Freestanding Ambulatory Surgical Center Research Articles

11789 Outpatient Robotic Assisted Hysterectomy Outcomes: Hospital Versus Freestanding Ambulatory Surgical Center

11789 Outpatient Robotic Assisted Hysterectomy Outcomes: Hospital Versus Freestanding Ambulatory Surgical Center

Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases

ObjectiveTo evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy in a freestanding ambulatory surgical center. MethodsPatients were treated between 2015-2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher risk populations. ResultsA total of 1267 patients underwent ambulatory percutaneous nephrolithotomy with a median stone diameter of 32mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (p=0.5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) p<.05). ConclusionsAmbulatory percutaneous nephrolithotomy may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multi-year paradigm shift in percutaneous nephrolithotomy from an inpatient procedure to an outpatient procedure in a surgery center.

Differential Utilization Patterns of Total Ankle Arthroplasty vs Arthrodesis: A United States National Ambulatory Database Analysis.

End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis. TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA. In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA. Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis. Level III, retrospective cohort study.

Improving Racial and Ethnic Disparities in Outpatient Anterior Cervical Discectomy and Fusion Driven by Increasing Utilization of Ambulatory Surgical Centers in New York State.

Retrospective cohort study. The purpose of this study was to assess trends in disparities in utilization of hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for outpatient ACDF (OP-ACDF) between White, Black, Hispanic, and Asian/Pacific Islander patients from 2015 to 2018 in New York State. Racial and ethnic disparities within the field of spine surgery have been thoroughly documented. To date, it remains unknown how these disparities have evolved in the outpatient setting alongside the rapid emergence of ASCs and whether restrictive patterns of access to these outpatient centers exist by race and ethnicity. We conducted a retrospective review from 2015 to 2018 using the Healthcare Cost and Utilization Project (HCUP) New York State Ambulatory Database. Differences in utilization rates for OP-ACDF were assessed and trended over time by race and ethnicity for both HOPDs and freestanding ASCs. Poisson regression was used to evaluate the association between utilization rates for OP-ACDF and race/ethnicity. Between 2015 and 2018, Black, Hispanic, and Asian patients were less likely to undergo OP-ACDF compared with White patients in New York State. However, the magnitude of these disparities lessened over time, as Black, Hispanic, and Asian patients had greater relative increases in utilization of HOPDs and ASCs for ACDF when compared with White patients ( Ptrend <0.001). The magnitude of the increase in freestanding ASC utilization was such that minority patients had higher ACDF utilization rates in freestanding ASCs by 2018 ( P <0.001). We found evidence of improving racial disparities in the relative utilization of outpatient ACDF in New York State. The increase in access to outpatient ACDF appeared to be driven by an increasing number of patients undergoing ACDF in freestanding ASCs in large metropolitan areas. These improving disparities are encouraging and contrast previously documented inequalities in inpatient spine surgery. III.

IBCOx-9 Enhanced Recovery After Metabolic Surgery: Results of a De Novo Program for Same-day Cases in a Free-standing Ambulatory Surgical Center

Abstract Background Metabolic Surgery (MS) is commonly performed in a hospital setting. Same-day case (SDC) MS has not been performed due to concern for patient safety and complications after discharge. Procedures performed in ambulatory surgical centers (ASC) provide several advantages over hospital-based surgery by improving patient experience, decreasing hospital acquired infections, decreasing cost, and increasing access to MS. We previously reported our experience with performing 2,534 patients who underwent sleeve gastrectomy (SG) in an ASC. The ability to replicate this program validates the safety of Enhanced Recovery After Metabolic Surgery (ERAMS) protocols. We have replicated the SDC program with a new team in a new facility using previously established ERAMS protocols. Objective To report safe and effective protocols for same-day metabolic surgery. Setting Free-standing ASC, Methods Data was collected retrospectively for all patients undergoing MS from June 2019 - December 2019, n = 18. Revisional procedures were not excluded from this study. Patients were excluded from the ASC criteria if they weighed &amp;gt;400 pounds, if anticipated surgery time was &amp;gt; 2 hours, if the patient had impaired mobility limiting early ambulation, if they had chronic obstructive pulmonary disease, severe sleep apnea or moderate cardiac risk. All surgeries were performed laparoscopically using a 38 French Bougie, staple line was initiated 4 cm from the pylorus. No buttress material was used. The upper 3 cm of the staple line was oversewn. Intraoperative blood pressure was raised 20 mm Hg to identify bleeding along the staple line. Drains were not routinely used. Patients were given 3-4 liters of intravenous fluid prior to discharge. Patients were discharged once ASC discharge criteria was met: ambulating, voiding, tolerating fluids, pain and nausea controlled and normal vital signs. Results Mean age was 41.3 years (21-70). Mean preoperative body mass index (BMI) was 43.2 (32-55). Mean operative time was 88.1 minutes (54-146). Average length of stay at the ASC was 386.7 minutes (165-547). There were no re-admissions, re-operations, or direct transfers from the ASC to the hospital. One patient was seen in the emergency department (ED) within 30 days (postoperative day 3) for anxiety and dysphagia. She was discharged from the ED after negative studies. Seventeen patients had SG. Four had concomitant hiatal hernia pairs. One had concomitant liver biopsy. Two patients were revisional: one patient had a previous gastric band; one patient had previous banded sleeve gastrectomy. Conclusion With an experienced metabolic surgeon, appropriate protocols, and a consistent operative team, MS can be performed safely as a SDC in a free-standing ASC on selective patients.

