Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States.

Importance: The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. Objective: To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. Design, Setting, and Participants: Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. Exposures: Tonsillectomy with or without adenoidectomy. Main Outcome and Measures: Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. Results: The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. Conclusions and Relevance: Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

Safety of vascular interventions performed in an office-based laboratory in patients with low/moderate procedural risk.

OBJECTIVE: An exponential increase in number of office-based laboratories (OBLs) has occurred in the United States, since the Center for Medicare and Medicaid Services increased reimbursement for outpatient vascular interventions in 2008. This dramatic shift to office-based procedures directed to the objective to assess safety of vascular procedures in OBLs. METHODS: A retrospective analysis was performed to include all procedures performed over a 4-year period at an accredited OBL. The procedures were categorized into groups for analysis; group I, venous procedures; group II, arterial; group III, arteriovenous; and group IV, inferior vena cava filter placement procedures. Local anesthesia, analgesics, and conscious sedation were used in all interventions, individualized to the patient and procedure performed. Arterial closures devices were used in all arterial interventions. Patient selection for procedure at OBL was highly selective to include only patients with low/moderate procedural risk. RESULTS: Nearly 6201 procedures were performed in 2779 patients from 2011 to 2015. The mean age of the study population was 66.5 ± 13.31 years. There were 1852 females (67%) and 928 males (33%). In group I, 5783 venous procedures were performed (3491 vein ablation, 2292 iliac vein stenting); with group II, 238 arterial procedures (125 femoral/popliteal, 71 infrapopliteal, iliac 42); group III, 129 arteriovenous accesses; and group IV, 51 inferior vena cava filter placements. The majority of procedures belonged to American Society of Anesthesiology class II with venous (61%) and arterial (74%) disease. A total of 5% patients were deemed American Society of Anesthesiology class IV (all on hemodialysis). There was no OBL mortality, major bleed, acute limb ischemia, myocardial infarction, stroke, or hospital transfer within 72 hours. Minor complications occurred in 14 patients (0.5%). Thirty-day mortality, unrelated to the procedure, was noted in 9 patients (0.32%). No statistically significant differences were noted in outcomes between the four groups. CONCLUSIONS: Our data suggest that it is safe to use OBL for minimally invasive, noncomplex vascular interventions in patients with a low to moderate cardiovascular procedural risk.

Early Postoperative Outcomes of Super Morbid Obese Compared to Morbid Obese Patients After Ambulatory Surgery Under General Anesthesia: A Propensity-Matched Analysis of a National Database.

BACKGROUND: Patients with body mass index (BMI) ≥50 kg/m2, defined as super morbid obesity, represent the fastest growing segment of patients with obesity in the United States. It is currently unknown if super morbid obese patients are at greater odds than morbid obese patients for poor outcomes after outpatient surgery. The main objective of the current investigation is to assess if super morbid obese patients are at increased odds for postoperative complications after outpatient surgery when compared to morbid obese patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2017 to 2018 was queried to extract and compare patients who underwent outpatient surgery and were defined as either morbidly obese (BMI >40 and <50 kg/m2) or super morbidly obese (BMI ≥50 kg/m2). The primary outcome was the occurrence of medical adverse events within 72 hours of discharge. In addition, we also examine death and readmissions as secondary outcomes. A propensity-matched analysis was used to evaluate the association of BMI ≥50 kg/m2 versus BMI between 40 and 50 kg/m2 and the outcomes. RESULTS: A total of 661,729 outpatient surgeries were included in the 2017-2018 NSQIP database. Of those, 7160 with a BMI ≥50 kg/m2 were successfully matched to 7160 with a BMI <50 and ≥40 kg/m2. After matching, 17 of 7160 (0.24%) super morbid obese patients had 3-day medical complications compared to 15 of 7160 (0.21%) morbid obese patients (odds ratio [OR; 95% confidence interval {CI}] = 1.13 [0.57-2.27], P = .72). The rate of 3-day surgical complications in super morbid obese patients was also not different from morbid obese patients. Thirty-five of 7160 (0.48%) super morbid obese patients were readmitted within 3 days, compared to 33 of 7160 (0.46%) morbid obese patients (OR [95% CI] = 1.06 [0.66-1.71], P = .80). When evaluated in a multivariable analysis as a continuous variable (1 unit increase in BMI) in all patients, BMI ≥40 kg/m2 was not significantly associated with overall medical complications (OR [95% CI] = 1.00 [0.98-1.04], P = .87), overall surgical complication (OR [95% CI] = 1.02 [0.98-1.06], P = .23), or readmissions (OR [95% CI] = 0.99 [0.97-1.02], P = .8). CONCLUSIONS: Super morbid obesity is not associated with higher rates of early postoperative complications when compared to morbid obese patients. Specifically, early pulmonary complications were very low after outpatient surgery. Super morbid obese patients should not be excluded from outpatient procedures based on a BMI cutoff alone.

