Outpatient Surgical Facility Research Articles

The Impact of Title VII on General and Pediatric Dental Education and Training

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Pregabalin Has Opioid-Sparing Effects Following Augmentation Mammaplasty

There has been a recent, growing concern regarding narcotic use in surgical patients. This issue, coupled with an ongoing desire to lessen postoperative discomfort, has prompted the search for alternative analgesic regimens. The purpose of this study was to determine whether the addition of pregabalin, an anticonvulsant indicated for the management of neuropathic pain, to an analgesic regimen reduced narcotic use and reported pain following augmentation mammaplasty. Eighty patients underwent submuscular augmentation mammaplasty with smooth shell saline mammary prostheses in an outpatient surgical facility. The patients were randomized into two groups. Group A (n = 40) used 5-mg hydrocodone tablets as needed to manage postoperative pain. Group B (n = 40) used pregabalin, 75 mg, twice daily in addition to 5-mg hydrocodone tablets as needed for postoperative pain management. Narcotic use was recorded and pain assessed daily using the Rogers Pain Scale from 1 (mild) to 10 (severe). Patients were surveyed for nausea and quality of pain. Group A used 115 +/- 32 mg hydrocodone during the immediate 7 day postoperative period and reported an average pain scale score of 5.3. Likewise, group B used 33 +/- 27 mg hydrocodone as well as the prescribed pregabalin dosage and reported an average pain scale score of 3.4. Patients in group B reported less nausea. These differences were statistically significant (P < .05). Patient age, implant size, and postoperative complications were similar between the two groups. Perioperative pregabalin administration in patients undergoing augmentation mammaplasty reduced postoperative narcotic use by 70%. There was also significantly less reported pain and a 46% reduction in nausea in the pregabalin-treated group. Pregabalin has few side effects, no drug interactions, and should be considered safe in an analgesic regimen.

Venous Thromboembolism in Abdominoplasty Patients: A Study of Incidence and Prophylaxis Recommendations

Introduction:Pulmonary embolism (PE) and deep vein thrombosis (DVT) comprise venous thromboembolism (VTE). VTE is the most common preventable cause of death in postsurgical hospitalized patients. The literature consistently defines prophylaxis as being integral to avoiding VTE. No study, however, specifically addresses this with abdominoplasty, a high-VTE-risk cosmetic procedure. This study aims to fill this void by providing specific data on VTE incidence and, through comprehensive literature review, providing specific abdominoplasty prophylaxis recommendations.Methods:A retrospective review of 267 patients undergoing abdominoplasty between January 2000 and June 2006 at a fully accredited outpatient surgical facility was performed to assess symptomatic VTE incidence. Analysis reviewed VTE risk factors and current prophylaxis practice. A review of current cosmetic, plastic, and general surgery prophylaxis measures in the literature was performed and correlated with the authors' practice to develop abdominoplasty-specific VTE prophylaxis recommendations.Results:Four of 267 abdominoplasty patients (1.5%) developed VTE (all DVT). None of the 97 patients undergoing abdominoplasty alone developed DVT. Four of 170 abdominoplasty patients undergoing additional cosmetic procedures developed DVTs (23%). Of these, 3 had liposuction and 1 had simultaneous breast augmentation/mastopexy. All patients underwent general anesthesia, received mechanical prophylaxis, and were encouraged to ambulate the morning after surgery.Conclusions:VTE is a real and preventable issue in patient safety. Cosmetic surgery patients frequently are treated with inconsistent and less aggressive VTE prophylaxis than similar noncosmetic surgery patients owing to scant relevant data and/or concerns of problematic bleeding. The authors present abdominoplasty-specific DVT and PE rates of 1.5% and 0%, respectively, when mechanical prophylaxis is used. Although the results mirror those in the literature, the demand for optimal VTE prevention led the authors to increase their current prophylaxis regimen to a higher standard. They soundly use and present a VTE prophylaxis protocol for abdominoplasty patients that includes mechanical as well as pharmacologic prophylaxis.