PD55-08 OPTIMIZATION OF PERCUTANEOUS NEPHROLITHOTOMY FOR A FREE-STANDING AMBULATORY SURGERY CENTER: OUTCOMES FROM 1200 CASES

You have accessJournal of UrologyCME1 May 2022PD55-08 OPTIMIZATION OF PERCUTANEOUS NEPHROLITHOTOMY FOR A FREE-STANDING AMBULATORY SURGERY CENTER: OUTCOMES FROM 1200 CASES Daniel Rosen, Meagan Dunne, Max Drescher, Brian Panish, Liam Hatch, Joel Abbott, and Julio Davalos Daniel RosenDaniel Rosen More articles by this author , Meagan DunneMeagan Dunne More articles by this author , Max DrescherMax Drescher More articles by this author , Brian PanishBrian Panish More articles by this author , Liam HatchLiam Hatch More articles by this author , Joel AbbottJoel Abbott More articles by this author , and Julio DavalosJulio Davalos More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002635.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Percutaneous Nephrolithotomy (PCNL) is frequently used as the primary treatment modality for patients with large stones or challenging anatomy. It has evolved from an inpatient procedure to one that is now routinely performed in the outpatient setting. We aimed to identify the patients who were able to be treated in a free-standing ambulatory surgical center (ASC). METHODS: We analyzed patients who underwent PCNL or mini-PCNL from 2015-2021 by one of three surgeons. Patients were selected for ambulatory surgery if there was not a mandatory imperative for inpatient admission e.g. BMI>50 or severe cardiac or respiratory comorbidities. Patients were not excluded from the ASC based on stone burden or age. Generally, patients were administered an intercostal block and left with a double J stent at the end of the procedure and a foley catheter that was removed in the PACU. The tract was plugged with gelfoam/thrombin. Demographic, preoperative, and postoperative data was prospectively collected. Descriptive statistics were used for analysis. RESULTS: 1215 patients were available for analysis. Demographic and intraoperative characteristics of the patients are shown in Table 1. Operative technique progressed over time with the usage of primarily smaller percutaneous access sheaths (24Fr replacing 30Fr as standard, and the implementation of common usage of 17.5Fr mini sheaths for smaller stones). Patients were generally limited to a maximum of 2 access sites. 1.7% of patients required transfer to the hospital postoperatively. CONCLUSIONS: PCNL can safely and routinely be done as an outpatient procedure with low risk of hospital transfer. Patients should be carefully selected for inpatient procedure and admission based on comorbidities and prior anesthetic complication history. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e950 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Rosen More articles by this author Meagan Dunne More articles by this author Max Drescher More articles by this author Brian Panish More articles by this author Liam Hatch More articles by this author Joel Abbott More articles by this author Julio Davalos More articles by this author Expand All Advertisement PDF DownloadLoading ...

