Unanticipated Admission Research Articles

Safety and Complications of Landmark-based Paravertebral Blocks: A Retrospective Analysis of 979 Patients and 4983 Injections.

This study aimed to determine the incidence of complications after landmark-based paravertebral blocks for breast surgery. The medical records of patients who received a paravertebral block for breast surgery between 2019 and 2022 were reviewed. Patient age, sex, type of procedure, number of injections, volume of injected anesthetic, and possible complications were noted. A record was identified as a possible serious block-related complication if there was concern or treatment for local anesthetic systemic toxicity, pneumothorax, altered mental status, or intrathecal/epidural spread. Other complications recorded were immediate postblock hypotension and nausea/vomiting requiring treatment and unanticipated postsurgical admission. Patients receiving ultrasound-guided paravertebral blocks were excluded from this study. Over a 3-year period, 979 patients received paravertebral blocks using the landmark technique for breast surgery, totaling 4983 injections. Overall, 6 patients required assessment for postblock issues (0.61%), including hypotension (2 patients), nausea (3 patients), and hypotension + altered mental status (1 patient). This latter patient was identified as having a serious complication related to the paravertebral block (0.1%). This patient had unintentional intrathecal spread and altered mental status that required mechanical ventilation. The incidence of block-related hypotension and nausea requiring treatment was thus 0.31% and 0.31% respectively. Four patients required unanticipated admission, but none were for block-related reasons. No patients in this study were found to have local anesthetic systemic toxicity or pneumothorax. Our study suggests that landmark-based paravertebral blocks for breast surgery result in a very low complication rate and are a safe technique for postsurgical analgesia.

Patient Selection Criteria for Improving Quality and Safety in Patients Undergoing Ambulatory and Day-Care Surgery

Abstract Introduction: With advances in monitoring, anesthesia, and minimally invasive techniques, same-day surgeries are expected to rise significantly in the coming years. In this group, patients undergo diagnostic and therapeutic procedures and are sent home on the same day. This poses a great responsibility on the doctors involved and the hospital services, in ensuring the absence of delays, unanticipated admissions, and unexpected adverse events. Patient selection criteria are being used effectively by various centers across the world to prevent elective case cancellation and unplanned hospital admission and identify high-risk cases for major complications including morbidity and mortality. In recent year patient selection criteria, based on the latest guidelines, are being used to identify the risk factors and channel patients for ambulatory, day-care, and inpatient categories. Aims and Objectives: This article purposes a proper patient selection process for the improvement of quality and safety in patients undergoing day-care and office-based procedures. The patient selection criteria, if understood by all the team players, is instrumental in providing clinical guidance and appropriate patient triaging for caring for an ever-increasing, large volume of same-day surgical population. As the volume and complexity of the patient population grow, it is important to revise the patient selection criteria from time to time. Conclusion: Patient selection criteria have to be developed and modified by bodies and institutions to suit local circumstances to channel patients for ambulatory, day-care, and inpatient categories. Processes, administrative, clinical, and technical standards must be in-built into place and the pathway need to be well understood by all the team players in an institution.

Early observations with an ERAS pathway for thyroid and parathyroid surgery: Moving the goalposts forward

