The Importance of Patient Selection at Out-Patient Ambulatory Centers

In the United States, there has been a shift in outpatient procedures being performed in the hospital setting to being done in outpatient surgery centers. As a result, it is very important to determine which patients are appropriate for procedures done in the outpatient facility and which patients need to be referred to the hospital setting. This project entailed contacting stand-alone surgery and endoscopy centers to determine a community standard of current anesthesia prescreening practices and creating a prescreening tool. It is very important from a patient safety view and a monetary aspect to carefully select the appropriate patient for procedures at ambulatory centers. Poor patient selection processes at stand-alone ambulatory surgery centers may jeopardize patient safety. Last minute cancellations at outpatient surgery centers contribute to millions of dollars of unnecessary healthcare expenses and may add increased risk to patient's safety. There are times when the anesthesia provider and the surgeon/procedure doctor may not agree on if a patient should be taken care of at an outpatient center due to the patient's comorbidities. The objectives for this project were to 1) Determine a community standard for current anesthesia prescreening tools used at ambulatory surgery centers and/or endoscopy centers. 2) Compare results gathered from centers with the review of the literature. 3) Develop an evidence-based patient exclusion screening protocol for a stand-alone outpatient endoscopy clinic. 4) Present the screening protocol to the center director and doctors at the endoscopy center for approval, implementation, and potential dissemination to other centers belonging to their corporate partner. Contact will also be made to the American Association of Nurse Anesthetists (AANA) for possible distribution to its members through its website. The literature review encompassed multiple topics on ambulatory surgery center screening. They were broken down into two main categories: type of surgery being performed and comorbidity status of the patient. The common surgeries being performed at ambulatory centers are endoscopies, steroid injections, general surgeries, cataracts, and orthopedic surgeries not requiring an overnight hospital stay. The comorbidities that need careful examination before scheduling at an outpatient center are age, sleep apnea, chronic obstructive pulmonary disease, nothing per oral status, American Society of Anesthesiologists (ASA) classification, BMI (body mass index), recent heart attack, use of supplemental oxygen, renal failure, and use of anticoagulants. The implementation of the project involved multiple steps. Ten ambulatory facilities were contacted using a questionnaire. These results along with information gathered from literature to construct a tool to aid in the prescreening process. The center director at a stand-alone endoscopy center was approached and a meeting was held to discuss the use of the protocol at this center. In summary, it is very important for the safety of the patient to be properly screened prior to performing a procedure at an outpatient surgery/endoscopy center. If proper screening is done, patient risk will decrease and last-minute surgery cancellations may be minimalized. A prescreening exclusion tool based on current literature and established community standards will help to achieve a more thorough screening.

Running head: PATIENT SELECTION AT AMBULATORY CENTERS The Importance of Patient Selection at Out-patient Ambulatory Centers Greg Sanders, CRNA, MSN University of Utah This document is in partial fulfillment of the requirements for the Doctor of Nursing Practice 1 PATIENT SELECTION AT AMBULATORY CENTERS 2 The Importance of Patient Selection at Out-patient Ambulatory Centers Executive Summary In the United States, there has been a shift in outpatient procedures being performed in the hospital setting to being done in outpatient surgery centers. As a result, it is very important to determine which patients are appropriate for procedures done in the outpatient facility and which patients need to be referred to the hospital setting. This project entailed contacting stand-alone surgery and endoscopy centers to determine a community standard of current anesthesia prescreening practices and creating a prescreening tool. It is very important from a patient safety view and a monetary aspect to carefully select the appropriate patient for procedures at ambulatory centers. Poor patient selection processes at stand-alone ambulatory surgery centers may jeopardize patient safety. Last minute cancellations at outpatient surgery centers contribute to millions of dollars of unnecessary healthcare expenses and may add increased risk to patient's safety. There are times when the anesthesia provider and the surgeon/procedure doctor may not agree on if a patient should be taken care of at an outpatient center due to the patient's comorbidities. The objectives for this project were to 1) Determine a community standard for current anesthesia prescreening tools used at ambulatory surgery centers and/or endoscopy centers. 2) Compare results gathered from centers with the review of the literature. 3) Develop an evidencebased patient exclusion screening protocol for a stand-alone outpatient endoscopy clinic. 