Outpatient Surgery Research Articles

Same day discharge after hepatectomy: Can it be done safely?

With the advent of minimally invasive techniques and enhanced recovery pathways, outpatient surgery is becoming increasingly common, but has not yet been extensively described in liver surgery. The aim of the present study was to analyze the incidence, characteristics, and outcomes of patients undergoing outpatient hepatectomy in the US. We utilized the National Surgical Quality Improvement Program (NSQIP) database for patients who underwent laparoscopic or robotic, elective hepatectomy from 2014 to 2021. Patients discharged on postoperative day 0 were assigned to the "same-day discharge" group, otherwise the patient was considered "admitted." Postoperative outcomes were compared with propensity-matched analysis. Multivariate analysis was performed to identify predictors of postoperative LOS (length of stay). We identified 7279 patients, of which 361 were in the same-day discharge cohort and 6918 were in the admitted cohort. For admitted patients, median postoperative length of stay was three days (SD = 6). Same-day discharge patients tended to be younger (age 59 vs. 62, p = .034) and more often ASA class ≤2 (49% vs. 29%, p < .001). Comorbidities such as hypertension (40% vs. 45%, p = .048) and diabetes (12% vs. 19%, p = .002) were less common in the same-day discharge cohort. On propensity-matched comparison, there was no significant difference in 30-day mortality (p > .9), 30-day readmission (p = .2), and overall postoperative complication rate (p = .2). Predictors of longer postoperative LOS included longer operative time, inpatient hospital status, preoperative transfusion, dependent functional status, and use of neoadjuvant chemotherapy. Our results indicate that for low-risk patients and uncomplicated cases, same-day discharge after minimally invasive, elective hepatectomy is feasible without compromising patient safety and outcomes.

A narrative review on the performance and outcomes of penile and scrotal surgery in the ambulatory setting.

Following the COVID-19 pandemic, surgical wait times have surged, creating a backlog in elective urological procedures. This review aims to address the need to explore ambulatory care for penile and scrotal surgeries, which can offer benefits by shifting these procedures away from traditional inpatient settings. Recent studies confirm the safety and efficacy of performing penile and scrotal procedures in an ambulatory setting using local anesthesia (LA) or loco-sedative techniques. Of 616 reviewed cases, over 90% of patients expressed high satisfaction with LA and reported minimal postoperative complications. Pain management advancements, particularly the use of liposomal bupivacaine, reduced the need for opioids postoperatively. Importantly, no intraoperative complications or hospital admissions were reported, and adverse events were managed conservatively. The data highlighted in this review supports a move towards outpatient surgeries as a safe alternative to inpatient care for select cases. This review highlights the strong potential for ambulatory urological surgeries to alleviate surgical backlogs significantly, while reducing strain on hospital resources, and maintaining high levels of patient satisfaction. As evidence continues to grow on the safety, feasibility, and effectiveness of LA in office-based procedures, expanding ambulatory urological will be quintessential in modernizing patient care and reducing healthcare burdens.

Comparison of a fixed dose of 0.15% Hypobaric and 0.5% Hyperbaric Bupivacaine for shortterm unilateral lower limb orthopedic surgeries.Retrospective study with two videos

Background: Unilateral spinal anesthesia in orthopedic surgery of a limb has its advantages, especially in patients undergoing outpatient basis surgeries. Low dose, slow speed of administration and remaining in lateral decubitus for a certain period facilitate unilateral distribution in spinal anesthesia. Isobaric solutions of local anesthetics are not suitable for this type of anesthesia. Hypobaric and hyperbaric solutions of bupivacaine were compared in unilateral spinal anesthesia in patients undergoing orthopedic surgeries of one limb on an outpatient basis. Methods: Retrospective study carried out between 2002 and 2020 with 497 patients were randomly divided into two groups to receive 6 mg of 0.15% hypobaric bupivacaine or 6 mg of 0.5% hyperbaric bupivacaine. The solutions were administered in the L3-L4 space with the patient in the left lateral decubitus and remaining in this position for 15 minutes. Sensitive anesthesia was evaluated by the pin prick test. Motor blockade was determined by the modified Bromage scale. Both blockades were compared with the opposite side and among themselves. Results: There was a significant difference between the side of the surgery and the opposite side in all two groups at 15 minutes, but the frequency of unilateral spinal anesthesia was 90.9% with the 0.15% hypobaric bupivacaine versus 93.2% with the 0.5% hyperbaric bupivacaine. Patients did not develop any hemodynamic changes. Post puncture headache and transitory neurological symptoms were not observed. Conclusion: Spinal anesthesia with hypobaric and hyperbaric solutions present a higher frequency of unilateral anesthesia, without cardiocirculatory alteration, and patient satisfaction in remaining with a limb without anesthesia.

