Same-day Procedures Research Articles

Cervical preparation for second trimester dilation and evacuation.

Abortion during the second trimester of pregnancy accounts for 10-15% of abortions performed worldwide. Dilation and evacuation (D&E) is the preferred method of second-trimester abortion in most parts of the developed world. Cervical preparation is recommended for dilation and curettage (D&C) after 12 weeks gestation and is standard practice for D&E beyond 14 weeks gestation. Prostaglandins, osmotic dilators, and Foley balloon catheters have been used and studied as cervical preparation prior to second-trimester D&E. However, no consensus exists as to which cervical preparation method is superior with regards to safety, procedure time, need for additional dilation, ability to perform the procedure, or patient and provider acceptability. Despite the fact that the advent of osmotic dilation has improved the safety of the D&E procedure during the second trimester, it is unclear whether a certain type of osmotic dilator is superior to another or whether osmotic dilation with adjuvant prostaglandin is superior to osmotic dilation alone or to prostaglandins alone. This review evaluates cervical preparation methods for second-trimester surgical abortion with respect to differences in procedure time, dilation achieved, need for additional dilation, complications, ability to complete the procedure, patient pain scores, and patient and provider acceptability and satisfaction. We searched for trials of cervical preparation prior to second-trimester D&E. We included all randomized controlled trials that compared osmotic, mechanical, antiprogesterone, prostaglandin, or other medical agents of cervical preparation for second-trimester surgical abortion from 14-24 weeks of gestation. Data were abstracted by two authors and data entry was verified by a third author. Mean difference and Peto Odds Ratio were calculated. Osmotic dilators were found to be superior to prostaglandins with respect to cervical dilation throughout the second trimester and with respect to procedure time within the early second trimester. Addition of prostaglandins to osmotic dilators was not found to increase cervical dilation, except after 19 weeks gestation, however, no impact was seen on procedure time. Addition of Mifepristone to misoprostol was found to improve cervical dilation, yet increase procedure time and frequency of pre-procedural expulsions. Two-day cervical preparation was found to produce greater cervical preparation than one-day, but had no impact on procedure time. Serious complication rates or ability to complete the procedure did not differ significantly between any of the preparation methods reviewed. Cervical preparation with osmotic dilators and/or misoprostol before second-trimester D&E is safe and effective. Osmotic dilators appear to provide superior cervical dilation when compared to prostaglandins alone or when combined with prostaglandins, however this difference in cervical dilation does not appear to result in differences in procedure time or complication rates. There does not appear to be clear clinical benefit from two days of cervical preparation compared to one-day prior to second-trimester D&E below 19 weeks gestational duration. Mifepristone plus misoprostol was associated with high rates of pre-procedural expulsions and does not appear to be a useful method of cervical preparation before second-trimester dilation and evacuation. Same-day procedures appear to be a safe and reasonable option in the early second trimester, however, more research is needed to assess the effectiveness and safety of same-day procedures in the later second trimester.

Safety of same-day endoscopic ultrasound and endoscopic retrograde cholangiopancreatography under conscious sedation

To assess the tolerability and safety of same-day tandem procedures, endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation. A retrospective review was conducted at Loma Linda University Medical Center, a tertiary-care center. All 54 patients who underwent EUS followed by ERCP (group A) from 2004 to 2006 were included in the study. A second group of 56 patients who underwent EUS only (group B), and a third group of 53 patients who underwent ERCP only (group C) during the same time period were selected consecutively as control groups for comparison. Conscious sedation was used in 96% of patients in group A. Mean dosages of meperidine and midazolam used in group A were significantly higher than in group B or C. Mean recovery time in group A was not statistically longer than in group B or C. There was no significant difference in the incidence of sedation-related and procedural-related complications. Tandem EUS/ERCP procedure can be safely performed under conscious sedation with minimal adverse events. Combined procedures, however, are associated with higher dosages of sedatives, and slightly longer recovery time.

Cervical dilation in second-trimester abortion.