4) Present the screening protocol to the center director and doctors at the endoscopy center for approval, implementation, and potential dissemination to other centers belonging to their corporate partner. Contact will also be made to the American Association of Nurse Anesthetists (AANA) for possible distribution to its members through its website. The literature review encompassed multiple topics on ambulatory surgery center screening. They were broken down into two main categories: type of surgery being performed and comorbidity status of the patient. The common surgeries being performed at ambulatory centers are endoscopies, steroid injections, general surgeries, cataracts, and orthopedic surgeries not requiring an overnight hospital stay. The comorbidities that need careful examination before scheduling at an outpatient center are age, sleep apnea, chronic obstructive pulmonary disease, nothing per oral status, American Society of Anesthesiologists (ASA) classification, BMI (body mass index), recent heart attack, use of supplemental oxygen, renal failure, and use of anticoagulants. The implementation of the project involved multiple steps. Ten ambulatory facilities were contacted using a questionnaire. These results along with information gathered from literature to construct a tool to aid in the prescreening process. The center director at a stand-alone endoscopy center was approached and a meeting was held to discuss the use of the protocol at this center. In summary, it is very important for the safety of the patient to be properly screened prior to performing a procedure at an outpatient surgery/endoscopy center. If proper screening is done, patient risk will decrease and last-minute surgery cancellations may be minimalized. A prescreening exclusion tool based on current literature and established community standards will help to achieve a more thorough screening. The content expert for this project is Bruce Carter, MD. He is the director of anesthesia at a surgery center. The committee consists of Project Chair, Clint Child DNP, MBA, RN; Program Director, Gillian Tufts, DNP, APRN, CFNP; Assistant Dean for MS & DNP, Pamela Hardin, PhD, RN, CNE. PATIENT SELECTION AT AMBULATORY CENTERS 3 Table of Contents Problem Statement ...........................................................................................................................5 Clinical Significance ........................................................................................................................6 Objectives ........................................................................................................................................7 Literature Review.............................................................................................................................8 Background ..................................................................................................................................8 Patient Morbidity .........................................................................................................................8 Surgery Selection .........................................................................................................................9 Patient Types for Selection ..........................................................................................................9 Age ...........................................................................................................................................9 ASA Classification.................................................................................................................10 Body Mass Index (BMI) ........................................................................................................10 Cardiac ...................................................................................................................................11 Nothing Per Oral (NPO) Status..............................................................................................11 Obstructive Sleep Apnea........................................................................................................11 Pulmonary ..............................................................................................................................12 Renal ......................................................................................................................................12 Theoretical Model ..........................................................................................................................13 Implementation and Evaluation ....................................................................................................14 Results ............................................................................................................................................17 Recommendations ..........................................................................................................................19 DNP Essentials...............................................................................................................................19 Conclusion .....................................................................................................................................20 PATIENT SELECTION AT AMBULATORY CENTERS 4 References ......................................................................................................................................21 Appendices .....................................................................................................................................24 Appendix A- PowerPoint Presentation ................................................................................24 Appendix B- Project Poster ..................................................................................................29 Appendix C- Prescreening Questionnaire .............................................................................31 Appendix D- Prescreening Information ................................................................................33 Appendix E- Outpatient Prescreening Data ..........................................................................35 Appendix F- Ambulatory Prescreening Recommendations .................................................37 Appendix G- AANA Correspondence ..................................................................................39 PATIENT SELECTION AT AMBULATORY CENTERS 5 Problem Statement Last minute surgery cancelations are a big contributor to millions of dollars in unnecessary healthcare expenses in the United States (Same-day, 2012). Further studies have shown that almost 12% of these cancelations are due to preexisting medical conditions (Kumar & Gandhi, 2012). In addition to financial loss, patient safety may be jeopardized by poor patient selection processes at stand-alone ambulatory surgery centers (ASC). It is very important from a patient safety view and a monetary aspect to carefully select the appropriate patient for procedures at