Pennsylvania Patient Safety Advisory Patient Screening and Assessment in Ambulatory Surgical Facilities ABSTRACT through a thorough preoperative screening and Ambulatory surgical facilities (ASFs) provide surgical assessment process is integral to providing safe patient care to patients who do not require hospital admission care in the ASF setting. This article will review medi- for their postoperative care. The popularity and growth cal conditions associated with increased perioperative of ASFs on a national scale has been attributed to an risk in the ASF setting. Risk reduction strategies are increased throughput of patients, reduction in staff presented to assist healthcare providers during the and surgical costs, and more personalized care. Along preadmission screening and preoperative assessment with the progression in volume, increasingly complex process, allowing early identification of patient procedures are being performed at ASFs. In addi- risk factors. tion, patients with more complex medical conditions are having surgery in the ASF setting. Thorough initial Authority Reports assessment of patients is required to identify any con- Reports submitted to the Authority from June 2004 cerns or disease processes, such as obstructive sleep to December 2008 were reviewed to identify poten- apnea or cardiovascular disease, which could poten- tial issues involving the preoperative screening or tially cause intraoperative or postoperative problems. assessment process. Of the 467 reports identified, From June 2004 to December 2008, the Pennsylvania 203 (43%) were reported as a Serious Event, most Patient Safety Authority received 467 reports related to often involving a complication requiring transfer to the preoperative screening or assessment process in an acute care setting. Two hundred thirty-four of the ASFs. Two hundred three of these reports indicate the total reports (50%) involved an elderly patient (older patient experienced harm. Risk factors are discussed, than 65). Twenty-three reports (5%) involved a pediat- as well as processes to ensure a thorough preopera- ric patient. tive screening and assessment of patients to identify risk factors. (Pa Patient Saf Advis 2009 Mar;6[1]:3-9.) One hundred twenty-four event reports (27%) submit- ted by ASFs indicated that screening and assessment processes required improvement. In 85 reports (18%), the patient had a condition, such as an arrhythmia Introduction or sleep apnea, which may have put the patient at Ambulatory surgical facilities (ASFs) are defined increased risk during the procedure, but no improve- by the Pennsylvania Health Care Facilities Act as a ment to the ASF’s screening and assessment process facility, not located upon the premises of a hospital, was recommended by the ASF. A variety of condi- which provides specialty or multispecialty outpatient tions were identified as potentially missed during surgical treatment.1 ASFs afford patients the oppor- the screening or assessment process; most frequently tunity to undergo surgical and procedural services in reported conditions include a cardiac history, arrhyth- a nonhospital setting. ASF popularity and volume mia, and poor respiratory status. The following are continues to grow, with the number of visits to free- examples of reports to the Authority in which the standing ASFs estimated to have increased nationally ASF indicated that the screening and/or assessment by 300% from 1996 to 2006.2 By 2006, an estimated process needed improvement: 57.1 million procedures were performed during 34.7 No patient prescreening was obtained prior to admis- million ambulatory surgery visits.2 The proliferation sion. After reviewing patient information, it was noted of ASFs has been attributed to a number of factors, the patient had a history of Clostridium difficile. including increased throughput of patients, reduc- Reviewed information with the anesthesiologist, and tion in staff and surgical costs, and more personalized then contacted the infection control nurse at the medi- care.3 Advances in anesthetic and surgical techniques cal center and was advised to cancel the procedure have also contributed to the growth in the number pending further data about the C. difficile [history]. and complexity of procedures in ASFs. Along with the greater complexity of procedures, there has been A patient with a history of drug abuse and smoking an increasing shift to performing procedures in ASFs had an upper endoscopy procedure. The procedure on patients who have more complex medical condi- was uneventful. At the end of the procedure the tions, including some that have been associated with patient went into laryngeal spasms