BackgroundEnhanced recovery after surgery pathways have become the standard of care in various surgical specialties. In this study, we discuss our initial experience with a staged enhanced recovery after surgery pathway in endocrine surgery and assess the impact of this pathway on select perioperative outcomes and unanticipated admissions. MethodsWe collected information regarding all thyroid/parathyroid surgeries performed by endocrine surgeons at our institution before and after the implementation of the multi-intervention enhanced recovery after surgery pathway. We compared relevant outcomes for all cases 1 year before (n = 479) and 1 year after (n = 166) implementation of the pathway. We also compared outcomes between enhanced recovery after surgery patient groups with varying levels of enhanced recovery after surgery compliance. ResultsEnhanced recovery after surgery was associated with a significant decrease in total length of stay (9.2 vs 7.5 hours, P < .0001). Whereas there was no significant decrease in all-cause unanticipated postoperative admissions, there was a decrease in patient-initiated admissions in the Enhanced recovery after surgery group. There was also a significant decrease in mean postoperative morphine milligram equivalents (14.4 vs 16.2 vs 24.8, P = .0015), average daily morphine milligram equivalents (25.6 vs 45.6 vs 53, P < .0001), and average daily pain scores (1.89 vs 2.38 vs 2.74, P = .0045) in the Enhanced recovery after surgery group (particularly with increasing Enhanced recovery after surgery compliance). There were no significant differences in the requirement for postoperative antiemetics or in the post-anesthesia care unit length of stay. ConclusionThis study demonstrates a significant benefit from Enhanced recovery after surgery pathways for thyroidectomies and parathyroidectomies, even with initial data and a staggered roll-out plan. Further directions include a follow-up study once we reach a higher level of institutional compliance with all components of the Enhanced Recovery After Surgery pathway and a prospective trial to identify the relative significance of different portions of the Enhanced Recovery after Surgery pathway, particularly the superficial cervical plexus block.

Emergency Department Frequentation and Unscheduled Visits of Liver Transplant Patients: Ten Years Experience in Tertiary Care Center, Saudi Arabia.

Introduction and objectives Liver transplantation and its indications represent an increased burden on patients' health. This can be represented in a variety of ways, such as in emergency visits, unscheduled clinic visits, and unanticipated admissions. This study aims to analyze emergency department (ED) visits, the most common presenting complaints, and the outcomes of those visits. Methods A retrospective observational study was performed in which electronic medical records were reviewed for all patients who underwent liver transplantation and presented to the emergency department between October 2011 and October 2021. The following data were collected: demographics, comorbidities, liver transplant features, and emergency department visit data and outcomes. Recurrent visits were assessed and labeled as first, second, third, fourth, and fifth or more. Results A total of 699 patients and 5,225 visits were included in the analysis. Living donors accounted for 80% of all transplants. The mean post-operative length of stay was 22.6 ± 17.8. The majority of patients (74%) had at least one comorbidity, with diabetes (47%), hypertension (31%), and chronic kidney disease (CKD) (16%) being the commonest comorbidities; however, comorbidities were not associated with an increased risk of emergency department visits. Out of the 5,225 visits to the emergency department, 2,265 (41%) were within the first year. Emergency department visits in the first seven days after discharge amounted to 22% of total first visits. By 30 days, six months, and one year, they increased to 46%, 83%, and 91%, respectively. Living donor recipients had an average of 7.3 ED visits as compared to deceased donor recipients, who had an average of 8.4 ED visits. The most common presenting complaints were gastrointestinal (GI) symptoms (18%), infectious disease symptoms (9%), and respiratory symptoms (8%). There were a total of 296 patients who were readmitted at least once since discharge after liver transplantation. Conclusion The majority of first-time presentations to ED occurred in the first year post-transplant, marking this time period as critical for liver transplant patients. Our study also highlighted the continual presentations of liver transplant patients to the ED a few years post-transplant. This requires close scrutiny of the main causes of such presentations as well as comparison with other transplant cases to identify whether they are specific to liver transplants or not.

Twenty-three-hour stays in the ambulatory surgical center: benefits, pathways and protocols.

To summarize recent evidence that discusses the clinical, financial, and logistical implications of a 23 h stay postsurgical stay unit in an ambulatory surgical center (ASC). Twenty-three-hour stays in ambulatory surgery centers are safe, but proper patient selection and optimization are key to maintaining a high level of safety. The financial implications of overnight stays in ASCs rely heavily on payment structures and comparative costs at hospital-based outpatient surgery centers. The establishment of pathways and protocols for clinical care are key to the success of a 23 h stay at an ASC. A concurrent concern with the recent increase in outpatient surgery and medical complexity of cases performed in an ambulatory surgical center (ASC) is the possibility that patients may need overnight stay. Further, whether certain patients would benefit from anticipated 23 h observation rather than same-day discharge is an emerging topic. Overnight stays in ASCs may have financial advantages and decrease the risk of unanticipated admission with proper patient selection. The use of protocols and established pathways is key to the success of this model.

