Outpatient Surgical Setting Research Articles

Utility of Mobile Apps for Video Conferencing to Follow Patients at Home After Outpatient Surgery.

Introduction:Outpatient surgery has a great opportunity to demonstrate the role of using mobile video conference (VC) postoperatively. Our patients use technology to help decision making in finding physicians. The authors aim to assess patient's perception on the use of mobile apps for VC with the surgeon and/or staff.Methods:Consenting patients completed a questionnaire of 10 questions preoperatively and postoperatively to assess the difference in opinion.Results:Overall, 120 patients completed the questionnaire preoperatively with 58% female population, 71% younger than 65 years, and 67% having a GED/higher education. Fifty-two patients had surgery with 54% female population, and 60% were younger than 65 years. All patients had mobile apps for VC with 55% using WhatsApp, 40% using Facetime, and 5% other. In person, being with a trained educator at the office was the preferred method for learning about surgical procedures. Overall, four patients contacted the surgeon directly preoperatively. After surgery, 8 of 52 patients (15%) used VC to the surgeon directly, and 37 patients used the VC with the team.Conclusion:With advances in new technology, the use of mobile video conferencing adds a new forum for communication with patients. In the outpatient surgical setting, this forum would improve patient-physician relations.

Effect of music tempo on operating room preparation time.

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

Predictors for Surgery-Related Emergency Department Visits within 30 Days of Foot and Ankle Surgeries

Presentation to an emergency department (ED) after foot and ankle surgeries not only causes inconvenience to patients but also increases healthcare costs. To minimize this, many major institutions have tracked these data as a part of quality improvement measures. Our previous study showed that factors associated with any (surgery-related and unrelated) postoperative ED visits were not easily modifiable by surgeons. Therefore, in the current study, we focused on factors associated specifically with surgery-related postoperative ED visits, because this may provide some insights for surgeons rather than just administrators. We examined 513 foot and ankle surgeries, of which 114 resulted in 30-day postoperative ED visits for surgery-related reasons. Demographic, medical, and surgical factors were evaluated, and risk factors were identified after adjusting for potential clinically relevant covariates. Both inpatient and outpatient surgical settings and outpatient surgical settings alone were analyzed separately. Regardless of the setting, we found that shorter surgery was protective against postoperative ED visits, as was having a previous ED visit within 6 months before surgery. In the outpatient setting, younger age and having no insurance were also proxies for a postoperative ED visit, in addition to the above factors.

Collagen disruption as a marker for basal cell carcinoma in presurgical margin detection.

Nonmelanoma skin cancers (NMSCs) are the most common malignancies in the United States. Surgery is the most common treatment for these tumors, but pre-operative identification of surgical margins is challenging. The objective in this study was to determine whether optical polarization imaging (OPI) could be used prior to surgery to detect the extent of subclinical tumor spread by monitoring disruption in collagen. OPI is a non-invasive and rapid imaging modality that highlights the structure of dermal collagen. OPI was used preoperatively at wavelengths of 440 and 640 nm to perform imaging of NMSCs on six patients scheduled to undergo Mohs surgery for biopsy-proven basal cell carcinoma. This pilot study did not alter the course of routine MMS for any of the patients. The surgeon was blinded from the preoperative imaging results and completed the entire procedure without relying on the new technology. The study was conducted in an outpatient surgical setting. Patients over 18 years of age with biopsy-proven basal cell carcinoma participated. OPI accurately predicted the presence or absence of tumor at the surgical margin in six out of six cases, as confirmed on histology. OPI may allow efficient surgical planning by identifying tumor extension beyond visibly involved skin. Lasers Surg. Med. 50:902-907, 2018. © 2018 Wiley Periodicals, Inc.