Short-term Outcomes of Ambulatory Colectomy for 157 Consecutive Patients.

OBJECTIVE: To evaluate short-term outcomes of laparoscopic colectomy for selected consecutive patients in an ambulatory setting at two institutions. BACKGROUND: Several studies showed that an enhanced recovery protocol for colorectal surgery reduces postoperative morbidity and mortality, and shortens the length of hospital stay. The development of such a program has allowed us to gradually reduce the length of stay for colorectal surgery, until ambulatory management. METHODS: Between February, 2013 and December, 2016, all patients scheduled for elective laparoscopic colectomy and meeting rigorous criteria for ambulatory surgery were included. Outcome was prospectively studied. RESULTS: One hundred fifty-seven patients (70 women) with a median age of 61 years (range 25-82 years) were included. The ambulatory rate for colectomy was 30.5%. Median operative time and length of in-hospital stay were 95 minutes (range 45-232 minutes) and 10.0 hours (range 7-14.7 hours), respectively. The admission rate was 7.0% due to operative difficulties (4 patients), medical reasons (4 patients), and social reasons (3 patients). Outcomes for these patients were uneventful and the median length of hospital stay was 3.1 days (range 1-14 days). An unscheduled consultation was necessary for 30 patients (20.5%). Nine patients required readmission (6.1%), of whom 6 required reoperation (3.8%). The overall 30-day morbidity rate was 24.8%. The mortality rate was 0%. CONCLUSIONS: This is the first case of consecutive patients undergoing ambulatory colectomy for malignant or benign disease. We demonstrated the feasibility, safety, and reproducibility of outpatient colectomy for selected patients. In our experience, 30% of patients scheduled for elective colectomy can be managed in an ambulatory setting.

Same-day discharge among patients undergoing elective PCI: Insights from the VA CART Program.

BACKGROUND: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30 days. RESULTS: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (P < .001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, P = .24; mortality: 0% vs. 0.07%, P = .99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.

Total Hip Arthroplasty and the Medicare Inpatient-Only List: An Analysis of Complications in Medicare-Aged Patients Undergoing Outpatient Surgery.

BACKGROUND: The Centers for Medicare and Medicaid Services has solicited public comments for the 2019 Proposed Rule to remove total hip arthroplasty (THA) from the inpatient-only list. Concerns exist regarding the safety of discharging higher risk Medicare patients as an outpatient and whether hospitals may still be reimbursed for an inpatient procedure. The purpose of this study is to determine whether Medicare-aged patients undergoing outpatient THA have higher complication rates than patients who underwent inpatient THA. We also sought to identify characteristics of Medicare-aged patients that are associated with increased risk of complications or longer stay following short-stay THA. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients over age 65 who underwent primary THA between 2015 and 2016. We compared demographics, comorbidities, and 30-day complication, reoperation, and readmission rates among outpatient, short-stay, and inpatient groups. A multivariate regression analysis identified patients who are at an increased risk for complications and a longer inpatient stay following short-stay THA. RESULTS: Of the 34,416 Medicare-aged patients who underwent THA, 310 (1%) were discharged on postoperative day 0, 5698 (16.5%) on postoperative day 1, and 28,408 (82.5%) were inpatients. The outpatient and short-stay patients had lower 30-day complication and readmission rates than the inpatient group. Independent risk factors for developing a complication or requiring an inpatient stay included general anesthesia, body mass index >35 kg/m2, diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, malnutrition, female gender, age >75 years, minority ethnicity, and an American Society of Anesthesiologists score of 4 (all P < .05). CONCLUSION: Outpatient and short-stay THA appears to be safe in a small subset of Medicare-aged patients. Centers for Medicare and Medicaid Services should allow surgeons flexibility in determining admission status based on each patient's risk profile.

