart review analysis was performed on all interventional spine procedures performed during one calendar year at a university-affiliated ambulatory surgery center by six nonanesthesia-trained spine interventionalists. Of the 3,342 procedures performed that year, 2,494 charts (74.6%) were available for review. Adverse events were documented immediately after the procedure and at a maximum 3-day follow-up phone call. The rate and type of adverse events were analyzed and compared between those who received conscious sedation with local anesthesia and those who received local anesthesia alone. Of the 2,494 cases reviewed, 1,228 spine procedures were performed with local anesthesia and conscious sedation, and 1,266 procedures were performed with local anesthesia alone. Of these cases, 66 immediate adverse events (5.12%) were documented in the conscious sedation group, and 61 immediate adverse events (4.82%) were documented in the local anesthesia alone group. At maximum 3-day follow-up, 670 patients of the conscious sedation group were available for contact, and 699 patients were available from the local anesthesia group. Thirty-two adverse events (4.77%) were noted in the conscious sedation group, and 28 adverse events (4.00%) were noted in the local anesthesia group. Comparison of these rates found no significant statistical difference. However, patients in the local anesthesia group had a significantly higher rate of postoperative hypertension. Adverse events reported both immediately and at follow-up were determined to be mild, with no serious adverse events reported. The findings of this study suggest that mild to moderate conscious sedation in interventional spine procedures is associated with low rates of adverse events when established protocols are followed.

Hysterectomy Is Feasible in a True Ambulatory Surgical Setting

Study Objective: To document the safety and feasibility of minimally invasive hysterectomy in an ambulatory setting.

Staged Surgical Management of Hypopharyngeal Traction Diverticulum

A 50-year-old woman who had undergone cervical spine fixation 6 years earlier presented with dysphagia, regurgitation of undigested food, halitosis, and weight loss. Operative examination demonstrated a hypopharyngeal diverticulum with spinal hardware visible in a defect in the mucosa. She underwent an open cervical approach to removal of the hardware. Endoscopic staple diverticulotomy as described by Scher and Richtsmeier was performed 8 weeks later in the ambulatory surgical setting. After a period of enteral feeding via a nasogastric tube in the initial postoperative period, she was able to resume oral nutrition in the interim between the surgical procedures. After the second procedure, she was able to resume a normal diet immediately and she experienced minimal symptoms. It is established that traction diverticulum is appropriately treated by removing the inciting anatomic factor(s). We propose that staged surgical management begin with the removal of the nidus followed by marsupialization of the diverticulum pouch. Standard staple diverticulotomy is a viable option for the second stage. This technique allows the patient to minimize the length of, or avoid, the second hospitalization for diverticulum management.