Managing prior approval for site-of-service referrals: an algorithmic approach

ObjectivesMany payers and health care providers are either currently using or considering use of prior authorization schemes to redirect patient care away from hospital outpatient departments toward free-standing ambulatory surgical centers owing to the payment differential between these facilities. In this work we work with a medium size payer to develop and lay out a process for analysis of claims data that allows payers to conservatively estimate potential savings from such policies based on their specific case mix and provider network.Study DesignWe analyzed payment information for a medium-sized managed care organization to identify movable cases that can reduce costs, estimate potential savings, and recommend implementation policy alternatives.MethodsWe analyze payment data, including all professional and institutional fees over a 15-month period. A rules-based algorithm was developed to identify episodes of care with at least one alternate site for each episode, and potential savings from a site-of-service policy.ResultsData on 64,884 episodes of care were identified as possible instances that could be subject to the policy. Of those, 7,679 were found to be attractive candidates for movement. Total projected savings was approximately $8.2 million, or over $1,000 per case.ConclusionsInstituting a site-of-service policy can produce meaningful savings for small and medium payers. Tailoring the policy to the specific patient and provider population can increase the efficacy of such policies in comparison to policies previously established by other payers.

The Safety of Foot and Ankle Surgical Procedures at an Ambulatory Surgery Center

Category:Ankle; Bunion; Hindfoot; Lesser Toes; Midfoot/ForefootIntroduction/Purpose:There is a growing trend to perform surgical procedures at freestanding ambulatory surgical centers. No literature exists evaluating the rate of adverse events and overall safety of foot and ankle outpatient surgeries at a freestanding ambulatory surgery center (ASC).Methods:A retrospective review of all foot and ankle cases performed over a two year period at a single freestanding ASC. A total of 313 cases were performed. Adverse events are state-reported events that cause harm or lead to additional treatment. Using state-reported adverse events criteria and previous literature from hand and upper-extremity cases, we categorized our adverse events into seven categories: 1) infection requiring intravenous abx or return to the operating room, 2) postoperative transfer to a hospital, 3) wrong-site surgery, 4) retention of a foreign object, 5) postoperative symptomatic thromboembolism (DVT), 6) medication error, and 7) bleeding complications.Results:The overall rate of adverse events was 3.5% with 11 events identified over the two year period. There were a total of 10 infections and 1 symptomatic DVT. There were no cases that resulted in transfer to a hospital, hospital admission after discharge, medication error, bleeding complications, wrong-site procedures, or retained foreign bodies.Conclusion:Outpatient foot and ankle procedures are not without complications, but the overall rate of complications postoperatively is farly low (3.5%). Overall, foot and ankle surgeries can be performed safely in an outpatient setting at an ASC.

Trends in Ambulatory Surgery Center Utilization for Otolaryngologic Procedures among Medicare Beneficiaries, 2010-2017.

Surgical care is increasingly shifting to freestanding ambulatory surgical centers (ASCs). The extent to which otolaryngologists use ASCs has implications for patient safety and health care spending. This study characterizes trends in utilization and resultant financial implications for common otolaryngologic procedures performed at ASC and hospital outpatient departments (HOPDs). Retrospective cross-sectional analysis. ASCs, HOPDs. Subjects included Medicare beneficiaries undergoing outpatient otolaryngologic procedures between 2010 and 2017. Procedures included the 20 highest-volume procedures performed by otolaryngologists at ASCs in 2017. Main outcomes included absolute and relative percentage difference in the proportion of procedures furnished at ASCs and HOPDs and estimated Medicare cost savings resulting from increased ASC utilization between 2011 and 2017. The proportion of outpatient otolaryngologic procedures performed at ASCs increased by 1.8% (relative difference: 10.0%; mean annual relative increase: 1.60%), and the proportion located at HOPDs decreased by 6.0% (relative difference: -11.8%; mean annual relative decrease: -1.6%) between 2010 and 2017. Rhinoplasty accounted for the largest absolute increase in ASC utilization over the study period (absolute [relative] 8.9% [33.5%]). Increased ASC utilization resulted in an estimated $7.1 million in cost savings to Medicare between 2011 and 2017. Otolaryngologists shifted outpatient surgical care from HOPDs to ASCs between 2010 and 2017, with resultant reductions in Medicare expenditures. Further research is necessary to examine the impact of this shift on patient safety.

Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice

BackgroundThe definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. AimTo evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries. MethodsA database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared. Main Outcome MeasureThe primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. ResultsA total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial. Clinical ImplicationsIPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer. Strengths & LimitationsThe strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding. ConclusionASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk.Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025–1032.

