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.