Maximizing Patient Satisfaction and Positive Outcomes in the Diagnosis and Treatment of Pelvic Congestion Syndrome in the Outpatient Surgical Setting: A Cohort of 102 Patients

Maximizing Patient Satisfaction and Positive Outcomes in the Diagnosis and Treatment of Pelvic Congestion Syndrome in the Outpatient Surgical Setting: A Cohort of 102 Patients

Health Care Workers’ Use and Cleaning of X-Ray Aprons and Thyroid Shields

We evaluated the use and cleaning of x-ray aprons and thyroid shields by surveying rural hospital system health care workers who wear x-ray aprons and thyroid shields. One hundred fifty-five of the 173 respondents were RNs (89.6%), and 94 respondents were from inpatient or outpatient surgical settings (54.3%). One hundred thirty-five respondents (78.0%) reported soiled x-ray aprons or thyroid shields, and 52 (30.1%) reported shield odors. Eighty-three participants (48.0%) indicated they never spot cleaned. Standard department cleaning never occurred for 37 x-ray aprons or thyroid shields (21.4%); and 114 x-ray aprons or thyroid shields (65.9%) contacted a patient or patient item 1 to 10 times per shift. Twenty-six participants (15%) specified there were policies and procedures for cleaning x-ray aprons and thyroid shields. Use of evidence-based cleaning guidelines and manufacturer’s requirements for effective spot and standard cleaning of the protective aprons and thyroid shields are warranted.

Is Outpatient Unicompartmental Knee Arthroplasty Safe to Perform at an Ambulatory Surgery Center? A Comparative Study of Early Post-Operative Complications

BackgroundUnicompartmental knee arthroplasty (UKA) lends itself to the outpatient surgical setting. Prior literature has established a low rate of readmission and post-operative complications when performed in a hospital outpatient setting (HOP). To our knowledge, there have been no studies comparing complications of UKA performed at an ambulatory surgery center (ASC) and those in a HOP. MethodsWe retrospectively reviewed all patients who underwent outpatient UKA by a single surgeon from 2012 to 2016. In all 569 outpatient UKAs were performed: 288 in the ASC group and 281 in the HOP group. We compared the groups with regard to all complications within the first 90 days after surgery. ResultsThirty minor and major complications occurred within 90 days (5.3%). There was no difference in the overall complication rate between groups (ASC 12, 4.2%; HOP 18, 6.4%) (P = .26). Day of surgery admission occurred once in the HOP group (0.4%) and did not occur in the ASC group (P = .49). There was 1 visit to the emergency department (ED) <24 hours from surgery in each group (ASC 0.3%, HOP 0.4%) (P = 1.0). ED visits occurred within 7 days in 3 ASC cases (1.0%) and 4 HOP cases (1.4%) (P = .72). Re-admissions in the first 90 days occurred in 5 ASC cases (1.7%) and 8 HOP cases (2.8%) (P = .41). ConclusionUKA at an ASC has a low early postoperative complication rate without increased risk of re-admission or ED evaluation when compared to UKAs performed at a HOP.

Effect of Pregnancy Reasonably Excluded Guide on Pregnancy Testing in Outpatient Gynecologic Surgery [23H

INTRODUCTION: The Pregnancy Reasonably Excluded Guide (PREG) questionnaire is based on traditional methods of excluding pregnancy including sterilization, menopause, and the World Health Organization criteria. The PREG has been validated and shows a 99-100% negative predictive value for pregnancy (Selected practice recommendations for contraceptive use, 2013: adapted from the world health organization selected practice recommendations for contraceptive use, 2nd edition. MMWR Recomm Rep 2013; 62:1‒60.). Pregnancy testing in our outpatient surgical settings varied by provider. This study compared utilization of pregnancy tests in the outpatient gynecologic surgery setting after implementation of universal PREG administration. METHODS: All women undergoing outpatient gynecologic surgery were prospectively evaluated between March and September 2016. Administration of the PREG to women 18-49, excluding those undergoing procedures related to pregnancy, was implemented in July and rates of pregnancy testing pre- and post-implementation were compared using Fisher’s exact test. RESULTS: 369 patients underwent an outpatient gynecologic procedure during the study period (excluding a two week washout period after implementation). In the pre-implementation group, 136 met inclusion criteria with 45 pregnancy tests performed (33.1%). After implementation, 80 patients met inclusion criteria and 17 pregnancy tests were performed as indicated by PREG response (21.3%), demonstrating over one third reduction in pregnancy test administration (p = 0.086). No pregnancy tests were positive and no false negative evaluations were identified. Physician and nursing staff requested continued use of the PREG after the trial. CONCLUSION: PREG administration on admission for outpatient gynecologic surgery consistently and effectively identifies patients in whom pregnancy testing improves the value of care.