ambulatory centers. There are times when the anesthesia provider and the Gastrointestinal (GI) doctor may not agree on if a patient should be taken care of at an outpatient center due to their comorbidities. Some illnesses by themselves are enough to warrant a patient's procedure be done at a hospital rather than an outpatient center. A patient presenting with comorbidities such as morbid obesity, undiagnosed arrhythmia, current chest pain, or supplemental oxygen could face potential morbidity or mortality due to an ambulatory center not having the proper resources needed to treat them if a complication arose. Patients with comorbidities who are scheduled at an ambulatory center instead of a hospital may cause increased pressure to the facility. There may be a push to perform procedures on patients with increased risk, or there may be a potential loss to the facility secondary to delays or same-day cancelations (Same-day, 2012). At an outpatient endoscopy center in Utah, similar situations to those above occur. Currently, there isn't a policy in place guiding GI doctors and the anesthesia providers regarding the patient type that should be treated at the facility, placing the providers at odds over patient scheduling. PATIENT SELECTION AT AMBULATORY CENTERS 6 Clinical Significance In the United States, there has been a significant increase in the number of ambulatory surgery centers over the last few years. As of 2013, there were close to 5800 centers nationwide with around 23 million procedures performed (Fields, 2013). Traditionally, procedures were hospital based. Now, physician-owned outpatient centers capable of performing procedures are becoming commonplace. This trend is what is driving the increase of stand-alone centers. Of these procedures, 24% are gastroenterology procedures, making it the most common surgical specialty in an ambulatory center (Fields, 2013). For many years, sedation for GI endoscopic procedures was maintained using versed and fentanyl by the GI doctor performing the procedure. This method is still in use at some facilities. The use of Propofol is becoming more common for endoscopic procedures at outpatient surgery centers. This shift in sedation has caused multiple changes at these centers. There are a few hospital settings that allow nurses to administer Propofol under the direction of the GI doctor after completing a sedation training. However, Propofol is a general anesthetic drug, has a small range for error, and, when used incorrectly, can significantly increase morbidity and/or mortality. Most commonly, Propofol is administered by an anesthesia provider who has advanced airway training: either an anesthesiologist or certified registered nurse anesthetist (CRNA). There are some differing opinions between surgeons/GI doctors and anesthesia providers about certain patient types and their inherent risk of being sedated. There have been instances when patients have presented with new-onset heart arrhythmias, and because the patient has already been prepped for a colonoscopy, the GI doctors have wanted to proceed with the procedure and send them to the cardiologist or emergency room afterwards. In some instances, PATIENT SELECTION AT AMBULATORY CENTERS 7 the anesthesia provider has been successful in interceding, but there needs to be more consistency to ensure patient safety by decreasing the need for last-minute intervention. If prescreening processes are left as they are, there is an increased risk of morbidity and mortality to the patient at this center. In addition, increased liability to the gastroenterologist and anesthesia providers may occur. There is also a potential for significant financial loss due to delays and cancelations. Reducing the number of patients with significant comorbidities arriving for outpatient procedures through the protocol development, morbidity and mortality rates may decrease, and financial losses can be minimized. Objectives The primary goal of this scholarly project is to develop an evidence-based anesthesia patient screening protocol at an outpatient endoscopy clinic. 1. Determine a community standard for current anesthesia prescreening tools used at ambulatory surgery centers and/or endoscopy centers 2. Compare results gathered from centers with the review of the literature 3. Develop an evidence-based patient exclusion screening protocol for a stand-alone outpatient endoscopy clinic 4. Present the screening protocol to the center director and MD's at the endoscopy center for approval, implementation, and potential dissemination to other centers belonging to their corporate partner. Contact will also be made to the American Association of Nurse Anesthetists (AANA) for possible distribution to its members through its website PATIENT SELECTION AT AMBULATORY CENTERS 8 Literature Review Background ASCs are more commonplace than they used to be. According to Fields (2013), approximately 23 million procedures were performed at ASCs around the country. There were around 2400 Medicare-certified ASCs as of 2014, which is more than the number of acute care hospitals (Carey, 2016). The amount of outpatient surgeries performed at hospitals has gone from 90% to around 45% since the early 1980's (Manchikanti, Parr, Singh, & Fellows, 2011). Performing an outpatient procedure at an ASC is more cost effective than a hospital for multiple reasons: shorter wait time, care of healthier patients, ability to not have best technologies, and not having to provide care for patients who can't afford it (Carey, 2016). Thus, it becomes important to select the correct patient type for these centers (Dejohn, 2013). Search methods used for this topic included CINAHL, PubMed, and google scholar. Keywords included anesthesia screening criteria, ambulatory screening, and outpatient. Professional websites of the American Society of Anesthesiologists (ASA) and the AANA were also researched. Patient Morbidity It is important to note that as a patient's number of comorbidities increase, so does potential morbidity and mortality for that patient (Kataria, Cutter, & Apfelbaum, 2013). One study showed that an ASA III patient accounted for 24% of the morbidity in outpatient procedures (Kataria, Cutter, & Apfelbaum, 2013). Another