Primary single-level lumbar microdisectomy/decompression at a free-standing ambulatory surgical center vs a hospital-owned outpatient department—an analysis of 90-day outcomes and costs

While free-standing ambulatory surgical centers (ASCs) have been extolled as lower cost settings than hospital outpatient facilities/departments (HOPDs) for performing routine elective spine surgeries, differences in 90-day costs and complications have yet to be compared between the two types of treatment facilities. We carried a comprehensive analysis to report the differences on payments to providers and facilities as a reflection of true costs to patients, employers and health plans for patients undergoing primary, single-level lumbar microdiscectomy/decompression at ASC versus HOPD. Retrospective review of Medicare advantage and commercially insured enrollees from the Humana dataset from 2007 to 2017Q1. To understand the differences in 90-day complications, readmissions, emergency department visits and costs for patients undergoing primary, single-level lumbar microdiscectomy/decompressions at an ASC versus HOPD. The Humana 2007 to 2017Q1 was queried using Current Procedural Terminology codes to identify patients undergoing primary, single-level lumbar microdiscectomy/decompressions. Patients undergoing two-level surgery, open laminectomies, fusions, revision discectomies, and/or deformities were excluded. Service Location codes for HOPD (Location Code 22) and free-standing ASC (Location Code 24) were used to determine surgery treatment facilities. Using propensity scoring, we matched two groups who had surgery performed in ASCs or HOPDs based on age, gender, race, region and Elixhauser comorbidity index. Multivariable logistic regression analyses were performed on matched cohorts to assess for differences in 90-day outcomes between facilities, while controlling for age, gender, race, region, plan, and Elixhauser comorbidity index. A total of 1,077 and 10,475 primary single-level decompressions were performed in ASCs and HOPDs, respectively. Following a matching algorithm with propensity scoring, the two cohorts were comprised of 990 patients each. Observed differences in 90-day complication rates were not statistically or clinically significant (ASC=9.1% vs. HOPD=10.3%; p=.362) nor were readmissions (ASC=4.5% vs. HOPD=5.3%; p=.466). On average, performing surgery in an ASC versus HOPD resulted in significant cost savings of over $2,000/case in Medicare Advantage ($5,814 vs. $7,829) and over $3,500/case ($10,116 vs. $13,623) in commercial beneficiaries. Performing single-level decompression surgeries in an ASC compared with HOPDs was associated with approximately $2,000 to $3,500 cost-savings per case with no statistically significant impact on complication or readmission rates.

Safety and Cost-Efficacy of Surgical Fixation of Isolated Ankle Fractures in a Free-Standing Ambulatory Surgical Center (ASC) vs. Hospital-Owned Outpatient Facility (HOPD)

Category:Ankle, TraumaIntroduction/Purpose:Free-standing Ambulatory Surgical Centers (ASCs) typically provide uncomplicated surgical procedures in a non-hospital setting, and function as ‘focused factories’ that replicate the delivery of quality care while achieving lower costs as compared to hospital-owned outpatient facilities (HOPD). Despite an increasing interest towards outpatient foot and ankle surgery, few studies have compared the safety and cost-savings associated with surgical fixation of isolated ankle fractures in a free-standing ASC vs. a HOPD.Methods:The 2007-2014 Humana Administrative Claims (HAC) database was queried using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. Location of surgery was identified using Service Location codes 22 (HOPD) and 24 (ASC). Propensity- score matching and multi-variate regression analyses were used to compare differences in 90-day complications, ED-visits and readmissions between the two groups. A 90-day cost comparison was also carried out to assess savings associated with surgery in an ASC vs. HOPD.Results:A total of 4,832 (80.1%) ankle fractures treated in a HOPD and 1,198 (19.9%) in a free-standing ASC were included in the study. Following propensity-score matching to account for differences in baseline demographics and clinical characteristics, each group consisted of 1,138 patients. Following multi-variate analyses, undergoing surgery in a free-standing ASC vs. a HOPD was not associated with a higher rate of 90-day complications (0.73 [95% CI 0.54 -1.00]; p=0.05), ED visits (OR 0.86 [95% CI 0.64- 1.16]; p=0.331) and readmissions (0.79 [95% CI 0.53 -1.18]; p=0.251). Furthermore, undergoing surgery in a free-standing ASC was associated with nearly $2500 cost-savings/case over the 90-day episode of care (ASC = $8,058 vs. HOPD = $10,619; p<0.001).Conclusion:Using national administrative claims of Commercial insurance beneficiaries, the results of the study show that performing surgical fixation of ankle fractures in a free-standing ASC is a safe and cost-effective option in a carefully selected patient population.