that required intu- a heightened risk of adverse postoperative outcomes.2 bation and subsequent transfer to the hospital. Reports submitted to the Pennsylvania Patient Safety A pediatric patient presented for surgery with a body Authority indicate that medical conditions that are mass index (BMI) greater than 30 and has a history not detected during the preoperative screening and of asthma. The case was canceled by the anesthesiolo- assessment process may place patients at increased gist because, per the facility guidelines, morbidly obese risk for postoperative complications requiring hospital patients are not appropriate candidates to have a admission. Identification of these medical conditions procedure at the surgi-center. Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 3 Pennsylvania Patient Safety Advisory The patient did not report a prior history of a low adequacy of postdischarge observation.7,8 The ASA platelet count. The patient experienced postoperative Practice Guidelines include a scoring system that can bleeding and was transferred to the hospital. The be used to help determine the appropriateness of preoperative screening tool was reevaluated to include ambulatory surgery in patients with OSA.7 an assessment of prior or current blood dyscrasias. Cardiovascular Disease A patient admitted for surgery revealed a history of Cardiovascular adverse events are the most com- a recent myocardial infarction, congestive heart fail- mon adverse events occurring during ambulatory ure, and chronic obstructive pulmonary disease. The surgery.9 A broad range of cardiovascular disease, patient’s cardiologist was notified and determined from hypertension to severe valvular disease, may the patient was not an appropriate candidate for the be encountered.10 All patients require assessment of surgery center. the presence of symptoms that could suggest cardiac The preoperative interview determined that a patient disease with positive responses addressed according admitted for a cystoscopy was morbidly obese and had to risk assessment guidelines, such as the guideline a history of sleep apnea and congestive heart failure. by the American Heart Association (AHA) and the The preoperative screening process will be evaluated. American College of Cardiology (ACC). The AHA/ ACC guideline suggests that the cardiovascular evalu- Risk Factors ation of a patient undergoing noncardiac surgery In a previous Patient Safety Advisory article, the follow- should include an assessment of disease, functional ing factors identified in the literature that predict an status, and extent of surgery.10,11 A baseline cardiac increased risk for hospital admission or death follow- assessment is recommended for patients who have ing outpatient surgery were discussed:4 known coronary artery disease (CAD) or who have onset of signs or symptoms of CAD. Cardiac condi- ■ Patient age greater than 85 years tions that would necessitate evaluation and treatment ■ Peripheral vascular disease before noncardiac surgery include significant or new onset arrhythmias (e.g. new onset atrial fibrillation) ■ Operating room (OR) time greater than one hour and severe valvular disease.11 Patients with unstable ■ Malignancy coronary syndromes or decompensated heart failure ■ Positive HIV status are not considered appropriate candidates for proce- dures in the ambulatory surgery setting.12 ■ Heart disease Patients with cardiovascular disease require assess- ■ A requirement for general anesthesia ment for the presence of a pacemaker.10 An ASA Additional factors have been identified in the litera- practice advisory suggests that preoperative evaluation ture that may place a patient at risk in the ambulatory include determining the reason for the pacemaker, setting. These factors support the importance of iden- the exact type of pacemaker, the patient’s underlying tifying patient conditions to help avoid unfavorable rhythm, and medications.13 Ensuring patient safety outcomes related to surgery in ASFs, and they include and proper maintenance of the device includes a obstructive sleep apnea, cardiovascular disease, hyper- number of considerations, such as whether electro- active reactive airway disease, obesity, and end-stage magnetic interference is likely to occur and whether renal disease (ESRD). reprogramming of the device is required.13 Patients Obstructive Sleep Apnea also require assessment for the presence of an auto- matic implantable cardioverter defibrillator (ICD), Obstructive sleep apnea (OSA) is undiagnosed in which must be disabled before and reset after the an estimated 80% of affected patients, and the inci- procedure. The presence of a pacemaker or an ICD dence