Certification for Office-Based Plastic Surgery

Office-based and freestanding ambulatory surgical facilities have become commonplace and the surgeries they perform more elaborate. Accreditation of all outpatient surgical facilities is necessary to maintain a standard of care that safeguards the patient and reduces liability for the physician. The accreditation entities that currently dominate the industry include JCAHO (Joint Commission for Accreditation of Hospital Organizations), the American Osteopathic Association's HFAP (Healthcare Facilities Accreditation Program), and AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities). All of these accrediting bodies provide standards of operation that maintain a level of care and improve patient safety. We will examine the impact of certification in the safe operation of outpatient surgical facilities.

Certificate-of-Need Regulation in Outpatient Surgery and Specialty Care: Implications for Plastic Surgeons

For plastic surgeons, independent development of outpatient surgical centers and specialty facilities is becoming increasingly common. These facilities serve as important avenues not only for increasing access and efficiency but in maintaining a sustainable, competitive specialty advantage. Certificate of Need regulation represents a major hurdle to plastic surgeons who attempt to create autonomy in this fashion. At the state level, Certificate of Need programs were initially established in an effort to reduce health care costs by preventing unnecessary capital outlays for facility expansion (i.e., managing supply of health care resources) in addition to assisting with patient safety and access to care. The purpose of this study was to examine the effect of Certificate of Need regulations on health care costs, patient safety, and access to care and to discuss specific implications of these regulations for plastic surgeons. Within Certificate of Need states, these regulations have done little, if anything, to control health care costs or affect patient safety. Presently, Certificate of Need effects coupled with recent provisions in the Medicare Modernization Act banning development of specialty hospitals may restrict patient access to ambulatory surgical and specialty care. For the plastic surgeon, these effects not only act as an economic barrier to entry but can threaten the efficiencies gained from providing surgical care in an ambulatory setting. An appreciation of these effects is critical to maintaining specialty autonomy and access to fiscal policy.

Review of operational decision making before the day of surgery based on operating room efficiency

Operations research provides insight into improved operational decision-making in surgical suites before the day of surgery. This article focuses on operating room allocation and case scheduling, including how to release allocated operating room time. Decisions differ from those based on operating room utilization. This article aims to provide guidance to the practitioner of operations research asked to assist in operational management decisions at a hospitals or free-standing outpatient surgical facility. In addition, the article considers how to calculate the potential cost reduction from reducing turnover times or changing OR allocations.

Sleeping characteristics of adults undergoing outpatient elective surgery: a cohort study

Study objective To describe sleeping patterns of adults before and after outpatient surgery. Design Observational cohort study Setting Outpatient surgical facility Patients 127 consenting adults, including 92 surgery patients and 35 community controls. Interventions Participants' sleep was measured for two days before and 2 days after outpatient surgery. Measurements Sleep was measured using actigraphy; additional measurements were made of anxiety (STAI), pain and energy (VAS), recovery (PHRI), and sleep history. Main results Approximately 23% of patients experienced clinically significant sleep impairment after surgery, a more difficult recovery, increased pain, and lower energy. In contrast, only 2.9% of the community control group experienced clinically significant sleep impairment during the same time period. Also, patients in the surgery group experienced significantly more True Wake Time postoperatively than did control patients (p = 0.029). The surgery group also experienced more Night Awakenings >5 minutes than the control group (p = 0.006), but not more overall Night Awakenings (p = 0.106). Finally, of the patients in the surgery group, those who had higher state anxiety in the holding area also had more difficulty sleeping over the 4-day monitoring period (True Sleep Time was lower, 352 ± 187 vs . 229 ± 225, p = 0.009). Conclusions A moderate proportion of adults experience postoperative sleeping problems.

