Unanticipated admission to the hospital following ambulatory surgery

Article Abstract:

Changes in the cost recovery mechanisms in American health care have led to a sustained shift of patients from hospitalization to ambulatory treatment. This includes an increased use of ambulatory surgery. In 1988, approximately 50 percent of all surgical procedures were performed on an outpatient basis and the trend is expected to continue, reaching 60 percent by the early 1990s. Since more complicated surgical cases are now treated on an ambulatory basis, the practices of anesthesiologists, internists and surgeons are being affected. This study evaluates the safety of increases in ambulatory surgery by examining the number of "unanticipated admissions" to the hospital that follow such surgery. Of 9,616 adult patients who underwent ambulatory surgery between 1984 and 1986, 100 were subsequently admitted to a university-affiliated hospital for postsurgical difficulties. The most common reasons for these admissions were pain (18 percent), bleeding (18 percent) and vomiting (17 percent). Risk factors for postsurgical hospital admission were the use of general anesthesia with subsequent vomiting, lower abdominal and urologic surgery and procedures lasting over one hour. A strong independent association with postsurgical vomiting indicates that these individuals should receive anti-nausea medication. Although the condition of the patient is a factor in hospital admission following ambulatory surgery, it is less important than the type of anesthesia and the surgical procedure.

Risk factors, Surgery, Outpatient, Ambulatory surgery

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Monitoring anesthetic care: new directions

Article Abstract:

A database of more than 1,000 closed claim files, collected from 17 insurance companies, was studied by the Committee on Professional Liability of the American Society of Anesthesiologists, in order to assess medical malpractice lawsuits related to anesthetic care. Previous studies have shown that adverse outcomes related to anesthesia were often a documented cause of death or major permanent disability (often brain damage). The National Association of Insurance Commissioners Closed Claims Study has focused on the practice of anesthesia as a correctable problem related to the provision of health care services. In addition, a study of anesthesia conducted by the Harvard Medical School has identified a number of preventable causes of adverse events. The American Society of Anesthesiologists is also funding research directed to improve patient safety in anesthesia by reducing anesthesia mishaps; the initial step in this research process requires a better database than that which may be drawn from the closed claim files of insurance companies. Complete data can only be obtained from a registry in which hospitals participate by providing information on anesthetic procedures. Considering that 25 million anesthetic procedures are performed annually, a national registry of anesthetic mishaps would be of great value in developing safer procedures.

Analysis, Prevention, Malpractice, Medical malpractice, Health surveys, editorial, Anesthesiologists

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Application of clinical indicators in the emergency department

Article Abstract:

In the emergency department of George Washington University Medical Center, responsibility for interpreting emergency X-rays is shared between emergency department doctors and radiology department faculty specialists. In a large series of 23,500 X-rays, a difference of opinion between the two departments occurred in only 3.3 percent of cases (776 X-rays). Three hundred fifty-two of these discrepancies were not due to inaccurate interpretation by the emergency department doctor, so the effective rate of discrepancy was only 1.8 percent. No undesirable patient outcomes could be attributed to a delay in obtaining accurate X-ray interpretations. The acceptable level of agreement between the emergency and radiology departments was attributed to effective communication and an interdisciplinary approach to patient care. Methods of improving the use of X-rays and other clinical indicators in the emergency setting are discussed.

Management, Diagnostic errors, Statistics, Radiology, Medical, Radiology, Emergency medicine

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