Surgeons may push anesthesia providers to participate in inappropriate or ill-fitting procedures at ambulatory surgery centers (ASCs), which is why it’s important to push back based on evidence-based practices to boost quality and positive outcomes.
“We should be the gatekeepers of patients coming to ASCs so we can be the gatekeepers of outcomes, too,” said Girish Joshi, MD, professor of anesthesiology and pain management at the University of Texas Southwestern Medical School, in Dallas, and past president of the Society for Ambulatory Anesthesia (SAMBA). Dr. Joshi spoke about patient selection in the ambulatory surgery setting at “Driving Change in Ambulatory Anesthesia,” a joint meeting held by SAMBA and the American Society of Anesthesiologists (ASA).
“One of the major factors we need to focus on now is patient selection,” he said. “And we need to know what the evidence says.”
For instance, a study that analyzed outpatients undergoing total knee arthroplasty found that rehospitalization was lower in patients who are younger and have less comorbidity (J Surg Orthop Adv 2014;23:2-8). Rehospitalization risk increased in those with existing comorbidities, especially a history of heart failure, and in older patients and those not receiving a femoral nerve block.
“We [anesthesiologists] are the ones facing these complex patient populations undergoing complex patient procedures,” Dr. Joshi said. “You can see here how patient selection is critical in improving perioperative outcomes.”
Data Are There To Be Tracked
When tracking data, anesthesiologists and their facilities should monitor several factors, including delayed discharge home, patient/family dissatisfaction, increased post-discharge complications, unplanned hospital admissions and unplanned readmissions. In particular, unplanned admission and readmission statistics can be valuable because they are documented in studies and can be used for comparative purposes. States such as New York, California and Florida have outpatient and inpatient databases that can be used to track data across medical record numbers, and present valuable preliminary information about unplanned admissions and readmissions.
In addition, anesthesiologists should consider factors that play into the procedures, such as surgical type, anesthetic type (i.e., local/regional vs. general anesthesia), the patient’s preoperative physical health, ASA physical status, the type of surgical facility (hospital outpatient department, ASC or office-based environment) and social considerations, such as caregiver availability. This last factor is becoming increasingly important, Dr. Joshi noted.
“We are moving the burden of care from the hospital to the patient and family,” he said. “Once the patients go home, who takes care of them? Must a family member take time off from work?”
Still under investigation are how important patient characteristics such as age, ASA physical status, obesity, difficult airway, cardiac disease and kidney disease are in influencing outpatient outcomes, Dr. Joshi added. For instance, the ASA physical status classification system can be subjective, particularly at level III. In addition, age alone may not predict suitability for surgery, although several studies have shown that patients older than 80 years face increased risks, especially with post-discharge issues such as supervision, equilibrium and social reintegration.
“At the same time, elderly patients benefit from ambulatory procedures because it allows them to recover in a home environment with minimal disruption to the daily routine,” Dr. Joshi said. “An avoidance of hospitalization leads to a reduction in respiratory events, sleep deprivation and other post-discharge complications.”
Most importantly, anesthesiologists must remember to look at comorbidities in concert, not in isolation. Obesity or body mass index alone may not predict suitability for surgery, but associated sleep apnea and medication use may, Dr. Joshi said. Anesthesiologists may find it helpful to use a tool such as those available at SurgicalRiskCalculator.com.
Similarly, heart failure patients often have higher readmission rates. The predictors often include unstable angina, myocardial infarction within 30 days, a high-grade atrioventricular block, arrhythmia, aortic or mitral stenosis, diabetes, renal insufficiency and cerebrovascular disease. Heart failure and atrial fibrillation are often the biggest predictive factors for mortality and readmission. Patients with heart failure or atrial fibrillation undergoing minor procedures incur a risk that is three times higher for complications. In general, heart failure and atrial fibrillation patients have a higher risk for postoperative mortality than coronary artery disease patients. A recent onset of atrial fibrillation, in particular, increases morbidity and mortality.
“The tak e-home message from all of these studies is that we have to be careful with new-onset atrial fibrillation,” Dr. Joshi said. “The problem doesn’t necessarily occur on the day of surgery, but several days after surgery.”
Current research is still determining the best course of action for these patients. In general, known atrial fibrillation cases with a controlled heart rate and anticoagulant regimen are safe to proceed to surgery. New-onset cases, however, should likely be postponed unless the procedure is more benign, such as bowel preparation for colonoscopy.
Anesthesiologists also should carefully assess patients with stents, particularly those requiring general anesthesia. There have been many changes in recent years in the drug types and materials that are used in stents. A multicenter prospective study (Circ Cardiovasc Qual Outcomes 2016;9:39-47) examined a 40,000-patient registry to study the epidemiology and outcomes from surgery in patients with different stent types. Older drug-eluting stents (DES) were associated with a higher risk for adverse events at any time point, but especially within the first year. Those with newer DES showed similar safety to bare-metal stents, particularly after the first six months.
“We need to identify these comorbidities during preoperative assessments and develop clinical pathways to improve our current selection process,” Dr. Joshi said. “Patient selection is a complex and dynamic process, and it’s time we start looking at our patients earlier.”