Proximal tibia for alveolar augmentation and augmentative rhinoplasty—a suitable option? A retrospective clinical study on donor and recipient site morbidity

BackgroundAutologous bone grafts are essential in reconstructive oral and maxillofacial surgery, and depending on the donor site, they can be associated with specific harvesting morbidities. One of the most commonly applied bone grafts is the iliac crest bone graft, irrespective of other grafts, which might be associated with an easier surgical procedure or the possibility of harvesting them under local anaesthesia. Objective of the study is the clinical evaluation of proximal tibia bone grafts regarding their eligibility for maxillofacial bone grafting.MethodsIn this retrospective study, proximal tibia bone grafts were examined with regard to associated donor and recipient site morbidity and their suitability for alveolar ridge augmentation and rhinoplasty.ResultsIn total, 21 tibia grafts were included. Fifty-seven percent of the bone grafts were used for alveolar ridge reconstruction, and 43% were used for augmentative rhinoplasty. No significant complications occurred during or after harvesting, but in 14.3% of the patients, minor wound healing disorders were recorded at the donor site, and in 19% of the patients, they were recorded at the recipient site. Statistically, patient sex, age, nicotine and alcohol abuse and metabolic diseases had no significant influence on the complication rate. Graft harvesting under local anaesthesia and at summer temperatures was associated with significantly more complications at the harvesting site (p < 0.05). In cases of dental implant insertion into augmented sites, the implants (n = 31) were followed up for a median period of 40.5 months, during this time 86.7% of the implants survived.ConclusionThe proximal tibia is a suitable donor site for harvesting autologous bone grafts for alveolar ridge augmentation or rhinoplasty because the donor site morbidity is low, and in contrast to iliac crest bone grafts, they can be harvested under local anaesthesia, which might be advantageous for outpatient surgeries.

A Qualitative Assessment of Adolescent Symptom Report and Caregiver Concordance Following Outpatient Surgery

Objectives: Limited data exist regarding recovery from surgery from the adolescent’s perspective, or data regarding concordance between adolescent and caregiver symptom report preventing appreciation of adolescent needs and hindering the provision of appropriate care. Methods: We conducted semi-structured interviews with adolescents ages 12-17 and a parent caregiver two weeks following a variety of outpatient elective surgeries about recovery symptoms. We used latent manifest content analysis to analyze interview data. Caregiver-adolescent response concordance was assessed using Cohen’s Kappa (κ). Results: Interviews were conducted with 31 adolescent-caregiver pairs (median age: 15y). Fifty-eight percent of adolescents and 84% of caregivers were female; 71% of adolescents were white. Twenty-three percent of children reported severe pain, some of which was not expected given the surgery. Severe pain was associated with nausea (71%, P= 0.002), pain-related sleep disturbance (86%, P= 0.007), and severe anxiety (43%, P= 0.008). Fatigue was also common (58%), but not associated with severe pain (P = 0.484) or sleep disturbance (P = 0.577). Thirty-nine percent reported anxiety; 32% experienced anger/frustration. Caregiver-adolescent concordance was only substantial for severe pain (κ = 0.71) and anger/frustration (κ= 0.67). Caregiver report also often included psychological symptoms not reported by their children, with qualitative evidence supporting caregiver accuracy. Discussion: Adolescents may experience significant physical symptoms such as pain and fatigue, even after minor surgeries. Fatigue symptoms may be unrelated to pain or sleep. Caregiver report of adolescent psychological symptoms may be necessary to gain a complete understanding of those symptoms in this population.