Retrospective single-centre series of 1300 consecutive cases of outpatient cervical spine surgery: complications, hospital readmissions, and reoperations.

Background: Outpatient surgery is becoming more common and is more cost-effective than inpatient surgery. Nonetheless, many surgeons and health care administrators are still hesitant to accept outpatient surgery for cervical degenerative spinal disease (C-DSD). This study assesses the types and rates of complications, hospital admissions, and reoperations after outpatient surgery of C-DSD.Methods: Complications, hospital admissions within 90 days of surgery, and reoperations within one year of surgery were recorded retrospectively in 1300 outpatients undergoing microsurgical decompression for C-DSD at the Oslofjord Clinic from 2008 to 2017. The surgical procedures performed were anterior cervical decompression and fusion (ACDF) in 1083 patients and posterior cervical foraminotomy in 217 patients.Results: The surgical mortality rate was 0%. Sixteen major complications were recorded in 15/1300 (1.2%) patients. The complications were neurological deterioration in four patients, postoperative hematoma in two, dural lesions with cerebrospinal fluid leakage in one, deep surgical-site infection in one, persistent hoarseness in three, and persistent dysphagia in five. The two potentially life-threatening hematomas were detected within the planned six-hour observation period. Two (0.2%) patients were admitted to hospital within hours of surgery completion with stroke-like signs and symptoms, and four (0.3%) patients were admitted to hospital within 90 days due to surgery-related events. The rate of reoperations for cervical radiculopathy within 12 months was 25/1171 (2%); eight patients' reoperations were due to inadequate primary decompression, one was due to recurrent disc herniation at the same level and side, and 16 were due to new-onset radiculopathy from an adjacent level or other side.Conclusions: Outpatient microsurgical decompression of the degenerative cervical spine in carefully selected patients appears to be safe and carries a low major complication rate, low hospital admission rate, and low one-year reoperation rate.

Temporal Trends, Determinants, and Outcomes of Inpatient versus Outpatient Arteriovenous Fistula Operations.

BACKGROUND: As high healthcare costs are increasing scrutinized, a movement toward reducing patient hospital admissions and lengths of stay has emerged, particularly for operations that may be performed safely in the outpatient setting. Our aim is to describe recent temporal trends in the proportion of dialysis access procedures performed on an inpatient versus outpatient basis and to determine the effects of these changes on perioperative morbidity and mortality. METHODS: The 2005-2008 American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary arteriovenous fistula (AVF) procedures using current procedural terminology codes. Changes in the proportions of inpatient versus outpatient operations performed by year, as well as the associated 30-day postoperative morbidity and mortality, were analyzed using univariable statistics and multivariable logistic regression. RESULTS: Two thousand nine hundred fifty AVF procedures were performed over the study period. Overall, 71.7% (n = 2,114) were performed on an outpatient basis. Inpatient procedures were associated with higher 30-day morbidity (10.5% vs. 4.5%) and mortality (2.8% vs. 0.7%) than outpatient procedures (both, P < 0.001). There was a significant increase in the proportion of procedures performed on an outpatient basis over time (2005: 56% vs. 2008: 75%; P < 0.001). There were no changes in postoperative morbidity or mortality for inpatient or outpatient AVF over time (P ≥ 0.36). Independent determinants of having an inpatient procedure included younger age (OR 0.99), increasing ASA class (ASA IV OR 1.56), congestive heart failure (OR 3.32), recent ascites (OR 3.25), poor functional status (OR 3.22), the presence of an open wound (OR 1.91), and recent sepsis (OR 6.06) (all, P < 0.01). Acute renal failure (OR 2.60) and current dialysis (OR 1.44) were also predictive (P < 0.001). After correcting for baseline differences between groups, the adjusted OR for both morbidity (aOR 1.93, 95% CI 1.38-2.69) and mortality (aOR 2.85, 95% CI 1.36-5.95) remained significantly higher for inpatient versus outpatient AVF. CONCLUSIONS: Dialysis access operations are increasingly being performed on an outpatient basis, with stable perioperative outcomes. Inpatient procedures are associated with worse outcomes, likely because they are reserved for patients with acute illnesses, serious comorbidities, and poor functional status. Overall, for appropriately selected patients, the movement toward performing more elective dialysis access operations on an outpatient basis is associated with acceptable outcomes.