of presumed or diagnosed OSA is predicted requires the immediate availability of backup defi- to rise five- to tenfold during the next decade.5,6 The brillation or cardioversion equipment during the number of patients with OSA undergoing surgery in perioperative period.13 the ambulatory surgery setting may be expected to increase commensurate with these estimates; however, Hyperactive Reactive Airway Disease there are currently no corroborative studies. None- Literature related to pulmonary risk following ambu- theless, the American Association of Anesthesiology latory surgery is limited; however, hyperactive reactive (ASA) Practice Guidelines support the preoperative airway disease has been associated with an increased evaluation of patients for identification of OSA. risk for perioperative complications during outpatient According to ASA, comparative literature is insuf- surgery.14 Chronic obstructive pulmonary disease ficient to evaluate the impact of preprocedure OSA (COPD) and asthma both involve hyperreactivity status identification on outcome but does suggest of the airway. In a prospective study of preexisting that OSA characteristics may put a patient at risk for medical conditions in ambulatory surgery, patients perioperative airway management issues.7 The guide- with asthma and smokers were identified as having lines emphasize that patient selection for ambulatory increased risk for postoperative respiratory events.15 surgery depends on the severity of OSA, coexisting A four-center study of 6,914 patients undergoing diseases, invasiveness of surgery, type of anesthesia, ambulatory surgery demonstrated that patients anticipated postoperative opioid requirements, and with asthma and COPD had an increased risk of Page 4 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory bronchospasm.16 Asymptomatic patients with asthma general, the goal of the preoperative anesthesia assess- have been demonstrated to be at low risk for periop- ment is to identify and manage any risks associated erative complications; however, those with asthma with anesthesia and surgery as early in the process as symptoms have been shown to have a 50% incidence possible. However, the assessment process continues of postoperative respiratory complication compared up to the point of surgery. with less than 2% of those without symptoms.17 ASA Physical Status Classification System Smoking cessation for 30 days before surgery and delay of surgery for symptomatic asthma patients has Patient conditions that may increase risk during been recommended.18 procedures performed in the ASF setting have been Obesity identified. However, research has not yet provided clear-cut support to guide patient selection decisions Obesity is defined as an excess of adipose tissue for ASF procedures. Nonetheless, there are guidelines or body weight greater than or equal to 20% more used by anesthesia providers to evaluate a patient’s than ideal weight or a BMI of greater than or equal risk for anesthesia and surgery, such as the ASA to 30 kg/m-2.19 A recent study evaluated whether patient classification system, which is excerpted as obesity is an independent risk factor for unplanned follows:21 hospital admission or readmission among patients scheduled for ambulatory surgery. Two hundred ASA 1. A normal healthy patient. thirty-five obese patients scheduled for ambulatory ASA II. A patient with mild systemic disease. surgery in a tertiary medical center were matched to a normal-weight control by age, sex, surgical procedure, ASA III. A patient with severe systemic disease. type of anesthesia, and date of surgery. Comorbidity ASA IV. A patient with severe systemic disease that is a was more frequent in the obese cohort. The study constant threat to life. demonstrated that obesity is not a significant inde- ASA V. A moribund patient who is not expected to pendent risk factor for unplanned admission after survive without the operation. ambulatory surgery.20 While obesity alone has not been associated with unanticipated admission follow- ASA VI.A patient that has been declared brain-dead, ing ambulatory surgery, obesity has been associated whose organs will be removed for donor purposes. with an increase in intraoperative respiratory events. In Pennsylvania, surgery in an ASF is limited to In a cohort study of 17,638 patients, 2,779 had a BMI patients that are a physical status (PS)-1, PS-2, or PS-3. of greater than or equal to 30 kg/m-2. Obese patients Physical status is consistent with ASA physical status did not experience increased cardiovascular risk but classification.1 were at a significantly increased risk of intraoperative events, including desaturation and