Dilation and evacuation, the most common method performed for second-trimester abortion in the United States, requires sufficient cervical dilation to reduce the risk of complications such as cervical laceration or uterine perforation. The cervix may be prepared with osmotic dilators such as laminaria, Lamicel, or Dilapan-S, or with pharmacologic agents such as misoprostol. Dilapan-S and Lamicel achieve their maximum dilation faster than laminaria, making same-day procedures possible. Misoprostol has limited data supporting its use in this setting. Decisions regarding which method is best are clinician-dependent, and factors such as gestational age and time allowed for preparation should be considered.

Trends in stress urinary incontinence inpatient procedures in the United States, 1979-2004

The purpose of this study was to describe national trends in surgery for female stress urinary incontinence (SUI). We used data from the National Hospital Discharge Survey, a federal dataset sampling patient discharges from US inpatient hospitals. We analyzed patient and hospital demographics and International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) diagnostic and procedures codes for 1979-2004. Age-adjusted rates per 1000 women were calculated with 1990 US Census population data. The number of women who have undergone SUI surgery each year increased from 48,345 in 1979 to 103,467 in 2004. In women > or = 52 years old, the age-adjusted rate more than doubled from 0.64-1.60 procedures per 1000 women; in women < 52 years old, the age-adjusted rate fell from 0.57-0.47. Age-adjusted rates for retropubic urethral suspension (ICD-9-CM, 59.5) fell from 0.37 in 1979 to 0.14 in 2004. For suprapubic sling procedures (ICD-9-CM, 59.4), the age-adjusted rates rose from 0.02 in 1979 to a peak of 0.10 in 1997 and then fell to 0.03 in 2004. Age-adjusted rates for other repair of urinary stress incontinence (ICD-9-CM, 59.79) rose from 0.06 in 1979 to 0.64 in 2004. The number of women who have undergone SUI surgery increased significantly from 1979-2004. Because the National Hospital Discharge Survey data do not include ambulatory procedures, accurate information on same-day surgeries is unavailable. Currently no ICD-9-CM procedure code exists specifically for midurethral sling procedures. Both missed sampling of same-day procedures and nonspecific or inaccurate coding may explain the surprising decline in suprapubic sling procedures and the rise in rates of other repair of SUI. A national ambulatory surgical database and a specific code for midurethral sling are needed to capture these important data.

Minor Endoscopic Complications in a Higher Risk Cohort Receiving Same-Day Duel (Double) Procedures Versus Single Endoscopy

Background: There is sparse published data on the rate of minor complications with same-day duel (double) endoscopy or single endoscopy. Duel endoscopy is often scheduled for patient convenience. No comparisons exist between the two practices. Purpose: To demonstrate the rate of minor complications after endoscopy and compare these rates between single endoscopy and same-day duel endoscopy procedures within a selected cohort of higher risk patients. Methods: From 1/1/08 through 5/31/08, all outpatients defined as higher risk receiving EGD, colonoscopy, or duel procedures were identified for post-procedure telephone contact within 3 days. Seven board-certified gastroenterologists participated. All duel procedures were completed by the same endoscopist. Patients were surveyed for complications and need for intervention. Higher risk was defined as the need for anti-coagulation or procedures requiring polypectomy, cautery, or other ablative technology (ie. APC). Minor complications were defined as nausea, vomiting, abdominal pain, fever, bleeding not requiring hospitalization or transfusion, and other (ie. sore throat). Patients with perforation or significant hemorrhage were excluded from the analysis of minor complications. Follow-up intervention was defined as a visit to the ER, urgent care, primary care provider, GI clinic, or admission to a hospital. Results: 3135 outpatients received endoscopy within the study period. 1345 (42.9%) patients were identified as higher risk. 1072(79.7%) higher risk patients (52.4% male) were contacted within 3 days. Mean age of all groups was 62.6 years. Females were more likely to have EGD and less likely to have colonoscopy (p<0.01). 154 EGD, 876 colonoscopies, and 42 duel procedures were contacted. Minor complications were significantly higher (p<0.01) after duel endoscopy (35.7%) than after EGD (5.8%), or colonoscopy (3.9%). Females were more likely than males to report complications across all procedures (7.5% vs 3.6%, p<0.01). However, gender did not explain the higher complications in duel procedures (p=0.11). Follow-up intervention was required in 28.9% of patients reporting minor complications. Duel procedures were more likely to result in intervention (7.9%) than EGD (1.3%) or colonoscopy (1.2%), p<0.02. Conclusions: In this higher risk cohort of endoscopic outpatients, minor complications are not uncommon and significantly more frequent following same-day duel procedures. Females are more likely to report complications. A fairly high percentage of patients reporting minor complications require medical intervention. Further study is planned to determine if these differences hold for all outpatient endoscopy.

