Proyecto DUCMA 2.0. Puesta al día sobre la situación actual de las unidades de Cirugía Mayor Ambulatoria en España / DUCMA 2.0 project: Update on the current situation of the outpatient surgery units in Spain

Introducción: La cirugía mayor ambulatoria (CMA) es un sistema de gestión seguro y eficiente para resolver los problemas quirúrgicos, pero su implantación y desarrollo ha sido variable. El objetivo de este estudio es describir las características, la estructura y el funcionamiento de las unidades de Cirugía Mayor Ambulatoria (UCMA) en España. Métodos: Estudio observacional, transversal, multicéntrico basado en una encuesta electrónica, con recogida de datos entre abril y septiembre de 2022. Resultados: En total, 90 UCMA completaron la encuesta. La media del índice de ambulatorización (IA) global es de 63%. Más de la mitad de las UCMA (52%) son de tipo integrado. La mitad las unidades imparte formación para médicos (51%) y personal de enfermería (55%). Los indicadores de calidad más utilizados son la tasa de suspensiones (87%) y de ingresos no previstos (80%). Conclusiones: Se necesita mayor coordinación entre administraciones para obtener datos fiables. Asimismo, se deben implementar sistemas de gestión de calidad en las unidades y desarrollar herramientas para la formación adecuada de los profesionales implicados.(AU)

Introduction: Ambulatory surgery is a safe and efficient management system to solve surgical problems, but its implementation and development has been variable. The aim of this study is to describe the characteristics, structure and functioning of ambulatory surgery units (ASU) in Spain. Methods: Multicenter, cross-sectional, observational study based on an electronic survey, with data collection between April and September 2022. Results: In total, 90 ASUs completed the survey. The mean overall ambulatory index is 63%. More than half of the ASUs (52%) are integrated units. Around half of the units provide training for physicians (51%) and for nurses (55%). The most frequently used quality indicators are suspension rate (87%) and the rate of unplanned admissions (80%). Conclusions: Greater coordination between administrations is needed to obtain reliable data. It is also necessary to implement quality management systems in the different units, as well as to develop tools for the adequate training of the professionals involved.(AU)

Safety of Outpatient Plastic Surgery: A Comparative Analysis Using the TOPS Registry with 286,826 Procedures.

BACKGROUND: Outpatient plastic surgery at office-based surgery facilities (OBSFs) and ambulatory surgery centers (ASCs) has become increasingly prevalent over the past 30 years. Importantly, historical data are inconsistent regarding the safety outcomes of these venues, with advocates for both citing supporting studies. This investigation's purpose is to provide a more definitive comparative evaluation of outcomes and safety for outpatient surgery performed in these facilities. METHODS: The most common outpatient procedures were identified using the Tracking Operations and Outcomes for Plastic Surgeons database between 2008 and 2016. Outcomes were analyzed for OBSFs and ASCs. Patient and perioperative information was also analyzed using regression analysis to identify risk factors for complications. RESULTS: A total of 286,826 procedures were evaluated, of which 43.8% were performed at ASCs and 56.2% at OBSFs. Most patients were healthy, middle-aged women categorized as American Society of Anesthesiologists class I. The incidence of adverse events was 5.7%, and most commonly included antibiotic requirement (1.4%), dehiscence (1.3%), or seroma requiring drainage (1.1%). Overall, there was no significant difference in adverse events between ASCs and OBSFs. Age, American Society of Anesthesiologists class, body mass index, diabetes, smoking history, general anesthesia, certified registered nurse anesthetist involvement, operative duration, noncosmetic indications, and body region were associated with adverse events. CONCLUSIONS: This study provides an extensive analysis of common plastic surgery procedures performed in an outpatient setting in a representative population. With appropriate patient selection, procedures are safely performed by board-certified plastic surgeons in ambulatory surgery centers and office-based settings, as evidenced by the low incidence of complications in both environments. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Use of chloroprocaine in orthopedic day surgery: a brief report in a cohort of patients undergoing knee arthroscopy.

