Use Of Ambulatory Surgery Research Articles

Encouraging Digital Patient Portal Use in Ambulatory Surgery: A Mixed Method Research of Patients and Health Care Professionals Experiences and Perceptions

As more complex surgery is performed in 1-day admissions there is a growing demand for appropriate postoperative follow-up. A digital patient portal (DPP) is a promising tool to support this and increase patients' quality of recovery. However, both patients and health care professionals have not fully embraced this eHealth technology. This study investigates the extent to which a patient portal is used in a tertiary ambulatory surgical care unit and assesses usability, applicability and user-friendliness both for the patient and health care worker. Mixed method research design combining qualitative and quantitative methods. Four hundred and fifteen patients undergoing knee arthroscopic surgery or endonasal sinus surgery were included. Quantitative log data from the patient platform, clinical outcome measures and a patient questionnaire were used. Additionally, qualitative data was collected through interviews (with patients, n=13; involved caregivers and physicians, n=7) and observations (first introduction to patient with platform and team meetings, n=15). Forty percent of the included patients effectively used the patient platform (≥1 login). The patients mainly used the platform for gathering information; 62% of the active patients on the platform registered questionnaires initiated from the surgery center (eg, preoperative questionnaire) or diaries (e.g, daily follow-up using the Quality of Recovery Scale). Different barriers and facilitators toward DPP implementation were noted. Attention should be paid to the intrinsic and extrinsic motivation for using the portal and to the added value of the portal for the patient and health care professionals. Patients' perceptions of the DPP were positive and an increase in DPP use was observed during the study due to adjustments (eg, technical adjustments). However, a decline over time was noticed. The role of intrinsic and extrinsic motivation of all included parties needs to be further corroborated.

The effect of intraoperative dexmedetomidine administration on length of stay in the post-anesthesia care unit in ambulatory surgery: A hospital registry study

Study objectiveDexmedetomidine, which is commonly used for procedural sedation and as adjunct to general anesthesia for ambulatory procedures, may affect patient discharge from the post-anesthesia care unit (PACU). We hypothesized that intraoperative dexmedetomidine use in ambulatory surgery is associated with delayed discharge from the PACU and that this is modified by surgical duration and anesthesia type. DesignRetrospective cohort study. SettingAcademic medical center. Patients130,854 adult patients undergoing ambulatory surgery between 2008 and 2018. InterventionsIntraoperative administration of dexmedetomidine. MeasurementsThe primary outcome was PACU length of stay. In secondary and exploratory analyses, we examined dose-dependency, effect modification by duration of surgery and anesthesia type, effects of timing of dexmedetomidine administration, and PACU discharge delays. Main resultsDexmedetomidine was associated with a prolonged PACU length of stay (adjusted absolute difference [ADadj] 15.0 min; 95%CI 12.7–17.3; p < 0.001). This effect was dose-dependent (p-for-trend < 0.001), magnified in surgeries of less than one hour (ADadj 20.7 min; 95%CI 16.7–24.7; p < 0.001) and in patients undergoing monitored anesthesia care compared to general anesthesia (ADadj 16.8 min; 95%CI 14.1–19.6; p < 0.001). The effect was more pronounced if dexmedetomidine was administered within the last 60 min of surgery (ADadj 18.7 min; 95%CI 15.7–21.7; p < 0.001). Dexmedetomidine was associated with discharge delays due to cardiovascular complications (ORadj 2.27; 95%CI 1.59–3.24; p < 0.001) and over-sedation (ORadj 1.28; 95%CI 1.11–1.48; p < 0.001). In patients who received dexmedetomidine (n = 2901), the use of bolus doses only versus the combination of bolus and infusions, magnified the effects on PACU length of stay (ADadj 29.5 min per μg/kg; 95%CI 17.3–41.8 versus 18.1 min per μg/kg; 95%CI 11.4–24.8; p < 0.001). ConclusionsThe intraoperative administration of dexmedetomidine was dose-dependently associated with a prolonged PACU length of stay. Clinicians should judiciously titrate dexmedetomidine, especially when using this long-acting drug for monitored anesthesia care for shorter procedures.