Decreased waiting periods in a public pregnancy termination clinic

Background In our public hospital, first-trimester pregnancy termination historically had been performed in an operating room by suction curettage on a separate day following the initial clinic visit. To increase efficiency, we instituted three changes over a 2-year period: (a) pregnancy termination procedures were relocated to the outpatient area; (b) same-day service was initiated; and (c) manual vacuum aspiration was introduced. Our primary objective was to assess the effects of these changes on the waiting period in days from the intake visit to the day of termination procedure. Our secondary objectives included assessing any decrease in gestational age at the time of procedure, increases in the numbers of procedures at <9 weeks, the numbers of procedures per session and the proportion done on the day of intake. Methods This is a retrospective cross-sectional review of the clinical records of patients who requested pregnancy termination. Data were obtained on 625 patients who underwent a surgical termination of pregnancy from February 1, 2004, to January 31, 2006. Results The waiting period decreased from 20.3 to 3.6 days (p<.01), and mean gestational age at termination decreased from 11 to 9 weeks (p<.01). The proportion at <9 weeks' gestation increased from 1.7% to 40% (p<.01). The number of procedures per session increased by 52.7% (p<.01). The percentage of same-day procedures increased from 7% to 62%. Conclusion We improved efficiency of care by reducing the waiting period and terminating pregnancies earlier in gestation with manual equipment.

Ensuring Timely Completion of Type and Screen Testing and the Verification of ABO/Rh Status for Elective Surgical Patients

A blood bank can provide compatible blood for an elective surgical procedure, provided a blood sample is received by the laboratory with sufficient time to allow pretransfusion testing and acquire enough compatible red blood cell units. With the push for same-day admission surgical procedures, a patient's pretransfusion blood sample is often collected the morning of surgery. However, if blood is needed, compatible units might not be immediately available. To define and improve the process of completing presurgical/preadmission type and screen testing and verifying the ABO/Rh status of scheduled surgical patients before they receive a transfusion. A list of surgical procedures that might necessitate blood transfusion was created. A checklist was used to ensure that the preoperative clinic nurse collects a baseline pretransfusion blood sample for type and screen testing from patients scheduled for a listed procedure. A new pretransfusion specimen was received on the day of surgery, if needed, so that a current specimen would be available for compatibility testing and to verify the accuracy of the patient's ABO/Rh status in case blood was requested. During the 1-year study period, 666 patients qualified for baseline type and screen testing. Cholecystectomy was the most commonly scheduled surgery. In 99% of cases, a baseline type and screen specimen was received in the laboratory at least 1 day before surgery. The interval between the preoperative clinic visit and date of surgery varied from same day (6 patients) to 3 months. Timely receipt of a presurgical specimen for type and screen testing and verification of a patient's ABO/Rh status can be ensured when clinical services collaborate and when the hospital blood utilization committee provides oversight to improve compliance.

Same-day endoscopic retrograde cholangiopancreatography after transduodenal endoscopic ultrasound-guided needle aspiration: do we need to be cautious?