study showed that in 1,141,418 surgeries performed in ambulatory centers, there were 23 deaths (Keyes et al., 2008). It is difficult to compare this with surgeries performed at hospitals due to the difference in patient comorbidities and the types of surgeries performed in hospitals. Surgeries at hospitals are mostly PATIENT SELECTION AT AMBULATORY CENTERS 9 reserved for extremely sick patients and surgeries of emergent circumstances that will require extensive monitoring of the patient following the surgery. Surgery Selection Selecting the type of patient for a ASC procedure is important but not the only factor to consider. Another factor to consider is the type of procedure being performed. The most commonly performed procedures at ASCs are endoscopies of large or small intestine, spinal cord injections, cataract surgery, tonsillectomy (with or without adenoidectomy), myringotomy with tube placement, and surgery on the muscle, tendon, bursa, or fascia (Cullen, Hall, & Golosinskiy, January 28, 2009). Any surgery requiring close monitoring for an extended period of time afterwards, or a potential for excessive blood loss, should be performed in a hospital setting. Prolonged operating time has been found to increase perioperative morbidity and mortality (Mathis et al., 2013). Patient Types for Selection When deciding whether or not to have a procedure done at an ambulatory center, a patient's comorbidities are the most important factors to consider. There are many illnesses that can increase morbidity and mortality when a patient is under anesthesia. Knowing how these comorbidities interact with an anesthetic is an important function of an anesthesia provider. Comorbidities with the greatest influence on one's potential morbidity will be discussed further. Age. Patients at either end of the spectrum can be at increased risk when undergoing general anesthesia. According to Gupta (2009), patients greater than 85 years of age may have a significant increased risk of morbidity and mortality undergoing anesthesia and should have their health optimized before being considered for any type of anesthetic procedure (Gupta, 2009). PATIENT SELECTION AT AMBULATORY CENTERS 10 ASA classification. Not all patients carry the same risk for undergoing anesthesia. Obviously, healthy patients with little or no comorbidities carry a lower risk than patients with multiple comorbidities. The ASA has developed a scale to rank patients according to their comorbidities to convey the physical status of the patient. The definition of an ASA I patient is a normal, healthy, non-smoking individual ("ASA physical status classification system," 2014). An ASA II patient is one with mild systemic disease such as controlled diabetes or high blood pressure, pregnant, or a smoker. ASA III patients are described as those having severe systemic disease such as uncontrolled diabetes or high blood pressure, COPD, pacemaker, morbid obesity, patient on dialysis, or a history of stents, heart attack, or stroke. An ASA IV patient has severe systemic disease that is a constant threat to life such as heart attack, stroke or cardiac intervention within last three months, or a renal failure patient not undergoing normal dialysis. ASA V is a moribund patient that is not expected to live unless surgery is performed. This would include patients with massive trauma or ruptured aortic aneurysms. The ASA VI patient is declared a brain-dead patient for organ donation. ASA I-III are widely accepted patient types at ambulatory centers, while an ASA IV patient has not been considered acceptable for procedures done at an ambulatory center (Friedman, Chung, & Wong, 2004). Body Mass Index (BMI). Obesity is an important consideration to take into account. As obesity increases, so does the potential for morbidity and/or mortality. The airway can be more difficult to maintain, oxygenation becomes harder, and other comorbidities are more likely to develop. BMI, by itself, shouldn't be the only factor used in determining if a patient should be seen at an ambulatory center (Joshi, Ahmad, Riad, Eckert, & Chung, 2013). However, patients with a BMI>50 have been shown to have a much greater perioperative risk, and patients with a PATIENT SELECTION AT AMBULATORY CENTERS 11 BMI between 40 and 50 with significant obesity-related comorbidities may be safer at a hospital setting (Joshi, Ahmad, Riad, Eckert, & Chung, 2013). Cardiac. According to the American College of Cardiology (ACC)/American Heart Association (AHA) taskforce, elective noncardiac surgery should be delayed to allow for proper recovery (Fleisher et al., 2014). The recommended wait times are a minimum of 14 days following balloon angioplasty, 30 days after bare metal stent (BMS) implantation, and 365 days after drug eluting stent (DES) placement (Fleisher et al., 2014). According to ASA guidelines, a myocardial infarction (MI) less than three months previous, classifies a patient as ASA IV, which at most ambulatory centers disqualifies them from eligibility ("ASA physical status classification system," 2014). Nothing Per Oral (NPO) status. The time required to wait after eating or drinking before safely having anesthesia administered depends on what is ingested. Clear liquids are allowed and recommended up to two hours prior to procedure, solid food eight hours' prior, breast milk six hours, and other milk 6 hours before elective procedures (Smith et al., 2011). Obstructive Sleep Apnea (OSA). Patients presenting for surgery with OSA are at a greater risk of morbidity and mortality than someone without OSA. Reasons for this are that they may be more difficult to mask-ventilate during induction of anesthesia, more difficult to intubate following induction of anesthesia, may increase difficulty to maintain adequate oxygen levels, may delay breathing tube removal following the surgery, may increase potential for prolonged post anesthesia care unit (PACU) stay, or may increase admittance to a hospital following procedure (Joshi, Ankichetty, Gan, & Chung, 2012). Recommendations by the ASA are that a patients' level of sleep apnea should be evaluated, their comorbid conditions optimized, and their CPAP machines used for multiple days following the procedure to minimize