OBJECTIVE: Spinal anesthesia with local anesthetics is a viable alternative to general anesthesia in orthopedic surgery, and it is currently considered the standard of care for knee arthroscopy. The use of chloroprocaine may offer several potential advantages over other local anesthetics, including, above all, its rapid onset and short duration of action. The aim of the present retrospective study is to evaluate the post-surgical outcomes of patients who underwent knee arthroscopy using spinal anesthesia with chloroprocaine in an outpatient orthopedic setting. PATIENTS AND METHODS: Data from patients who underwent elective knee arthroscopy between January 2022 and December 2022 were collected for the present study. Spinal anesthesia with chloroprocaine 10 mg/mL was administered in the designated subarachnoid space (L3-L4 in the majority of patients). A dosage of 40 mg was used to obtain a satisfactory sensory and motor block. RESULTS: A total number of 302 patients met the inclusion criteria. No complications were reported during surgery in the present series of patients. None of the patients required bladder catheterization. In 84% of cases, the PADSS (Post-Anesthetic Discharge Scoring System) score at discharge was 10, whereas in 16% of cases, the PADSS score was 9. The mean time from anesthesia induction to first urination was 75±9.4 minutes, while the mean time from the anesthesia induction to the discharge from the hospital was 152±18.5 minutes. CONCLUSIONS: Spinal chloroprocaine for knee arthroscopy demonstrated a short motor block duration, resulting in a fast time to discharge. These limited data show that chloroprocaine may be safely and effectively applied in outpatient knee arthroscopy procedures. However, more studies, possibly with a randomized design, are required to confirm these findings.

Manejo anestésico de un paciente con síndrome de Churg-Strauss en el contexto ambulatorio: informe de un caso / Anesthesia management in a patient with Churg-Strauss syndrome in the ambulatory setting: A case report

La granulomatosis eosinofílica con poliangitis, también denominada síndrome de Churg-Strauss, es una vasculitis rara con compromiso multisistémico. Existe poca literatura en cuanto al enfoque anestésico de los pacientes con esta enfermedad. A nuestro saber, presentamos aquí el primer informe sobre cirugía ambulatoria en un paciente con granulomatosis eosinofílica con poliangitis. Este caso subraya la preocupación por la seguridad de la cirugía ambulatoria y el manejo anestésico exitoso de un paciente con granulomatosis eosinofílica con poliangitis con anestesia regional.(AU)

Eosinophilic granulomatosis with polyangiitis, also known as Churg-Strauss syndrome, is a rare type of vasculitis with multisystemic involvement. Very few authors have described the anaesthesia technique in these patients. We present the first report on ambulatory surgery in a patient with eosinophilic granulomatosis with polyangiitis. This case dispels concerns about the safety of day surgery and reports successful regional anaesthesia management in a patient with eosinophilic granulomatosis with polyangiitis.(AU)

Editorial Commentary: Cost Savings Related to Ambulatory Surgery Center Use Almost Exclusively Benefit the Payor.

Use of ambulatory surgery centers for orthopaedic procedures has been on the rise. The cost of any given ambulatory procedure tends to be less at an ambulatory surgery center than at a hospital outpatient department. People may assume that these cost savings benefit the patient, but recent research using claims and reimbursement databases shows minimal patient out-of-pocket cost reduction, and this minimal reduction is gradually increasing. The research also shows lower surgeon and facility reimbursement. The payor primarily benefits. The explanation probably lies in the fact that for procedures such as hip arthroscopy, patients are likely to meet their deductibles and out-of-pocket maximums regardless of venue, and any cost reduction for these types of procedures almost exclusively benefits the payor. Compounding this, increasing deductibles and copayment requirements, as have been prevalent in recent years, likely contribute to overall increased patient out-of-pocket expenditures seen over time.

The high-risk pediatric patient for ambulatory surgery.