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

Quality assurance in office-based surgery: No longer just a choice

James H. Carraway, MD , is Senior Scientific Editor of Aesthetic Surgery Journal. We have all read the highly publicized stories: medical errors in our hospitals, complications and deaths in outpatient and office-based surgical facilities. Incidents like these are troubling to physicians striving to provide patients with the highest quality medical care. Of course, with each new occurrence that hits the headlines, patient confidence is eroded a bit more. The magnitude of this problem is huge. Real progress has been made in a few states, although office-based surgery continues to be unregulated in most others. The trend, nationally, appears to be toward increased regulation to help ensure a higher standard of care in office-based surgery, but such measures will not be broadly implemented overnight—particularly when they are vigorously opposed by those whose self-interest is best served by the …

Hysteroscopic tubal sterilization with the essure nonincisional permanent contraception system

The objective of this paper was to determine the safety effectiveness and tolerance of a new transcervical fallopian tube permanent contraception device the Essure microinsert. In a previous study histology of fallopian tubes of women who had worn the device for periods of 5-15 weeks demonstrated that the device was benignly incorporated into the fallopian tubes with a localized tissue reaction. Enrolled women requesting permanent contraception underwent hysteroscopic sterilization with Essure microinserts. Following successful device placement the women were instructed to use alternative contraception for 3 months after device placement and to have hysterosalpingography performed prior to discontinuing alternative contraception. Study subjects were seen at outpatient surgical facilities and physicians offices at investigational sites. Their ages ranged from 21-45 years and they had documented fertility. Hysteroscopy-directed placement of the Essure microinserts was performed under local anesthesia or analgesia or both. Of the 871 women who were involved 745 (85%) women were attempted. 603 out of 627 (96.2%) women with satisfactorily placed microinserts had bilateral occlusion at 3 months; 625 (99.5%) had bilateral occlusion at 6 months. 193 women have been relying on the Essure microinsert for more than a year. No pregnancies have occurred. The procedure was well tolerated by over 90% of the women; it averaged 13-18 minutes and resulted in tolerable or no postoperative discomfort. Local anesthesia and intravenous sedation were the anesthesia used for 92.9% of the patients. Favorable clinical results and marked patient satisfaction have been noted in this investigational study. Preliminary results suggest that the hysteroscopic tubal sterilization method with the Essure system offers promise as an alternative to presently used methods of permanent contraception. (authors)

Incidence of intraoperative flap complications in laser in situ keratomileusis

Purpose: To evaluate the incidence of intraoperative flap complications in laser in situ keratomileusis (LASIK) and compare the incidence between eyes and between the Hansatome and Automated Corneal Shaper® (Bausch & Lomb) microkeratomes. Setting: Open-access outpatient excimer laser surgical facility. Methods: A retrospective analysis was done of 84711 primary LASIK cases performed between November 1998 and May 2000 in 28 national open-access laser facilities. The intraoperative flap complications were identified and categorized into type of complication, eye involved, and microkeratome type. All cases used the Automated Corneal Shaper or the Hansatome microkeratome. Results: Two hundred fifty-six complications (0.302%) were identified: 29 failures to achieve intraocular pressure (0.034%), 84 partial flaps (0.099%), 59 buttonholes (0.070%), 74 thin or irregular flaps (0.087%), and 10 free flaps (0.012%). There were 134 right eye complications and 122 left eye complications ( P = .45). No patient developed an intraoperative flap complication in both eyes. A comparison of Hansatome and Automated Corneal Shaper microkeratomes was possible for the cases performed between December 1999 and May 2000: 46 of 28 201 Hansatome procedures (0.16%) had a complication versus 21 of 329 Automated Corneal Shaper procedures (6.38%). This difference was statistically significant ( P < .005). Conclusion: The incidence of intraoperative flap complications during LASIK was acceptably small. The overall complication rate was similar in both eyes. The Hansatome was associated with a lower complication rate than the Automated Corneal Shaper.