the inherent risk of PATIENT SELECTION AT AMBULATORY CENTERS 12 OSA for someone undergoing sedation or anesthesia (Joshi, Ankichetty, Gan, & Chung, 2012). If a patient hasn't been evaluated for sleep apnea, a STOP-Bang questionnaire should be used. This questionnaire evaluates sleep apnea by checking for snoring, determining if the patient is tired, observing breathing cessation during sleep, the current treatment of high blood pressure, checking for morbid obesity, age discrimination of patients older than 50 years, measuring for large neck circumference, or gender discrimination of male patients (Joshi, Ankichetty, Gan, & Chung, 2012). For patients meeting these criteria, it is recommended that procedures done are those requiring minimal narcotics post-operatively (Joshi, Ankichetty, Gan, & Chung, 2012). For patients that either test positive on the STOP-Bang scale but are in need of narcotic pain medications, or those diagnosed OSA patients that don't have access to CPAP, it is suggested their procedures not be done in an outpatient setting. They should be performed at a hospital due to increased risks of anesthesia that carry over for several days post administration (Joshi, Ankichetty, Gan, & Chung, 2012). Pulmonary. Asthma, chronic obstructive pulmonary disease (COPD) and smoking have been associated with an increased risk in outpatient adults (Dabu-Bondoc & Shelley, 2015). According to Mathis et al., a patient with COPD requiring medications is an additional risk factor that other studies haven't taken into account. Ferguson (2012) describes patients with COPD requiring oxygen of any amount at any time during the day as an ASA IV patient. COPD was a common risk factor associated with postoperative pulmonary complications (Kataria, Cutter, & Apfelbaum, 2013). Renal. End stage renal disease (ESRD) is commonly associated with many other disease processes. A careful evaluation prior to any outpatient surgery is needed for patients with ESRD ("Patient screening and assessment in ambulatory surgical facilities," 2009). Fluid and PATIENT SELECTION AT AMBULATORY CENTERS 13 electrolyte balance are important considerations, as well as timing of dialysis ("Patient screening and assessment in ambulatory surgical facilities," 2009). However, according to Kaiser Permanente, patients on hemodialysis are classified as ASA IV patients and would be ineligible for treatment at an ambulatory center (Ferguson, 2012). In summary, the literature has shown that there are multiple aspects surrounding prescreening recommendations for ambulatory surgery centers. The highest risk comorbidities with the greatest influence on an increase of morbidity and mortality include hypertension, COPD, history of trans-ischemic attack (TIA) or stroke, previous percutaneous cardiac intervention (PCI)/heart surgery, morbid obesity, ASA classification IV or greater, OSA, increased age, and type of procedure being performed (Mathis et al., 2013). Theoretical Model The theoretical model chosen to guide this project is the transtheoretical model. This model discusses change in a system or an individual. It focuses on the process involved when change is introduced into a system (Edberg, 2015). This model was helpful because of the focus it provides on the effect this change conveys to the system. The transtheoretical model stresses the evaluation of potential benefits and/or drawbacks to the system by the change before its introduction (Edberg, 2015). The theoretical model has two places in its process that allow for exit from the change cycle. This can be seen in figure 1. The first potential exit is at the point where a decision must be made to carry out a change or not. The other time comes when the change has been done and is being actively maintained; there is no further use for the process at this point. An important part in this process is the contemplative step. This is where the benefits and disadvantages of a change are compared. Then the decision is made whether or not to begin implementation of the PATIENT SELECTION AT AMBULATORY CENTERS 14 change. This piece of the model will allow the implementer to carefully and methodically make a change rather than jumping into a situation and altering it before it is known that it will help. This project is meant to change the way in which patients are pre-screened at an endoscopy center. This model will drive the change and guide the timing and amount of implementation to submit to the system that will maximize its effectiveness. Since the beginning steps of the model focus on the thought process it takes to decide to make a change, this will help to focus on the individuals involved in the system change and their potential reactions to the proposed change. Figure 1. Transtheoretical model. This figure illustrates the different stages of change Implementation and Evaluation The steps for the project are broken down and discussed in detail; they are also included in image 2. The DNP project was presented and passed, see appendix A, and then the implementation phase of the project was begun. The conclusion of the project was presented to the College of Nursing, see appendix B. PATIENT SELECTION AT AMBULATORY CENTERS 15 Objective 1. Determine a community standard for current anesthesia prescreening tools used at ambulatory surgery centers and/or endoscopy centers. To address this objective, contact was made to ten endoscopy and/or ambulatory surgery centers requesting a copy of their anesthesia prescreening process. This was done in order to establish current practice trends in the community. Due to the fact that the community in which the center is located is small and doesn't contain this number of centers, contact was also made to centers outside of the immediate area to establish a pattern of screening both in the community and between the two different types of centers. The implementation of this objective was performed by contacting centers via phone and requesting a hard copy (either via mail or email) of their current prescreening process. Evaluation began with the creation of a questionnaire that guided the contact and data collection with these centers, see appendix C. Institutional Review Board (IRB) approval was sought on November 