Digital Arterial Anastomosis as an Outpatient Surgery

Background: In incomplete amputation with a skin bridge, patency of the artery indicates digit survival if sufficient venous return is secured. This study aimed to investigate the effectiveness of digital arterial repair on an outpatient basis without using intravenous anticoagulants. Methods: We identified a total of 34 patients (34 digits) who underwent arterial repair for single vascular bundle injury between January 2000 and December 2022 on an outpatient basis. The following information were obtained from the patients’ medical records: sex, age, comorbidities, active smoking status, number of affected digits, level of amputation, type of the fracture type, mechanism of injury, arterial diameter, needle used, requirement of vein graft and the outcome. Results: Only a few fingertip injuries and severe injuries were included. Arterial patency was achieved in most patients after repair of an outpatient basis. Conclusion: Outpatient arterial repair may be acceptable under inevitable circumstances or to cater to patients’ preferences, when the injury is neither on the fingertip nor severe. Background: In incomplete amputation with a skin bridge, patency of the artery indicates digit survival if sufficient venous return is secured. This study aimed to investigate the effectiveness of digital arterial repair on an outpatient basis without using intravenous anticoagulants. Methods: We identified a total of 34 patients (34 digits) who underwent arterial repair for single vascular bundle injury between January 2000 and December 2022 on an outpatient basis. The following information were obtained from the patients’ medical records: sex, age, comorbidities, active smoking status, number of affected digits, level of amputation, type of the fracture type, mechanism of injury, arterial diameter, needle used, requirement of vein graft and the outcome. Results: Only a few fingertip injuries and severe injuries were included. Arterial patency was achieved in most patients after repair of an outpatient basis. Conclusion: Outpatient arterial repair may be acceptable under inevitable circumstances or to cater to patients’ preferences, when the injury is neither on the fingertip nor severe.

Patient-Initiated Communication After Parotidectomy.

We sought to study the incidence of patient-initiated communication after parotidectomy, identify patient and surgical factors associated with patient-initiated communication, and evaluate trends and possible areas for improvement. A retrospective cohort study of patients who underwent parotidectomy without combined procedures from 2018 to 2022 in a single tertiary-care institution was performed. We reviewed all patient communications documented within the electronic medical record within 30 days of discharge. We categorized patient communications as requiring an action by the surgeon, instruction by support staff, or reassurance. A total of 363 patients were included. Most patients were women (55.4%), Caucasian (78.8%), and had an average age of 56 years ± 16. We found 123 (33.9%) patients initiated postoperative communications. Swelling (47.2%) was the most common concern followed by wound concerns (15.4%). Switching from planned inpatient to outpatient surgery increased (OR = 2.635; 95% CI = 1.200-6.146, p = 0.026) propensity for postoperative communication. We found 31 (25.2%) postoperative communications required an action by the surgeon, 40 (32.5%) required instruction by the support staff, and the other 52 (42.3%) required reassurance or clarification. Multivariate analysis showed swelling (OR = 6.5, CI = 2.2-19, p < 0.001), male sex (OR = 3.27, CI = 1.127-9.459, p = 0.029), previous smoking (OR = 3.468, CI = 1.181-10.185, p = 0.024), and cancer (OR = 6.862, CI = 1.757-26.804, p = 0.006) were predictive of requiring an action by the surgeon. This is the first study to evaluate patient-initiated communication after parotidectomy and found it occurred 33.4% of the time. We found significant opportunities to improve perioperative care, enhance patient satisfaction, and reduce the overall burden on medical personnel. Level IV Laryngoscope, 2024.

The relationship between urodynamic bladder compliance and urinary fibrosis markers in children with neurogenic bladder dysfunction