Supporting Efficiency in Health Care at the Community Level

Health care providers and payers in the United States have worked to provide care at reasonable costs. This has frequently been a challenge. For example, the COVID epidemic has generated large expenditures with limited efforts to contain costs. Based on the experiences of providers in Syracuse, New York, this study suggested that realistic approaches are necessary to improve health care efficiency. It described three programs that have improved utilization at the community level. They have included the diversion of large numbers of ambulances that directed patients to emergency departments where care was most available. They have also involved length of stay reduction that saved thousands of patient days and made additional inpatient care available in hospitals. They have also included the use of ambulatory surgery to reduce the need for inpatient care. The data from these programs demonstrated that efforts to improve the efficiency of care can reduce inpatient utilization and improve outcomes. The Syracuse hospitals have used them to make additional capacity available for COVID patients and other populations.

Patient-reported outcomes for ambulatory surgery.

To discuss the importance of validated tools that measure patient-reported outcomes and their use in ambulatory surgery. Sustained increases in ambulatory surgical care reflect advances in surgical techniques and perioperative anaesthetic care. Use of patient-reported outcomes allows identification of minor adverse events that are more common in this population compared with traditional endpoints such as mortality. Variability in reported outcomes restricts research potential and limits the ability to benchmark providers. The standardized endpoints in perioperative medicine initiative's recommendations on patient-reported outcomes and patient comfort measures are relevant to evaluating ambulatory care. Combining validated generic and disease-specific patient-reported outcome measures (PROMs) examines the widest spectrum of outcomes. Technological advances can be used to facilitate outcome measurement in ambulatory surgery with digital integration optimizing accurate real-time data collection. Telephone or web-based applications for reviewing ambulatory patients were found to be acceptable in multiple international settings and should be harnessed to allow remote follow-up. Use of validated tools to measure patient-reported outcomes allows internal and external quality comparison. Tools can be combined to measure objective outcomes and patient satisfaction. These are both key factors in driving forward improvements in perioperative ambulatory surgical care.

Major Ambulatory Surgery in Breast Diseases

IntroductionThe use of ambulatory surgery (AS) for breast pathology (BP) has increased. The objective of this study is to analyse a group of patients treated surgically for breast pathology in order to evaluate its quality and security in a MAS setting in 2017. MethodsA retrospective review of all patients undergoing breast surgery was conducted within an AS programme from January to December 2017 in Consorcio Hospital General Universitario of Valencia (CHGUV). The number of patients, exclusion reasons, the type of surgical procedures, the evolution of substitution rate (SI), the rate and the causes of conversion to admission, the post-operatory complications, the motives of not including in the ambulatory program and the satisfaction rate of the patients operated with ambulatory surgery have been studied. This has been compared with a 2013 group. ResultsIn 2017, 396 procedures for BP were performed. 170 operations were carried out for benign and 226 for malignant. The SI for the global mammary pathology is 72.8%. The SI for benign pathology was 93.4%. The SI for malignant pathology was 57.2%, which has increased in the last years from 45.4% in 2013. The index of unexpected admission (TI) of the malignant pathology was 14.1%, while the TI in the benign pathology was 0.6%. Patients hospitalized for malignant pathology presented higher complications (17%) than ambulatory ones (8.5%) and benign (6.5%). ConclusionsAt the CHGUV, the SR has steadily increased in malignant pathologies. The unexpected hospitalization rate is determined by perioperative sentinel lymph node biopsy results. AS for the treatment of mammary pathology is efficient and safe.

Total intravenous anaesthesia in ambulatory care.