15, 2016 from the University of Utah IRB via telephone. After an explanation of the project, verbal consent to proceed without IRB approval was received. Most of the centers that were contacted focused on similar aspects for screening, but their interpretations were different. No two centers had the exact same prescreening process. A written summary of center prescreening information is listed below in the results section. Objective 2. Results gathered from the centers were compared with the review of the literature. A side-by-side comparison was performed using a table to help determine similarities and differences among surgery and endoscopy centers. This allowed for easier dissemination of the information. Further analysis with standard-of-care recommendations was conducted. The literature review brought to light different comorbidities that put a patient at an increased risk for an outpatient procedure; sometimes these risks were too great to assume at an outpatient center. These areas include hypertension, COPD, history of trans-ischemic attack (TIA) or stroke, PATIENT SELECTION AT AMBULATORY CENTERS 16 previous percutaneous cardiac intervention (PCI)/heart surgery, morbid obesity, ASA classification IV or greater, OSA, increased age, and type of procedure being performed (Mathis et al., 2013). The centers that were contacted focused on several of these points but not all of them. The objective was successful by completing the summary and table. Objective 3. An evidence-based patient exclusion screening protocol for a stand-alone outpatient endoscopy clinic was created. Using the findings from the different centers and the evidence from the literature, a tool was constructed in a simple flow chart style to identify high risk patients that would be best referred to a hospital for their procedure. Addendums and references were attached to the protocol to ensure standards of care and accuracy of information portrayed. The measurement of this objective was the completion of the tool. Objective 4. Dissemination of the protocol. Contact was made to the center director at this stand-alone endoscopy center to schedule a meeting with the director and the doctors practicing at this center. This meeting was held on March 21, 2017. Evaluation was made by reporting of contact made to the center director. An executive summary was also sent to the American Association of Nurse Anesthetists (AANA) for possible distribution to its members through its website. Evaluation was the submission of an executive summary to the AANA. Image 2 Objective Determine current trends in prescreening patients at outpatient surgery centers Implementation Make personal or phone contact with 5 surgery centers and 5 endoscopy centers (both local and surrounding areas) for their current prescreening processes. Hard copies will be requested either by mail or electronically Evaluation • • • Questionnaire constructed Centers contacted Information obtained PATIENT SELECTION AT AMBULATORY CENTERS Compare results gathered from different centers with the findings from literature review • • • Develop an evidence-based prescreening tool for a standalone endoscopy center • • • Present approved prescreening tool to center director and doctors with intent of use at their facility • • A table will be constructed displaying each center contacted. Side by side comparison of different exclusion criteria Literature review findings will be displayed 17 Written summary and corresponding comparison table completed Prescreening tool Using findings from information gathering, a developed tool will be constructed to aid in prescreening process Specific exclusion criteria for high risk patients Current recommendations in community and literature Center director will be approached about conducting a meeting to discuss the use of protocol Contact AANA for potential distribution to members • • Center director contacted and meeting held Distribution of executive summary to the AANA Results The results for the different objectives are listed below. For objective one, contact was made to ten ambulatory surgery centers using the constructed questionnaire. No two centers had the same prescreening process (see appendix D). While no process was the same, most of the centers used similar comorbidities, their cutoff points were the variation. PATIENT SELECTION AT AMBULATORY CENTERS 18 For objective two, the information gathered from the literature and the different centers was compared to each other (appendix E). There were many similarities between the different centers, but the variations were due to different interpretations of information gathered from the literature and/or one's training as an anesthesia provider. Also, the AAAHC have regulations limiting some centers from providing care to ASA IV patients. None of the centers had processes that went against current literature recommendations. Completing objective three was not as simple as originally thought it would be (appendix F). All of the centers contacted, along with the literature review, showed many variations and possibilities in the limits for some comorbidities. Some areas of concern were addressed in the literature with hard and fast guidelines for cutoff. These were the waiting period after a cardiac event, an ASA IV patient, end stage renal disease without dialysis, and the respiratory status. Other areas were not as straight forward for the recommendations. These included age, and an exact number for BMI. As stated above, morbidity and mortality increases substantially over 50 regardless of existence of comorbidities, and is higher for patients with a BMI between 40 and 50 with comorbidities. Because of this, every center had a different BMI set point. These variations were attributed to respect given to the trained professionals and may be why there are so many different interpretations at outpatient centers rather than one all-inclusive protocol. Being able to construct a tool to screen out absolutes was a little difficult to do with the current research available and because of the many variations in the community. For objective four, the center director was contacted, and interest was expressed on his part. A meeting with the director, and the