BackgroundDecreased bladder compliance is an important risk factor for upper urinary tract in children with neurogenic bladder dysfunction (NBD). Urodynamics is the gold standard in determining bladder compliance. ObjectiveTo investigate the relationship between low bladder compliance and urinary fibrosis markers in NBD. Study designSpina bifida patients with NBD, who admitted between March 2021 and July 2021 were included. Patients with low compliant bladders, no renal scar, no recurrent urinary tract infections formed low compliance, LC group. Normal compliance, NC group, was comprised of patients with normocompliant bladders and the same characteristics. Control group (Group C) consisted of patients for outpatient surgery and had no known bladder dysfunction. Compliance was calculated with the formula ΔV/ΔP and a value of under 15 ml/cmH2O was accepted as low. Age, gender, urine density, serum urea, creatinine levels and urodynamic parameters were noted. Urinary type 1, type 3 collagen and its precursor procollagen type 3 and serum type 1 and 3 collagen were determined by ELISA. Results72 patients were included (LC group, n:31, NC group, n:24, C group n:17, mean age 7,39±1,24 years). No significant difference was observed in the comparison of age, gender, urine density and serum urea and creatinine values. No significant difference was observed between the LC and NC groups for urodynamic parameters, except for bladder compliance. Urinary collagen type 1 in LC group (11,71±3,02 ng/ml) was found to be significantly higher than that of the C group (9,45±1,97 ng/ml) (p=0,03). Urinary procollagen type 3 was significantly higher in LC group (103,15±24 ng/ml) when compared to C group (82,42±22,26 ng/ml) (p=0,016). Urinary collagen type 1 level above 9,20 ng/ml was 80,6% sensitive and 70,6% specific and urinary procollagen type 3 level above 78 ng/ml was 87% sensitive and 70,6% specific in predicting low compliance. DiscussionThis study seems to be the first study in the literature to evaluate bladder fibrosis and compliance, biochemically, by measuring urinary collagen levels in NBD. Urinary fibrosis markers are not currently an alternative to urodynamics for bladder compliance, but they may have potential to reduce the need for urodynamics with this indication. ConclusionDetermination of urinary collagen levels may be a marker of bladder wall fibrosis and may indirectly show decreased bladder compliance. It is plausible to say that invasive methods such as urodynamics may be less preferred for defining bladder compliance, instead, urinary biomarkers may have merit for this purpose in the future.

Outcomes and Cost-Effectiveness of Hospital Outpatient Versus Ambulatory Surgery Center Lumbar Decompression Surgery.

Retrospective Chart Review. Outpatient spinal surgeries in Ambulatory Surgery Centers (ASCs) have gained traction due to their potential cost efficiencies and improved perioperative processes. This study aims to compare the cost-effectiveness and patient outcomes of lumbar laminectomies performed in hospital settings vs ASCs. A retrospective analysis was conducted on 771 patients who underwent 1 or 2-level outpatient laminectomy between 2019 and 2023. Patient demographics, 90-day and one-year clinical and patient-reported outcomes (PROs), and one-year episode of care costs were evaluated. A one-year cost-effectiveness analysis was performed using the EQ-5D to measure quality-adjusted life years (QALYs). ASC patients demonstrated lower body mass index and American Society of Anesthesiologists (ASA) scores, with a higher prevalence of 1-level laminectomies compared to hospital patients. ASC-based laminectomy was associated with lower initial surgery cost and one-year episode of care costs ($5662 ± 4748 vs $10229 ± 9202, P < 0.001), with similar rates of complications and postoperative resource utilization. These trends remained after controlling for patient demographics, comorbidities, and number of levels treated. In patients completing baseline and 1-year EQ-5D scores, ASC-based laminectomy was over twice as cost-effective as hospital procedures ($64873/QALY gained vs $152630). The findings support the safety and one-year cost effectiveness of ASCs for appropriately selected patient populations undergoing lumbar laminectomy. Additional studies are needed to replicate these findings across institutions, and to assess the cost effectiveness of ASC-based laminectomy beyond one-year postoperatively.

Outpatient Upper Extremity Fracture Surgery Is Associated with Increased Post-operative Emergency Department Visits.

This study aimed to determine if outpatient upper extremity fracture surgery was associated with increased post-operative ED visits and identify related risk factors. Design: Retrospective cohort. This multi-center study was conducted within a single academic institution, encompassing two level 1, two level 2, and one level 3 trauma center. All patients >18 years of age that underwent upper extremity fracture surgery from 2015-2021 were included. Risk factors for postoperative ED visit that were investigated included age, sex, tobacco use, alcohol abuse, psychiatric diagnosis, Elixhauser comorbidity score, race, location of upper extremity fracture, surgical setting (inpatient vs. outpatient), upper extremity block, surgical specialty, and Area Deprivation Index. Variables with a p<0.1 in bivariate analysis were included in a multivariable logistic regression to determine factors associated with a postoperative ED visit at 30 and 90-days. A total of 6,315 patients with an average age of 51±19 years were identified of which 52% were female and 65% had outpatient surgery. Post-operatively, 188 patients (3.0%) presented to the ED within 30 days and 304 (4.8%) presented within 90 days. Thirty-seven percent of ED visits were directly related to the procedure, most commonly for pain (20%), cast issues (4.3%), and swelling (3.9%). At 30 days postoperatively, 2.8% of patients who underwent surgery in an outpatient setting and 3.4% of those who underwent inpatient surgery returned to the ED, with these rates increasing to 4.4% and 5.6%, respectively, by 90 days. In multivariable analysis, outpatient surgery (OR:1.5, p=0.030), tobacco use (OR:2.1, p<0.001), higher Elixhauser Comorbidity scores (OR:1.2, p<0.001), non-White race (OR:1.9, p<0.001) elbow fractures (OR:1.8, p=0.016), and hand fractures (OR: 1.6, p=0.046) were associated with 30-day ED visits. Outpatient surgery was associated with increased rate of 30-day ED visits. Patients that smoke, had increased number of comorbidities or were non-White presented to the ED more frequently. III.