The purpose of this article is to review the use of total intravenous anaesthesia (TIVA) in ambulatory care. The number of ambulatory surgery cases is likely to increase in coming years. Recent meta-analyses suggest that TIVA offers decreased postoperative nausea and vomiting (PONV) and decreased pain scores in the postanaesthesia care unit (PACU) in day case/ambulatory surgery patients when compared with volatile anaesthesia. Particular improvements have also been shown in endoscopic nasal surgery in terms of decreased blood loss. TIVA consistently scores higher than volatile techniques in patient satisfaction surveys. Surveys of anesthetists suggest that TIVA is not in widespread use. This may be because of the perceived lack of training or confidence in the technique, therefore, recent internationally agreed guidelines aimed at formalizing its practice are welcome. There is also some recent evidence to suggest that intraoperative dexmedetomidine is superior to remifentanil with respect to postoperative pain and speed of recovery, and that intraoperative lignocaine infusion may reduce chronic pain incidence in breast surgery. Review of recent evidence of TIVA's use in ambulatory surgery and summary of new international guidelines on its use.

Cirugía mayor ambulatoria en patología mamaria

IntroductionThe use of ambulatory surgery (AS) for breast pathology (BP) has increased. The objective of this study is to analyse a group of patients treated surgically for breast pathology in order to evaluate its quality and security in a MAS setting in 2017. MethodsA retrospective review of all patients undergoing breast surgery was conducted within an AS programme from January to December 2017 in Consorcio Hospital General Universitario of Valencia (CHGUV). The study analysed the number of patients, exclusion reasons, type of surgical procedures, evolution of substitution rate (SR), rate and causes of conversion to admission, postoperative complications, motives for not being included in the ambulatory programme and the satisfaction rate of the patients treated with ambulatory surgery. This has been compared with a 2013 group. ResultsIn 2017, 396 procedures for BP were performed: 170 for benign and 226 for malignant disease. The SR for the global mammary pathology was 72.8%. The SR for benign pathology was 93.4% and the SR for malignant pathology was 57.2%, which has increased in recent years from 45.4% in 2013. The unexpected hospitalization rate (HR) of malignant pathologies was 14.1%, while the HR in benign pathologies was 0.6%. Patients hospitalized for malignant pathologies presented higher complications (17%) than ambulatory patients (8.5%) and benign pathologies (6.5%). ConclusionsAt the CHGUV, the SR has steadily increased in malignant pathologies. The unexpected hospitalization rate is determined by perioperative sentinel lymph node biopsy results. AS for the treatment of mammary pathology is efficient and safe.

Improving access to health services in Canada.

The Commonwealth Fund 2017 report ranked Canada's healthcare system low in access to care and last among all 11 counties studied in terms of timeliness of care. While long wait times for certain elective surgical procedures appear to be emblematic of Canadian Medicare, they are not inevitable. Wait times could be improved by focusing on public awareness and measurement of wait times and improving the appropriateness, efficiency (eg, with implementation of single-entry models for surgical referrals and greater use of ambulatory surgery), and productivity of surgical care (eg, by activity-based funding for surgical procedures and by reducing the cost of perioperative care). Ideas on how physician leaders can build on recent accomplishments are provided.

To strengthen the clinical study of ambulatory surgery anesthesia and improve the quality of ambulatory surgery