bronchospasm.17 The relationship of ASA classification to patient out- Lower respiratory events were more common in obese comes following ambulatory surgery has been studied; members of a 7,000 patient cohort undergoing ambu- however, conclusions are inconsistent. A retrospective latory surgery.18 case-controlled review of 896 ASA III patients dem- onstrated no significant difference in postoperative End-Stage Renal Disease complications within the first 24 hours of surgery in Patients with ESRD may have one or several other ASA III and ASA I and II patients.22 More than 75% diseases, including coronary artery disease, diabetes, of anesthesiologists surveyed in a Canadian study or congestive heart failure, which may place them at were willing to include ASA III patients in their selec- risk in the ambulatory surgical setting.10,12 A patient tion criteria. In the same study, more than 75% of with ESRD who undergoes an ambulatory surgical the respondents found ASA IV patients—including procedure requires a detailed history and physi- patients with high-grade angina pectoris and conges- cal assessment that includes consideration of their tive heart failure, sleep apnea with postoperative underlying disease processes. The most commonly narcotics, morbid obesity with comorbidities, and no performed procedure in patients with ESRD in the patient escort—to be unsuitable for ambulatory anes- ambulatory surgery setting is hemodialysis vascu- thesia.23 Other studies have not found a correlation lar access.12 Important concerns for these patients between ASA classification and outcome.5 Potential include fluid and electrolyte balance, particularly problems related to ASA IV patients undergoing sur- potassium.10,12 Timing of dialysis treatments is gery in the outpatient setting include the requirement important because the patient has relative volume for invasive monitoring, vasoactive drug infusions, depletion on the day of dialysis. Patients with ESRD and postoperative ventilator support.24 are at increased risk for bleeding due to platelet dysfunction. Anemia is also common in this patient Risk Classification population. Gastric emptying may be impaired, plac- The ASA classification system has been considered ing these patients at risk for aspiration.10,12 limited unless the risk of the surgical procedure is also considered.25 A risk classification system developed Risk Assessment at the Johns Hopkins University School of Medicine The preoperative assessment process starts when the proposed that risk of surgery is a function of several surgeon or the proceduralist schedules the case. In factors, including procedure invasiveness, associated Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 5 Pennsylvania Patient Safety Advisory blood loss and fluid shift, entry into specific body ■ Development of a care plan cavities, postoperative anatomic and physiologic ■ Documentation and communication of all infor- alterations, and need for postoperative intensive care mation per facility policy monitoring. Procedures are classified from category 1 (i.e., minimal risk, minimally invasive, with little or ASFs can also consider a number of strategies used no blood loss) to category 5 (i.e., major risk, highly successfully by other facilities to assist in the gathering invasive, with blood loss greater than 1,500 ml).25 of appropriate information during the preoperative The author notes that both the ASA classifications screening process. One Pennsylvania ASF with a low and the Johns Hopkins risk classification system are surgical cancellation rate (1%) uses a comprehensive consensus-driven. preadmission packet and automated preoperative phone calls in its presurgical process.27 When the Risk Reduction Strategies decision for surgery is made, the surgeon’s office Since current research has not provided clear-cut begins completing the packet, which includes the patient selection criteria, all ASFs need to ensure surgical consent, registration forms, health history that their patient selection and assessment criteria questionnaire, surgical admission form with orders, will adequately guide the preoperative screening and and patient instructions. The surgeon completes a assessment process. ASFs also need to ensure that reli- history and physical form or dictates it by means of able methods are implemented to ensure timely and the hospital’s transcription service. The anesthesiolo- adequate preoperative assessment. Such efforts will gists use consensus guidelines for preoperative testing help to provide a high level of care and produce the and have agreed on which response on the health his- best patient outcomes. tory will trigger a call to