Evolución del programa de recuperación rápida a cirugía ambulatoria en artroplastia total de cadera

IntroductionThe implementation of enhanced recovery programs has transformed total hip arthroplasty (THA) surgery. Outpatient prosthetic surgery is a safe and beneficial technique. Few centers in our country perform outpatient total hip arthroplasty (OTHA). We present the preliminary results of our experience. Material and methodThis is a prospective observational study conducted in 2023 with a sample of 30 patients proposed for THA following an outpatient surgery protocol by the orthopedic surgery and traumatology service. ResultsIn 2023, we performed 132 THAs in our center. Thirty patients, 27 men and 3 women with an average age of 55.7 years were included for an outpatient surgery circuit. Three patients did not meet the inclusion criteria identified by the Anesthesiology Department. Of the 27 patients included in the program, 25 were discharged on the same day. Two patients were admitted: one due to an intraoperative fracture and the other due to poor pain control and dizziness. No secondary complications related to the program were observed after discharge. All patients except one would recommend the outpatient protocol. ConclusionsOTHA programs should evolve from rapid recovery programs. Their implementation depends on an experienced multidisciplinary team. In this study, inclusion criteria were defined, achieving high satisfaction without increased complications. Outpatient surgery is a good option, and the implementation of this circuit is a safe, effective, and a satisfactory practice for selected patients.

Structural Requirements for the Outpatient Treatment of Benign Diseases of the Uterus.

In many cases, outpatient surgical treatment of benign diseases of the uterus has advantages over inpatient care. This has been demonstrated by the healthcare situation in other countries. However, the prerequisite for the provision of outpatient services is that this does not lead to any impairment in the quality of care or of patient safety. The ultimate goal should not be to reduce costs but rather to maintain and, ideally, improve the quality of care. This requires that services are not just defined by the surgical procedure but also by the entire treatment chain, including, for example, psychosocial support, and are remunerated accordingly. It is particularly worrying that the final decision as to whether an outpatient operation is possible is not the responsibility of the operating unit, but of the "Medizinischer Dienst," with the corresponding options and threats of sanctions. This situation is unique internationally and requires a paradigm shift. Furthermore, structural prerequisites must be maintained which currently only exist inadequately in Germany. Since a substantial proportion of planned outpatient operations require immediate or secondary inpatient treatment, there must be a barrier-free transition between the outpatient and inpatient sectors. This will require the creation of networks between outpatient service providers and one or more hospitals that are equipped and competent to manage even complex complications. It is important to create structures that, with intensive involvement of the operating unit, include adequate preoperative evaluation and patient education as well as needs-oriented postoperative care at home. The current separation of sectors is a significant hinderance. Moreover, when expanding and promoting outpatient surgery, the aspect of training and further education of specialist staff must be taken into account, as well as cross-sectoral quality assurance. Based on a review of the international literature, this article presents 13 recommendations for adequate structures when providing outpatient services which should serve as a prerequisite for the greatest possible guarantee of patient safety.

Updates on Evidence-Based Controversies for Outpatient Joint Arthroplasties

Total joint arthroplasty in the outpatient setting is becoming more common and is a topic of notable debate and discussion in orthopaedic surgery. Rapid changes in technology, surgical techniques, and policies surrounding hip and knee arthroplasty surgeries are making successful same-day surgery possible. In response to these changes, this comprehensive review examines the most recent developments and controversies based on the published literature within the past five years. Critical issues surrounding outpatient joint arthroplasty include debates on surgical techniques, proper patient selection, anesthesia techniques, perioperative pain management, discharge readiness, and complications. Evolving consensus statements and guidelines emphasize the need for ongoing research and multidisciplinary cooperation to ensure the best outcomes and patient safety.