Resident impact on operative duration for elective general surgical procedures

BackgroundResident involvement in operations increases operative duration. This study investigated resident impact on operative time for a single general surgeon in an outpatient surgical setting. MethodsA retrospective review was performed of index general surgical operations meeting inclusion criteria. Operative duration, patient demographics, 30-day complication/readmission rates, and degree of resident involvement were collected. Results625 cases were analyzed. Patient demographics were similar for all procedural comparison groups. Operative time increased with resident involvement for each operation—umbilical hernia repairs were associated with a 19% increase (22.3 ± 6.7 versus 26.5 ± 7.5 min, p = 0.002), laparoscopic cholecystectomies demonstrated a 15% increase (25.8 ± 8.7 versus 29.7 ± 10.2 min, p = 0.001), and laparoscopic inguinal hernia repairs demonstrated a 25% increase (32.1 ± 11.3 versus 40.2 ± 8.9 min, p < 0.001). ConclusionsEach surgeon must decide if the increase in operative duration caused by resident involvement is justified by the intangible benefits residents provide.

Implementing No Interruption Zones in the Perioperative Environment

The perioperative arena is one of the most information-intensive, intricate, and complex work environments in health care, and it depends on sound communication to help ensure patient safety. Surgical procedures require attention, vigilance, and situational awareness. Noise and other distractions have the potential to cause mental lapses, impair thought processes, and divert attention away from tasks, increasing the likelihood of adverse patient events. However, there is no way to eliminate all noise from an OR. AORN advocates for a controlled environment in which distractions and noise are minimized. Our project presents an overview of how the No Interruption Zone concept was introduced in an outpatient surgical setting through an educational intervention. Our findings suggest that noise levels during critical phases of surgery can be reduced through focused education for perioperative team members.

Methods in obtaining split-thickness skin grafts from skin reduction surgery specimens.

BackgroundTo devise a method for obtaining bacterial culture-negative split-thickness skin grafts from specimens removed from living donors undergoing skin reduction surgery.MethodsSpecimens were obtained from patients undergoing abdominal skin reduction surgery in inpatient and outpatient surgical settings. Skin specimens were cleaned in a method adapted from the former Yale Skin Bank’s methods. The specimens were attached to the autoclave container for the dermatome using towel clips or sutures to provide tension. Normal saline clysis was injected subdermally and a Padgett Electric Dermatome was used to obtain skin grafts. These were then photographed and discarded.ResultsEight specimens were obtained from seven women and one man. The mean age was 46.6 years and mean weight at time of surgery was 87.7 kg. Bacterial cultures obtained from all specimens were negative. All procured grafts were transparent, with visible dermis, suggesting that they could be used in a clinical setting.ConclusionBacterial culture-negative split-thickness skin grafts can be obtained from skin reduction surgery specimens, offering a potential source of split-thickness allograft during regional or national shortages.

Surgical Management of Endometrial Polyps in Infertile Women: A Comprehensive Review.

Endometrial polyps are benign localized lesions of the endometrium, which are commonly seen in women of reproductive age. Observational studies have suggested a detrimental effect of endometrial polyps on fertility. The natural course of endometrial polyps remains unclear. Expectant management of small and asymptomatic polyps is reasonable in many cases. However, surgical resection of endometrial polyps is recommended in infertile patients prior to treatment in order to increase natural conception or assisted reproductive pregnancy rates. There is mixed evidence regarding the resection of newly diagnosed endometrial polyps during ovarian stimulation to improve the outcomes of fresh in vitro fertilization cycles. Hysteroscopy polypectomy remains the gold standard for surgical treatment. Evidence regarding the cost and efficacy of different methods for hysteroscopic resection of endometrial polyps in the office and outpatient surgical settings has begun to emerge.

