A recent survey of anesthesiologists across the United States found a lack of consensus on appropriate patient selection criteria at ambulatory surgery centers (ASCs).
The study’s authors said the survey results call attention to an urgent need to obtain a consensus on evidence-based inclusion and exclusion criteria for these facilities.
Researchers at the University of Nebraska Medical Center sent a survey to approximately 13,000 anesthesiologists in the United States who primarily practice in ASCs, receiving responses from about 1,200 (9%). Respondents answered questions regarding patient selection criteria with the answers “yes,” “no” or “no defined policy.” Patient factors addressed included ASA physical status, pregnancy and body mass index (BMI), as well as a host of comorbidities including obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), congestive heart failure and diabetes mellitus.
Presenting at this year’s Society for Ambulatory Anesthesia annual meeting (abstract 1838), Nicholas Heiser, MD, the director of anesthesia at Nebraska Medicine’s Fritch Surgery Center, in Omaha, and Allyson Hascall, MD, the director of ambulatory anesthesiology at Nebraska Medicine–Bellevue, said the findings were in-line with their expectations. “The reason this came about is that we were setting up an ASC here at Nebraska Medicine, and in the process, we had to decide on which patients we would allow to have surgery here,” Dr. Heiser said. “Initially we thought to allow all ASA I and II patients, but then we realized we would have to look at allowing ASA III patients to have any significant volume and take pressure off of our main campus.
“We wanted to see if there was a consensus but just a lack of published data,” Dr. Hascall elaborated. “Or if there did turn out to be a lot of variability, whether there were patterns we could identify that explained why some centers allow patients with certain risk factors, while others don’t.
“But we didn’t find those kinds of differences,” she said. “For instance, we expected criteria might tend to be looser at centers with overnight capacity, or at centers attached to an ambulatory center, as opposed to freestanding surgery centers. But we found no significant differences in that regard, which reinforces the idea that there’s a great deal of variability in patient inclusion/exclusion criteria at ASCs, regardless of setting.”
Lack of Consensus Not Surprising, and Not Good
Commenting on the findings, Wanda Chin, MD, the medical director of the ambulatory care center’s ophthalmology and otolaryngology suite at NYU School of Medicine, in New York City, said the report mirrored her own experience.
“I am not surprised at all at the findings from this study. I had the same experience when I was setting up the ambulatory surgery center where I am currently working,” said Dr. Chin, who was not involved in the study. “We wanted to establish patient criteria for our unit that chose patients carefully to optimize the patient experience without increasing the risk for transfer or escalation of care. But instead of finding clear guidelines in a central location, I had to search various societal recommendations from ACS [American College of Surgeons], AAP [American Academy of Pediatrics] and ASA, as well as polling my own colleagues at different health centers for their experiences and recommendations.
“The lack of consensus means that we might not always be doing what’s best for the patient,” she added. “Some centers may be pushing the envelope by doing riskier patients and potentially putting those patients at higher risk for poor outcomes, while others might be too conservative and limiting patients’ access to ambulatory surgery centers, and therefore access to timely procedures, by having too narrow patient selection criteria.
“I am sure that a lot of protocols are adapted to overall experience of the anesthesia and surgical teams, but then it becomes of question of practicing medicine anecdotally or using evidence-based practices.”
Echoing this sentiment, Drs. Heiser and Hascall said the first step toward evidence-based criteria is gathering evidence.
“We’ve been analyzing our own data at our two ambulatory centers that have been open for a couple years now,” Dr. Hascall said. “We’ve been looking at which comorbidities and types of adverse events have played a role in unexpected admissions. We’ve tweaked our own criteria based on trends we’ve noticed, but will need to further analyze this data before it can be shared.”
Dr. Heiser said this issue will only continue to move to the forefront for anesthesiologists practicing at ASCs.
“Due to advances in both surgical and anesthetic techniques, in addition to the economic advantages associated with ambulatory surgery, we are seeing an ever-increasing number of cases being done in the outpatient setting,” he said. “Simultaneously, the general population is increasingly obese, elderly, among other trends that lead to an increase in patient comorbidities. Anesthesiologists will be tasked with being the gatekeepers with respect to determining who is and who is not safe for outpatient surgery. We believe this to be a pressing issue that requires the attention of our profession.”