Short-Cycle Autoclave Sterilization of Instruments in Same-Day Ophthalmic Surgeries

What Is the Issue? The volume of ophthalmic surgeries is increasingly high, with cataract surgery being 1 of the most performed surgeries in Canada. Infections following ophthalmic surgeries, while rare, can cause severe complications that may lead to irreversible vision loss. Reducing postsurgery infections is a high priority in clinical practice. Running a full wrapped, terminal steam sterilization cycle for ophthalmic instruments in autoclaves may be inefficient for ophthalmic surgeries and may cause unnecessary heavy economic and environmental burdens due to high surgical volumes. Using instruments sterilized on a short cycle between sequential same-day ophthalmic surgeries may help improve efficiency and reduce resources used. These instruments are generally processed using autoclaves (i.e., steam sterilizers); the effectiveness of a shorter-cycle method of sterilization is unclear. What Did We Do? To inform decisions regarding the use of autoclaves for short-cycle sterilization for sequential same-day instrument use in ophthalmic surgery, we sought to identify and summarize evidence comparing this method to full-cycle sterilization of wrapped instruments and identify any relevant recommendations. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2012. One reviewer screened articles for inclusion based on predefined criteria. What Did We Find? In a laboratory setting to simulate sequential same-day procedures, short-cycle sterilization with interrupted dry time for unwrapped ophthalmic instruments is feasibly as effective as full-cycle sterilization for wrapped instruments using the STATIM autoclave. Similarly, short-cycle sterilization with interrupted dry time for contained ophthalmic instruments is feasibly as effective as full-cycle sterilization for contained instruments using the AMSCO autoclave. For sequential same-day ophthalmic procedures, wet instruments sterilized by a short-cycle process with an interrupted dry time can remain sterile for at least 3 minutes if kept in a covered sterilizer containment device. One guideline recommends that wrapped or unwrapped ophthalmic instruments sterilized by a short-cycle process without full drying should be stored in a covered containment device until retrieved by staff wearing sterile gloves and gowns in the operating room for the subsequent surgery after a short delay. Phaco handpieces should be immediately primed with a balanced salt solution and remain wet as they sit on the sterile instrument table. We did not identify any clinical setting evidence from studies or autoclave manufacturers. It is unclear if clinical outcomes differ between patients undergoing sequential same-day ophthalmic surgeries using short-cycle sterilized instruments and those undergoing surgery using full-cycle sterilized instruments. What Does This Mean? Preliminary laboratory evidence and guideline recommendations supporting the use of autoclaves for short-cycle sterilization of instruments for sequential same-day ophthalmic surgeries are available. However, there is no clinical effectiveness evidence available on this process in patient settings. Future research is necessary to understand the clinical safety of using instruments sterilized by short cycles for sequential same-day use for patients undergoing ophthalmic surgeries. In addition to the evidence and recommendations identified, other factors, such as environmental influence, may be useful considerations when making decisions about short-cycle sterilization for sequential same-day instrument use for ophthalmic surgery.

The effect of intraoperative methadone on postoperative opioid requirements in children undergoing orchiopexy: A randomized clinical trial.