Hyperopic laser in situ keratomileusis to treat overcorrected myopic LASIK

Purpose To evaluate the safety and efficacy of hyperopic laser in situ keratomileusis (LASIK) in treating hyperopia caused by overcorrected myopic LASIK and to evaluate a new technique to place the hyperopic treatment after lifting the initial myopic flap. Setting Open-access outpatient excimer laser surgical facility. Methods A retrospective analysis was performed of 54 eyes in 47 patients who had spherical hyperopic LASIK by 21 surgeons for the treatment of significant hyperopia after overcorrected LASIK for myopia. In 42 eyes, the initial LASIK flaps were lifted and in 12 eyes, new flaps were cut. The mean age of the 25 men (53%) and 22 women (47%) was 48.2 years ± 8.4 (SD). Outcome measures included refractive error, uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and complications. The mean follow-up was 2.97 months. Results In eyes in which postoperative emmetropia was attempted (n = 45), the mean spherical equivalent improved from +1.21 ± 0.49 diopters (D) preoperatively to –0.38 ± 0.50 D postoperatively ( P < .001). The mean UCVA improved from 20/38.6 ± 16.3 to 20/27.4 ± 9.4 ( P < .001). At the last follow-up, 69% of eyes were within ±0.5 D and 96% were within ±1.0 D of emmetropia; 42% had a UCVA of 20/20 and 96% had a UCVA of 20/40 or better. No eyes lost 2 or more lines of BSCVA. No vision-threatening complications occurred. Results in patients who had initial flaps lifted and those who had new flaps cut were statistically indistinguishable. On average, achieved hyperopic corrections were 18% greater than intended. Conclusion Hyperopic LASIK was safe, predictable, and effective in the treatment of hyperopia caused by overcorrected myopic LASIK. Results were similar whether the original flap was lifted or a new one was cut.

A New Ligation Approach to the Management of Chronic Epistaxis

Standard cauterization therapy for chronic epistaxis is less than ideal because of the inadequacy of topical anesthesia and the difficulty of treating young, often uncooperative patients. The author has developed a new procedure for treating these patients, which entails ligation and cauterization while the patient is under light general anesthesia in an outpatient surgical facility. Of the approximately 75 procedures the author has performed, only one failed to achieve expected results. This article describes how this safe, simple, and ultimately cost-effective procedure is performed.

Saving money on anesthesia drugs: Does this decrease efficiency?

T HE NEW chief executive officer (CEO) of your hospital has learned that the operating room (OR) is no longer a profit center. Cost of surgical supplies, anesthesia supplies, and support personnel have all increased while at the same time managed care has seriously decreased the reimbursement for and volume of hospital services.1 No longer does the cost-plus concept of traditional indemnity insurance reimbursement apply. 2 Managed care has placed strict controls on the use of services. Profit margins for your hospital as well as most others are now only approximately 5% and have been stagnant for the last several years) Most cases in the OR now have a fixed-price reimbursement for anesthesia and surgery. To make matters worse, an outpatient surgical facility has recently opened nearby and is siphoning the most desirable cases from your institution. The CEO knows that he must once more achieve profitability in areas such as the OR because profits generated here help support unprofitable services that are essential in fulfillment of the hospital's mission. The CEO has assembled all of the section chairs to ask for their help in returning this venerable institution to profitability. He specifically asks you, the new chairman of the anesthesia section, to help him control anesthesia costs while still maintaining excellent and efficient preoperative, intraoperative, and postoperative patient care. You reply that you will certainly do all you can to help but that your primary concern is, and must be, the patient. You state emphatically that there must be no decrease in value to the patient, the surgeons, the anesthesiologists, or the institution if your efforts are to be worthwhile. You are concerned that just decreasing costs may also decrease value if the quality of care decreases more than the costs (value = quality/cost). 4 You also worry that if you are not careful and judicious in your decisions, you may decrease overall efficiency of the OR and thus actually increase the total costs of the OR and anesthesia. In this article I will review and analyze techniques of anesthesia and their costs. I will define and examine efficiency as it relates to anesthesia and surgery and try to reach some conclusions on the cost-efficient delivery of value-based anesthesia. Hopefully you, the reader, will be able to make some firm decisions on how you can help return your OR to profitability while still delivering excellent anesthesia care.

