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Administration/Should outpatient surgery centers do ASA class IV patients?

QUESTION:

"We are a free standing outpatient surgery center.  Currently, we do not do ASA Class IV patients.  However, we are seeing more and more patients presenting as Class IV.  It seems as if we are cancelling more and more patients due to ASA 4 classifications. We do a lot of cataracts and many of those pts. have a lot of health issues. Are there any other outpatient surgery centers that do ASA IV under general anesthesia?"

-- From Diana McDaniel, MSN, CASC

REPLY:

There are two main problems associated with undertaking ambulatory surgery in the ASAPS IV patient in a free standing center, namely resuscitation in the event of an adverse event and the need for admission to an inpatient facility.

Risk factors for hospital admission or death were identified in a recent retrospective study of 783,483 outpatients (1). There were 4,351 (1:180) admissions and 19 deaths (1:41,235). 744,356 procedures were performed in hospital based centers and 39,202 in free standing centers. The nine risk factors identified included age over 85 years, duration of surgery of 60-119 minutes and greater than 120 minutes, cardiac disease, peripheral vascular disease, cerebrovascular disease, malignancy, HIV positive status, and general anesthesia. By assigning a point to each of the factors and two points to surgery duration greater than 120 minutes, the authors developed an index to try to predict risk of adverse outcome.  Predictors of adverse outcome were the presence of 2 risk factors (odds ratio {OR} 8.564.) and 3 or more risk factors (OR 5.875).  76% of the patients had none or one risk factor and an odds ratio of 0.117.  

Another retrospective study evaluated 564,267 Medicare beneficiaries who underwent outpatient surgery (2). The predictors of death within 7 days of outpatient surgery included age greater than 85 years (OR 2.30), surgery performed at an outpatient hospital (OR 1.47), invasiveness of the surgery, and prior inpatient admission within 6 months (OR 1.44). The number of prior admissions was the strongest predictor of postoperative inpatient hospital admission: 1 prior admission - OR1.5, 2 prior admissions – OR 2.06, 3 admissions – OR 2.43, and 4 or more – OR 3.39. Prior vascular surgeries were associated with higher admission rates (OR 6.27), laparoscopic cholecystectomy (OR 4.27), transurethral resection of the prostate (OR 4.7), and femoral herniorraphy (OR 4.83).   

Patients with severe systemic disease may require invasive monitoring, vasoactive drug infusions, and ventilatory support postoperatively, even after relatively minor surgeries.  Free standing ambulatory centers may have manpower and equipment limitations that may preclude this type of management.  Furthermore, in the case of an emergency, these limitations may hinder attempts at adequate resuscitation. While the anesthesiologist may be capable of managing most emergencies, these establishments rarely have immediate access to physician consultants such as cardiologists or electrophysiologists who may be needed to diagnose and treat complex arrhythmias. In the event that transfer to a hospital becomes necessary, it would require transport by ambulance which could result in a potential delay in the initiation of definitive treatment and a less than optimal result. Therefore, I would conclude that it is not advisable for ASA PS IV patients to undergo ambulatory surgery in a free-standing outpatient surgery center.

-- Shireen Ahmad, MD, Chicago, IL

References:

1. Fleisher LA, Pasternak R, Lyles A: A novel index of elevated risk for hospital admission or death immediately following outpatient surgery. Anesthesiology 2002; 96:A38 (abstract)
2. Fleisher LA, Pasternak R, Herbert R, Anderson GF: Inpatient hospital admission and death after outpatient surgery in the elderly. Arch Surg 2004; 139: 67-72

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