R E V I E W S & A N A LY S E S Survey of Ambulatory Surgical Facility Preoperative Screening Processes in Pennsylvania Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority In 2010, Pennsylvania ambulatory surgical facilities (ASFs) reported 3,648 events to the Pennsylvania Patient Safety Authority; 66% (n = 2,403) of these events were reported as “Incidents” and 34% (n = 1,245) of these events were reported as “Serious Events.” Of the reported serious events, 34% (n = 423 out of 1,245) indicated that the patient ABSTRACT was transferred from the ASF to an acute care hospital. ASFs also reported 335 cancel- The Pennsylvania Patient Safety Author- lations of procedures on the day of surgery in 2010. Transfers from an ASF to an acute ity developed and administered a care hospital may represent good patient care but may also be the result of insufficient statewide survey to inform its ambula- rigor in patient or procedure selection.1,2,3 Similarly, cancellations on the day of surgery tory surgical facility (ASF) collaboration may be an indicator that practice patterns or patient selection criteria are in need of that examines presurgical screening review. The Authority initiated a northeast Pennsylvania regional ASF collaboration in and assessment processes and the January 2012 to examine presurgical screening and assessment processes and the fre- frequency of ASF cancellations and quency of ASF transfers and cancellations. In order to understand the factors related to transfers. The results identified that transfers and cancellations, a statewide survey of ASF presurgical screening and assess- 37.4% of facilities have implemented ment practices and transfer and cancellation information was conducted. an electronic health record and 41.7% receive medical forms electronically. METHODS Secretaries and schedulers are the pri- The survey evaluated freestanding ASFs as defined by the Pennsylvania Department of mary contact person 11.7% of the time Health4 and was made up of 37 questions: for preoperative screening and 20.5% — 13 organizational characteristic questions of the time for preoperative instruc- tions. The 2010 ASF transfer rate was — 10 patient characteristic questions 1.16 per 1,000 completed procedures, — 7 history and physical questions and cardiac conditions were the most — 3 cancellation questions frequent reason for an ASF transfer. The — 2 preoperative screening questions 2010 ASF cancellation rate was 18.09 — 2 transfer questions per 1,000 completed procedures, and medical conditions were the most fre- The questions focused on ASF activities that occurred during the 2010 calendar year. quent reason for an ASF cancellation. Not all respondents answered all of the questions, so non-responses were removed The baseline ASF prescreening activi- from the analysis with the percentages calculated based on the actual responses for ties, transfer rates and reasons, and each question. The 10 patient characteristic questions focused on gender, insurance cancellation rates and reasons obtained status, and physical health status. Questions about patient gender mix and insurance in this survey provide direction for the status accounted for 7 of the 10 questions. Because response rates for the gender and Ambulatory Surgical Facility Preop- insurance status questions were less than 25%, which limited the reliability of this erative Prescreening and Assessment data, these questions were removed from the analysis. The unit of analysis was the Collaboration. (Pa Patient Saf Advis ASF facility. 2012 Mar;9[1]:18-22.) RESULTS Response Rate An e-mail invitation was sent to 260 Pennsylvania ASFs. Excluding 13 e-mails that were undeliverable, there were a total of 247 delivered invitations. The response rate was 46.5% (n = 115 out of 247). Organizational Characteristics Over half (63.5% [n = 73 out of 115]) of the responding ASFs are owned by physicians. The remaining ASFs are owned by hospitals or healthcare systems (16.5% [n = 19 out of 115]), corporations (11.3% [n = 13 out of 115]), and partnerships or joint ventures between physicians and hospitals (8.7% [n = 10 out of 115]). Page 18 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority Ninety-seven percent of the responding Class 1 patients were the most commonly The survey also evaluated the number ASFs are accredited, four ASFs are not treated group in 17% (n = 17 out of 102) of facilities that had an electronic health accredited, and two ASFs have accredita- of ASFs, Class 2 patients were the most record (EHR) and whether a facility tions with two different organizations. The commonly treated group of patients in receives any medical forms