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136-150-Practice Management/Rehabilitation I
Wednesday, Mar 12, 2014, 9:48 AM - 9:54 AM
The Safety of Outpatient Hand and Upper Extremity Surgery - A Statistical Review of Complications in 28,737 Cases
+Quality Improvement (Practice Mgmt)
Outcomes; Research / Clinical; Miscellaneous
, MD, Columbus, Ohio
Joseph E. Imbriglia
, MD, Wexford, Pennsylvania
INTRODUCTION: As the cost of medicine increases and the effectiveness of regional anesthesia improves, there has been a large increase in the number of procedures being done on an outpatient basis. It is estimated that over 70% of all surgical procedures are done in outpatient surgery centers. Despite the rapid growth in the number of outpatient surgical procedures being performed, there remains a paucity of literature on the subject. The purpose of our study was to determine the safety and rate of complications in outpatient hand and upper extremity surgery. We hypothesized that hand and upper extremity surgery was safe to perform in the outpatient setting.
METHODS: A retrospective review of cases at a single ambulatory surgery center over an 11-year period was performed. A total of 28,737 procedures were performed and included in our analysis. Procedures canceled in the pre-operative holding area (101 total) were not counted. Adverse events were defined as events causing harm to a patient or leading to additional treatment. Using state reportable adverse events criteria as a guideline, we broke these into seven main categories; infection, post-operative transfer to a hospital, wrong site surgery, retention of a foreign object, post-operative deep vein thrombosis, medication error and ‘other’ surgery-related complication. These adverse events were than analyzed to see if they lead to additional laboratory testing, hospital admission, return to the operating room, emergency department visits, physical or mental disability.
RESULTS: There were 65 reportable events for an overall complication rate of .23%. There were no mortalities. There were 21 infections (.07%), 11 of which required return to the operating suite for I&D; the remaining 10 were able to be treated solely with antibiotics. Seventeen (.06%) patients were transferred from the surgery center to the hospital post-operatively. The causes of these transfers consisted of cases of irregular heart rhythms, uncontrolled hypertension, low oxygen saturations, issues with pain control, post operative drowsiness and generalized seizures. In all of these cases the abnormality was detected in the operating suite or in the post anesthesia care unit, and the procedure was able to be safely completed. Twenty-one patients (.07%) were admitted to the hospital during the postoperative period, with poor pain control being the single largest cause. There were no cases of wrong site surgery or retained foreign bodies. There was one case (.003%) of post-operative pulmonary embolism after an open rotator cuff repair and acromioplasty. There was one medication error (.003%) that led to a rash and no further morbidity. There were four patients (.01%) who were taken back to the operative suite due to excessive bleeding or hematoma formation.
DISCUSSION AND CONCLUSION: Outpatient surgery centers can offer certain advantages over hospital based surgery leading to improved outcomes. By specializing in certain procedures, outpatient surgery centers can generate increased volume of these procedures; leading to increased staff familiarity, improved coordination and communication and fewer adverse events. Selection bias among patients operated on in an outpatient surgery center exists. This selection bias may lead to inflated patient outcome scores for outpatient surgery centers, but it still does not undermine the fact that with proper patient selection excellent outcomes can be achieved. Our study shows that with proper patient selection, a very low (.23%) complication rate can be achieved. Our review showing few complications, and no deaths, supports our view that hand and upper extremity surgery can be completed safely in the outpatient setting.
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