Patients who are undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for suspected pancreatic tumors frequently undergo endoscopic retrograde cholangiopancreatography (ERCP) for palliation of their symptoms. Performing EUS-FNA and ERCP in tandem may be cost-effective and may reduce procedure time, but the potential risks associated with this approach have not been clearly defined in the literature. We report two patients who underwent same-day therapeutic ERCP after transduodenal EUS-FNA for pancreatic tumors. Endoscopic biliary manipulation during ERCP aggravated an inadvertent and subclinical needle puncture injury to the bile duct sustained during the preceding EUS-FNA. This resulted in leakage of bile into the retroperitoneal space, and both patients required laparotomy and surgical drainage. Additional clinical evidence is needed to clarify these issues and to determine whether it would be prudent to perform therapeutic ERCP prior to diagnostic transduodenal EUS-FNA when these two procedures are planned as sequential or same-day procedures.

95 Retrospective review of post-operative complicationsin patients with sleep apnea syndrome undergoing same-day procedures

To clarify the association between obstructive sleep apnea (OSA) and postoperative outcomes, investigate whether preoperative diagnosis and continuous positive airway pressure (CPAP) therapy reduce the risks and examine the impact of OSA severity on postoperative outcomes.The PubMed, Cochrane Library and Embase databases were searched from inception until April 2021 for studies evaluating the association between OSA and postoperative adverse events. A random effects model was used to calculate the pooled outcome. Sensitivity analysis and publication bias were conducted to verify the robustness and reliability of the results.In total, 46 studies were eligible for further analysis. OSA was significantly associated with higher risks of postoperative respiratory complications (OR = 1.91; 95% CI = 1.54 to 2.36) and cardiac complications (OR = 1.74; 95% CI = 1.25 to 2.42), and the risks increased with OSA severity. OSA also increased the risk of intensive care unit (ICU) transfer (OR = 1.92; 95% CI = 1.32 to 2.80), increased the risk of postoperative delirium (OR = 1.83; 95% CI = 1.26 to 2.66) and prolonged the length of hospital stay (WMD = 0.48; 95% CI = 0.15 to 0.82). Subgroup analysis indicated that preoperative diagnosis and use of CPAP decrease the risk of postoperative respiratory complications (OR = 1.87; 95% CI = 1.43 to 2.43) and cardiac complications (OR = 1.17; 95% CI = 0.91 to 1.51).Patients with OSA have a higher risk of postoperative cardiopulmonary complications, ICU transfer, delirium, pneumonia, bleeding and prolonged length of hospital stay. OSA severity is an important risk modifier for postoperative complications, preoperative diagnosis and CPAP therapy may attenuate the occurrence of postoperative complications. The conclusions need to be interpreted with caution due to the limitations in the data, despite this, the results indicate and inform the need for further and larger trials.CRD42021254374.

Atopy: a patient-specific risk factor for diffuse lamellar keratitis

Objective To identify whether atopy is a patient-specific risk factor for the development of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK). Design Retrospective survey study. Participants Three hundred sixty consecutive patients who underwent same-day bilateral myopic astigmatic primary LASIK procedures during March 1, 2000, through July 31, 2000. Methods We collected data for 360 consecutive patients undergoing LASIK during a 4-month period. On preoperative medical history questionnaires, patients self-identified whether they were atopic. All patients also indicated whether they were taking antiallergy medications or were untreated for allergy. Main outcome measures The incidence of DLK after LASIK surgery. Results The risk of DLK in untreated atopic patients was much greater than the risk of DLK among nonatopics (odds ratio, 5.85; 95% confidence interval, 2.89–11.85; P = 0.001). However, the risk of DLK among atopic patients taking an oral systemic nonsedating histamine receptor 1 antagonist and among nonatopic patients did not differ significantly (odds ratio, 0.54; 95% confidence interval, 0.12–2.46; P = 0.43). Conclusions Atopy is a patient-specific risk factor for the development of DLK after primary bilateral LASIK for either myopia or myopic astigmatism. Atopic individuals benefit from preoperative treatment to minimize the incidence of DLK and the potential for visual loss.