Ensuring Patient Safety and Optimizing Efficiency During Gastrointestinal Endoscopy

The volume of outpatient gastrointestinal (GI) endoscopy has grown dramatically in the past three decades, fueled by advancing technologies and evolving payment policies. This magnifies the need to ensure high-quality, safe, and cost-effective endoscopic services. In recent years, publicized breaches in standards of care for GI endoscopy have intensified the focus on patient safety. Because of these patient safety concerns and changes in regulatory policies, some ambulatory surgery center surveyors and inspectors have held GI endoscopy suites to the same standards as hospital ORs. The American Society for Gastrointestinal Endoscopy and other endorsing organizations drafted the Guidelines for Safety in the Gastrointestinal Endoscopy Unit, which published in January 2014. These safety guidelines relevant to sedation, infection control, staffing, training, technical equipment, traffic patterns, and personal protective equipment differ from other published guidelines for the outpatient surgical setting.

Improving the accuracy of prolapse and incontinence procedure epidemiology by utilizing both inpatient and outpatient data

The epidemiologic description of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) procedures is documented in several large studies using national database cohorts. These studies, however, may underestimate the number of procedures performed because they only capture procedures performed in either the inpatient or outpatient settings alone. We present a complete annual description of all inpatient and outpatient surgeries for POP and SUI in California. We reviewed a record of all inpatient and outpatient POP and SUI surgeries performed in California in 2008 using data from the Office of Statewide Health Planning (OSHPD). In 2008, 20,004 and 20,330 women in California underwent POP and SUI procedures, respectively. Of these, 3,134 (15.6%) and 9,016 (44.3%) were performed in an outpatient setting. The age-adjusted rates of POP and SUI were 1.20 and 1.20 per 1,000 US females, respectively. This correlates to 186,000 POP and 186,000 SUI procedures per year nationally. Vaginal apical suspensions were more common in those undergoing surgery as an inpatient (45.1 vs 19.4%). The use of mesh to augment prolapse repairs was similar (22.3% inpatient vs 19.3% outpatient). SUI procedures performed in the outpatient setting were more likely to be performed as stand-alone procedures (82.9 vs 18.8%, respectively). In California, 16% of POP and 44% of SUI procedures were performed in an outpatient surgical setting in 2008. Epidemiologic studies of POP and SUI should account for the fact that a substantial number of repairs are performed in the outpatient setting in order to achieve accuracy.

Improvised Method to Retrieve a Proximally Displaced Ureteral Stent in a Remote Surgical Setting

To present an improvised method for repositioning a proximally displaced stent using only a cystoscope and a guidewire. A Glidewire guidewire (Boston Scientific) was passed through a cystoscope and into the distal ureter, and manipulated up the ureteral stent into the renal pelvis, reflected, and passed antegrade down the ureter and into the bladder. The guidewire was then grasped in the bladder, clamped at the penis, and retracted, pulling the stent back into the bladder. The patient proceeded with lithotripsy, and the stent was removed in 2 weeks without complication. Methods at retrieving proximally displaced ureteral stents after deployment have been previously reported; however, these methods necessitated access to a ureteroscope and special graspers/baskets that may not be available in an outpatient surgical center setting. Here, an improvised method for stent repositioning using only a cystoscope and a guidewire allowed successful retrieval of a proximally migrated stent.

Tonsillectomy Healing

We performed a prospective observation study in an outpatient surgical and office setting to compare human post-tonsillectomy healing to human cutaneous wound healing and to established animal models of oral healing. Fourteen teenaged patients underwent planned tonsillectomy. Intraoral digital photographs were collected at the time of tonsillectomy, during the management of complications, and at postoperative office visits. Serial intraoral photographs of one patient were taken at 48-hour intervals from the time of surgery until postoperative day 17. Intraoral photographs from the days after tonsillectomy revealed a pattern of inflammation and healing that closely paralleled that in human skin and in canine and porcine oral wound models. Edema and pain are greatest immediately after surgery, probably as a result of thermal effects and expression of inflammatory mediators that stimulate pharyngeal nociceptors. Pain gradually decreases over time, with an increase in analog pain measures on postoperative days 3 to 5 corresponding to the maximal wound inflammation documented in experimental models. Epithelial ingrowth beneath a fibrin clot begins shortly after wounding. Separation of the fibrin clot about 7 days after surgery exposes vascular stroma. Involution of the vascular stroma and completion of epithelial coverage correlate with decreased pain levels and a lessened risk of bleeding.