PURPOSE OF REVIEW: The aim of this article is to briefly review the pediatric ambulatory surgery landscape, identify two of the most common comorbidities affecting this population, examine the influence of pediatric obesity and sleep disordered breathing (SDB)/obstructive sleep apnea (OSA) on perioperative care, and provide information that can be used when formulating site specific criteria for ambulatory surgical centers. RECENT FINDINGS: Most pediatric surgeries performed are now ambulatory, a majority of which take place outside of academic centers. Children with comorbidities such as obesity and SDB/OSA are undergoing surgical or diagnostic procedures which were previously deemed unacceptable for ambulatory surgery. The increase in pediatric ambulatory surgery coupled with a recent shortage of pediatric anesthesiologists means many children will receive anesthesia care from general clinicians who care for children intermittently and may be unfamiliar with the perioperative risks these comorbidities can present. SUMMARY: Our pediatric ambulatory surgical population is anticipated to demonstrate increasing rates of obesity and SDB/OSA. Bringing attention to potential perioperative complications associated with these comorbidities provides a stronger foundation upon which to formulate criteria for individual ambulatory centers. It allows for targeted anesthetic management, influences provider assignments and/or staffing ratios, and informs scheduling times. For anesthesiologists who do not practice pediatric anesthesia daily, knowing what to anticipate plays a significant role in the ability to eliminate surprises and care for these patients safely.

Enucleación prostática con láser de holmio (HoLEP) mediante cirugía sin ingreso: una alternativa posible y segura / Holmium laser enucleation of the prostate (HoLEP) as same-day surgery: A safe and feasible option

Objetivo Estudiar la viabilidad de la enucleación prostática con láser de holmio (HoLEP) en circuito de cirugía mayor ambulatoria. Material y métodos Se realiza un estudio prospectivo observacional en el que se incluyen 25 pacientes intervenidos de HoLEP que han sido dados de alta el mismo día de la cirugía según criterios previamente establecidos. Resultados La edad media de los pacientes intervenidos fue de 65,1 años. El volumen prostático medio fue de 45,8cc. Todos los pacientes fueron dados de alta el día de la cirugía (alta efectiva 100%). El porcentaje de complicaciones en nuestra serie fue del 12%, todas ellas grado I según la Clasificación Clavien Dindo. Ningún paciente precisó reingreso en los 30 días posteriores al procedimiento. El porcentaje de satisfacción con el circuito de cirugía ambulatoria fue del 95%. Conclusiones Tras el análisis inicial de nuestros datos podemos concluir que el HoLEP ambulatorio es una técnica eficaz y segura con bajo riesgo de complicaciones. El circuito de cirugía ambulatoria es el preferido por los pacientes intervenidos de HoLEP (AU)

Objective To study the feasibility of holmium laser enucleation (HoLEP) performed as a same-day surgery. Material and methods Prospective observational study including 25 patients submitted to HoLEP. Patients were discharged the same day if they met the established criteria. Results The mean age of the patients was 65.1 years and prostate volume was 45.8cc. All patients were discharged the same day of surgery. The overall complication rate at 30 days was 12% (Clavien I 100%). The rate of re-hospitalization was 0%. Patient satisfaction rate with the day surgery pathway was 95%. Conclusions The initial analysis of our results suggests that outpatient HoLEP is a safe and effective alternative with low rate of complications. According to satisfaction rates, patients prefer the day surgery pathway for the performance of HoLEP (AU)

Ambulatory Orbital Fracture Repair: An Analysis of ER Visits After Surgery From a Multistate Study.

OBJECTIVE: To determine the 30-day postoperative emergency room (ER) visit rate following ambulatory orbital fracture repair with same-day discharge, and the causes and risk factors associated with ER visit. STUDY DESIGN: Database study. SETTING: State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) for California, New York, and Florida for 2011. METHODS: We identified orbital fracture repair procedures among adults from the SASD, which was linked to the SEDD to identify the incidence and causes of ER visits within 30 days. Univariate and multivariable logistic regression models were used to determine the factors associated with ER visit. RESULTS: Among 762 patients, the 30-day postoperative ER visit rate was 4.5%. Most ER visits (58.9%) occurred during the first week after surgery. The most common reasons for ER visits were related to pain, swelling, headache, dizziness, and fatigue (29.4%), followed by ophthalmologic etiologies including visual disturbances and infection of the eye (14.7%). There was no case of retrobulbar hematoma. In the multivariate analysis, patients living in Florida were at a significantly higher risk for ER visit compared to those in California (odds ratio: 4.48 [1.43-14.10], p = .010). CONCLUSION: Ambulatory orbital fracture repair appears to be safe. Common reasons for ER visit included pain, swelling, and ophthalmic symptoms. An increased risk for ER visit was seen with certain geographic regions but not with medical comorbidities or concurrent facial fractures or procedures.