Ambulatory surgery is widely practiced in developed countries Since it was first proposed by Dr. James Nicoll. There are significant differences in anesthesia management between ambulatory surgery and hospital surgery. With the development of minimally invasive surgical and anaesthetic techniques, short-acting anesthetics, the use of ambulatory surgery has grown rapidly. Anesthesiologist is a necessary condition for the safety of perioperative patients and the implementation of ambulatory surgery. Anesthesiologist participates in preoperative evaluation and choice of patients, intraoperative anesthesia, safe discharge after operation, as well as the management of postoperative pain and complications in the perioperative period. For successful ambulatory anesthesia, the anesthesiologist must consider various factors relating to the patient and surgery. Patient selection is a particularly important factor. Appropriate surgical and anesthetic techniques should be used to minimize postoperative complications, especially postoperative pain, nausea, and vomiting.It has become increasingly important to identify patients at risk of perioperative complications and to use appropriate methods to decrease these risks. Future studies should be focus on data derived from ambulatory surgery patients and prospective, randomized, double-blind studies in a large population of patients in order to first identify the patient at risk and the quality system of ambulatory surgery anesthesia, subsequently to use drugs and techniques that reduce these perioperative risks and perioperative complications, allow quick recovery from anesthesia and improve the quality of ambulatory surgery. Key words: Ambulatory surgery; Anesthesia; Pain, postoperative; Postoperative nausea and vomiting

Reducing Hospital Utilization and Related Expenses at the Community Level

The reduction of health care expenses continues to be a major challenge for the economy and society of the United States and other nations. This study focused on a major source of health care expenses, inpatient hospitals, at the community level. It was based on the assumption that fewer inpatient hospital admissions per population contribute to lower health care costs. The study demonstrated that the hospitals of Syracuse, New York have generated fewer inpatient admissions and discharges than those of other New York State metropolitan areas per population. It suggested that the application of utilization rates for inpatient hospitalization in Syracuse to some other New York State areas could result in substantial savings. Between 2016 and 2017, the hospital discharge rates in Syracuse were 1.6 - 3.1 percentage points lower than those of Albany, 2.2 - 5.0 percentage points lower than those of Rochester, 4.1 - 4.9 lower than those of New York City, 5.4 - 8.2 percentage points lower than those of Buffalo, and 17.2 - 18.3 percentage points lower than those of Utica. The study suggested that the conservative hospitalization rates in Syracuse were developed and sustained over long periods of time through the use of ambulatory surgery, reduction of admissions through hospital emergency departments, and limitation of the inpatient bed supply. This was a lengthy process that resulted in a conservative hospital admission pattern. The study demonstrated, more recently, that specific programs such as the reduction of inpatient hospital readmissions and hospital lengths of stay have supported additional reductions of hospital and related utilization in Syracuse.

Anesthesia for ambulatory surgery.

Ambulatory anesthesia allows quick recovery from anesthesia, leading to an early discharge and rapid resumption of daily activities, which can be of great benefit to patients, healthcare providers, third-party payers, and hospitals. Recently, with the development of minimally invasive surgical techniques and short-acting anesthetics, the use of ambulatory surgery has grown rapidly. Additionally, as the indications for ambulatory surgery have widened, the surgical methods have become more complex and the number of comorbidities has increased. For successful and safe ambulatory anesthesia, the anesthesiologist must consider various factors relating to the patient. Among them, appropriate selection of patients and surgical and anesthetic methods, as well as postoperative management, should be considered simultaneously. Patient selection is a particularly important factor. Appropriate surgical and anesthetic techniques should be used to minimize postoperative complications, especially postoperative pain, nausea, and vomiting. Patients and their caregivers should be fully informed of specific care guidelines and appropriate responses to emergency situations on discharge from the hospital. During this process, close communication between patients and medical staff, as well as postoperative follow-up appointments, should be ensured. In summary, safe and convenient methods to ensure the patient's return to function and recovery are necessary.

An update on pain management for elderly patients undergoing ambulatory surgery

The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting. Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h. The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.