Laparoscopic Resection of Metastatic Mucosal Melanoma Causing Jejunal Intussusception

A 47-year-old female was seen in an outpatient surgical setting for intermittent obstructive symptoms and abdominal pain. Computed tomography scan and upper GI series showed typical findings of intussusception. Laparoscopic-assisted small bowel resection was carried out. Histologic diagnosis revealed malignant melanoma. The patient had a history of right maxillary sinus melanoma greater than 12 years before presentation. We report the first case of a jejunojejunal intussusception caused by metastatic sinonasal melanoma, and its subsequent laparoscopic-assisted resection.

The Effect of Bupivacaine and Morphine in a Coculture Model of Diarthrodial Joints

To perform a controlled laboratory study to evaluate the effect of bupivacaine and morphine on chondrocytes and synovium in a coculture model of diarthrodial joints. A proven coculture model that allows for the assessment of cartilage and synovium exists. The model allows for simulation of the diarthrodial joint in both health and disease by using culture media with or without the addition of interleukin-1. Effects of the presence of bupivacaine and morphine were evaluated by measuring media concentration of glycosamino glycans (GAG), nitric oxide (NO), and prostaglandin E(2) (PGE(2)), and tissue concentration of GAG, water, and collagen. Cell viability was determined through the use of confocal microscopy on days 1 and 2. Cell viability 2 days after exposure to 0.5% bupivacaine was significantly less in the presence of bupivacaine than in the other groups, nearing a 100% decrease in viability. There was little effect of bupivacaine on cartilage water content or the tissue concentration of GAG and collagen. Morphine and bupivacaine both inhibited the expected rise in NO and PGE(2) when interleukin-1 was added to the media. Continuous 0.5% bupivacaine exposure has a clear detrimental effect on chondrocytes in this in vitro study. Both bupivacaine and morphine appear to have anti-inflammatory effects. Continuous morphine exposure does not cause gross chondrotoxicity in vitro and presents itself as a potential alternative intra-articular analgesic. Intra-articular bupivacaine infusion is an effective analgesic strategy and is frequently used in both office and outpatient surgical settings. This study provides evidence that the continued usage of postoperative bupivacaine continuous infusion pumps may have a detrimental effect on chondrocytes. Morphine has been shown to be an effective intra-articular analgesic, and its anti-inflammatory role seen in this study makes it a potential alternative to bupivacaine.

Is There a Relationship Between Physician and Facility Volumes of Ambulatory Procedures and Patient Outcomes?

This study explores associations between patient outcomes (7- and 30-day hospitalization and mortality) and healthcare provider (physician and facility) volumes of outpatient colonoscopy, cataract removal, and upper gastrointestinal endoscopy performed in outpatient surgical settings in Florida. Findings indicate that patients treated by high-volume physicians or facilities had lower adjusted odds ratios for hospitalizations and mortality. When physician and facility volume were assessed simultaneously, physician volume accounted for larger effects than facility volume in hospitalization models. When assessing both physician and facility volume together for mortality, facility volume was a stronger predictor of mortality outcomes at 30 days. Further examinations of associations of outpatient physician and facility volumes and patient outcomes are suggested.

Urethral reconstruction

To present an up-to-date review on the main surgical techniques used to treat urethral strictures. Anterior urethroplasty can be treated in outpatient surgical settings, thus decreasing the impact of urethroplasty. To improve outcome in adult patients, reconstructive surgeons have learned to apply the principles of hypospadias surgery, such as delicate tissue handling, avoidance of overlapping suture lines, tissue and the development of preputial skin flaps, to adult urethral surgery. Penile skin has been used as a free graft or harvested as a flap for some time, thanks to its location, hairless skin and durability. Since the early 1990s the use of buccal mucosa was introduced in genital reconstructive surgery and has become popular for complex urethral reconstructions. The use of fibrin glue was recently suggested to fix the buccal mucosal graft in a better way and to cover the anastomosis between the graft and urethral plate. Urethral reconstructive surgery is changing rapidly and this change has posed problems for surgeons who see the principles that previously defined their profession becoming obsolete or unworkable. New techniques, new tools, such as fibrin glue, and new engineered material are a part of our future.