Outcome of Uncomplicated Inguinal Hernia Repair by Desarda Technique in Adult Male as a Day Case Surgery at Mugda Medical College Hospital

Background: Mesh repair (Lichtenstein and Laparoscopic) for inguinal hernia is the most frequently performed operation round the world. In recent years inguinal hernia surgery has undergone numerous advances. Among them, Desarda technique provides a new concept of hernia repair based on physiological principle using an undetached strip of external oblique aponeurosis. Worldwide, day case inguinal hernia surgery has been markedly increased irrespective of technique. Due to benefit of cost effectiveness and freeing of mesh related complication, Desarda technique needs to be considered as day case hernia surgery. Objectives: To evaluate outcome of day case inguinal hernia surgery in terms of immediate and early postoperative complications, rate and reasons of unanticipated admission after surgery, time of return to basic activities and recurrence rate in our setup. Methods: This observational study was carried out at the department of surgery, Mugda Medical College Hospital included 50 male patients with uncomplicated inguinal hernia during August 2019 to July 2021. Data was collected by researcher himself with using a prepared structured questionnaires &amp; checklist and analyzed on Statistical Packages for Social Science (SPSS) 22. Results: Among 50 male patients 60% belong to low-income status, mean age was 44.09 ±10.93 years. The mean operative time was 46.31 ±12.27 mins. In the first postoperative day 22 patients reported mild pain and on third postoperative day majority (42) reported no pain. The mean duration of hospital stay was 18.16 ±11.24 hours and only 6 (12%) patients needed unanticipated admission. No severe postoperative complication, one recurrence has been reported. The mean time of return to basic activities 2.3 ±1.33 days. Conclusion: The results of the present study demonstrate that Desarda technique can be safely offered as day case hernia surgery in our country. Further study is needed for better outcome.

Association of Obstructive Sleep Apnea With Unanticipated Admission Following Nonotolaryngologic Pediatric Ambulatory Surgery.

Approximately 2% of ambulatory pediatric surgeries require unanticipated postoperative admission, causing parental dissatisfaction and suboptimal use of hospital resources. Obstructive sleep apnea (OSA) occurs in nearly 8% of children and is known to increase the risk of perioperative adverse events in children undergoing otolaryngologic procedures (eg, tonsillectomy). However, whether OSA is also a risk for unanticipated admission after nonotolaryngologic surgery is unknown. The objectives of this study were to determine the association of OSA with unanticipated admission after pediatric nonotolaryngologic ambulatory surgery and to explore trends in the prevalence of OSA in children undergoing nonotolaryngologic ambulatory surgery. We used the Pediatric Health Information System (PHIS) Database to evaluate a retrospective cohort of children (<18 years) undergoing nonotolaryngologic surgery scheduled as ambulatory or observation status from January 1, 2010, to August 31, 2022. We used International Classification of Diseases codes to identify patients with OSA. The primary outcome was unanticipated postoperative admission lasting ≥1 day. Using logistic regression models, we estimated the odds ratio (OR) and 95% confidence intervals (CIs) for unanticipated admission comparing patients with and without OSA. We then estimated trends in the prevalence of OSA during the study period using the Cochran-Armitage test. A total of 855,832 children <18 years underwent nonotolaryngologic surgery as ambulatory or observation status during the study period. Of these, 39,427 (4.6%) required unanticipated admission for ≥1 day, and OSA was present in 6359 (0.7%) of these patients. Among children with OSA, 9.4% required unanticipated admission, compared to 5.0% among those without. The odds of children with OSA requiring unanticipated admission were more than twice that in children without OSA (adjusted OR, 2.27; 95% CI, 1.89-2.71; P < .001). The prevalence of OSA among children undergoing nonotolaryngologic surgery as ambulatory or observation status increased from 0.4% to 1.7% between 2010 and 2022 ( P trends < .001). Children with OSA were significantly more likely to require unanticipated admission after a nonotolaryngologic surgery scheduled as ambulatory or observation status than those without OSA. These findings can inform patient selection for ambulatory surgery with the goal of decreasing unanticipated admissions, increasing patient safety and satisfaction, and optimizing health care resources related to unanticipated admission.

