Ambulatory surgery in orthopedics: experience of over 10,000 patients

doi:10.1007/s00776-013-0501-3

Journal of Orthopaedic Science

Volume 19, Issue 2, March 2014, Pages 332-338

https://doi.org/10.1007/s00776-013-0501-3 Get rights and content

Abstract

Purpose

The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient’s surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures.

Methods

We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined.

Results

The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved.

Conclusions

Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.

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Cited by (32)

Total Joint Arthroplasty at a Novel “Hyperspecialty” Ambulatory Surgical Center With Extended Care Suites is as Safe as Inpatient Arthroplasty
2022, Arthroplasty Today
New “hyperspecialty” ambulatory surgical centers (HASCs) have been introduced to deliver safe and cost-efficient care, allowing patients to spend additional nights in an extended care suite before discharge. This study compared the 90-day complications and readmissions of total joint arthroplasty (TJA) at an HASC and inpatient TJA at a tertiary hospital.
We retrospectively reviewed 1365 primary, unilateral, TJAs (658 total hip arthroplasty, 707 total knee arthroplasty) performed at 4 HASCs in 2017-2021. Following their outpatient procedure, patients were discharged to an extended care suite staffed full-time by nurses and physical therapists. These patients were matched 1:1 with 1365 inpatient TJAs (628 total hip arthroplasty, 737 total knee arthroplasty) based on demographics, joint, and American Society of Anesthesiologists (ASA) score. Ninety-day complications and readmissions were compared.
The mean age was 60.0 ± 9.8 years and 59.4 ± 8.1 years in the inpatient and outpatient groups, respectively (P = .106). There was no difference in ASA≥3 patients (16.4% vs 17.7%; P = .387) and operative time (86.9 ± 31.8 vs 88.7 ± 27.9 minutes; P = .118). Five patients (0.4%) in the outpatient group were transferred to an acute hospital. When comparing 90-day outcomes between the inpatient and outpatient groups, there was no difference in pulmonary embolism (0.1% vs 0.0%; P = .317), mechanical complications (0.3% vs 0.7%; P = .165), periprosthetic joint infections (0.5% vs 1.1%; P = .092), or readmissions (1.2% vs 1.5%; P = .513). A subgroup analysis of ASA≥3 patients yielded similar findings.
Patients undergoing outpatient TJA at a novel HASC had similar complication and readmission rates as those undergoing TJA at a tertiary hospital. Based on these data, such facilities seem appropriate for the care of outpatient TJA patients with ASA<4.
Radial head arthroplasty: a descriptive study of 970 patients in an integrated health care system
2022, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Information on returns to care, including ED visits and readmissions, following RHA is lacking. This is in contrast to general surgery literature, as well as following orthopedic procedures specifically, with 1.2% of patients returning to the ED within the first 24 hours and 2.5% of patients having an unanticipated ED visit or readmission within 30 days after same-day surgery.4,24 Navarro et al25 found 6.9% of rotator cuff repair patients returned to the ED or urgent care within 7 days for any reason and a third returned for potentially avoidable reasons.
Radial head arthroplasty (RHA) is commonly performed for isolated comminuted radial head fractures and in conjunction with traumatic elbow instability. However, there is a paucity of literature directly describing the characteristics and outcomes of patients who undergo RHA in a community-based setting. We describe a cohort of 970 RHA performed in the California regions of a US integrated health care system over a 9-year period. Patient demographics, implant selection, 90-day acute postoperative events, and cumulative reoperation/revision rates are included.
Patients aged ≥18 years who underwent primary RHA were identified (2009-2017). Patient characteristics and demographics, including age, body mass index, gender, diabetes status, American Society of Anesthesiologists (ASA) classification, primary diagnosis, and concomitant procedures were described. Crude cumulative revision and reoperation probabilities were calculated as 1 minus the Kaplan-Meier estimator, with follow-up time calculated as the time from the index RHA to revision/reoperation date for those with the outcome of interest and time from index RHA to censoring date (eg, date of death, health care termination, study end date [March 31, 2018]) for those without the outcome. Ninety-day postoperative incidence of emergency department (ED) visit, readmission, and mortality was calculated as the number of patients with the event of interest over the number of patients at risk.
A total of 970 patients underwent primary unilateral RHA by 205 surgeons during the study period. Annual procedure volume increased from 53 procedures in 2009 to 157 procedures in 2017. More patients were female, without diabetes, and had an ASA classification of 1 or 2. Fracture was the predominant indication for RHA (98.4%) and more than half (54.3%) had concomitant procedures performed. Most implants were press fit (63.2%) over loose fit, and >90% were monopolar. Three-year cumulative revision and reoperation probabilities following RHA were 6.5% (95% confidence interval [CI] = 5.0%-8.5%) and 8.2% (95% CI = 6.5%-10.3%), respectively. Revisions and reoperations tended to occur within the first postoperative year. Of the 970 RHA patients, 83 (8.5%) had a 90-day ED visit, 58 (6.0%) had a 90-day readmission, and 1 (0.1%) died within a 90-day postoperative period.