A zero-inflated Poisson mixed model to analyze diagnosis related groups with majority of same-day hospital stays

With increasing trend of same-day procedures and operations performed for hospital admissions, it is important to analyze those Diagnosis Related Groups (DRGs) consisting of mainly same-day separations. A zero-inflated Poisson (ZIP) mixed model is presented to identify health- and patient-related characteristics associated with length of stay (LOS) and to model variations in LOS within such DRGs. Random effects are introduced to account for inter-hospital variations and the dependence of clustered LOS observations via the generalized linear mixed models (GLMM) approach. Parameter estimation is achieved by maximizing an appropriate log-likelihood function using the EM algorithm to obtain approximate residual maximum likelihood (REML) estimates. An S-Plus macro is developed to provide a unified ZIP modeling approach. The determination of pertinent factors would benefit hospital administrators and clinicians to manage LOS and expenditures efficiently.

Integrating Baseline Health Status Data Collection into the Process of Care

Health status data are an increasingly important component of outcomes assessment and can be used to facilitate quality assessment and improvement efforts. An enormous challenge to the use of health status data among hospitalized patients, however, is collecting baseline data at the time of treatment, an essential component for risk-adjusting subsequent outcomes. The Mid America Heart Institute of Saint Luke's Hospital (Kansas City, Mo), attempted to integrate the collection of health status assessments within the process of performing coronary revascularization. The data collection strategy was developed for each admission portalelective outpatients (admissions for same-day procedures), inpatients, and emergent cases. Health status data were collected on all patients with coronary artery disease who were receiving a percutaneous coronary intervention or coronary artery bypass graft with no disruption to physician scheduling or nursing staff. In general, patients were agreeable to completing the health status survey. Despite initial efforts to educate the hospital staff about the goal and purpose of health status assessment, staff members who were unaware of the uses of these data seemed to minimize their value. Providing examples of how to use these data relative to the staff member's specific occupational role facilitated buy-in for this project. After the pilot study, which lasted until June 1999, data were continually collected for 18 months, through August 2000, even with the cessation of external grant funding for this project. Baseline data collection finally stopped, primarily because of a failure to accommodate data collection into the routine flow of patient care by existing nursing staff.

Feasibility of Ambulatory Carotid Artery Stenting

P202 Background: Ambulatory procedures have been shown to increase patient’s comfort and cost-efficacy. We sought to determine the feasibility of ambulatory carotid stenting in a series of patients undergoing the procedure. Methods: Patients were electively admitted and discharged the same-day if they had successful uncomplicated carotid stenting and had demonstrated complete vascular access site hemostasis following ambulation 4–6 hours after the procedure. Patients were followed for neurological events and vascular access site complications. Results: A total of 76 same-day carotid stenting procedures were performed on 73 patients (76 arteries). There were 53 (73 %) males and the mean age was 70 ± 8 years. Seventy-nine percent of the patients were asymptomatic on presentation. Fourteen patients (18 %) had prior ipsilateral CEA, 3 (4%) had prior ipsilateral neck radiation and 6 (8 %) had contralateral occlusions. Successful access site hemostasis was achieved in all patients, using suture-mediated vascular sealing devices in 75 cases (99%). In one case hemostasis was achieved manually after failure of the sealing device. Late follow-up currently available on 62 (98%) patients at a mean of 4 ± 3 months. There have been no neurological events, deaths, repeat procedures or significant access site complications. One patient developed serous discharge from the access site at 6 weeks without evidence of infection or hematoma and was managed conservatively without complications. Conclusion: Ambulatory carotid stenting is feasible and safe. This approach will foster the applicability of the procedure by increasing patient s comfort and potentially reducing procedural costs.