the patient’s physician before Preoperative Screening the surgery. A nurse practitioner reviews the flagged charts. The preadmission packets are processed by the The initial screening process is the first step in iden- hospital’s presurgical office. The following are ele- tifying any concerns or diseases processes that could ments of the process:27 potentially cause intra- or postoperative problems. The Association of periOperative Nurses (AORN) has ■ Secretaries send registration forms to the admis- issued a guidance statement for nursing preoperative sions department and file the rest of the packets by evaluation in the ambulatory surgery setting.26 An date of surgery, adding test results and other infor- initial element of a comprehensive preoperative policy mation when received. and procedure is careful preoperative screening, ■ Secretaries flag charts meeting criteria for further which can take place by telephone or in a face-to-face review. interview in a preadmission clinic setting. AORN recommends that a professional registered nurse (RN) ■ A nurse practitioner reviews the flagged charts conduct the preoperative screening to include assess- for anesthesia issues and orders tests or consults ment of the following:26 as needed. ■ A baseline physical assessment ■ Two days or more before surgery, secretaries begin assembling the chart. A worksheet on the front ■ Allergies and sensitivities tracks information. Secretaries follow up on miss- ■ Signs of abuse or neglect ing information. ■ Cultural, emotional, and socioeconomic assessment ■ On the day before surgery, an RN reviews the ■ Pain assessment charts and completes the preoperative checklist. ■ Medication history, including over-the-counter ■ The master surgical schedule notes any informa- medications, herbal medications and supplements, tion missing in red. and illicit drugs ■ Preanesthesia and nursing assessments are con- ■ Anesthetic history ducted on the day of surgery. ■ Results of radiological examinations and other pre- ■ Automated phone calls communicate preoperative operative testing information to patients. The calls cover preopera- ■ Discharge planning tive instructions, arrival times, and follow-up after surgery. ■ Referrals ■ Staff contact patients who were not reached by the ■ Identification of physical alterations that require automated call. additional equipment or supplies Another Pennsylvania ASF considers a close rela- ■ Preoperative teaching, including which medica- tionship with the primary care physician’s office an tions are to be taken or withheld before surgery, integral part of the preoperative screening process. preoperative shower and NPO (nils per os; nothing (The Patient Safety Authority learned of this screen- by mouth) requirements ing process through the ASF’s interaction with the ■ Informed consent and/or knowledge of the Authority’s Patient Safety Liaison Program.) The ASF procedure sends a history and physical form to the patient’s Page 6 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory primary care physician for completion. The form Preoperative Anesthesia Assessment elicits information about the patient’s medical history The preoperative anesthesia assessment is the part and current status that the ASF may not otherwise of the overall preoperative assessment process that obtain. One to two days before surgery, an RN calls identifies issues related to perioperative anesthesia the patient to provide preoperative instructions and management of the patient.28 ASA guidelines for completes a preadmission phone call form, which is ambulatory anesthesia endorse the following as a reviewed by anesthesia services. On the day of surgery baseline for preanesthesia patient care:29 a preoperative RN or licensed practical nurse sees ■ Preoperative instructions and preparation the patient and performs an assessment before the ■ An appropriate preanesthesia evaluation and exam- patient’s admission. If potential issues are identified, ination by an anesthesiologist or before anesthesia an anesthesia provider further screens the patient and surgery before admission. The patient is then admitted, and a ■ Verification of information and repeat of key ele- preoperative and anesthesia form is completed. ments of the evaluation if nonphysician personnel Preoperative Nursing Assessment are involved in the process After the preoperative screening is completed, the ■ Preoperative studies and consultation as medically preoperative nursing assessment is an opportunity indicated to verify information and obtain missed or forgotten ■ An anesthesia plan discussed with the patient information that may affect patient outcome. The AORN guidance