Outpatient parotidectomy: Outcomes, safety and satisfaction.

PURPOSE: Parotidectomies are rarely performed on an outpatient basis. The specific perioperative outcomes and their management remains insufficiently described to change daily practice. The objectives were to study the outcomes, the complications and the patient satisfaction rate in parotidectomy performed on an outpatient basis. MATERIALS AND METHODS: We conducted a retrospective monocentric database study on 85 patients who underwent parotidectomy as a first and sole procedure from 2015 to 2020. We analyzed perioperative outcomes between outpatients and inpatients. RESULTS: Among 28 outpatients and 57 inpatients, no significant differences in total perioperative complications (p = .66; OR = 1.25; 95 % confidence interval (CI) [0.47; 3.36]), reoperations (p = .55), readmissions (p = 1), or unplanned visits (p = .52) were shown in multivariate analysis. The conversion rate for surgical reasons was 8.6 %, and the satisfaction rate was high. CONCLUSION: Although outpatient parotidectomies should be as safe as for inpatients, the high rate of minor complications requires specific perioperative management, such as a systematic early postoperative visit and optimized preoperative information in order to be carried out with minimal issues.

Holmium laser enucleation of the prostate (HoLEP) as same-day surgery: A safe and feasible option.

OBJECTIVE: To study the feasibility of holmium laser enucleation (HoLEP) performed as a same-day surgery. MATERIAL AND METHODS: Prospective observational study including 25 patients submitted to HoLEP. Patients were discharged the same day if they met the established criteria. RESULTS: The mean age of the patients was 65.1 years and prostate volume was 45.8cc. All patients were discharged the same day of surgery. The overall complication rate at 30 days was 12% (Clavien I 100%). The rate of re-hospitalization was 0%. Patient satisfaction rate with the day surgery pathway was 95%. CONCLUSIONS: The initial analysis of our results suggests that outpatient HoLEP is a safe and effective alternative with low rate of complications. According to satisfaction rates, patients prefer the day surgery pathway for the performance of HoLEP.

Spinal anesthesia in ambulatory surgery.

Spinal anesthesia is a safe alternative to general anesthesia but remains underrepresented in the ambulatory setting. Most concerns relate to low flexibility of spinal anesthesia duration and the management of urinary retention in the outpatient setting. This review focuses on the characterization and safety of the local anesthetics that are available to adapt spinal anesthesia very flexibly to the needs of ambulatory surgery. Furthermore, recent studies on the management of postoperative urinary retention provide evidence for safe, but report wider discharge criteria and much lower hospital admission rates. With the local anesthetics that have current approval for usage in spinal anesthesia, most requirements for ambulatory surgeries can be met. The reported evidence on local anesthetics without approval supports clinically established off-label use and can improve the results even further.

Resultados preliminares de la implementación de la prostatectomía radical robótica en régimen de cirugía mayor ambulatoria / Preliminary results of the implementation of robotic radical prostatectomy in a major ambulatory surgery regimen