electronically. majority of ASFs, 66.9% (n = 77 out of 71% (n = 73 out of 102) of ASFs, and Fewer than half (37.4% [n = 43 out of 115), are accredited by the Accreditation Class 3 patients were the most commonly 115]) of ASFs have implemented an EHR Association for Ambulatory Health Care, treated group in 12% (n = 12 out of 102) and 41.7% (n = 48 out of 115) of ASFs 20.8% (n = 24 out of 115) are accredited of ASFs. receive medical forms electronically. by the Joint Commission, 9.5% (n = 11 See Table 2. out of 115) are accredited by the American History and Physical In assessing how ASFs received the H&P, Association for Accreditation of Ambula- The quality of systems and processes used EHR transmission was the fourth-most tory Surgical Facilities, and 0.9% (n = 1 to obtain a completed history and physical common method. Fifty-four percent (n = out of 115) is accredited by a magnet (H&P) for an ASF was evaluated. Three- 60 out of 112) of facilities indicate two or organization. ASF size, as indicated by quarters of ASF respondents (75.7% [n more means of receiving the H&P infor- the number of operating rooms and/or = 87 out of 115]), have a policy in place mation. See Table 3. procedure rooms, ranged from 1 to 20 requiring a completed H&P prior to the rooms per facility, with an average of 3.56 Out of 74 facilities that perform their actual day of surgery; the other 24.3% rooms per facility. Three facility responses own H&P, 95.9% (n = 71) rely heavily (n = 28 out of 115) of ASFs do not have were removed from the analysis because on information from the patient, family a policy in place requiring a completed these facilities opened in 2011; therefore, member, or caregiver; 47.3% (n = 35) H&P prior to the actual day of surgery. they did not match the 2010 survey time indicated that they obtain H&P informa- The time a completed H&P is received frame. The majority of responding facili- tion from medical records; 31.1% (n = 23) prior to the surgery date varied from one ties (59.3% [n = 64 out of 108]) identified noted that they obtain H&P information week to one month. ASFs completing themselves as providers of specialty surgi- from diagnostic tests; and 8.1% (n = 6) the H&P on the day of surgery reported cal or diagnostic services. The remaining indicated that they obtain H&P informa- that the time frame was inapplicable. See 40.7% (n = 44 out of 108) of facilities tion from a provider physical assessment Table 1. identified themselves as providers of gen- or phone call. eral surgical or diagnostic services. Ninety-nine percent (n = 83 out of 84) of Table 1. Actual Time Prior to Surgery Date to Having Completed History and Physical responding ASFs provide ongoing patient safety educational programs or activities FACILITY for their staff, and 42.3% (n = 33 out of TIME RESPONSES PERCENTAGE 78) of responding ASFs participated in a 1 to 7 days prior to surgery date 68 61.3% culture of safety survey. 8 to 14 days prior to surgery date 16 14.4% Patient Characteristics 15 to 21 days prior to surgery date 2 1.8% The Pennsylvania Department of Health 22 to 30 days prior to surgery date 11 9.9% classifies patients based on physical sta- No specified time frame 14 12.6% tus. A Class 1 patient has no organic, Total 111 100% physiologic, biochemical, metabolic, or psychiatric disturbance. 5 A Class 2 patient has a mild or moderate systemic distur- Table 2. Facility Use of Electronic Health Records (EHRs) and Facilities Sharing Information bance that is either controlled or has not Electronically changed in severity for some time. A Class ELECTRONIC ACTIVITY YES NO TOTAL 3 patient suffers from significant distur- Implemented an EHR system 43 72 115 bance, although the degree to which it limits the patient’s functioning or causes (37.4%) (62.6%) (100%) disability may not be quantifiable. ASFs Receive medical forms electronically 48 67 115 were asked to identify the class of patients (i.e., fax, electronic mail, EHR) from (41.7%) (58.3%) (100%) that they served the majority of the time. other office practices Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 19 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S ASFs were asked to identify which regular H&P, 60.4% (n = 67 out of 111) contact for preoperative screening at healthcare provider completed the H&P of facilities also require a separate history 12.6% (n = 14 out of 111) of facilities, fol- the majority of the time. According to form from the patient, family member, lowed by secretaries and ASF schedulers, the survey, surgeons complete the H&P or caregiver. who were noted as the primary patient 50.5% (n = 55 out of 109) of the time; Preoperative screening, including