doctors at the center, occurred on March 21, 2017. The protocol was presented to these individuals and approved for immediate implementation at this facility. The executive summary of this project was also sent to the AANA (appendix G). PATIENT SELECTION AT AMBULATORY CENTERS 19 Recommendations Enough interest was generated at the facility in this project to realize the importance of a community-based standard for screening out high-risk patients at ambulatory centers. It was recommended to pursue a submission to the AANA for potential disbursement to nurse anesthetists nationwide. Having nationally established protocols to alleviate the many variations among ambulatory centers would be advantageous. However, due to multiple facets (provider, patient comorbidities, procedure, and facility) that must be considered to determine whether a center has the needed equipment and personnel to provide the safest care possible to a patient, general guidelines have been used up to this point (Kataria, Cutter, & Apfelbaum, 2013). A nationally recognized algorithm that would alleviate so much personal interpretation would be a good future project. DNP Essentials The DNP essential that ties in with this DNP scholarly project is essential II, which addresses organizational and systems leadership for quality improvement and systems thinking. This project focuses on admission criteria at an outpatient surgery center in order to maintain safety and minimize harm caused to patients. The DNP essential II supports this idea through systems leadership component focusing on improving health outcomes and ensuring patient safety. That is exactly what this project is trying to accomplish by evaluating a current process and using evidence-based studies in anesthesia to improve the selection criteria of patients undergoing outpatient procedures. This part coincides with essential III also. Essential III is the importance of clinical scholarship and analytical methods for evidence-based practice. This is where research is translated into practice. By incorporating this, patient safety will improve and the quality of care delivered at this center will increase. There is also the component of cost- PATIENT SELECTION AT AMBULATORY CENTERS 20 effectiveness that applies to this scenario as well. Delays and cancelations due to inappropriate patient selection can cause a loss in overall revenue and/or increase functioning costs at the center. Conclusion Currently, the majority of same-day surgeries/procedures are being performed at outpatient centers instead of hospitals. Since there are so many more procedures being done at outpatient centers, the risks for patients, and for these centers, are increasing. It is vitally important to decrease risk to patients in order to make outpatient centers as safe as possible. This requires ensuring the right type of patient is being taken care of at a facility that can manage all of his/her needs. Having a tool to help screen out high-risk patients would help to reduce risk to the patient and help to minimize last-minute procedure cancelations. This project entailed contacting ten different surgery and/or endoscopy centers to determine current trends in prescreening processes. A thorough review of current literature was also performed. Many different opinions and recommendations were discovered during this process. Some of the current practices are the same for all centers contacted, while some have varying opinions of what is safe to do at an outpatient center. In summary, it is of vital importance to have a prescreening process in place in order to minimize risk to patients and outpatient surgery centers. Currently, there is not a standardized protocol to help in this matter. This project sought to close this gap at a rural ASC but remains an area needing further research and subsequent implementation. PATIENT SELECTION AT AMBULATORY CENTERS 21 References ASA physical status classification system. (2014, October 15). American Society of Anesthesiologists. Retrieved from http://www.asahq.org/resources/clinical-information/asaphysical-status-classification-system Carey, K. (2016). Ambulatory surgery centers and prices in hospital outpatient departments. Medical Care Research and Review, 1-13. Cullen, K. A., Hall, M. J., & Golosinskiy, A. (2009). Ambulatory surgery in the United States, 2006. National Health Statistics Reports, (Number 11), 1-28. Dabu-Bondoc, S., & Shelley, K. (2015). Management of comorbidities in ambulatory surgery: A review. Dovepress, 2015:2, 39-51. DeJohn, P. (2013). Careful screening and scrutiny needed to select ambulatory surgery patients. OR Manager, 29(9), 1-3. Edberg, M. (2015). Essentials of health behavior: Social and behavioral theory in public health (Second). Jones & Bartlett Learning. Ferguson, M. (2012). KPCO guidelines for determining appropriate ambulatory surgery venue. Retrieved November 19.2016, from http://info.kaiserpermanente.org/info_assets/cpp_cod/cod_ambSurg_determination.pdf Fields, R. (2010). 35 Statistics about GI/Endoscopy. Retrieved June 30.2016, from http://www.beckersasc.com/gastroenterology-and-endoscopy/35-statistics-about-giendoscopy-inascs.html Fleisher, L., Fleischmann, K. E., Auerbach, A. D., Barnason, S. A., Beckman, J. A., Bozkurt, B., … Wijeysundera, D. N. (2014). 2014 ACC/AHA guideline on perioperative cardiovascular PATIENT SELECTION AT AMBULATORY CENTERS 22 evaluation and management of patients undergoing noncardiac surgery. Circulation, Volume 130(24). Friedman, Z., Chung, F., & Wong, D. T. (2004). Ambulatory surgery adult patient selection criteria: A survey of Canadian anesthesiologists. Canadian Journal of Anesthesia, 51(5), 437-443. Gupta, A. (2009). Preoperative screening and risk assessment in the ambulatory surgery patient. Current Opinion in Anaesthesiology, 22(6), 705-711. http://doi.org/10.1097/aco.0b013e3283301fb3 Joshi, G. P., Ahmad, S., Riad, W., Eckert, S., & Chung, F. (2013). Selection of obese patients undergoing ambulatory surgery: A systematic review of the literature. Anesthesia & Analgesia, 117(5), 1082-1091. https://doi.org/10.1213/ANE.0b013e3182a823f4 Joshi, G., Ankichetty, S. P., Gan, T. J., & Chung, F. (2012). Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesthesia & Analgesia, 115(5), 1060-1068. http://doi.org/10.1213/ane.0b013e318269cfd7 Kataria, T., Cutter, T. W., & Apfelbaum, J. L. (2013). Patient selection in outpatient surgery. Clinics in Plastic Surgery, 40(3), 371-382. Keyes, G. R., Singer, R., Iverson, R. E., McGuire, M., Yates, J., Gold, A., … Thompson, D. (2008). Mortality in outpatient surgery. Plastic and Reconstructive Surgery, 122(1). https://doi.org/10.1097/PRS.0b013e31817747fd Manchikanti, L., Parr, A. T., Singh, V., & Fellows, B. (2011). Ambulatory surgery centers and interventional techniques: A look at long-term survival. Pain Physician Journal, 14, E177-E215. PATIENT SELECTION AT AMBULATORY CENTERS 23 Mathis, M. R., Naughton, N. N., Shanks, A. M., Freundlich, R. E., Pannucci, C. J., Chu, Y., … Kheterpal, S. (2013). Patient selection for day case eligible surgery: Identifying those at high risk for major complication. Anesthesiology, 119, 1310-1321. Patient screening and assessment in ambulatory surgical facilities. (2009). Pennsylvania Patient Safety Advisory, 6(1). Retrieved from http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/mar6(1)/documents/03.pd f Smith, I., Kranke, P., Murat, I., Smith, A., O'Sullivan, G., Soreide, E., … in't Veld, B. (2011). Perioperative fasting in adults and children: Guidelines from the European society of anaesthesiology. European Journal of Anaesthesiology, 28(8), 556-569. PATIENT SELECTION AT AMBULATORY CENTERS Appendix A "The Importance of Patient Selection at Out-patient Ambulatory Centers" (PowerPoint Presentation) 24 PATIENT SELECTION AT AMBULATORY CENTERS 25 PATIENT SELECTION AT AMBULATORY CENTERS 26 PATIENT SELECTION AT AMBULATORY CENTERS 27 PATIENT SELECTION AT AMBULATORY CENTERS 28 PATIENT SELECTION AT AMBULATORY CENTERS Appendix B "The Importance of Patient Selection at Out-patient Ambulatory Centers" (Poster) 29 PATIENT SELECTION AT AMBULATORY CENTERS The Importance of Patient Selection at Out-patient Ambulatory Centers 30 PATIENT SELECTION AT AMBULATORY CENTERS Appendix C "Ambulatory Surgery Center Prescreening Questionnaire" 31 PATIENT SELECTION AT AMBULATORY CENTERS 32 Ambulatory Surgery Center Prescreening Questionnaire (Phone questionnaire to center director/Anesthesia provider) The purpose of this questionnaire is to determine various ways ambulatory endoscopy and/or surgery centers prescreen patients in order to identify those that shouldn't have procedures performed in an outpatient center. This will be done in an effort to establish a best practice recommendation for ambulatory surgery center screenings. 1. Do you have a screening process in place at your facility to help decrease the risk of morbidity/mortality? 2. Are these criteria related to the delivery of anesthesia? 3. Are there certain patient types you refer to the hospital setting that are too high risk for your facility? 4. Who makes final determination whether or not a patient is cleared for the intended procedure: anesthesia, surgeon, etc.? 5. Would you be willing to share that information to help establish a community standard? 6. Would you like to receive a copy of the results and recommendations? PATIENT SELECTION AT AMBULATORY CENTERS Appendix D "Center Prescreening Information" 33 PATIENT SELECTION AT AMBULATORY CENTERS 34 Center Information Center 1-BMI >50, defibrillators, new onset heart arrhythmias, ASA IV or higher Center 2-BMI>40 Center 3-ASA IV or higher, patients with a history of Malignant Hyperthermia (MH), pediatrics <1-year-old, MI or CVA have six month waiting period, BMI >45 must be otherwise healthy, and a BMI>50 Center 4-There are no absolute restrictions; every case is brought to the center. Anesthesia makes final decision prior to surgery Center 5-ASA IV or greater, weight >350 pounds Center 6-Cardiac stents or MI in last six months, defibrillators, current use of blood thinners. Center 7-No formal prescreening process, every patient is scheduled. Anesthesia evaluates immediately prior to surgery Center 8-Cardiac stents or MI in last six months, BMI>35, age >80 must be seen by MD prior to procedure, >3L oxygen, history of sleep apnea, must be ambulatory. Center 9-Age>80, cardiac stents or MI in last six months, BMI>35, MD prior to procedure, >3L oxygen, history of sleep apnea, must be ambulatory Center 10-Hemodynamically unstable, ASA IV or greater. *Information listed above denotes exclusion criteria at respective center PATIENT SELECTION AT AMBULATORY CENTERS Appendix E "Outpatient Center Prescreening Data" 35 PATIENT SELECTION AT AMBULATORY CENTERS 36 Outpatient Center Prescreening Data BMI ASA Clas s Dialysi s Home 02 Defibrillato r Age Sleep Apnea Heart Literatur e 50 4 ok Allowed Allowed No -- Allowed Center 1 Center 2 Center 3 Center 4 Center 5 Center 6 50 40 --350 lb -- 1-3 -1-3 -1-3 1-3 Allowed ----Allowed Allowed ----Allowed No ----No ------- Allowed ----Allowed >3 months for stent placement/ heart attack -----Evaluate prior Center 7 No formal prescreening processpatient evaluated by anesthesia at time of procedure 35 -- -- -- -- -- -- -- 1-3 No >3LHospital No >80, clinic visit with surgeon hospital >6 months for stent placement More Strict Than Center 8 -- -- -- Hemodynamic stable 1-3 No -- No -- -- No Center 8 Center 9 Center 10 *-- represents information not used to evaluate at the center PATIENT SELECTION AT AMBULATORY CENTERS Appendix F "Ambulatory Prescreening Recommendations" 37 PATIENT SELECTION AT AMBULATORY CENTERS Ambulatory Prescreening Recommendations AGE <85, ok to proceed >85, evaluate comorbidities ASA CLASS ASA I,II,III-ok to proceed ASA >4, Schedule at hospital BMI Cardiac <50, minimal comorbidities-ok to proceed >50, schedule at hospital Pacemaker, heart attack, stroke, stent placement >3 months-ok to proceed Defibrillator, heart attack, stroke, stent placement <3 months-schedule at hospital Renal ESRD undergoing regular hemodialysis-ok to proceed ESRD not undergoing regular hemodialysis-schedule at hospital Respiratory Controlled asthma, COPD, obstructive sleep apnea-ok to proceed Uncontrolled asthma, COPD (on oxygen), obstructive sleep apnea-consider scheduling at hospital 38 PATIENT SELECTION AT AMBULATORY CENTERS Appendix G "AANA Correspondence" 39 PATIENT SELECTION AT AMBULATORY CENTERS AANA Correspondence 40