Efficacy and financial benefit of an anesthesiologist-directed university preadmission evaluation center

Study Objective: To study the effectiveness of an anesthesiologist-directed preadmission evaluation center (PEC) in our institution. Design: I: Preoperative test costs were measured on two sets of patients undergoing same-day surgery, II: Rate of cancellation was measured on all patients undergoing same-day surgery in a subsequent one-year time period. Setting: The PEC, short procedure unit, and same-day admission unit of a university hospital. Patients: I: 3,062 male and female patients undergoing same-day surgery between January 1, 1992, and August 31, 1992. II: 9,454 male and female patients undergoing same-day surgery between July 1, 1993, and June 30, 1994. Interventions: Age, ASA physical status, type of surgery performed, and tests ordered were recorded in two groups of same-day surgical patients. Group S had testing primarily ordered by surgeons, augmented by the anesthesiologists in the PEC. Group A had testing primarily ordered by the anesthesiologists in the PEC, but surgeons could still order tests they felt necessary. On the day of surgery, the attending anesthesiologist recorded any additional testing that was required or would have altered intraoperative management. In a follow-up study, cancellations of same-day surgical patients were recorded for a one-year period. Measurements and Main Results: I: With the exception of complete blood counts with differentials, significantly fewer tests were ordered in Group A than Group S. These changes produced an average cost savings of $20.89 per patient. There were no recorded cancellations or apparent alterations in intraoperative management attributable to inadequate testing. II: Of the 9,454 same-day procedures from 7/1/93 to 6/31/94, 66 were cancelled on the day of the procedure. None of the patients seen in the PEC were cancelled due to causes possibly preventable by a PEC, unlike the cases of 4 patients who had not been evaluated in the PEC and were cancelled. Conclusion: A PEC, in which the anesthesiologist primarily orders preoperative tests and approves patients' readiness for surgery, is both an efficient and cost-effective system.

Same-day-stay head and neck surgery.

The purpose of this study was to determine if selective head and neck surgical procedures on a same-day basis are justifiable. Two hundred consecutive head and neck same-day procedures were reviewed, including 84 parotidectomies and 116 other procedures previously managed as inpatients. Of the 200 patients, 36 (18%) were admitted, 33 for overnight observation, and 164 (82%) were discharged the same day. There were no complications reported in the discharged patients and a later questionnaire showed that 97% of the patients were satisfied. The advantages of selective same-day procedures outweigh the disadvantages for otolaryngologist and patient. The study shows that same-day-stay head and neck surgery for selective procedures is safe, reasonable, and cost-effective, but the combined efforts of the otolaryngologists, nurses, and administrators are required. Because of rising healthcare costs, experts are predicting a significant increase in the next few years of outpatient surgery, including surgery of the head and neck.

Extracorporeal Shock Wave Lithotripsy: An Outpatient Procedure

At many centers circumstances have dictated that extracorporeal shock wave lithotripsy (ESWL*) be performed on an outpatient (that is same-day surgery or 1-day stay) basis. At our center, Louisiana Lithotripter, Inc., which is a privately owned ESWL unit located at Tulane University Hospital, we have had the opportunity to treat patients in the inpatient and outpatient setting since inception. Since our first ESWL treatment on December 18, 1985 we have treated more than 2,500 patients. Additionally, our unit was named an American Urological Association Training Center in October 1986, resulting in more than 200 urologist, nurse and technician trainee visits. The first 1,779 cases through December 31, 1988 have been thoroughly reviewed. The rate of outpatient ESWL has increased from 22% of the first 100 cases to more than 90% of the last 100. The cumulative over-all rate reached 70%. Currently, more than 95% of our cases are planned as same-day procedures. Safe and effective outpatient ESWL is able to be performed with first generation technology, paving the way for appropriate clinical application to newer technological modalities.

Same-day versus separate-day sigmoidoscopy and double contrast barium enema: a randomized controlled study

A randomized controlled study was carried out in 400 patients to investigate whether same-day sigmoidoscopy impairs the quality of a double contrast barium enema. There was no difference with regard to spasm, fluid, and air retention as well as barium coat in patients undergoing both procedures during the same day or on different days. The overall quality of the radiographic films received similar ratings in a blind appraisal by an outside radiologist. In contrast, the performance of sigmoidoscopy was facilitated by the more thorough bowel cleansing for same-day procedures. It is concluded that same-day sigmoidoscopy and double contrast barium enema diminishes the cost and patient discomfort for colonic investigation without impairing its quality, provided that CO2 instead of air is used during the endoscopic study.