Objetivo Reportar nuestra experiencia inicial de prostatectomía radical robótica (PRR) en régimen ambulatorio. Material y métodos Análisis retrospectivo de los pacientes intervenidos de PRR en cirugía mayor ambulatoria (CMA) en nuestro centro entre marzo de 2021 y mayo de 2022. Recopilamos las características basales de los pacientes, los resultados intraoperatorios y los datos del postoperatorio (necesidad de asistencia médica no planificada y complicaciones al mes de la cirugía). Se recogieron las características oncológicas al diagnóstico de la enfermedad (PSA, estadificación, ISUP, RMN) y el resultado anatomopatológico tras la intervención. Resultados Identificamos un total de 35 pacientes, con una edad promedio de 60,8 ±6,88 años y un IMC de 27 ±2,9kg/m2. Todos presentaban un riesgo anestésico bajo y un 25,71% tenían alguna cirugía abdominal previa. El tiempo quirúrgico fue de 151,66 ±42,15 minutos y el sangrado promedio fue de 301,2 ±184,38mililitros. Dos pacientes (5,7%) ingresaron la primera noche de la cirugía y 7 pacientes (20%) consultaron en urgencias en el mes siguiente, de los cuales 3 (8,57%) reingresaron. Registramos una complicación intraoperatoria, 7 complicaciones postoperatorias leves (ClavienI-II) y una complicación grave (ClavienIIIb). La complicación grave transcurrió al octavo día postoperatorio y no tuvo relación con la ambulatorización del procedimiento. Conclusión La ausencia de complicaciones graves en el postoperatorio inmediato avala la PRR en régimen de CMA como una técnica segura dirigida a pacientes seleccionados (AU)

Objective To report our initial experience with robotic radical prostatectomy (RRP) as an outpatient procedure. Material and methods Retrospective analysis of patients who underwent RRP as major ambulatory surgery (MAS) at our center between March 2021 and May 2022. We collected baseline patient characteristics, intraoperative outcomes and postoperative data (need for unplanned medical care and complications at one month after surgery). Oncologic characteristics at disease diagnosis (PSA, staging, ISUP, MRI) and postoperative pathologic outcomes were collected. Results We identified a total of 35 patients with an average age of 60,8 ±6,88years and a BMI of 27 ±2,9kg/m2. All patients had a low anesthetic risk and 25.71% had undergone previous abdominal surgery. The surgical time was 151,66 ±42,15minutes and the average blood loss was 301,2 ±184,38milliliters. Two patients (5.7%) were admitted for one night and 7 patients (20%) consulted the emergency department in the following month, of which 3 (8.57%) were readmitted. We recorded one intraoperative complication, 7 mild postoperative complications (ClavienI-II) and one severe complication (ClavienIIIb). The severe complication occurred on the eighth postoperative day and was not related to the procedure being ambulatory. Conclusion The absence of serious complications in the immediate postoperative period supports RRP in MAS as a safe technique for selected patients (AU)

Comprehensive review of a large cohort of outpatient versus inpatient open renal and bladder surgery in children.

INTRODUCTION: Outpatient surgery and pediatric ambulatory surgery centers continue to have increasing popularity among pediatric urologist for minor surgeries. Past studies have shown that open renal and bladder surgeries (i.e. nephrectomy, pyeloplasty and ureteral reimplantation) can also be done in an outpatient setting. With health care costs continuing to rise, it may be reasonable to explore performing these surgeries as an outpatient and consider performing them in a pediatric ambulatory surgery center. OBJECTIVE: Our study assesses the safety and utility of outpatient open renal and bladder surgeries in children compared to those done as inpatients. STUDY DESIGN: IRB-approved chart review was performed on patients undergoing nephrectomy, ureteral reimplantation, complex ureteral reimplantation, and pyeloplasty by a single pediatric urologist between January 2003-March 2020. Procedures were performed at a freestanding pediatric surgery center (PSC) and a children's hospital (CH). Demographics, type of procedures, American Society of Anesthesiologists score, operative times, time to discharge, ancillary procedures, readmission or ER visits within 72 h were reviewed. Home zip codes were used to determine the distance from pediatric surgery center and children's hospital. RESULTS: 980 procedures were evaluated. Of these, 94% procedures were performed as an outpatient and 6% procedures were performed as inpatients. 40% of patients underwent ancillary procedures. Outpatients had a significantly lower age, ASA score, operative time, and readmission or return to ER within 72 h (1.5% vs. 6.2%). Twelve patients were readmitted (9 outpatient, 3 inpatient) and six returned to the ER (5 outpatient, 1 inpatient). 15/18 of these patients underwent reimplantations. Four required early reoperation on postoperative day (POD)2-3. Only one outpatient reimplant was admitted one day later. PSC patients lived farther away. DISCUSSION: Outpatient open renal and bladder surgery was found to be safely performed in our patients. In addition, it did not matter whether the operation was done in the children's hospital or pediatric ambulatory surgery center. Since outpatient surgery has been shown to be significantly less expensive than inpatient surgery, it is reasonable for pediatric urologist to consider performing these operations in the outpatient setting. CONCLUSIONS: Our experience shows that an outpatient approach to open renal and bladder procedures is safe and should be considered when counseling families about treatment options.

Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients.

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

Ambulatory appendectomy for acute appendicitis: Can we treat all the patients? A prospective study of 451 consecutive ambulatory appendectomies out of nearly 2,000 procedures.

BACKGROUND: Acute appendicitis represents the leading cause of acute gastrointestinal disorders, but only a small series regarding ambulatory appendectomies are available. The aim of this study was to report the results of ambulatory (day-case) appendectomy for acute appendicitis in a large consecutive cohort and to improve selection criteria in order to extend the indications. METHODS: All appendectomy procedures for acute appendicitis (March 2013 to June 2020) were included retrospectively. Criteria to select patients eligible for ambulatory appendectomy were based on our clinico-radiological St-Antoine's score ≥4. RESULTS: In total, 1,730 consecutive patients had an appendectomy for acute appendicitis: 1,279 (74%) in conventional settings and 451 (26%) in ambulatory settings. In the conventional group, 360 (28%) patients had surgery deferred to the next morning, whereas in the ambulatory group, 309 patients (70%) were readmitted the next morning (P < .0001). In the ambulatory group, 376 (83%) patients satisfied the criteria (score ≥4), and 90.9% were discharged on postoperative day 0. Rates of unplanned consultation and readmission were not significantly different (5.1% vs 6.6% P = .243). Multivariate analysis of the entire cohort confirmed absence of radiological perforation as highly predictive of early discharge (odds ratio = 6.073). In our cohort, these patients had an early discharge rate of 86.4% compared to 90.2% in those with a St-Antoine's score ≥4. Considering only radiological evidence of perforation as a selection criterion for ambulatory appendectomy, 581 more patients would be eligible for ambulatory surgery (+60%). CONCLUSION: Ambulatory surgery for acute appendicitis based on St-Antoine's score is safe. We propose to extend the indication for ambulatory management to all patients without radiological evidence of perforation.

Postoperative Discharge Scoring Criteria After Outpatient Anesthesia: A Review of the Literature.

PURPOSE: The aim of this review was to explore the existing literature on discharge criteria, tools and strategies used in the postanesthesia care unit (PACU) after ambulatory surgery and to identify the essential components of an effective and feasible scoring system based on applicable criteria for the three phases of anesthesia recovery to assess patient discharge after outpatient anesthesia. DESIGN: A review of the literature. METHODS: In this study, a review of sixteen articles was conducted to analyze the affecting factors, evaluation tools, and the current research status of patients discharge after outpatient anesthesia. FINDINGS: The main factors affecting the discharge after diagnostic or therapeutic procedures under outpatient anesthesia were hospital management, medical treatment and patients themselves. Physiological systems-based discharge assessment had several advantages over traditional time-based discharge assessment. The Aldrete scoring scale was often used for patients in the first stage of anesthesia recovery to leave the PACU, and the Chung's scoring scale was often used to evaluate patients in the second stage of recovery until they leave the hospital. These two scales were often used in combination for outpatient anesthesia. The Fast-tracking assessment tool was used in patients who directly returned to the ward or discharge of patients after ambulatory surgery. There is currently no uniform standard or tool for assessing patients discharge after diagnostic or therapeutic procedures under the outpatient anesthesia. CONCLUSIONS: Optimal care under anesthesia should allow the patient to recover from anesthesia smoothly and quickly and leave the hospital safely. When the patients can safely leave the hospital after outpatient anesthesia is still a problem that needs to be solved in the nursing field. Various existing scoring systems have their historical advancements, but we need to formulate more in line with the current status of postoperative patients discharge standards.

