Appropriate ASC / Outptient

[stonemd]

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Our hospital is asking us to generate more rules regarding:

Appropriate patient for ASC/OP (outpatient surgery at an ambulatory surgery center)

and

Reasons a patient should be cancelled DOS (day of surgery)

I am interred in rules you have regarding these issues. We currently have few- premi with PCA < 55 weeks, pregnant past 1st trimester, ASA NPO requirements for elective surgery...

If you have document rules your group / department follows please post or message me. Little of this is based on evidence so I am interested in usual practice of colleagues.

 

[deleted171991]

We tried to limit this in my academic place, just because the bean counters wanted a written set of rules for the surgeons. Honestly, there are no rules that could cover everything, but here are a few, just off the top of my head:

1. BMI limit. Ours is 48.
2. No pedi under 2 y/o. Healthy or with minor diseases. (We are not doing them at all anymore.)
3. No pregnant women, except for pregnancy termination.
4. No emergent procedures. Also no non-NPO patients.
5. No patients with pacemaker/AICD, unless the surgeon uses only bipolar. We don't have a way to interrogate them post-op.
6. No truly difficult intubation history.
7. No dialysis patients, except for minor procedures (e.g endoscopy).
8. No procedures or patients that would require hospital admission for observation.
9. No low EF (<25%) patients, especially for GA. No severe valvular disease. No severe lung disease.
10. Pretty conservative with ASA 4 patients for certain procedures (prolonged GA, laparoscopies etc.).
11. Also depends on the procedure. For example, a retrobulbar block case will make us way less tolerant towards heart disease than a carpal tunnel.
12. No mentally-challenged adult patients who cannot walk to the OR or don't tolerate pre-op IV's.

We cancel on the day of surgery if:
1. The sugar is 300 or higher.
2. The patient is far from being optimized for surgery.
3. The patient is not NPO.
4. The patient has a very difficult airway (for anything more than minor sedation). This does not automatically include morbidly obese ladies, for example.
5. We feel that the patient is at high risk for complications, especially the kind that are difficult to treat in our ASC (we don't have ABG, A-lines etc. , and most of the day there is just one more anesthesiologist around to help), and would benefit from being rescheduled at the hospital.
6. The patient would probably not tolerate MAC, and is high risk for GA.

 

[sevoflurane]

No BMT or tongue tie releases or dental restoration on the < 2 y/o? How about endos of <2 y/o?
Nobody with a pacer or AICD? What if you're doing foot surgery...? BG of 300 isn't an automatic cancellation in my book or need to move to the inpatient side.

OP, I think you'll get different answers from diff. people.

Having direct access to a hospital (same building) really changes what you can do at an ASC in my mind.

 

[deleted171991]

No BMT or tongue tie releases or dental restoration on the < 2 y/o? How about endos of <2 y/o?
Nobody with a pacer or AICD? What if you're doing foot surgery...? BG of 300 isn't an automatic cancellation in my book or need to move to the inpatient side.

OP, I think you'll get different answers from diff. people.

Having direct access to a hospital (same building) really changes what you can do at an ASC in my mind.

We are 10 minutes by ambulance to the hospital, and we have limited resources, including human ones. So we are more conservative. Despite this, we do sicker patients than the average freestanding ASC. Over half of our patients are ASA 3-4.

Of course foot surgery would not be an issue with a pacemaker/AICD, even with a Bovie.

I can't really comment about pedi, because I caught only the tail end of it. We are not doing them anymore at my location.

To cover everything, the list of rules and exceptions would be long and complicated. With time, the OP will figure out what the most important ones are, in his/her setting. What I wrote is more like food for thought.

 

[pjl]

FFP: Why BMI <48?
That was the most odd requirement I saw.

Ours is attached to hospital so the requirements are much different than if it were not.
We do try to keep poorly optimized and emergent cases to the main OR. Same with high anticipated blood loss, or need for invasive monitoring. However these are not absolutes.

 

[IlDestriero]

We actually have a fairly detailed policy with guidelines. You should be able to determine what is appropriate for your practice based on location, equipment, etc. Once they're established, review them again in a year. I'm sure it will need some tweaking.
If you establish a guideline, all your partners should hold the line and try to stick to the guidelines or they won't be useful.

