Outpatient criteria

[patriot6]

My group is attempting to establish criteria for patient selection at an outpatient, free standing surgical hospital. Currently, charts are reviewed preoperatively by us, but there’s a wide range of comfort in proceeding depending on patient comorbidities. It’s not uncommon that a patient is “cleared” by one partner reviewing the chart, only to be canceled by another on the DOS. Is anyone using RCRI scores for patient selection? Any other objective scoring systems that would provide safety and consistency to patient selection?

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[zizzer]

I would consider having a BMI cutoff, as well as not allowing severe cardiac valvular lesions, LVEF <40%, moderate or severe RV dysfunction or pulmonary hypertension, severe COPD, off the top of my head. Also, discretion based on airway exams. Some under the BMI cutoff may be those no neck difficult airway, severe OSA type patients. Consider criteria such as checking RCRI for who needs a stress test and a certain length of time for follow up TTE of HFrEF or moderate valvular lesions. Patients with CIEDs or CAD should have a cardiologist visit within a certain amount of time.

It seems like the key to this is that it's easy to follow and sent to the surgeons. You might as well include a list of medications patients should continue or avoid on morning of surgery for the surgeons too. This way there is less variability and surprises.

 

[GassYous]

BMI < 40
ASA < 4

 

[PainDrain]

One factor that people typically do not think of are patients on chronic narcotics, chronic pain conditions or those on suboxone. These people can have uncontrollable pain post op and need admission. They seem like it’s no big deal until they spend 12 hours in your pacu.

 

[patriot6]

BMI < 40
ASA < 4

BMI of 40 is crazy low; I'm in south Louisiana.
I canceled a BMI of 67 last week, lol.

 

[med2010]

BMI < 40
ASA < 4

Are there still places that have such a low BMI cutoff? Not talking office based stuff or single room centers.

 

[DrOwnage]

BMI of <40 is the criteria at most free standings, some 45. Just let the surgeon book them for the main OR he works at, I don't see a problem there. Besides things that have been said already, very old age, bad dementia, parkinsons, basically if they come with a caregiver and can't consent that's a bad SC patient.

 

[deleted1147063]

Anybody who's a potentially difficult airway (hence BMI<40-45, no severe OSA etc.)
Anybody who needs monitoring beyond standard ASA monitors (A-line etc.)
Anybody who will likely need prolonged recovery in the PACU or hospital admission
Anybody who's ASA 4 for anything more than a minor surgery always under MAC (e.g. think cataract, carpal tunnel)
Anybody who needs significant assistance (most ASCs don't have the resources)

Think about big things like this, based on the ASC resources, and then narrow it down to the specifics.

 

[Gator7]

My weekday job is outpatient ortho.
Here’s our hard cut offs:
- BMI >50
- EF <35%
- AICD
- ESRD
- Severe COPD
- Suspected difficult airway
- ASA 4
- Non-ambulatory
- No care giver available for first 24 hours post-op
- MH
- age <8
- true latex allergy
- surgery expected >4 hrs or blood loss >500cc

Those are just the hard cut offs. Every case is prescreened by PAE nurses and the bigger cases or anyone with a concerning hx is seen in person by me personally. We do our best to reduce same day cancellations. Those are usually due to severe htn, hyperglycemia, npo status, new a fib etc.

 

[crash2500]

What's the consensus for peds at an outpatient center, specifically a center that's not specifically for pediatrics with fellowship trained anesthesiologists?

 

[GassYous]

Are there still places that have such a low BMI cutoff? Not talking office based stuff or single room centers.

The fact that you think that bmi 40 is low says it all about our society

 

[DocVapor]

What's the consensus for peds at an outpatient center, specifically a center that's not specifically for pediatrics with fellowship trained anesthesiologists?

No syndromic kids and need to be "healthy."

 

[crash2500]

No syndromic kids and need to be "healthy."

What about age, case length?