statement recommends that an RN The following is a summary of the ASA Practice Advi- conduct a preoperative nursing assessment on the sory for Preanesthesia Evaluation recommendations, day of surgery.26 The data collection process involves which are based on a synthesis of opinion surveys, the patient and his or her significant other or guard- literature, and ASA task force consensus:30 ian. Information obtained during the preadmission ■ Content of the preanesthesia evaluation includes screening is verified. The guidance statement provides (1) readily accessible medical records; (2) patient an extensive list of information to be obtained and interview; (3) a directed preanesthesia examina- documented. Additional guidelines address commu- tion, which includes at a minimum, an assessment nication of the assessment to surgical team members, of the airway, lungs, and heart; (4) preoperative formulation of a nursing care plan, and development testing as indicated; and (5) other consults as of a process for reporting and acting on abnormal appropriate. findings. The following interventions should be con- ■ Timing of the preanesthesia evaluation can be sidered in the assessment:26 guided by surgical invasiveness and severity of ■ Verification of the patient’s identity using two disease. identifiers ■ Routine preoperative tests, which include tests to discover disease or disorder in an asymptomatic ■ Review of the preadmission screening/assessment patient, do not make an important contribution ■ A baseline physical assessment to anesthesia preoperative assessment and management. ■ Assessment of NPO status ■ Selective preoperative tests, ordered after consid- — Hypothermia assessment and management eration of information from the medical record, — Pain scale assessment patient interviews, physical examination, and type or invasiveness of the procedure, may assist in pre- ■ Identification of the presence of an advanced operative assessment and management. directive ■ Decision-making parameters for the type and tim- ■ Identification of the planned procedure by the ing of preoperative tests cannot be determined patient, significant other, or guardian based on the current literature. Specific tests and timing should be patient-specific. ■ Verification of site, side, or level, as applicable One Pennsylvania ASF’s approach to preanesthesia ■ Implementation of the prescribed surgical assessment is to conceptualize two goals. First, the preparation patient’s condition—whether it is optimal or as good ■ Assessment for prosthetic devices and implantable as possible at this point in time—is evaluated, con- electronic devices sidering all the elements of the history and physical, including the review of systems. The following are ■ Evaluation of the availability of safe transportation also components involved in meeting the first goal: home and aftercare ■ Have all indicated and abnormal labs, electro- ■ Obtaining contact information of the patient’s cardiogram, and other diagnostic studies been significant other addressed? ■ Is the patient on appropriate medical therapy? ■ Assessment of the patient’s understanding of pre- operative teaching and discharge planning ■ Is the current medical therapy effective? Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 7 Pennsylvania Patient Safety Advisory [online]. 2005 Sep [cited 2008 Nov 13]. Available from Accompanying Patient Safety Tools Internet: http://patientsafetyauthority.org/ADVISO- RIES/AdvisoryLibrary/2005/sep2(3)/Documents/ Visit the Pennsylvania Patient Safety Authority Web 06.pdf. site (http://www.patientsafetyauthority.org) to view or download the following resources based on 5. Young T, Skatrud J, Peppard PE. Risk factors for this article. obstructive sleep apnea in adults. JAMA 2004 Apr;291(16):2013-6. ■ “Health History,” a sample form that may be 6. den Herder C, Schmeck J, Appelboom DJ, et al. Risks sent to the primary care physician or the refer- of general anaesthesia in people with obstructive sleep ring physician for completion before the day of apnoea. BMJ 2004 Oct 23;329(7472): 955-9. surgery at an ambulatory surgery facility (ASF). 7. Gross JB, Bachenberg KL, Benumof JL, et al. Practice ■ “Nursing Preoperative Screening,” a sample guidelines for the perioperative management of patients form that may be used for nursing preadmis- with obstructive sleep apnea: a report by the American sion screening before the day of surgery at Society of Anesthesiologists Task Force on Perioperative an ASF. Management of patients with obstructive sleep apnea. Anesthesiology 2006 May;104(5):1081-93. 