 

[deleted171991]

FFP: Why BMI <48?
That was the most odd requirement I saw.

Ours is attached to hospital so the requirements are much different than if it were not.
We do try to keep poorly optimized and emergent cases to the main OR. Same with high anticipated blood loss, or need for invasive monitoring. However these are not absolutes.

We needed a cut-off for morbidly obese patients. It's mostly about difficult airways and OSA in a remote non-hospital setting. We think we are pretty generous with the number.

Since you are not a freestanding ASC, your tolerance levels should be much different. There is much less I would turn away if I were in a hospital wing.

 

[pjl]

I agree, and thought your requirements were all understandable for a freestanding place far from help. Just wondered about the 48, why not 49 or 47.

 

[deleted171991]

I agree, and thought your requirements were all understandable for a freestanding place far from help. Just wondered about the 48, why not 49 or 47.

No evidence. It used to be much higher, but some of our colleagues felt it was too risky. So we went by the lowest common denominator. I used to do upper endoscopies in non-intubated BMI 50+ patients.

Whatever you decide, make sure that everybody is comfortable with your criteria, and nobody gets to overrule another anesthesiologist's decision ever. Not the floor runner, not the boss, not anybody. Convince? Yes. Overrule? No.

In certain areas of my acacademic place, one cannot cancel a case without approval from some non-royal highness, even when it's staring one in the face. Not OK. I am the guy in the room; I know my limits, and what my team can(not) do, and overruling me won't change them. Where I work, I first cancel, then tell about it to the boss and my colleagues, matter of factly. If we feel the need to comment on a colleague's cancellation (less than 10% of the situations), it's more for future reference and private. But most of us have a PP-like work ethic; it might be different in a corporate (read lazy) group of people.

 

[Gas you down]

I'd say OSA shouldn't go to a ASC, either. I used to think that was too conservative, until we had an otherwise healthy man stop breathing a few hours after he got home.

edit: and he was nowhere close to BMI 48!

second edit: I'm talking GETA cases, not the little rinky dink stuff

 

[stonemd]

Thanks for the comments. Can some of you expand on the OSA? Do treat different known OSA treated with CPAP, OSA doesn't tolerate CPAP, possible OSA by on symptoms. Do you review or order sleep studies or home sleep test? ASA has a guideline but the OSA severity scoring system is only a guide, is not evidence based and clinical judgement should be used ??

Also do you have a way of stratifying pulmonary disease to predict who will not tolerate an ISB without postop supplemental oxygen, hereby requiring admission?

 

[OneFellSwoop]

Gas you down: you say that he stopped breathing hours AFTER getting home. If you did the same day case at the hospital how would the outcome be different? Basically are you saying all OSA (or osa GAs) should be watched overnight in a hospital bed, would they all get continuous etco2 and/or O2 sat monitoring?

We contemplate the same stuff just like everyone here, but it seems like the biggest concern for OSA patients is when they get home rather than immediate post op so location of surgery doesn't seem to matter as much unless you do admit overnight. Curious what everyone else thinks?

 

[aneftp]

There is no "evidence" on morbidly obese patients at stand a lone centers because there will only be two results for these stand a lone centers

1. That morbidly patients can be done safely at these centers (means these centers maintain same revenue)

2. The study will show morbidly patient have increased periop risk and should be done at hospital setting. (Immediately means decrease revenue)

Now you see why no one wants to fund such a study.

 

[nimbus]

Some food for thought

https://cme.ucsd.edu/OSAonline/osa monograph_web.pdf

 

[deleted171991]

The problem with OSA is that some smart lawyer will always find some pseudoexpert ready to testify that the patient should have been kept under observation till death, and that it's all your fault for discharging the patient too early. They will always find a study showing that you should have observed the patient for X more hours.

From where I stand, OSA patients are a Russian roulette. I think we take a lot of risk just so that the bean counters get their year-end incentives, instead of automatically admitting every, single, OSA, patient for 12-hour (post-anesthesia or post last narcotic dose) inpatient observation, period.