Intrathecal anaesthesia for day-case knee arthroscopy 2

Sahni et al. make very sensible points about the use of spinal anaesthesia for day-case knee arthroscopy 1, in light of Ambrosoli et al.'s paper 2. As a past President of Regional Anaesthesia UK, I am very keen to promote the use of regional anaesthesia. However, I do not promote regional anaesthesia where I feel that the risk/benefit is, in general, not in favour of the technique. Most patients having day-case knee arthroscopy are young and fit. They present a minimal risk for general anaesthesia and local anaesthetic infiltration into the joint, which results in excellent postoperative analgesia and rapid uncomplicated discharge from hospital. The alternative of having two needles, one in the hand and one in the back, with the associated risks of painful insertion, intra-operative discomfort or even pain (because of the low dose or short acting techniques required), postdural puncture headache, falls, urinary retention, hypotension, neuropraxia, paralysis and even cardiac arrest and death, does not bear rational comparison, other than in exceptional circumstances. For these reasons, I would not consent for a spinal anaesthetic for day case knee arthroscopy myself, or a peripheral regional anaesthesia technique, and I would therefore be surprised if more than a very few properly informed, rational ASA 1/2 patients would do so either. The facts that so many patients do consent for these techniques as described in the numerous publications, and do so routinely in many institutions, makes me question the validity of the consent processes employed. There are reputably financial advantages in promoting theatre efficiency, but even these are questionable. Spinal anaesthesia has a 5% failure rate. This means that up to 1 in 20 patients will either have a prolonged spinal induction followed by conversion to general anaesthesia, or intra-operative conversion to general anaesthesia. Every time this happens, all the efficiency advantages are lost. General anaesthesia fails far less frequently in this patient group and induction takes < 5 min. The fact that patients receiving general anaesthesia spend a few more minutes in recovery is irrelevant to theatre turnover, as this time is not a limiting factor. Even if there are financial advantages, for example by using a block room to get round the former problems, I have grave doubts that this justifies the means. Spinal anaesthesia is a very useful technique and the indications for its use in ambulatory surgery have increased hugely with newer shorter-acting agents. This has undoubtedly allowed many more patients to benefit from day surgery and there will still be several fit young patients who will choose it, even when rational and fully informed. However, it is inappropriate to use it indiscriminately for the majority, just as it is unreasonable to use any single anaesthetic technique for everyone. Patients must be given a fully informed choice of the options available and that choice must be respected.

Anesthesia for the elderly outpatient.

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly patients will assume increased importance. Increasing evidence supports the expanded use of ambulatory surgery for managing elderly patients undergoing elective surgery procedures. This review article describes the demographics of ambulatory surgery in the elderly population. This review article describes the effects of aging on the responses of geriatric patients to anesthetic and analgesic drugs used during ambulatory surgery. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative side-effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. Finally, we discuss the future challenges related to the continued expansion of ambulatory surgery practice in this growing segment of our surgical population. The role of anesthesiologists as perioperative physicians is of critical importance for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. Providing high-quality, evidence-based anesthetic and analgesic care for elderly patients undergoing elective operations on an ambulatory basis will assume greater importance in the future.

Postoperative impact of regular tobacco use, smoking or snuffing, a prospective multi‐center study

The aim was to study the effects of different tobacco administration routes on pain and post-operative nausea and vomiting (PONV), following three common day surgical procedures: cosmetic breast augmentation (CBA), inguinal hernia repair (IHR) and arthroscopic procedures (AS). We have prospectively investigated the effects of regular tobacco use in ambulatory surgery. The 355 allocated patients were followed during recovery and the first day at home. Thirty-two percent of the patients used tobacco regularly, 33% of CBA, 27% of IHR and 34% of AS. Pain was well controlled in the post-anesthesia care unit at rest; during ambulation, 37% of all patients reported VAS>3. Tobacco use had no impact on early post-operative pain. Post-operative nausea was experienced by 30% of patients during recovery while in hospital. On day 1, 14% experienced nausea. We found a significant reduction of PONV among tobacco users (smoking and/or snuffing). Smoking or snuffing reduced the risk of PONV by nearly 50% in both genders on the day of surgery and at the first day at home. The reduction of PONV was equal, regardless of tobacco administration routes. We found that regular use of tobacco, both by smoking and snuffing, had a significant effect on PONV during the early post-operative period. Non-tobacco users undergoing breast surgery were found to have the highest risk for PONV. We could not see any influence of nicotine use on post-operative pain. Thus, it seems of value to identify regular tobacco use, not only smoking, as a part of the pre-operative risk assessment.