Children undergoing outpatient surgery are at risk of inadequate postoperative pain control. Methadone has a long duration of action and an intraoperative dose may provide stable analgesia throughout the postoperative period. Intraoperative methadone has been shown to improve pain control in adolescents but its use for postoperative pain in pediatric patients undergoing outpatient surgery has not been studied before. Therefore, we conducted a double-blind randomized placebo-controlled trial to investigate the effects of a single dose of intraoperative methadone in children aged less than 5 years undergoing orchiopexy for undescended testis. A total of 68 children were randomized to receive either methadone (0.1 mg/kg) or isotonic saline following induction of anesthesia. Exclusion criteria included preterm birth, previous scrotal surgery, and parents' inability to consent. Primary outcomes were opioid requirements (first primary outcome) and pain intensity in the post-anesthesia care unit. Secondary outcomes included episodes of desaturation and time until readiness to discharge from the post-anesthesia care unit, sleep on the first postoperative night, pain intensity, and opioid requirements at home until the evening on the first postoperative day. Follow-up was 4 days. Sixty children completed the study (age, mean ± SD, 26.2 ± 13.9 months), 29 children received methadone, and 31 children received placebo. Eighteen children required opioids in the post-anesthesia care unit, five children in the methadone group (proportion = 0.17, 95% confidence interval (CI): 0.07, 0.36) compared to thirteen patients in the placebo group (0.42, 95% CI: 0.26, 0.60) (mean difference = -0.24 and 95% CI: -0.03, -0.47) (p = 0.037). Five children in the methadone group (0.17, 95% CI: 0.03, 0.31) versus ten in the placebo group (0.32, 95% CI: 0.16, 0.49) had a face, legs, activity, cry, consolability score of ≥5 in the post-anesthesia care unit (mean difference = -0.15, 95% CI: -0.36, 0.06) (p = .179). More children in the placebo group woke up due to pain the first night following surgery (seven children vs. one child). The methadone group had a longer stay in the post-anesthesia care unit. There were no differences between the two groups regarding the other secondary outcomes. A single dose of intraoperative methadone reduces short-term postoperative opioid requirements in children after orchiopexy for nondescended testes but prolongs the duration of their stay in the post-anesthesia care unit.

Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study.

The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery. Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management. From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures. There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

Length of stay and cost of care differences between postoperative patients who board in PACU and those that proceed directly to inpatient bed

BackgroundBottlenecks in PACU throughput are frequently encountered challenges that OR managers must face. This study seeks to examine the impact of extended PACU stay (e.g. boarding) on both total hospital length of stay and overall cost of care. MethodsA total of 4,740 patients were studied having same-day admit surgeries for seven procedure types including: arthroplasty total knee, arthroplasty total hip, fusion spine transforaminal interbody lumbar, revision arthroplasty total knee, revision arthroplasty total hip, posterior cervical fusion, and anterior cervical fusion. 4,471 were identified as non-PACU boarders and 269 as PACU boarders (>6 h in PACU). Included in the analysis were demographics, date of admission, surgical procedure, PACU and hospital length of stay (HLOS), hospital direct costs, case mix index (CMI), and ASA status. ResultsThe median (IQR) PACU times in minutes were 57.00 (80) and 488.00 (453.50) minutes for PACU non-boarders and boarders (p < 0.001). HLOS was significantly (p < 0.001) more elevated in PACU Boarders compared to PACU Non-boarders: median (IQR) 2.00 (2.00) and 2.00 (3.00), (mean HLOS 3.16±2.83 vs 2.60±2.71 days). Median direct costs were ≈14.36% higher (p = 0.008) for the PACU boarders compared to Non-boarders. Direct costs were also not significantly different when using a 4-hour criteria for PACU boarders (14.39% higher median direct costs, p = 0.004). ConclusionsPACU boarding (>4 h) is associated with a statistically significant increased length of stay as well as direct costs compared with non-boarders across a variety of elective orthopedic and spine procedures. Thus, when frequent PACU boarding occurs, OR managers should consider the potential impact to patient care and hospital margins.

Promoting health information system in guiding decisions for improving performance: an intervention study at the Research Institute of Ophthalmology, Giza, Egypt.

This study aims to design and test a platform of key performance indicators (KPIs) and indices emphasizing achievements and improvement and helping decision-making. An operations research study was designed to analyze data from the Hospital Management Information System (HMIS) from July 2017 to June 2018 at the Research Institute of Ophthalmology (RIO), Giza, Egypt. The HMIS data were submitted to reform covering parameters in service delivery and corresponding indicators and indices. Data were grouped into four themes: human resources and outpatient, inpatient, and surgical operations. A total of 14 performance indicators were deployed to four specific indices and total performance indices and applied to six teams of ophthalmologists at RIO. The decision matrices were deliberated to demonstrate achievements and provide recommendations for subsequent improvements. Throughout 1 year, six teams of ophthalmologists (n = 222) at RIO provided the following services: outpatient (n = 116,043), inpatient (n = 8,081), and surgical operations (n = 9,174). Teams 2, 1, and 6 were the top teams in the total performance index. Team 4 had plunges in the outpatient index, and Team 5 faced limitations in the inpatient index. The study provided a model for upgrading the performance of the management information system (MIS) in health organizations. The KPIs and indices were used not only for documenting successful models of efficient service delivery but also as examples of limitations for further support and interventions.