Is ambulatory laparoscopic Roux-en-Y gastric bypass associated with higher adverse events?

OBJECTIVE: To determine the impact of length of stay upon 30-day outcomes. BACKGROUND: It has been recommended the goal length of stay (LOS) after laparoscopic Roux-en-Y gastric bypass (LRYGB) should be 1 day to improve resource utilization. This study's aim was to assess LRYGB outcomes by LOS. METHODS: Data were obtained from the BOLD (Bariatric Outcomes Longitudinal Database) for 51,788 laparoscopic gastric bypass (LRYGB) procedures performed between 2007 and 2010. Logistic regression models were used to evaluate age, sex, race, body mass index, insurance status, comorbidities, and LOS as predictors for 30-day mortality, serious complications, and readmissions. RESULTS: Overall patient demographics were as follows: median age, 45 years; median body mass index, 46.3 kg/m; % female, 78.6; % white, 77.8; % private insurance, 86.2; and % comorbidities more than 5 (39.1%). Overall, 30-day outcomes included mortality, 0.1%; serious complications, 0.5%; and readmissions, 3.8%. median LOS was 2 days, and the distribution of LOS was as follows [n (%)]: 0 (1.0), 1 (18.4), 2 (59.0), 3 (17.5), and 4 (4.1). Using the median LOS 2 days as reference, the logistic regression analysis revealed that ambulatory LOS of was significantly associated with increased risk of 30-day mortality (odds ratio: 13.02; P < 0.0001) as was LOS 1 day (odds ratio: 2.02; P < 0.0552). For LOS of 0 day, there was a trend toward an increase in the rate of 30-day serious complications (odds ratio: 1.9; P < 0.16). There was no significant trend between LOS status and 30-day readmission rates. CONCLUSIONS: In this large, prospective, clinical database, LOS of 1 day or less for LRYGB patients was significantly associated with an increased risk of 30-day mortality and a trend toward increased risk of 30-day serious complications.

Office-based anesthesia: safety and outcomes.

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Anaesthetic regimens for day-procedure laparoscopic cholecystectomy.

BACKGROUND: Day surgery involves admission of selected patients to hospital for a planned surgical procedure with the patients returning home on the same day. An anaesthetic regimen usually involves a combination of an anxiolytic, an induction agent, a maintenance agent, a method of maintaining the airway (laryngeal mask versus endotracheal intubation), and a muscle relaxant. The effect of anaesthesia may continue after the completion of surgery and can delay discharge. Various regimens of anaesthesia have been suggested for day-procedure laparoscopic cholecystectomy. OBJECTIVES: To compare the benefits and harms of different anaesthetic regimens (risks of mortality and morbidity, measures of recovery after surgery) in patients undergoing day-procedure laparoscopic cholecystectomy. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 10, 2013), MEDLINE (PubMed) (1987 to November 2013), EMBASE (OvidSP) (1987 to November 2013), Science Citation Index Expanded (ISI Web of Knowledge) (1987 to November 2013), LILACS (Virtual Health Library) (1987 to November 2013), metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/) (November 2013), World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) portal (November 2013), and ClinicalTrials.gov (November 2013). SELECTION CRITERIA: We included randomized clinical trials comparing different anaesthetic regimens during elective day-procedure laparoscopic cholecystectomy (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS: Two authors independently assessed trials for inclusion and independently extracted the data. We calculated the risk ratio, rate ratio or mean difference with 95% confidence intervals based on intention-to-treat or available data analysis. MAIN RESULTS: We included 11 trials involving 1069 participants at low anaesthetic risk. The sample size varied from 40 to 300 participants. We included 23 comparisons. All trials were at a high risk of bias. We were unable to perform a meta-analysis because there were no two trials involving the same comparison. Primary outcomes included perioperative mortality, serious morbidity and proportion of patients who were discharged on the same day. There were no perioperative deaths or serious adverse events in either group in the only trial that reported this information (0/60). There was no clear evidence of a difference in the proportion of patients who were discharged on the same day between any of the comparisons. Overall, 472/554 patients (85%) included in this review were discharged as day-procedure laparoscopic cholecystectomy patients. Secondary outcomes included hospital readmissions, health-related quality of life, pain, return to activity and return to work. There was no clear evidence of a difference in hospital readmissions within 30 days in the only comparison in which this outcome was reported. One readmission was reported in the 60 patients (2%) in whom this outcome was assessed. Quality of life was not reported in any of the trials. There was no clear evidence of a difference in the pain intensity, measured by a visual analogue scale, between comparators in the only trial which reported the pain intensity at between four and eight hours after surgery. Times to return to activity and return to work were not reported in any of the trials. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to conclude that one anaesthetic regimen for day-procedure laparoscopic cholecystectomy is to be preferred over another. However, the data are sparse (that is, there were few trials under each comparison and the trials had few participants) and further well designed randomized trials at low risk of bias and which are powered to measure differences in clinically important outcomes are necessary to determine the optimal anaesthetic regimen for day-procedure laparoscopic cholecystectomy, one of the commonest procedures performed in the western world.

Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients.

The purpose of the present study is to determine the differences in cost, complications, and mortality between knee arthroplasty (TKA) patients who stay the standard 3-4 nights in a hospital compared to patients who undergo an outpatient procedure, a shortened stay or an extended stay. TKA patients were identified in the Medicare 5% sample (1997-2009) and separated into the following groups: outpatient, 1-2 days, 3-4 days, or 5+ days inpatient. At two years, costs associated with the outpatient and the 1-2 day stay groups were $8527 and $1967 lower than the 3-4 day stay group, respectively. Out to 2 years, the outpatient and 1-2 day stay groups reported less pain and stiffness, respectively, though the 1-2 day group also had a higher risk for revision.

Patient selection for day case-eligible surgery: identifying those at high risk for major complications.

BACKGROUND: Due to economic pressures and improvements in perioperative care, outpatient surgical procedures have become commonplace. However, risk factors for outpatient surgical morbidity and mortality remain unclear. There are no multicenter clinical data guiding patient selection for outpatient surgery. The authors hypothesize that specific risk factors increase the likelihood of day case-eligible surgical morbidity or mortality. METHODS: The authors analyzed adults undergoing common day case-eligible surgical procedures by using the American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2010. Common day case-eligible surgical procedures were identified as the most common outpatient surgical Current Procedural Terminology codes provided by Blue Cross Blue Shield of Michigan and Medicare publications. Study variables included anthropometric data and relevant medical comorbidities. The primary outcome was morbidity or mortality within 72 h. Intraoperative complications included adverse cardiovascular events; postoperative complications included surgical, anesthetic, and medical adverse events. RESULTS: Of 244,397 surgeries studied, 232 (0.1%) experienced early perioperative morbidity or mortality. Seven independent risk factors were identified while controlling for surgical complexity: overweight body mass index, obese body mass index, chronic obstructive pulmonary disease, history of transient ischemic attack/stroke, hypertension, previous cardiac surgical intervention, and prolonged operative time. CONCLUSIONS: The demonstrated low rate of perioperative morbidity and mortality confirms the safety of current day case-eligible surgeries. The authors obtained the first prospectively collected data identifying risk factors for morbidity and mortality with day case-eligible surgery. The results of the study provide new data to advance patient-selection processes for outpatient surgery.

Nineteenth century mortality at the Royal Hospital for Sick Children, Glasgow.

BACKGROUND AND AIMS: Since Glasgow's Royal Hospital for Sick Children opened in 1882, significant advances have been made in child health. Our aim was to investigate the hospital mortality that occurred in the last decade of the 19th century at Royal Hospital for Sick Children. METHODS AND RESULTS: Hospital mortality records for the decades, 1890-1899, were collected from the Archives of the Royal Hospital for Sick Children. Data were extracted from the hospital inpatient records and the pathology records. In the decade 1890-1899, there were 731 hospital deaths. The main cause of death at that time in the 19th Century was infection, particularly of the respiratory tract. The age at which death occurred was analysed and the recorded cause were analysed as was the distance patients travelled to the hospital. The ratio of boys to girls and length of inpatient stay was similar to that seen in the hospital currently. CONCLUSION: This study records the mortality in a children's hospital in a large developing industrial city in the 19th century as experienced in a children's hospital.

