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High-reliability organizations standardize processes to deliver consistent results. Unplanned visits (UV) to emergency department (ED) or urgent care (UC) settings after ambulatory surgery (AS) are costly and disruptive. Therefore, we implemented a collaborative, multidisciplinary, standardized care protocol to improve postoperative outcomes after AS for open inguinal hernia repair (OIHR). METHODS: A quality improvement intervention composed of 9 perioperative elements was implemented across 14 hospitals as a collaborative effort between surgery, anesthesia, and nursing. Data on patient factors, protocol adherence, post-anesthesia care unit, and post-discharge outcomes were collected. Bivariate comparisons assessed outcome differences by adherence to protocol elements. Multivariate models controlling for patient factors and hospital clustering examined the effect of specific intervention elements on outcomes. RESULTS: Data were collected for 2,390 patients undergoing AS for OIHR over a 14-month period. Rates of UV were 6.3% (for any cause) and 2.8% (for avoidable causes: pain/urinary retention/constipation/nausea/vomiting). Adherence varied across the 9 elements (24% to 95%). Preoperative education reduced UV for any cause, for avoidable causes, and for nausea/vomiting; giving prescriptions preoperatively reduced UV for avoidable causes and constipation. Use of monitored anesthesia care (MAC) instead of general anesthesia reduced postoperative pain scores. Patients receiving all elements (3%) were older and riskier, but had lower postoperative pain (p ¼ 0.01). CONCLUSIONS: A multidisciplinary, multihospital intervention to standardize best practices for AS significantly reduced postoperative pain and unplanned visits to emergency care. Preoperative education and preferential use of MAC contributed most strongly to these changes. Further refinement of this protocol may yield additional improvements.

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