Unplanned Emergency Visits and Admissions After Orthopaedic Ambulatory Surgery in the First 2 Years of Operation of a University Ambulatory Surgery Center

Abstract

Background: Ambulatory surgeries have increased in recent decades to help improve efficiency and cost; however, there is a potential need for unplanned postoperative admission, clinic visits, or evaluation in the emergency department (ED). Purpose/Hypothesis: The purpose was to determine the frequency, reasons, and factors influencing hospitalizations, return to clinic, and/or ED encounters within 24 hours of ambulatory surgery. The time frame for data collection was the first 2 years of operation of a university sports medicine ambulatory surgery center (ASC). We hypothesized that the percentage of encounters would be low and primarily because of pain or postoperative complication. Study design: Case-control study; Level of evidence, 3. Methods: A retrospective review was performed of all patients undergoing ambulatory surgery at an ASC during the first 2 years of its operation (November 2016 to October 2018). Data including age, sex, Current Procedural Terminology code, procedure performed, American Society of Anesthesiologists classification, body mass index, medical history, and tobacco use were collected. Patients seeking care in the ED, inpatient, or outpatient setting within the first 24 hours after surgery were identified and the reasons for these encounters were categorized into 1 of 3 groups: (1) medical complication, (2) postoperative pain, or (3) other postoperative complication. Logistic regression models were used to assess risk factors for these encounters. Results: A total of 4650 sports medicine procedures were performed at the university ASC during the study period. A total of 35 patients (0.75%) sought additional care within 24 hours of surgery. Medical complications were the primary reason for seeking care (n = 16; 45.7%). Patients who sought treatment within 24 hours of surgery tended to be older, had more medical comorbidities, and were more likely to have undergone upper extremity (particularly shoulder) procedures. In the multivariable analysis, patients with higher ASA scores were more likely to seek additional care ( P < .005) and there was a trend toward increased risk of seeking additional care with upper extremity surgery ( P = .077). Conclusion: Orthopaedic procedures performed in an ASC result in a relatively low percentage of patients seeking additional care within the first 24 hours after surgery, consistent with other reports in the literature. Upper extremity procedures, particularly those of the shoulder, may carry an increased risk of requiring medical treatment within 24 hours of surgery. Even in the first 2 years of operation of a university-based ASC, low rates of postoperative complications and unplanned admissions can be maintained.

Risk Factors of Emergency Department Utilization After Outpatient Surgery for Sports-Related Injuries

“…The ED utilization rates after surgeries for sports-related injuries were slightly lower compared with those in previous studies on postoperative ED utilization rates of outpatient rotator cuff repair (3.2% 7 days and 5.0% 30 days), 17 elective hip arthroscopy (1.8% 7 days, 3.5% 30 days, and 6.6% 90 days), 15 ankle surgery (7.2% 30 days), 18 and outpatient hand surgery (1.8% 7 days and 4.4% 30 days). 16 For sports medicine procedures, a recent study by Brown et al reported an unplanned medical care utilization rate of 0.75% within the 24-hour postoperative period, 30 which is lower than the ED utilization rates in this study but is primarily representative of the immediate postoperative period. Of note, postoperative ED utilization rates for sports-related injuries were markedly lower than the 4.5 to 13.8% reported in the total joint arthroplasty literature, 12,[21][22][23][24] which can be partially explained by the invasive nature of joint arthroplasty procedures and their higher postoperative pain and complication profiles.…”

Unplanned Emergency and Urgent Care Visits After Outpatient Orthopaedic Surgery

“…Contrary to our study, most unplanned ED/UC visits reported in the literature are accompanied by a chief report of postoperative pain. 18 , 20 , 21 , 23 Only 9.0% of the patients presenting to an ED/UC visit in our study stated a pain-specific report. The most frequently reported reports prompting ED/UC visits in our study were medication-related concerns (13.2%).…”

“…Multiple studies have quantified the frequency of and identified risk factors contributing to unplanned ED/UC visits after outpatient orthopaedic surgeries. 11 , 18 , 20 21 22 23 24 Although the recorded incidence of ED/UC visit is generally lower, variability exists within the literature. 11 , 18 , 20 21 22 23 24 Sivasundaram et al 20 reported a slightly lower incidence of ED visit utilization (4.4%) within 30 days of outpatient surgery, compared with our study (5.4%), and 6.9% of patients presented to an unplanned ED within 7 days of surgery in the study of Navarro et al.…”

“… 11 , 18 , 20 21 22 23 24 Although the recorded incidence of ED/UC visit is generally lower, variability exists within the literature. 11 , 18 , 20 21 22 23 24 Sivasundaram et al 20 reported a slightly lower incidence of ED visit utilization (4.4%) within 30 days of outpatient surgery, compared with our study (5.4%), and 6.9% of patients presented to an unplanned ED within 7 days of surgery in the study of Navarro et al. Contrary to our study, most unplanned ED/UC visits reported in the literature are accompanied by a chief report of postoperative pain.…”

The ASA Classification System as a Predictive Factor to Stay at the Virtual Hybrid Care Hotel

“…Although the procedures that qualify for stay in the Care Hotel are all considered one-night observation in nature, some surgical teams may have chosen to emphasize the risk of post-procedural complications differently based on the patients’ comorbidities. Overall, less complex and healthier patients are more likely to be discharged to home as opposed to be observed in a hospital, 17 since higher ASA PS Classes have been associated with complications, 13 unplanned readmissions, 18,19 block failures, 20 and a higher mortality risk in this setting. 13 These are some of the reasons why some surgical teams consider ASA PS Classes 1 and 2 a part of the inclusion criteria for immediate discharge after surgery, 21 while others extend it to Class 3 based on the low risk of complications following a specific procedure.…”