Is day surgery safe? A Danish multicentre study of morbidity after 57,709 day surgery procedures.

BACKGROUND: Day surgery is expanding in several countries, and it is important to collect information about quality. The aim of this study was to assess morbidity and unanticipated hospital visits 0-30 days post-operatively in a large cohort. METHODS: We prospectively recorded data from 57,709 day surgery procedures performed in eight day surgery centres over a 3-year period. We cross-checked with the National Patient Registry to identify complications 0-30 days post-operatively, and registrations from The Danish Register of Cause of Death were requested. We retrieved the records of 1174 patients to assign a relation between secondary contact and day surgery. RESULTS: The overall rate of return hospital visits was 1.21% [95% confidence interval (CI): 1.12-1.30%] caused by a wide range of diagnoses. No deaths were definitely related to day surgery. The return hospital visits were due to haemorrhage/haematoma 0.50% (95% CI: 0.44-0.56%), infection 0.44% (95% CI: 0.38-0 49%) and thromboembolic events 0.03%. Major morbidity was rare. The surgical procedures with the highest rate of complication were tonsillectomies 11.4%, surgically induced abortions 3.13% and inguinal hernia repairs 1.23%. CONCLUSION: This large-scale Danish national study confirmed that day surgery is associated with a very low rate of return hospital visits. Despite the rapid expansion of day surgery, safety has been maintained, major morbidity being very rare, and no deaths being definitely related to day surgery.

Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal.

BACKGROUND: This is a continued examination of 10 years of prospectively collected Florida in-office adverse event data and new comparable data from mandatory Alabama in-office adverse event data reporting. OBJECTIVE: To determine which office surgical procedures have resulted in reported complications. METHODS: This study is a compilation of mandatory reporting of office surgical complications by Florida and Alabama physicians to a central agency. Reports resulting in death or a hospital transfer were further investigated over the telephone or on-line to determine the reporting physician's board certification status, hospital privilege status, and office accreditation status. RESULTS: In 10 years in Florida, there were 46 deaths and 263 procedure-related complications and hospital transfers; 56.5% (26/46) of deaths and 49.8% (131/263) of hospital transfers were associated with non-medically necessary (cosmetic) procedures. The majority of deaths (67%) and hospital transfers (74%) related to non-medically necessary (cosmetic) procedures were from procedures performed on patients under general anesthesia. Liposuction and liposuction with abdominoplasty or other cosmetic procedure resulted in 10 deaths and 34 hospital transfers. Thirty-eight percent of offices reporting adverse events were accredited by an independent accrediting agency, 93% of physicians were board certified, and 98% of physicians had hospital privileges. The most common specialty of physicians reporting adverse events was plastic surgery (45% of all reported complications). Dermatologists reported four total complications (no deaths) and accounted for 1.3% of all complications over the 10-year period. In 6 years in Alabama, there were three deaths and 49 procedure-related complications and hospital transfers; 42% (22/52) of hospital transfers and no deaths were associated with non-medically necessary (cosmetic) procedures. The majority of hospital transfers related to cosmetic procedures (86%) were from procedures performed on patients under general anesthesia. Liposuction accounted for no deaths and two hospital transfers. Seventy-one percent of offices reporting adverse events were accredited by an independent accrediting agency, and 100% of physicians were board-certified. Plastic surgery was the most common specialty represented in adverse event reporting (42.3% of all reported complications). Dermatologists reported one complication (no deaths) and accounted for 1.9% of all complications over the 6-year period. CONCLUSIONS: Continued analysis reveals that medically necessary office surgery does not represent an emergent hazard to patients. The data obtained from 10 and 6 years of adverse event reporting in Florida and Alabama, respectively, are comparable and consistent. Medically necessary surgical procedures performed in the office setting by dermatologists have an exceedingly low complication rate, and complications that arose were largely unexpected, isolated, and possibly unpreventable. Cosmetic procedures performed in offices by dermatologists under local and dilute local anesthesia yielded no reported complications. Complications from cosmetic procedures accounted for nearly half of all reported incidents in Florida and Alabama, and in both states, plastic surgeons were most represented in adverse event reports. Liposuction performed under general anesthesia requires further investigation because deaths from this procedure continue to occur despite the ability to use dilute local anesthesia for this procedure. Requiring physician board certification and physician hospital privileges does not seem to increase safety of patients undergoing surgical procedures in the office setting. Mandatory reporting of adverse events in the office setting should continue to be championed. Reporting of delayed deaths after hospital outpatient and ambulatory surgery center procedures should be implemented. All data should be made available for scientific analysis after protecting patient confidentiality.