1057: PROCESS MAPPING POSTOPERATIVE PICU ADMISSIONS

Introduction: The lack of a standard communication process around anticipated postoperative destination for patients leads to inefficiencies and staffing challenges in the pediatric intensive care unit (PICU). Many PICU admissions are unanticipated; however, many of the complex or prolonged surgical cases can be anticipated. We aim to identify opportunities in perioperative scheduling communications to facilitate optimization of staffing and efficiency for planned post-operative admissions to the PICU. Methods: Over 45 days, a daily REDCap survey was administered to PICU charge nurses aiming to identify new admissions from the operating room, whether they were considered planned, how the team learned about the new patient admission (overnight OR list, bed reservation email, call from perioperative team day of admission, etc.), and if the intended destination was posted on Epic. The perioperative team can use more than one way to notify the PICU team of an admission for one patient. There were 67 total OR admissions, but 17 of these survey submissions were removed because they were previously admitted to the PICU (n=11), they had an unforeseen surgical complication (n=3), or they were scheduled to go to the PICU and did not show up (n=3). 50 surveys were processed for their data. Results: Of the 50 survey submissions, 35% were considered unplanned by the PICU charge nurse. These unanticipated admissions resulted in one less nurse requested for the shift during which they were admitted. Of unplanned admissions, 11% were posted on the overnight OR list, 53% were called in by a perioperative team member the day of admission, and 29% appeared to the PICU without any type of communication to the team. 85% of planned admissions were posted to the overnight OR list. They also utilized bed reservation email (6%), surgery call the day of admission (3%) and the bed reservation book (21%). Conclusions: Unplanned admissions from the OR indicate scheduling communication gaps across surgical disciplines. This is likely due to the lack of standardization in communicating PICU admissions from the operating room. Since a majority of planned admissions utilized Epic and the overnight OR list for communication, we propose to make the postoperative destination field a required field within the posting process in the EHR.

Evaluation of risk factors for unanticipated hospital admission following ambulatory surgery - An observational study.

Unanticipated admissions following ambulatory surgery significantly affect hospital admission and operation room flow. Most of the factors responsible for unanticipated admission following ambulatory surgery were preventable. It is, therefore, crucial to improve patient selection criteria and to identify the risk factors for unanticipated admission during preoperative period. These unanticipated admissions have now been considered as quality care indicator and a target to improve healthcare costs. To assess the reasons and risk factors for unanticipated hospital admission after ambulatory surgery. Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia. In this case-control study, cases who were re-admitted within 48 hours following ambulatory surgery were included. The convenience sampling was used to identify controls. Data including patients' demographics, type of anesthesia and surgery, any intraoperative or postoperative complications, etc., were extracted. Descriptive statistics is used to summarize the study variables. Mean and standard deviation were used for quantitative variables. Percentage and frequencies were used for qualitative variables. Univariate and multivariate logistic regressions were used to assess risk factors for unanticipated hospital admission after ambulatory surgery. There were 153 cases and 147 controls in this study. The study found postoperative pain as the most common reason for re-admission after ambulatory surgery followed by bleeding, fever, and asthma exacerbation. Multivariate logistic regression showed age, BMI more than 40, and presence of respiratory disease as risk factors (P < 0.05). Age, high BMI more than 40, and presence of respiratory disease increase the risk of unanticipated hospital admission after ambulatory surgery.

Patient and operative factors associated with unanticipated intensive care admission and outcomes following posterior fossa decompressions in children: A retrospective study.