preoper- contact for preoperative screening at referring physicians 23.8% (n = 26 out ative testing, was another part of the H&P 11.7% (n = 13 out of 111) of responding of 109) of the time; non-surgeon physi- process to evaluate. For the survey, ASFs ASFs. The remaining 11.7% (n = 13 out cians 8.3% (n = 9 out of 109) of the time; identified the primary patient contacts of 111) of facilities do not have a primary nurse practitioners, certified registered for preoperative screening. Nurses are by patient contact for preoperative screening. nurse anesthetists (CRNAs), or physician far the primary patient contact for any assistants 7.3% (n = 8 out of 109) of the preoperative screening, serving in this role Cancellations time; primary care physicians 6.4% (n = 7 for 63.9% (n = 71 out of 111) of respond- Based on 56 facility responses, the ASF out of 109) of the time; and registered ing ASFs. Nurse practitioners, physician survey revealed a 2010 cancellation rate nurses and anesthesiologists 3.7% (n = 4 assistants, and surgical and non-surgical of 18.09 per 1,000 completed surgeries out of 109) of the time. In addition to the physician offices are the primary patient or procedures (95% CI: 17.5 to 18.68). The cancellation rates ranged from 0 to 144.22 cancellations per 1,000 completed Table 3. Methods of Delivering the History and Physical surgeries or procedures performed. There METHOD OF DELIVERY FACILITY RESPONSES PERCENTAGE* was great variation in the reported num- Faxed from provider 79 69.9% ber of cancellations. The range of ASF Delivered by patient, family member, 35 31.0% cancellations for 2010 was from 0 to 650 or caregiver cancellations. The average number of Mailed by provider 28 24.8% cancellations was 64.88, with a standard deviation of 127.66, median of 96.27, and Electronic health record transmission 23 20.4% mode of 5. Hand delivered 15 13.3% ASFs were asked to identify when the Electronic mail 13 11.5% majority of their same-day patient cancel- History and physical performed at 13 11.5% lations occurred: prior to admission, after the facility admission, or after anesthesia. In this Unidentified delivery method 6 5.3% survey, out of 100 facilities, 56% indi- cated that the majority of their same-day Total number of responding facilities 113 patient cancellations occurred prior to * Facilities could choose more than one item admission, 31% indicated the majority of their same-day cancellations occurred after Table 4. Ambulatory Surgical Facility Cancellations admission, 13% did not know when the MOST FREQUENT REASON FOR FACILITY majority of their same day cancellations ASF CANCELLATIONS RESPONSES PERCENTAGE occurred, and none indicated that the Medical 44 44% majority of their same day cancellation occurred after anesthesia. See Table 4 for Patient (e.g., no show, changed mind 27 27% the reasons for patient cancellations. about surgery) ASFs were asked who the primary patient Failure to follow protocol (e.g., incomplete 24 24% history and physical, failure to maintain contact was for any preoperative instruc- nothing by mouth status, failure to stop tions. Out of 112 facilities, 70% have a medications, no ride home) nurse as the primary contact; 20.5% have Other (e.g., unsuccessful completion of 5 5% a scheduler, secretary, or technician as the all conditions for the procedure, no one primary patient contact; and 8% designate main reason (i.e., multiple reasons), no the primary patient contact as a nurse cancellations, unsure, data unavailable) practitioner, CRNA, physician assistant, Total 100 100% clinical staff member, or non-ASF Page 20 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority physician. One facility indicated that they reason for an ASF transfer to a hospital. percentage (>75%) of missing data do not have a primary patient contact for Table 6 provides a breakdown of the facil- focused on the type of anesthesia. The preoperative instructions. ity-level reasons for transferring patients missing data prevented the analysis of to the hospital. these patient characteristics and their Transfers potential association with ASF transfers. ASF transfer rates were calculated using LIMITATIONS the 74 facility responses that provided Hospital-based ASFs were not included in CONCLUSIONS answers to the questions asking for the this survey, which limits the results to free- This survey of freestanding ASFs came total number of ASF transfers to the inpa- standing ASFs. Hospital-based ASFs may from facilities that were physician-owned, tient setting in 2010 and the total number have different presurgical screening and accredited by the American Association of completed surgeries and/or