Ambulatory Lumbar Fusion: A Systematic Review of Perioperative Protocols, Patient Selection Criteria, and Outcomes.

STUDY DESIGN/SETTING: Systematic review. OBJECTIVE: The primary purpose was to propose patient selection criteria and perioperative best practices that can serve as a starting point for an ambulatory lumbar fusion program. The secondary purpose was to review patient-reported outcomes (PROs) after ambulatory lumbar fusion. SUMMARY OF BACKGROUND: As healthcare costs rise, there is an increasing emphasis on cost saving strategies (i.e. outpatient/ambulatory surgeries). Lumbar fusion procedures remain a largely inpatient surgery. Early studies have shown that fusion procedures can be safely preformed in an outpatient setting but no review has summarized these findings and best practices. MATERIALS AND METHODS: This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, The Cochrane Library, and Embase were searched. The following data were collected: (1) study design; (2) number of participants; (3) patient population; (4) procedure types; (5) procedure setting; (6) inclusion criteria; (7) protocols; (8) adverse events; (9) PROs; and (10) associations between patient/surgical factors, setting, and outcomes. RESULTS: The search yielded 20 publications. The following selection criteria for ambulatory lumbar fusion were identified: age below 70, minimal comorbidities, low/normal body mass index, no tobacco use, and no opioid use. The perioperative protocol can include a multimodal analgesic regimen. The patient should be observed for at least three hours after surgery. The patient should not be discharged without an alertness check and a neurological examination. Patients experienced significant improvements in PROs after ambulatory lumbar fusion; similarly, when compared to an inpatient group, ambulatory lumbar fusion patients experienced a comparable or superior improvement in PROs. CONCLUSION: There are two critical issues surrounding ambulatory lumbar fusion: (1) Who is the ideal patient, and (2) What needs to be done to enable expedited discharge? We believe this review will provide a foundation to assist surgeons in making decisions regarding the performance of lumbar fusion on an ambulatory basis. LEVEL OF EVIDENCE: Level III.

Short-Term Patient Outcomes After Implementation of Robotic-Assisted Radical Prostatectomy Under Opioid Free Anesthesia at an Ambulatory Surgery Center.

PURPOSE: Opioid free anesthesia (OFA) is associated with decreased risk of PONV and need for rescue analgesia, making it ideal for patients anticipating same-day discharge. The purpose of this project was to describe the perioperative care and short-term outcomes for patients undergoing robotic-assisted radical prostatectomy (RARP) under OFA at an ambulatory surgical center (ASC). DESIGN: A retrospective descriptive design was used to examine the perioperative care and short-term outcomes of patients undergoing RARP under OFA at an ASC. METHODS: The records of all sequential patients undergoing RARP over an 18-month period were reviewed. Data collected included patient comorbidities, surgical procedures, medications administered, verbal numeric rating scale (VNRS) for pain scores, times to oral intake, ambulation, and discharge, patient disposition, and unplanned return to the ER or hospital within 30 days. FINDINGS: Data were extracted from 54 sequential records. Median VNRS scores were zero throughout PACU stay. Fifty-three patients (98.1%) were successfully discharged home, with an average postoperative stay of 250.8 (SD 35.0) minutes. There were no complaints of post-discharge nausea and vomiting or intractable pain at 72 hours after surgery. One patient was transferred to the hospital and two patients returned to the emergency room within 30 days. CONCLUSIONS: Although generalizability is limited, these results suggest that carefully selected patients can be discharged home after RARP under a balanced OFA technique. Innovative practices are needed to address the current backlog of patients needing non-emergent surgery. Discharge home avoids the increase in resource consumption and infection risk associated with hospital admission.

Risk stratification of patients undergoing outpatient lumbar decompression surgery.

BACKGROUND CONTEXT: Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers. PURPOSE: To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay. STUDY DESIGN/SETTING: Retrospective single-institution cohort. PATIENT SAMPLE: A total of 1656 patients undergoing primary lumbar decompression. OUTCOME MEASURES: Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay. METHODS: Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified. RESULTS: A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.