IntroductionPosterior fossa decompression for Chiari I Malformation is a common pediatric neurosurgical procedure. We sought to identify the impact of anesthesia‐related intraoperative complications on unanticipated admission to the intensive care unit and outcomes following posterior fossa decompression.MethodsMedical records of all patients <18 years who underwent surgery for Chiari I malformation between 1/1/09 and 1/31/21 at the Ann & Robert H. Lurie Children's Hospital of Chicago were included. Records were reviewed for patient characteristics, anesthesia‐related intraoperative complications, postoperative complications, and surgical outcomes. The primary outcome was the incidence of unanticipated admission to the intensive care unit, and the primary variable of interest was an anesthesia‐related intraoperative complication. Patient, surgical characteristics, and year of surgery were also compared between patients with and without an unanticipated admission to the intensive care unit, and a multi‐variable adjusted estimate of odds of unanticipated admission to the intensive care unit admission following an anesthesia‐related intraoperative complication was performed. Secondary outcomes included anesthesia factors associated with an anesthesia‐related intraoperative event, and postoperative complications and surgical outcomes between patients admitted to the intensive care unit and those who were not.ResultsTwo hundred ninety‐six patients with Chiari I Malformation were identified. Clinical characteristics associated with an unanticipated admission to the intensive care unit were younger age, American Society of Anesthesiologist (ASA) physical status >2 and an anesthesia‐related intraoperative complication. 29 anesthesia‐related intraoperative complications were observed in 25 patients (8.4%). Two of 25 patients (8%) with an anesthesia‐related intraoperative complication compared with 3 of 271 (1%) patients without anesthesia‐related intraoperative complication had an unanticipated admission to the intensive care unit, odds ratio 7.8 (95% CI 1.2–48.8, p = .010). When adjusted for age, sex, ASA physical status, presenting symptoms, concomitant syringomyelia, previous decompression surgery and year of surgery, the odds ratio for an unanticipated admission to the intensive care unit following an anesthesia‐related intraoperative complication was 5.9 (95% CI 0.51–59.6, p = .149). There were no differences in surgical outcomes between patients with or without an unanticipated admission to the intensive care unit.ConclusionOur study demonstrates that although anesthesia‐related intraoperative complications during posterior fossa decompression are infrequent, they are associated with an increased risk of an unanticipated admission to the intensive care unit.

Development of a predictive model for emergency room utilization and unanticipated hospital admission in patients receiving cancer treatment for solid tumor malignancies.

e18674 Background: Unanticipated healthcare resource utilization, in the form of either emergency department utilization (EDUs) or hospital admission (HA), is an indicator of lower quality of cancer care. The objective of this study was to develop a comprehensive predictive model for emergency department utilization and hospital admission (HA) for patients with solid tumors who received chemotherapy within 30 days. Methods: We abstracted electronic health data on oncology encounters from all patients receiving systemic therapy chemotherapy for solid tumors from March 01, 2015 to August 21, 2020. Patients included in the cohort met the following criteria:1) Ages &gt; = 18 years old 2) Diagnosed with any solid tumor (3) Had any oncology treatment plan related to their solid tumor diagnosis; 4) Received at least one chemotherapy during March 01, 2015 through August 21, 2020. We defined a primary composite outcome of emergency visit or unanticipated hospitalization within 30 days after the encounter. Patient information was abstracted. We developed a predictive model for the primary outcome using LASSO logistic regression modeling. To evaluate the model, we calculated the Area Under the Receiver Operator Characteristic (AUROC) and the calibration slope. Results: 12,917 unique patients with 134,641 encounters were included. Of these, 9100 (6.7%) of encounters were ED visits or hospitalizations. 714 patients (5.5%) had at least one ED visit or hospitalization within 30 days of treatment; patients at highest risk for this outcome included those with pancreatic cancer, lung cancer and ovarian/endometrial cancer (9.1%, 7.4% and 6.8% respectively). 38 variables were identified as contributing to the LASSO model. The top predictors, in order of importance, were fever, hypernatremia, hypotension and low albumin. The model’s AUC was 0.83, indicating good model sensitivity to outcome. Conclusions: Approximately 7% of healthcare encounters in patients undergoing treatment for solid malignancies were ED visits or hospitalizations. Identifying patients at highest risk for this outcome may prevent unnecessary resource utilization and optimize patient care during cancer treatment. The model developed in this study demonstrated good sensitivity and could be implemented in clinical practice to allow for preventive outpatient interventions. Work is ongoing to integrate this model into clinical care at our institution.[Table: see text]

Medical disease and ambulatory surgery, new insights in patient selection based on medical disease.