Proyecto nacional para la gestión clínica de procesos asistenciales.Tratamiento quirúrgico de la hernia inguinal

The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators.To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientific-technical quality, efficiency, effectiveness, and patient satisfaction.A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review.Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staffs kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks.Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tension-free procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.

Restricted Spinal Anaesthesia for Ambulatory Surgery: A Pilot Study

KUUSNIEMI, K. S.; PIHLAJAMÄKI, K. K.; IRJALA, J. K.; JAAKKOLA, P. W.; PITKÄNEN, M. T.; KORKEILA, J. E. Author Information

Adenotonsillectomy: day-case procedure

The use of ambulatory surgery for adenotonsillectomy is becoming a well-established procedure. An audit analysis of this procedure, on the basis of no overnight hospital stay, is reported from the ENT department at the Royal Lancaster Infirmary (RLI). Patients, who had their surgery performed and were discharged from the hospital on the same day, had no more complications than those who were hospitalised for 24 hour post-operatively. Reactionary haemorrhage was not recorded in any of the 30 patients involved. Three patients (10%) needed provision for overnight hospital stay after the operation, because of nausea and vomiting in one patient, severe dysphagia in another and the insistence of the third patient to stay in as he liked the food and the play facilities on the ward. Suggestions are made for patient election and the determining factors for safe day-case adenotonsillectomy.

Modificationsto the postanesthesia score for use in ambulatory surgery

The Aldrete Score has withstood the changes in anesthesia and surgical care that have developed in the past three decades. Nevertheless, it is imperative that (1) a modification is made to incorporate the most effective monitor of the respiratory and hemodynamic functions, e.g., pulse oximetry; and (2) the five indices previously used be expanded by incorporating five more indices including dressing, pain, ambulation, fasting/feeding, and urine output to evaluate patients undergoing ambulatory surgery and anesthesia. A patient's recovery from anesthesia and surgery, using 10 indices graded 0, 1, or 2, would provide criteria for street fitness and discharge to home when the patient reaches a postanesthesia recovery score of 18 or higher.

Recovery Pattern and Home-Readiness After Ambulatory Surgery

Despite increased use of ambulatory surgery, few data exist regarding patient recovery patterns and home-readiness. We prospectively identified the pattern of home-readiness, the persistent symptoms after surgery, and the factors that delay discharge after home-readiness criteria are satisfied. Five hundred patients were scored by the same investigator using the Postanesthetic Discharge Scoring System (PADSS) every 30 min, commencing 30 min after surgery, until the PADSS score was > or = 9. The same investigator telephoned each patient 24 h after discharge to administer a standardized questionnaire so that postoperative symptoms could be identified. Eighty-two percent of patients were discharged 2 h and 95.6% 3 h after surgery. These patients could have been discharged earlier. After home-readiness criteria were satisfied, some patients had delayed discharge because of the unavailability of immediate escorts or the recurrence of pain. Persistent symptoms delaying discharge occurred in 4.4% of patients. Patients who underwent certain ambulatory surgical procedures, such as laparoscopy or orthopedic and general surgery, had a sixfold increased risk of developing persistent symptoms in the ambulatory surgery unit. The time to home-readiness was 2.5-fold longer and the incidence of 24-h postoperative symptoms, two- to eightfold higher in the group with persistent symptoms in the ambulatory surgery unit. In summary, periodic objective evaluation of home-readiness revealed that the majority of patients would achieve a satisfactory score on or before 2 h after surgery. The time to home-readiness by objective evaluation correlated with the type of surgery. Most delays after satisfactory home-readiness scores were reached were due to nonmedical reasons.(ABSTRACT TRUNCATED AT 250 WORDS)