Laser in situ keratomileus using the LaserSight 200 laser: results of 950 consecutive cases

Purpose To examine the refractive outcome in 950 consecutive eyes having laser in situ keratomileusis (LASIK) by 1 surgeon with experience in keratomileusis. Setting Outpatient excimer laser surgical facility. Methods This study comprised 950 consecutive eyes of 475 patients having LASIK as a primary procedure with a LaserSight 200 excimer laser (8.51 software). A nasal hinged flap and a Chiron microkeratome were used. Preoperative cycloplegic refraction was done only in patients younger than 25 years and in all hyperopic cases. Subjective preoperative and postoperative manifest refractions were done after autorefractometry in all cases. In cases of hyperopia, the software was modified by adding 30% to the refractive error. Enhancement results are not included. Results Of the 950 eyes, 893 (94.00%) were myopic and 57 (6.00%), hyperopic. In the low myopia group (1.00 to 3.99 D) of 223 eyes (24.97%), mean spherical equivalents (SEs) were −2.90 D ± 0.56 (SD) preoperatively, −0.46 ± 0.6 D 3 months postoperatively, and −0.41 ± 0.5 D 6 months postoperatively. In the moderate myopia group (4.00 to 5.99 D) of 205 eyes (22.96%), respective mean SEs were −4.90 ± 0.7 D, −0.90 D ± 0.9 D, and −0.67 ± 0.7 D. In the high myopia group (6.00 to 9.99) of 266 eyes (25.30%), the respective means were −7.70 ± 1.3 D, −0.76 ± 0.99 D, and −0.60 ± 0.8 D. In the extreme myopia group (10.21 to 30.00) of 199 eyes (22.28%), the respective means were −13.30 ± 2.9 D, −1.30 ± 1.4 D, and −1.13 ± 1.3 D. For the entire myopic group, the mean astigmatism was +1.55 ±1.38 D, +1.09 ± 0.92 D, and +0.87 ± 0.77 D, respectively. The low hyperopia group (1.00 to 2.99 D) of 39 eyes (68.42%) had a mean preoperative SE of +1.80 ± 0.59 D and mean postoperativeSEs of +1.00 ± 0.76 D at 3 months and +1.16 ± 0.52 D at 6 months. The respective means in the moderate hyperopia group (3.00 to 6.00) of 18 eyes (31.57%) were +4.62 ± 1.19 D, +3.71 ± 1.12 D, and +4.00 ± 1.07 D. Conclusions Laser in situ keratomileus for myopia using the LaserSight 200 excimer laser was stable with time and safe for the correction of different degrees of myopia. In the hyperopic group, marked regression occurred in a large percentage of patients. Thus, we will not perform LASIK for hyperopia until the software improves.

THE IMPACT OF EEG-BISPECTRAL INDEX MONITORING ON DRUG USAGE AND RECOVERY DURING AMBULATORY ANESTHESIA

S51 INTRODUCTION: The Bispectral Index (BIS) is a processed EEG parameter that has been validated as a measure of the sedative-hypnotic effects of anesthetic drugs. Controlled studies have shown that BIS use facilitates the administration of intravenous and inhaled anesthetics, resulting in decreased propofol use and improved recovery. [1,2] These studies, however, involved only limited number of patients and included a specific requirement to titrate the sedative-hypnotic drug according to a predetermined target BIS values. The impact of BIS monitoring on drug usage in routine clinical practice remains to be confirmed. Therefore, we evaluated the effect of BIS monitoring on propofol use and on patient recovery during standard ambulatory anesthesia. METHODS: Following IRB approval, the hospital records of 1043 patients who had undergone orthopedic surgery under general anesthesia at our outpatient surgical facility during a 45 month period were reviewed. Patient demographic, anesthesia and recovery data were obtained for two groups of patients, namely, those treated during a 30 month period "Prior to BIS use", and those treated during the 15 month period of "BIS use". Anesthesia providers received only a standard instruction in the use of BIS (A-1050, Aspect Medical, Inc.). Patient management was according to routine clinical practice. After premedication with midazolam, 1-2 mg i.v., anesthesia was induced with 2-2.5 mg/kg propofol and maintained with a variable rate infusion of propofol supplemented with sufentanil, 2.5-5 [micro sign] g boluses, as needed, and 65% nitrous oxide in oxygen. Data on neuromuscular blocking and reversal agents were not included. Data were analyzed using Student t-and Chi-square tests, as appropriate. P values < 0.05 were considered statistically significant (*). Data are presented as mean +/- SD. RESULTS: There were no significant demographic differences between the two study groups (Table 1). All procedures were conducted by the same small group of surgeons and anesthesia provides. A difference in propofol use was not evident in the grand total propofol dose. However, the introduction of BIS monitoring was associated with a significant reduction in the normalized total propofol dose (total propofol dose divided by weight and case duration), (p<0.001). Likewise, there was a reduction in the average maintenance rate of propofol during the anesthesia maintenance period of 8.9 [micro sign] g/kg/min (p<0.001). There was a small but significant increase in the average intraoperative opioid dosage (p<0.001). The difference in recovery times was minimal but the incidence of postoperative nausea and vomiting (PONV) was reduced (p<0.01).Table 1DISCUSSION: These results suggest that BIS has a significant impact on the use of anesthetic drugs in routine clinical practice. Titration of propofol using BIS resulted in decreased maintenance rates. The reduction in propofol use for the "average" case in this study was approximately 77 mg/case. Contrary to previous reports, [1] we found an increase in the use of intraoperative opioids. This may relate to the ability to maintain "lighter" planes of anesthesia with BIS. Thus, in addition to its influence on the amount of hypnotics used, BIS monitoring also affects the choice of drugs during outpatient anesthesia.