Improvements in perioperative care contributed to enlarge the eligibility criteria for day case surgery and more and more patients with comorbidities may be concerned. However, underlying medical diseases may influence postoperative outcomes, and therefore, must be considered when selecting patients to undergo ambulatory surgery. To limit postoperative complications, rigid patient selection criteria are often applied in ambulatory surgery. In practice, however, most of these criteria predict the occurrence of treatable perioperative adverse events but not the need for unanticipated admission or readmission. The underlying medical diseases should not be considered as sole criteria but they should rather be regarded as a dynamic process, which includes the surgical procedure as well as the experience and expertise of the perioperative setting.

Risk factors for immediate failure of outpatient surgery in gynecologic surgery.

To describe the risk factors for immediate failure of gynecologic outpatient surgery. The secondary objective was to describe the risk factors for rehospitalization within 30 days after surgery. This is a single-center retrospective cohort study conducted on all patients operated on in outpatient surgery in gynecology at the Lille University Hospital. The primary outcome was defined as any unanticipated admission to the inpatient postoperative care unit on the day of the operation. The secondary outcome was defined as any rehospitalization within 30 days following the intervention. Our statistical analysis included 916 patients operated on between January and July 2019. In our study, 84 patients (9.2%) had an immediate failure of outpatient surgery. The most frequent etiologies were surgical (58.3%). In multivariate analysis with logistic regression, the following variables were associated with an increased risk of immediate failure of outpatient surgery: urogynecologic surgery (P< 0.001), complex laparoscopy (P= 0.004), endometriosis surgery (P< 0.001), and a duration of intervention longer than 1 hour (P< 0.001). We find an increased risk of immediate failure of gynecologic outpatient surgery depending on the type of surgery as well as for surgeries lasting more than 1 hour.

AB203. SOH22ABS104. The implementation of novel heating devices to reduce the incidence of perioperative hypothermia in adult surgical patients: a quality improvement project

Background: Perioperative hypothermia is one of the most common phenomena seen amongst surgical patients, leading to numerous adverse outcomes such as increased blood loss, perioperative cardiac events, delayed wound healing, longer hospital stay, unanticipated admission to high dependency units and reduced patient satisfaction. The Australian health system estimates costs associated with hypothermia to be $1,259,725,856/annum. All major advisory bodies, including The National Institute for Health and Care Excellence (NICE) and World Health Organisation (WHO), have strongly recommended the maintenance of intraoperative normothermia during surgery.

Recognition, treatment, and prevention of perioperative anaphylaxis: a narrative review

&lt;abstract&gt; &lt;p&gt;Perioperative anaphylaxis events are allergic reactions which occur in the perioperative period when patients are exposed to a multitude of agents, received anesthesia, and undergo a procedure. These reactions are rare and can be life-threatening, with the common signs being hypotension, hypoxia, elevated airway pressures and urticaria. Perioperative anaphylaxis can be mediated by immunoglobulin E (IgE) or non-IgE mechanisms. Globally, the incidence of reactions and frequency of specific triggers varies considerably. Perioperative anaphylaxis events often result in discontinuation of surgery, extended hospital stays, unanticipated intensive care admissions and increased morbidity and mortality. Common causative agents include neuromuscular blocking agents (NMBA's), beta-lactam antibiotics, chlorhexidine, and latex. The primary treatment of perioperative anaphylaxis is removal of the offending agent, epinephrine, and adequate fluid resuscitation. Post-operative workup involves serial serum tryptase measurements, skin testing, in-vitro testing and challenges to determine the culprit agent. Several countries including the UK, Spain, France, Australia, and New Zealand have established guidelines, reporting systems, and specialized clinics dedicated to perioperative hypersensitivity reactions. Future efforts should address diagnostic challenges as well as increasing awareness of other perioperative anaphylaxis triggers. This narrative review will provide an overview of the epidemiology, diagnosis, management, and prevention of perioperative anaphylaxis events.&lt;/p&gt; &lt;/abstract&gt;

Day Surgery Conversion: Rate and Possible Causes in King Fahad Specialist Hospital, Buraydah, Saudi Arabia.