Safety and efficacy of outpatient sleeve gastrectomy: 2534 cases performed in a single free-standing ambulatory surgical center

BackgroundSleeve gastrectomy (SG) is currently the most widely performed operation for treatment of morbid obesity. SG leads to significant weight loss and reduction in weight related comorbidities. Procedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. We present results of 2,534 consecutive patients who underwent SG in an ASC. ObjectiveAssess the safety and efficacy of outpatient SG in a freestanding ASC. SettingFree-standing ASC, Eviva Bariatrics, Seattle WA. MethodsData was collected retrospectively for all patients undergoing SG from January 2008 – January 2018, n = 2,534. Revisional procedures were not excluded from this study. Patients were excluded from the ASC if they weighed >450 pounds, if anticipated surgery time was > 2 hours, if the patient had impaired mobility limiting early ambulation, or if there were medical problems requiring postoperative monitoring beyond 23 hours. ResultsMean age was 45.9 years. Mean preoperative body mass index (BMI) was 41.9. Mean operative time was 70 minutes. 30-day complications included 3 mortalities (0.12%), 60 (2.53%) re-admissions, 35 (1.42%), re-operations, and 31 (1.22%) direct transfers from the ASC to a nearby hospital. There were 25 staple line leaks (0.99%). There were no open conversions. At 6 months average excess body weight loss (EWL) was 56.3% and total weight loss (TWL) was 20.9% (n = 1,758/2,303). At 1 year, EWL was 70.1% and TWL was 26.4% (n = 1,199/2,125). ConclusionWith experienced surgeons, appropriate protocols, and a consistent operative team, SG can be performed safely in a free-standing ASC.

Is it safe? Outpatient total joint arthroplasty with discharge to home at a freestanding ambulatory surgical center.

BackgroundTotal joint arthroplasty (TJA) is trending toward shorter hospitalizations; as a result, there are many ambulatory surgical centers (ASCs) starting to perform outpatient TJA. However, there are limited studies examining the safety of outpatient TJA in the freestanding ASC setting. This study aims to evaluate 30-day and 90-day complication rates in patients who underwent outpatient TJA at a freestanding, independent ASC with direct discharge to home.MethodsA retrospective cohort review using health records was performed on the first 115 TJAs performed between August 2015 and March 2017 by one of the 4 orthopedic surgeons. Before the first TJA, the ASC had developed a multidisciplinary TJA pathway.ResultsOf the 115 TJAs, 37 (32%) were total hip arthroplasties (THAs), 53 (46%) total knee arthroplasties (TKAs), and 25 (22%) unicompartmental knee arthroplasties, with a mean age of 57 ± 7 years and body mass index of 30 ± 5 kg/m2. There were no intraoperative or direct ASC-related complications. There was 1 instance (0.9%) of a postoperative minimally displaced intertrochanteric femur fracture after THA due to a fall treated nonoperatively complication within 30 days of surgery. Of the 90-day complication events, there were 2 patients (2%) with postoperative arthrofibrosis of the knee after TKA requiring manipulation under anesthesia, 1 postoperative patellar tendon rupture during therapy after TKA requiring surgical repair and 1 delayed hematogenous infection after international travel after THA requiring 2-staged exchange.ConclusionsOutpatient TJA with discharge to home at a freestanding, independent ASC is a safe option after development of a multidisciplinary TJA pathway.

A5107 - One hundred eighty-one low BMI sleeve gastrectomy patients performed in a free-standing ambulatory surgical center

A5107 - One hundred eighty-one low BMI sleeve gastrectomy patients performed in a free-standing ambulatory surgical center

High acuity sleeve gastrectomy patients in a free-standing ambulatory surgical center

BackgroundProcedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. Understandably, concerns have been raised regarding “high acuity” cases in the ASC setting. Recently the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) presented protocols for ASCs to follow, requiring them to perform only “low acuity” cases to be compliant with accreditation. ObjectiveAssess the safety and efficacy of outpatient sleeve gastrectomy (SG) on the “high acuity patient” in a free-standing ASC. SettingFree-standing ASC, Eviva Bariatrics, Seattle, Washington. MethodsData were collected retrospectively for all patients who underwent sleeve gastrectomy from January 1, 2013 to December 31, 2015, n = 1112. Of those patients, 120 were classified as “high acuity.” ResultsMean age was 51.7 years (24–73), mean body mass index was 42.4 (26.2–65.9). Mean operative time was 91 minutes. Five patients (4.2%) were readmitted within 30 days. Causes of re-admission were portal vein thrombosis (n = 2), intra-abdominal abscess (n = 1), infected hematoma (n = 1), and postoperative bleeding (n = 1). One patient (0.83%) was transferred from the ASC to a nearby hospital due to a postoperative bleed. One patient (0.83%) had a re-operation to evacuate a hematoma. One patient had a re-operation to wash out an infected hematoma. There were 0 confirmed staple line leaks. There were no open conversions and no deaths within 30 days or at 1 year. Follow-up was 83% (n = 100) at 6 months, and 65.0% at 1 year (n = 78). ConclusionCriteria such as age, body mass index, or prior bariatric surgery did not reflect worse outcomes in a specialized ASC. With experienced surgeons, appropriate protocols, and a consistent operative team, SG can be performed safely in a free-standing ASC on select “high acuity” patients.

Children with heart disease: Risk stratification for non-cardiac surgery

Study objectiveChildren with congenital or acquired heart disease have an increased risk of anesthesia related morbidity and mortality. The child's anesthetic risk is related to the severity of their underlying cardiac disease, associated comorbidities, and surgical procedure. The goal of this project was to determine the ease of use of a preoperative risk stratification tool for assigning pediatric cardiac staff and to determine the relative frequency that children with low, moderate, and high risk cardiac disease present for non-cardiac surgery at a tertiary pediatric hospital. DesignA risk-stratification tool was prospectively applied to children with congenital heart disease who presented for non-cardiac surgery. SettingPerioperative. PatientsWe identified a subset of 100 children with congenital heart disease out of 2200 children who required general anesthesia for surgical or radiological procedures over a 6 week period. InterventionsA risk stratification tool was utilized to place the patient into low, moderate, or high risk categories to help predict anticipated anesthetic risk. Each grouping specified assignment of staff caring for the patient, clarified preoperative expectations for cardiac assessment, and determined if patient care could be performed at our freestanding ambulatory surgical center. MeasurementsElectronic perioperative records were reviewed to obtain demographic information, the underlying heart disease, prior cardiac surgery, associated conditions, anesthetic management, complications, and provider type. Main resultsApproximately 4.5% of children presented with cardiac disease over a 6 week period. In 100 consecutive children with cardiac disease, 23 of the children were classified as low risk, 66 patients were classified as moderate risk, and 11 of the patients were classified as high risk. Pediatric cardiac anesthesiologists provided care to all high risk patients. There were no serious adverse events. ConclusionsWe found this risk stratification method an effective method to differentiate children into low, moderate, and high risk categories for anesthesia planning and management.

A5254 - Sleeve Gastrectomy in a Free Standing Ambulatory Surgical Center

Sleeve gastrectomy (SG) is currently the most widely performed procedure for the treatment of morbid obesity. SG leads to significant weight loss as well as a reduction in weight related comorbidities. Procedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. We present our results of 1036 consecutive patients who underwent SG in an ASC.

A117 - High Acuity Sleeve Gastrectomy Patients in a Free Standing Ambulatory Surgical Center

A117 - High Acuity Sleeve Gastrectomy Patients in a Free Standing Ambulatory Surgical Center

A comparison of ambulatory perioperative times in hospitals and freestanding centers

BackgroundThe volume of surgical procedures performed in ambulatory surgical centers has increased rapidly. MethodsAmbulatory surgical visits of Medicare beneficiaries were compared for hospital-based and freestanding ambulatory surgical centers (ASCs). The main outcomes were time in surgery, time in operating room, time in postoperative care, and total perioperative time. ResultsThe mean total perioperative time for all procedures examined was 39% shorter in freestanding ASCs then in hospital-based ASCs (83 vs 135 min; P < .01); surgery time was 37% shorter (19 vs 30 min; P < .01), operating room time was 37% shorter (34 vs 54 min; P < .01), and postoperative time was 35% shorter (48 vs 74 min; P < .01). ConclusionsPerioperative times were significantly shorter in freestanding ASCs than in hospital-based ASCs. It is unclear how much of the difference was the result of efficiency versus patient selection.