Auricular laser acupuncture as an adjunct for parental anxietymanagement during children's surgery: Arandomized-controlled study.

Pediatric surgery is associated with high levels of anxiety for both children and parents/caregivers. To mitigate anxiety, auricular acupuncture has shown its potential in the perioperative setting. Accordingly, our team developed a wearable prototype auricular laser acupuncture system, AcuHealth V1.0, as a portable acupuncture device and conducted a proof-of-concept evaluation with parents of children undergoing surgery. The primary aim of this study was to conduct feasibility testing of the AcuHealth V1.0 system in delivering auricular laser acupuncture. Parents of children who were scheduled to undergo outpatient surgery were randomly assigned to one of three groups: authentic acupuncture (laser beams at known anxiolytic acupoints, n = 13), sham acupuncture (non-anxiolytic acupoints, n = 14), or a placebo control group (inactive laser, n = 14). Parent self-reported anxiety (0-10 numerical rating scale) was assessed at baseline, pre-intervention (once child was taken to the OR), post-intervention, and at 30 min after the intervention. Usability and acceptability data regarding the device were assessed after the intervention. Baseline data revealed no significant difference in anxiety between the three groups. Parent-reported anxiety level at 30-min post-intervention as compared to baseline in the authentic group was significantly decreased (delta mean ± std = -3.58 ± 2.07) compared to both the sham acupuncture (-1.35 ± 2.65) and placebo control group (0.54 ± 1.13). Evaluation of changes in parent-reported anxiety between groups over time using two-way repeated-measures analysis of variance (ANOVA) revealed a significant difference between the three groups (p = 0.001). Post hoc analysis with Scheffe test pairwise comparisons showed that at 30-min post-intervention compared to baseline, the authentic intervention group was significantly less anxious compared with both the sham group (p = 0.033) and the placebo control group (p = 0.001). Additionally, feedback regarding the usage of the device supported the acceptability and usability of the device with no adverse events. This pilot study administering laser auricular acupuncture via the AcuHealth V1.0 system decreased parental anxiety after 30 min in parents who received treatment immediately after their children were taken to the operating room with no adverse effect.

Laparoscopic Type IV Hiatal Hernia Repair in the Elective and Emergency Settings, Clinical Presentation, Outcomes, and Same-Day Surgery in Elective Repairs

Objective: We aimed to compare the outcomes of laparoscopic type IV hiatal hernia repairs in elective and emergent settings and assess the feasibility of same-day surgery (SDS) in elective repairs. Methods: SDS was defined as discharge on the day of the procedure. The feasibility of SDS in elective repairs was assessed. Results: There were 265 primary type IV hernia repairs: 208/265 (78.5%) elective versus 57/265 (21.5%) in emergent settings, age:70.0 (64.0-75.0) versus 73.0 (60.8-82.0), P = .059, BMI: 30.1 (26.6-33.8) versus 27.5 (24.4-32.4), P = .025, ASA IV: 5/208 (2.4%) versus 11/57 (19.3%), P &lt; .001, LOS:1 (0-2) versus 2 (1-4), P &lt; .001, 30-day mortality: 0/208 (0.0%) versus 2/57 (3.5%), P = .046. SDS was planned in 83/208 (39.9%) elective procedures and performed in 65/83 (78.3%); 18/83 (21.7%) were transitioned from SDS to observation/inpatient. NGT was attempted in 18/57 (31.6%) in emergent setting and was successful in 5/5 at the bedside and 11/13 (84.6%) endoscopically. Ischemia was seen in 4/57 (7.0%) in emergent settings and perforation in 1/4. Time from surgical consultation to arrival to the OR in patients without ischemia/perforation/obstructive gastric volvulus (n = 50) was 57.9 hours (44.0-79.7) versus 5.5 hours (4.1-8.9) in those with, (n = 7). Conclusion: Type IV hiatal hernia can be repaired laparoscopically with good outcomes in elective and emergent settings and as SDS in elective repairs. Emergent presentations can occur in about 20% of type IV hernias in older patients with lower BMI and higher ASA. Ischemia/perforation are rare. Emergent presentations without ischemia/perforation can be treated with gastric decompression and urgent repair during the same admission.