8. Joshi GP. Are patients with obstructive sleep apnea Determination of whether medical therapy is effective syndrome suitable for ambulatory surgery? ASA Newsl in patients with chronic disease is usually conducted [online]. 2006 Jan [cited 2008 Nov 14]. Available from by their primary care provider. In patients with Internet: http://www.asahq.org/Newsletters/2006/ 01-06/joshi01_06.html. multiple, serious, or complex medical problems, an appropriate medical specialist may be needed to deter- 9. Melloni C. Morbidity and mortality related to anesthe- mine optimization or make recommendations for sia outside the operating room. Minerva Anestesiol 2005 optimization of the patient’s condition before surgery. Jun;71(6):325-34. The second goal is to determine whether the planned 10. Mathews DM, Twersky RS. Adult clinical challenges. In: Twersky RS, Philip BK, eds. Handbook of ambulatory procedure and anesthesia are appropriate for the anesthesia. New York: Springer; 2008:78-9. patient. For example, a patient with an ischemic cardiomyopathy or with renal disease may be an 11. Fleisher LA, Beckman JA, Brown KA, et al. ACC/ appropriate candidate for an ASF procedure that is AHA 2007 guidelines on perioperative cardiovascular performed under minimal or moderate sedation but evaluation and care for noncardiac surgery: executive not for an ASF procedure that requires deep sedation summary: a report of the American College of Cardiol- ogy/American Heart Association Task Force on Practice or general anesthesia. It is also possible that outpa- Guidelines. Anesth Analg 2008 Mar;106(3):685-712. tient surgery is not appropriate for such a patient. 12. Helsley SE. Ambulatory anesthetic management of com- Conclusion mon diseases. Ch. 4. In: Steele SM, Neilsen KC, Klein As the popularity of ASFs continues to grow and SM, eds. Ambulatory anesthesia and perioperative analgesia. increasingly complex procedures are performed in the New York: McGraw Hill Professional; 2005:441-2. ASF setting, thorough screening and assessment and 13. American Society of Anesthesiologists. Practice advi- preparation of patients before ambulatory surgery sory for the perioperative management of patients with are essential to ensure optimal patient outcomes. cardiac rhythm management devices: pacemakers and Although the body of evidence to support that implantable cardioverter-defibrillators [online]. 2005 Jul certain comorbidities may make some patients less [cited 2008 Feb 23]. Available from Internet: http:// suitable for surgery in the ambulatory setting is not www.asahq.org/publicationsAndServices/ large, a number of patient comorbidities have been CRMDAdvisory.pdf. associated with increased risk of intraoperative and 14. Bryson GL, Chung F, Finegan B, et al. Patient selection postoperative complications. Consideration of these in ambulatory anesthesia—an evidence-based review: comorbidities during screening and assessment is an part I. Can J Anaesth 2004 Oct;51(8):768-81. important part of a thorough preoperative evaluation. 15. Chung F, Mezei G, Tong D. Pre-existing medical condi- Notes tions as prediction of adverse events in day-case surgery. 1. 28 Pa. Code § 551.3 [online]. [cited 25 Feb 2009] Avail- Br J Anaesth 1999 Aug;83(2):262-70. able from Internet: http://www.pacode.com/secure/ 16. Duncan PG, Cohen MM, Tweed WA, et al. The Cana- data/028/chapter551/s551.3.html. dian four-centre study of anaesthetic outcomes: III. Are 2. Cullen AJ, Hall MJ, Golosinskiy A. Ambulatory surgery anaesthetic complications predictable in day surgical in the United States, 2006. National Health Statistics practice? Can J Anaesth 1992 May;39(5 Pt 1):440-8. Reports. No. 11. Hyattsville (MD): National Center for 17. Warner DO, Warner MA, Barnes RD, et al. Periopera- Health Statistics; 2009. tive respiratory complications in patients with asthma. 3. Stierer T, Fleisher LA. Challenging patients in an Anesthesiology 1996 Sep;85(3):460-7. ambulatory setting. Anesthesiol Clin North America 2003 18. Møller AM, Villebro N, Pedersen T, et al. Effect of Jun;21(2):243-61, viii. preoperative smoking intervention on postoperative 4. Expecting the unexpected: ambulatory surgical facili- complications: a randomised clinical trial. Lancet 2002 ties and unanticipated care. PA PSRS Patient Saf Advis Jan 12;359(9301):114-7. Page 8 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory 19. Adams JP, Murphy PG. Obesity in anaesthesia and 25. Pasternak LR. Risk assessment in ambulatory sur- intensive care. Br J Anaesth 2000 Jul;85(1):91-108. gery: challenges and new trends. Can J Anaesth 2004 20. Hofer RE, Kai T, Decker PA, et al. Obesity as a risk Jun;51(6):R1-5. factor for unanticipated admissions after ambulatory 26. Association of periOperative Nurses (AORN). AORN surgery. Mayo Clin Proc 2008 Aug;83(8):908-16. guidance statement: preoperative patient care in the 21. American Society of Anesthesiologists (ASA). ASA physi- ambulatory surgery setting. AORN J 2005 Apr;81(4):871-8. cal status classification system [online]. [cited 2008 Dec 27. What works to smooth preop process? OR Manager 2007 26]. Available from Internet: http://www.asahq.org/ Feb;23(2):10-3. clinical/physicalstatus.htm. 22. Ansell GL, Montgomery JE. Outcome of ASA III 28. Pasternak LR. Preoperative screening for ambula- patients undergoing day case surgery. Br J Anaesth 2004 tory patients. Anesthesiol Clin North America 2003 Jan;92(1):71-4. Jun;21(2):229-42, vii. ? 