Ideas and Approaches for Quality-Assessment and Performance-Improvement Projects in Ambulatory Surgery Centers.

Identifying a performance-improvement project can be a struggle when a facility's data demonstrate desirable performance. Quality-improvement teams may be limiting their data collection to only required or traditional outcome indicators. Facility personnel may need guidance on how to broaden the vision to monitor for additional issues that affect the quality of care. This article focuses on approaches and indicators customary to the services and operations of an ambulatory surgery center, going beyond reviewing data from routine outcome measures and explaining the effect these ideas can have on improving quality of care. These approaches and indicators can enable personnel to identify and conduct quality-assessment and performance-improvement projects that affect patient safety, patient satisfaction, efficiency, and cost of care.

Using preoperative assessment and patient instruction to improve patient safety.

Rates of patient transfers, cancellations, and patient visits to the emergency department after discharge are quality metrics for ambulatory surgery centers. To improve these metrics, it is imperative to establish best practices for conducting preoperative assessments, including identifying key patient conditions (ie, obstructive sleep apnea, cardiovascular disease, reactive airway disease, obesity). To guide appropriate patient selection, practitioners should review the patient's allergies and sensitivities, alcohol use, medications, and medical history. To help ensure good patient outcomes, it is imperative to provide complete preoperative instructions (eg, NPO guidelines, medications, what to bring, cancellation instructions) and discharge instructions (eg, postoperative medications, appropriate activity restrictions, diet, surgical and anesthetic side effects, special circumstances [eg, regional blocks], symptoms of possible complications, treatment and tests, access to postdischarge follow-up care). Generally, the routine outpatient surgical patient is discharged home; however, there are circumstances that occasionally necessitate transfer or admission to a higher level of care. For transfers, ambulatory surgery centers should adhere to applicable federal and state guidelines and should have a clear policy in place to guide transfers.

Cytotoxic T cell mechanisms of beta cell destruction in non-obese diabetic mice.

CD8+ T cells are the principal cellular mediators of beta cell destruction in the NOD mouse. Molecular mediators include perforin and granzymes from the cytotoxic granule, Fas ligand and pro-inflammatory cytokines. Our studies in NOD mice have shown that beta cell-specific CD8+ T cells use both the perforin and Fas pathway in vitro. Reducing antigen presentation on beta cells, for example by reducing class I MHC expression by overexpression of SOCS1, protects beta cells in vivo. Perforin deficiency effectively reduces diabetes in NOD mice but in NOD8.3 mice other mechanisms compensate. We have been unable to identify a major role for direct toxicity of cytokines in NOD mice. However, in the LCMV glycoprotein model they may be more important. Deficiency of IL1 or TNF or Fas has a protective effect (greatest for TNF deficiency) but this appears to be due to effects of these cytokines on the immune response rather than on the beta cell. Combinations of interventions, for example, beta cell overexpression of SOCS1 combined with IL1 deficiency may be highly protective. It should be possible to define all the molecular mediators of beta cell destruction, and it may be possible to inhibit at least some of these.