procedures assessment processes, as well as different for Ambulatory Health Care, and provid- in 2010. Responses such as “unknown” cancellation and transfer information and ers of patient safety education programs or “unavailable,” those using the percent- rates. Many of the ASF facilities indicated and activities. The results uncover varia- age of transfers rather than the number, that some of the information requested tion in how H&P information is obtained and responses that were inconsistent for this survey (e.g., number of male and and collected. Seventy percent of facilities (e.g., transfer rates greater than number female patients, number of patients with receive H&Ps by fax and 20.4% by EHR of completed surgeries or procedures) specific types of insurance coverage) was transmission. While less than half of the were removed from the calculations. The not routinely collected, which limited their ASFs have implemented an EHR system, transfer rate was 1.16 transfers per 1,000 ability to answer some of the questions. the number of ASFs transmitting informa- completed surgeries or procedures (95% The other set of questions with a high tion with an EHR is expected to rise as CI: 1.04 to 1.29). The 2010 ASF number of transfers range from 0 to 50 with a median of 2, mode Table 5. Comparison of Ambulatory Surgical Facility (ASF) Transfer Rates by Number of Medical Specialties of 0, and average of 4.35. These numbers were deemed to be statistically valid. ASF MEDICAL SPECIALTY TRANSFER RATE PER 1,000 COMPLETED Twenty facilities had no transfers in 2010, GROUPING SURGERIES AND/OR PROCEDURES and seven facilities had 11 or more trans- All ASF medical specialties 1.16 (95% CI: 1.04 to 1.29) fers in 2010. A detailed analysis of the combined (n = 74) transfers and facility organizational char- ASFs that offer 4 or fewer 0.75 (95% CI: 0.63 to 0.87) acteristics was performed and revealed medical specialties (n = 55) that the 20 facilities with no transfers ASFs that offer 5 or more 2.06 (95% CI: 1.76 to 2.36) were facilities that provided services for medical specialties (n = 19) four or fewer medical specialties. Six of the seven facilities with 11 or more transfers in 2010 were generalists that provided Table 6. Ambulatory Surgical Facility Transfers to Hospitals services for six or more medical special- MOST FREQUENT REASON FACILITY ties. ASF facilities were then divided into FOR TRANSFERS RESPONSES PERCENTAGE two groups based on the number of medi- Cardiac (e.g., arrhythmias, chest pain) 37 52.9% cal specialties they provided (i.e., one to four medical specialties and five or more Uncontrolled pain 11 15.7% medical specialties). Transfer rates were Unspecified surgical complications 6 8.6% recalculated for each group. See Table 5 Perforations 5 7.1% for a comparison of transfer rates based Respiratory 4 5.7% on medical specialty designation. Anesthesia difficulties 3 4.3% Facilities were asked to identify the most frequent reason their facility transferred Bleeding 2 2.9% their patients to a hospital setting. Car- Hypertension 1 1.4% diac conditions (e.g., arrhythmias, chest Procedural complication 1 1.4% pain), which 52.8% (n = 37 out of 70) of Total 70 100% facilities reported as the most frequent Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 21 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S more ASFs implement an EHR system. transfers and cancellations and will help ACKNOWLEDGMENTS The information provided in this survey guide the Authority’s ASF collaboration Denise Martindell, RN, JD, Pennsylvania Patient provides a starting point to address ASF in Pennsylvania’s northeast region. Safety Authority and Megan Shetterly, RN, MS, Pennsylvania Patient Safety Authority, contributed to the development of the ambulatory surgical facility survey. NOTES 1. Haeck PC, Swanson JA, Iverson RE, et al. patient. Curr Opin Anaesthesiol 2009 Dec; 4. 28 Pa. Code § 551.31 (1999). Also avail- Evidence-based patient safety advisory: 22(6):705-11. able: http://www.pacode.com/secure/ patient selection and procedures in ambu- 3. Fleisher LA, Pasternak RL, Lyles A. A data/028/chapter551/s551.31.html. latory surgery. Plast Reconstr Surg 2009 novel index of elevated risk of inpatient 5. 28 Pa. Code Ann. A § 551.3 (1999). Oct; 124(4 Suppl):6S-27S. hospital admission immediately following Also available: http://www.pacode. 2. Gupta A. Preoperative screening and risk outpatient surgery. Arch Surg 2007 Mar; com/secure/data/028/chapter551/ assessment in the ambulatory surgery 142(3):263-8. s551.3.html. Page 22 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 1—March 2012. 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