This large cohort of RHA patients provides information about the practice of RHA at large and in the community. Surgeons are performing more RHA over time and choosing press fit stems more often. Revisions and reoperations tended to occur early. Readmission and ED visits were low but not negligible, with pain being the most common reason for ED visit.
The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery
2021, Journal of Foot and Ankle Surgery
We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m² underweight, ≥20 to <25 kg/m² normal weight, ≥25 to <30 kg/m² overweight, ≥30 to <40 kg/m² obese, ≥40 kg/m²to <50 kg/m² severely obese, and ≥50 kg/m² extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.
A systematic review of surgical site infections following day surgery: a frequentist and a Bayesian meta-analysis of prevalence
2019, Journal of Hospital Infection
Citation Excerpt :
The present meta-analysis found a significant downward trend. It could be thought that studies with a large population (>10,000 subjects) might influence the results for the overall prevalence of SSI [4,21,22,42,43,60,62,63,70,71,74,76,79,107]. However, as shown in the sensitivity analyses, as removing each study one by one did not change the overall prevalence, it is likely that the large studies did not influence the results.
Since 1990, several studies have focused on safety and patient satisfaction in connection with day surgery. However, to date, no meta-analysis has investigated the overall prevalence of surgical site infections (SSI).
To estimate the overall prevalence of SSI following day surgery, regardless of the type of surgery.
A systematic review and a meta-analysis of the prevalence of SSI following day surgery, regardless of the type of surgery, was conducted, seeking all studies before June 2016. A pooled random effects model using the DerSimonian and Laird approach was used to estimate overall prevalence. A double arcsine transformation was used to stabilize the variance of proportions. After performing a sensitivity analysis to validate the robustness of the method, univariate and multi-variate meta-regressions were used to test the effect of date of publication, country of study, study population, type of specialty, contamination class, time of postoperative patient visit after day surgery, and duration of hospital care.
Ninety articles, both observational and randomized, were analysed. The estimated overall prevalence of SSI among patients who underwent day surgery was 1.36% (95% confidence interval 1.1–1.6), with a Bayesian probability between 1 and 2% of 96.5%. The date of publication was associated with the prevalence of SSI (coefficient −0.001, P = 0.04), and the specialty (digestive vs non-digestive surgery) tended to be associated with the prevalence of SSI (coefficient 0.03, P = 0.064).
The meta-analysis showed a low prevalence of SSI following day surgery, regardless of the surgical procedure.
Unplanned emergency department or urgent care visits after outpatient rotator cuff repair: potential for avoidance
2018, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
In our study, pain was the most common reason for returning to the ED or UC. This finding was seen in previous studies, which also reported that pain was the most common reason for adverse events after outpatient surgical procedures.5,14,15,27 Our study supports the belief that better pain control after surgery is warranted; however, the variable response to pain regimens makes it difficult to predict which patients require a greater level of pain control.
With the cost of health care rising, the potential to avoid costs from an unplanned return to the emergency department (ED) or urgent care center (UC) after elective outpatient rotator cuff repair (RCR) has been discussed but not extensively assessed.
Outpatient RCR procedures were queried in a closed health care system, and all unplanned ED and UC visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction). Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention. Final tallies of all visits versus visits with ADs were compared.
From June 2015 to May 2016, 1306 outpatient RCRs were performed (729 male and 577 female patients; average age, 60 years). Of the patients, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common (P = .007), whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied (P < .001).
Unplanned ED visits within 7 days of outpatient RCR are measurable and in many cases, such as ED or UC visits for pain, are avoidable. Visits for urinary retention are seen more commonly after RCR. Outpatient RCR led to more unplanned ED and UC visits than other common outpatient orthopedic surgical procedures.
Outpatient Pediatric Orthopedic Surgery
2018, Orthopedic Clinics of North America
Citation Excerpt :
Although most prevalent in adult orthopedic surgery, this trend has been observed in the pediatric population as well.3,4 As experience with outpatient surgery increases, selection criteria has widened.5 Outpatient surgery is an attractive option for a variety of procedures that can lead to decreased individual and societal costs compared with inpatient hospitalization while achieving equivalent health outcomes.1

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Original ArticleAmbulatory surgery in orthopedics: experience of over 10,000 patients

Abstract

Purpose

Methods

Results

Conclusions

Current Anaesth Critical Care.

Br J Anaesth.

J Clin Anesth.

Gac Sanit.

at hospitals and hospital districts—a summary of demand, production and finance

Helsinki: Finnish Local and Regional Authorities;

Care periods in 2006 and trends of care periods in the years 1997-2006

Finnish official statistics

Return hospital visits and hospital readmissions after ambulatory surgery

Ann Surg.

What happens after discharge? Return hospital visits after ambulatory surgery

Anesth Analg.

Original Article
Ambulatory surgery in orthopedics: experience of over 10,000 patients