23. Freidman Z, Chung F, Wong DT, et al. Ambula- 29. American Society of Anesthesiologists (ASA). Guidelines tory surgery adult patient selection criteria—a survey for ambulatory anesthesia and surgery [online]. 2008 of Canadian anesthesiologists. Can J Anaesth 2004 Oct 22 [cited 2008 Dec 21]. Available from Internet: May;51(5):437-43. http://www.asahq.org/publicationsAndServices/ standards/04.pdf. 24. Society for Ambulatory Anesthesia. Administration/ should outpatient surgery centers do ASA class IV 30. American Society of Anesthesiologists. Practice advisory patients? SAMBA Talks [discussion forum online]. [cited for preanesthesia evaluation: a report by the American 2008 Dec 23] Available from Internet: http://sambahq. Society of Anesthesiologists Task Force on Preanesthesia org/professional-info/da-3d-clas-iv.html. Evaluation. Anesthesiology 2002 Feb;96(2):485-96. ? Self-Assessment Questions The following questions about this article may be useful for internal education and assessment. You may use the following 4. A 76-year-old patient with end-stage renal disease and new- onset atrial fibrillation is scheduled for the placement of examples or come up with your own. a hemodialysis vascular access in an ambulatory surgical 1. Risk reduction strategies to help ensure timely and ade- facility (ASF). quate preoperative anesthesia assessment include all of the Which of the following statements is inaccurate about the following EXCEPT: preoperative assessment of this patient before surgery in an a. Conducting routine preoperative tests ambulatory surgical setting? b. Conducting a preanesthesia evaluation that is guided a. Important concerns for this patient include preop- by surgical invasiveness and severity of disease erative evaluation of fluid and electrolyte balance, c. Repeating key elements of the anesthesia evaluation particularly potassium. if nonphysician personnel are involved in the initial b. The patient’s new onset of atrial fibrillation is a car- assessment diac condition that may necessitate evaluation and d. Discussing the anesthesia plan with the patient treatment by a cardiologist before placement of a hemodialysis vascular access in an ASF. 2. Which of the following statements is inaccurate about pre- operative risk assessment in ambulatory surgery? c. The patient’s age is a factor identified in the literature that predicts an increased risk for hospital admission a. The relationship of the American Association of Anes- following surgery in an ASF. thesiology (ASA) classification to patient outcomes has d. The preoperative evaluation of this patient includes, in been studied but is inconclusive. consultation with the patient’s cardiologist as appropri- b. Procedure risk classification systems consider the risk ate, determination of the reason for the pacemaker, of surgery to be a function of surgical invasiveness, the exact type of pacemaker, the patient’s underlying associated blood loss and fluid shift, and the need for rhythm, and medications. postoperative intensive care monitoring. c. Potential problems related to ASA IV patients undergo- 5. A comprehensive preadmission screening of a patient ing surgery in the outpatient setting include the need before an ambulatory surgical procedure includes all of the for invasive monitoring, vasoactive drug infusions, and following EXCEPT: postoperative ventilator support. a. Medication history d. Routine preoperative tests make an important contri- b. Allergies bution to anesthesia assessment and management. c. Anesthetic history 3. All of the following are clinical conditions that have been d. Exercise tolerance test associated with an increased risk of adverse outcomes in the ambulatory surgical setting EXCEPT: a. Patient age greater than 85 years b. A BMI (body mass index) greater than 25 kg/m-2 c. Obstructive sleep apnea d. Asthma Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 9 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 1—March 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.