Developing an ambulatory surgery programme

Since the late 1970s out-patient surgery has been the fastest growing segment of surgical and anaesthetic care. This trend is likely to continue as advances in surgical technique and technology make surgery less invasive and therefore more amenable to the out-patient setting. The arthroscope, laparoscope, thoracoscope, and laser are the tools of ‘minimally invasive surgery’. Health care policy and economic factors will also continue to force more surgical procedures, as well as more infirm patients, into the out-patient setting. Conversely, the rate of shifting procedures and patients to the outpatient setting has slowed. The economic heyday of outpatient surgery in the United States is over and with it the boom in building hospital-independent (freestanding) out-patient surgical facilities. Most new or developing programmes will therefore locate within hospital walls or on the hospital grounds. Many hospitals mix ambulatory surgery patients with in-patients having elective surgery. Surgical outpatients may also compete with patients in need of urgent or emergency surgery. While this arrangement involves a minimum investment in space, staff and equipment, it fails to address the needs of the out-patient surgical population or to define the basis for an autonomous programme in ambulatory surgery. To define the needs of an ambulatory programme requires dedicated resources and a well-defined system to safely, effectively and efficiently meet the needs of out-patient physicians (surgeon, anaesthesiologist, oncologist, gas-

Harvesting bone marrow in an outpatient setting using newer anesthetic agents.

To evaluate the results of outpatient bone marrow harvest (BMH). Seventy-two adult patients with various malignancies had 79 BMH procedures performed for future autologous bone marrow transplantation (BMT) in our institution's outpatient surgical facility. All patients were evaluated and educated before the procedure. Newer anesthetic agents specifically developed to have shorter half-lives, more rapid recovery from general anesthesia, and fewer unpleasant side effects were chosen. Propofol was used for induction of anesthesia in 76 patients, the other three were induced with sodium pentothal. The blood volume removed was replaced by colloid (6% hydroxyethyl starch). Also, a new parenteral nonnarcotic pain medication, ketoroloc, was used during the last part of general anesthesia to help with expected postoperative pain in 76 patients. BMH took 111 +/- 24 minutes and patients were in postanesthesia care unit (PACU) for 220 +/- 72 minutes before being sent home with a companion and Tylenol with codeine (acetaminophen with codeine; McNeil Pharmaceutical, Spring House, PA). PACU complications were minor and included transient mild dizziness (7.6%), vomiting (3.8%), and fever (2.6%). No life-threatening complication was observed. Only one patient was hospitalized for observation (fever) and then sent home. Seventy-five patients (94.9%) were contacted at home by the hospital nursing staff the day following the procedure. Five (6.7%) complained of nausea or vomiting, and four (5.3%) developed fever at home (temperature, 37.2 to 38.3 degrees C). Only 36% of patients actually took oral narcotic pain medication at home. Autologous BMH (AuBMH) is a safe outpatient procedure with minimal side effects when newer anesthetic agents are used.