IntroductionDay surgery is defined as the admission of a patient and discharge after the surgical procedure within the same day. It is becoming increasingly popular as it provides multiple advantages for the health care system and patients, including better resource utilization in the form of decreasing the cost, increasing the number of patients served, a reduction in the waiting list length, and preservation of hospital beds for complex advanced cases. Internationally, patients' admission rate after a planned day surgery was found at 1.5%. Etiologies for day surgery conversion vary among studies, 75% of which were labeled as potentially preventable. As patients are admitted, the benefits of day surgery decrease.AimThis study aimed to measure the unanticipated admission rate of day surgery while evaluating the reasons for admission in King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia.Materials and methodsThis is a retrospective review study in which all medical records of patients admitted and operated as day surgery from January 1, 2015 to February 28, 2021 in King Fahad Specialist Hospital in Buraydah, Qassim region in Saudi Arabia were evaluated. Variables collected included baseline characteristics such as age, gender, body mass index (BMI), chronic diseases, surgical history, operation name, complications, and causes of conversion.ResultsA total of 6,771 day surgery cases were found from January 1, 2015 to February 28, 2021. Of them, 231 cases were converted to inpatient admission, and the prevalence of conversion was 3.4%. The most common cause of conversion was pain (35.1%) followed by postoperative care (16%), need of antibiotics (12.1%), and bleeding (8.2%); most of these cases were associated with laparoscopic cholecystectomy. Furthermore, laparoscopic cholecystectomy (36.4%), hernia repair (12.1%), and pilonidal sinus excision were the most frequent surgical intervention.ConclusionThe day surgery conversion rate was minimal in this study (3.4%). Pain, postoperative care, and the need for antibiotics were the most common reasons for conversion. Continuous monitoring of day surgery conversion rate and causes will all help the institution to gain the maximum benefits of day surgeries.

The predictive power of the National Early Warning Score (NEWS) 2, as compared to NEWS, among patients assessed by a Rapid response team: A prospective multi-centre trial

AimEarly identification of patients at risk of serious adverse events (SAEs) is of vital importance, yet it remains a challenging task. We investigated the predictive power of National Early Warning Score (NEWS) 2, as compared to NEWS, among patients assessed by a Rapid response team (RRT). MethodsProspective, observational cohort study on 898 consecutive patients assessed by the RRTs in 26 Swedish hospitals. For each patient, NEWS and NEWS 2 scores were uniformly calculated by the study team. The associations of NEWS and NEWS 2 scores with unanticipated admissions to Intensive care unit (ICU), mortality and in-hospital cardiac arrests (IHCA) within 24 h, and the composite of these three events were investigated using logistic regression. The predictive power of NEWS and NEWS 2 was assessed using the area under the receiver operating characteristic (AUROC) curves. ResultsThe prognostic accuracy of NEWS/NEWS 2 in predicting mortality was acceptable (AUROC 0.69/0.67). In discriminating the composite outcome and unanticipated ICU admission, both NEWS and NEWS 2 were relatively weak (AUROC 0.62/0.62 and AUROC 0.59/0.60 respectively); for IHCA the performance was poor. There were no differences between NEWS and NEWS 2 as to the predictive power. ConclusionThe prognostic accuracy of NEWS 2 to predict mortality within 24 h was acceptable. However, the prognostic accuracy of NEWS 2 to predict IHCA was poor. NEWS and NEWS 2 performed similar in predicting the risk of SAEs but their performances were not sufficient for use as a risk stratification tool in patients assessed by a RRT.