The importance of assessing both inpatient and outpatient surgical quality.

OBJECTIVE: We aimed to determine whether hospital-level surgical performance was similar across outpatient and inpatient settings. BACKGROUND: The majority of surgical procedures in the United States are performed in an outpatient setting but most quality improvement focuses on inpatient care. METHODS: Using data from the 2006 to 2008 American College of Surgeons- National Surgical Quality Improvement Program, risk-adjusted hospital observed to expected ratios for morbidity and mortality were compared for inpatient and outpatient cases. In addition, hospital outpatient performance in each year was compared with performances in subsequent years. RESULTS: Hospitals demonstrated variation in outcomes for outpatient morbidity with both good and poor outliers in each year. Outpatient mortality was so rare as to not support robust modeling. There was a lack of congruence between hospital performance for outpatient morbidity and either inpatient morbidity or inpatient mortality in each year, indicating that inpatient performance is not interchangeable with outpatient performance. Outpatient morbidity performance correlation between years was only moderate (correlations 0.449-0.534, all P < 0.001) indicating that although outcomes from 1 year mildly predict subsequent years, substitution of data would likely lead to missed opportunities for improvement. CONCLUSIONS: Assessments of risk-adjusted hospital-level outpatient morbidity performance demonstrate (1) variability across American College of Surgeons- National Surgical Quality Improvement Program sites; (2) a lack of congruence between outpatient morbidity performance and either inpatient morbidity or mortality performance; (3) year-to-year variation of outpatient morbidity performance at individual institutions. Continuing evaluation of both outpatient and inpatient outcomes is supported. Given the substantial volume of outpatient care delivered, outpatient assessments are likely to be an important component of ongoing quality improvement efforts.

Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave.

BACKGROUND: There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period. METHODS: We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission. RESULTS: There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery. CONCLUSIONS: There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Changing practice locations for upper urinary tract stone disease.

PURPOSE: Complex surgical procedures are migrating out of hospitals and into ambulatory surgery centers. We evaluated the extent to which surgery for urolithiasis could be a candidate for such migration. MATERIALS AND METHODS: Patients undergoing stone surgery in Florida (107,417) between 1998 and 2004 were included in the study. Poisson models were fit to assess temporal changes in the setting (inpatient, outpatient and ambulatory surgery center) and type (open, percutaneous, extracorporeal, ureteroscopy and stenting) of stone surgery. For inpatient procedures secular trends in comorbidity burden (0 or 1 diagnoses vs 2 or more) and procedure acuity (elective vs emergency) were also assessed. Admission requirements and mortality rates were measured according to the surgery setting. RESULTS: Of the 107,417 discharges from 1998 to 2004 surgery rates per 100,000 increased from 35.5 to 38.2 for inpatients (p <0.05), 84.2 to 104.7 for hospital outpatients (p <0.01) and 9.4 to 26.9 for ambulatory surgery centers (p <0.01). For hospitalized patients routine admissions decreased (41.8% to 29.5%, p <0.01) and procedure acuity increased (16.8% to 28.2%, p <0.01). No deaths occurred at ambulatory surgery centers and the rate of admission to acute care hospitals was 2.5/100,000 cases. CONCLUSIONS: Despite the safety and efficiency of ambulatory surgery centers hospital outpatient departments remain the preferred setting for urinary stone surgery. For patients requiring surgical intervention for urinary stone disease ambulatory surgery centers could be an underused resource.