Peer Review for Anesthesia and Emergency Care

SUMMARY Within a very short time, all 50 states in the United States will have enacted dental anesthesia and sedation acts. It is reasonable to have standardized implementation of the oral/maxillofacial surgery peer review as the standard of care for surgeons and all other professionals providing anesthesia. Watered-down versions of the examination neither protect the public's welfare nor ensure safe and sane anesthesia provided by competent doctors. If a doctor does not perform satisfactorily during the examination, provisions are made for a re-examination. Compliance with both the initial examination and the re-examination has been high because of the new vertical orientation of the component state societies in the AAMOS and the legal action by the state board of dental examination in states where his evaluation is mandatory. Unlike other one-time examinations of competency, anesthesia evaluations need to be on the forefront with considerations for re-examination after 5 years. All who practice anesthesia on a day-to-day basis have seen pharmacology changes as well as an explosion in monitoring technology. It behooves all who practice anesthesia in either an inpatient or an outpatient facility to keep abreast of these changes. Although this article discusses only the involvement of oral and maxillofacial surgeons in the examining process, the National Institutes of Health has adopted a Consensus Statement on Anesthesia that includes a directive concerning anesthesia training for the use of conscious sedation techniques.4 The American Dental Association and the American Dental Society of Anesthesiology have been supportive of this increased training for dental students, general dentists, and other dental specialists. At one time there was a movement for dental anesthesiology residencies, but, for a variety of political, economic, and practical reasons, these programs are few in number. An adjunct program that helps the anesthesia assistant in the office setting has been the development of the Oral and Maxillofacial Surgery Anesthesia Assistants' Program (OMAAP), founded in 1988. This program consists of a 6-month home-study course with five different areas of emphasis that in large part parallel the anesthesia evaluation sections. The five basic study modules consist of basic sciences, drugs, anesthetic techniques, monitoring, and medical emergencies. The surgeon works closely with the assistant, monitoring progress, giving quizzes, and being a resource person prior to the final examination. This is administered by the American College Testing Program (ACT) and is given periodically throughout the United States and Canada. Because this is not a pass or fail examination, it is meant to be used as an learning and evaluating instrument for the assistant. One further developing trend that augments the anesthesia evaluation is accreditation by the Accreditation Association for Ambulatory Health Care (AAAHC). In a recent article in an AAOMS publication,1 this accreditation process is viewed as a means of establishing an oral and maxillofacial surgery office as an appropriate facility for the delivery of outpatient surgery similar to an am-bulatory surgical center. AAAHC was founded in 1979 to assist ambulatory health care facilities in achieving accreditation for compliance with their guidelines. These standards include quality assurance, medical record evaluation, clinical and pharmaceutical services, environmental safety, and administration and professional development. Although AAAHC was founded to help standardize and measure performance of outpatient surgical facilities, AAOMS became a corporate member in November of 1989 with the expectation that some private practice offices might like to participate in an evaluation for accreditation. Unlike the office an-esthesia evaluation, this process is entirely voluntary. The cost of the examination, which takes an average of 1.5 days, is paid by the examinee and can run between $4000 and $4500. Because this alliance is new, the trend of the examination is not known. Finally, the field of oral and maxillofacial surgery has been blessed with foresighted visionaries who correctly determined and guided the future of the safe practice of anesthesia in the office setting for the benefit of patient and doctor. This “win-win” situation has helped practitioners control their professional destinies and serves as a reminder of the necessity for involvement as an organized and united group.

Endophthalmitis investigative protocol: A plan for source identification and patient protection

A survey of randomly selected ophthalmic outpatient surgical facilities revealed a lack of established investigative protocols to follow when postoperative endophthalmitis occurs. The survey also provided information about the incidence of endophthalmitis, the microorganisms encountered, and the precautions used to prevent postoperative infections. We present an endophtlialinitis investigative protocol which provides a task list, investigation forms, incidence log, and quality assurance measures to identify patients at risk and to minimize the risk of recurrence of this rare but serious complication of ophthalmic surgery. This standardized protocol will also assist in source identification when aseptic iritis occurs postoperatively. The purpose of this paper is to stimulate a dialogue which may result in an international standard for an endophthalmitis investigative protocol.