Torsades de pointes in the PACU after outpatient endoscopy: a case report

BackgroundThis case demonstrates the severe electrolyte derangements that may present after a common therapy such as a bowel preparation for an outpatient procedure and the rare yet potential detrimental outcomes of those abnormalities. It also highlights the implications of long QT syndrome regarding pharmacology and treatment.Case presentationWe present a case of 48 year-old female with severe electrolyte derangements and long QT syndrome (LQTS) leading to Torsades de Pointes (TdP), pulseless ventricular fibrillation, and unsynchronized defibrillation in the post anesthesia care unit (PACU) after uneventful upper and lower endoscopy. This led to an unanticipated intensive care unit admission for aggressive electrolyte repletion, cardiology consultation, and implantable cardioverter defibrillator (ICD) placement.ConclusionsThis is a rare presentation after an outpatient procedure that would have had a detrimental outcome if not promptly diagnosed and treated appropriately. Therefore, we aim to provide further insight into the diagnosis and treatment of severe hypokalemia and long QT syndrome resulting in Torsades de Pointes and ventricular fibrillation.

Factors Associated With Unanticipated Admission After Outpatient Endoscopic Sinonasal Surgery.

To identify factors that may increase the risk of unplanned admission following elective outpatient endoscopic sinonasal surgery (ESS). Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP). All cases of ESS were extracted from the 2010 to 2018 NSQIP database using Current Procedural Terminology codes. Only cases coded as outpatient, elective, and nonemergent procedures were included. Unplanned admissions were defined as cases with a total hospital stay of 1 day or more. Univariate and multivariate analyses were performed to identify variables that independently predicted unanticipated admission. A total of 971 cases met inclusion criteria, of which 274 (28.2%) were unanticipated admissions. Patients in the unplanned admission group were more likely to be older (46.8 vs. 41.1 years, P < .001), male (57.7% vs. 48.4%, P=.009), obese (54.8% vs. 43.8%, P=.003), and have hypertension (35.0% vs. 25.0%, P=.002). Unplanned admitted patients were also more likely to be included under American Society of Anesthesiologists (ASA) classification III-IV (43.1% vs. 27.2%, P < .001). There were no significant differences in race, smoking, diabetes, or chronic steroid use. Unplanned admitted patients had a higher rate of surgical complications (2.9% vs. 1.0%, P=.041). Upon multivariate analysis, independent preoperative risk factors for unplanned admission included age (OR: 1.018, P=.002), male gender (OR: 1.415, P=.025), obesity (OR: 1.527, P=.008), and ASA III-IV (OR 1.501, P=.018). Factors independently associated with unplanned admission following outpatient ESS were older age, male gender, obesity, and higher ASA. Identification of patients at risk may reduce unanticipated hospital admission after ESS. 4 Laryngoscope, 132:518-522, 2022.

262 Analysis of the Factors Contributing to Unplanned Admissions of Surgical Day Cases

Abstract Introduction Day surgery has many benefits including a reduction in waiting lists, cancellations, hospital acquired infections and need for inpatient beds. It is also highly cost effective. The aim of this study is to identify which factors lead to the unanticipated admission of day cases, in order to adjust future patient selection, and retain efficiency Method A list of day cases that took place in 2017 was obtained from the HIPE department in St. Luke’s General Hospital. Day case patients who required admission were retrospectively analysed with the use of patient charts. Patient factors such as age, gender and co morbidities were recorded. The root cause of admission was identified, and the data collated. Results 457-day cases took place during 2017. 35/457 patients were admitted postoperatively (admission rate of 7.8%). The majority of patients were admitted post cholecystectomy (22) and incisional hernia repair (8). Surgical factors were responsible for almost all admissions. Conclusions Surgical factors/complications are not always predictable, but a thorough review of a patient’s background history and imaging can lead to the identification of patients, who should be directed away from day surgery, minimising the need for unexpected admissions, and maximising the efficiency of the unit.