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Guideline Summary
Guideline Title
Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery.
Bibliographic Source(s)
Haeck PC, Swanson JA, Iverson RE, Schechter LS, Singer R, Basu CB, Damitz LA, Glasberg SB, Glassman LS, McGuire MF, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):6S-27S. [101 references]
Guideline Status

This is the current release of the guideline.

This guideline updates two previous versions: Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg 2002 Oct;110(5):1337-42. [14 references]

Iverson RE, Lynch DJ. Patient safety in office-based surgery facilities: II. Patient selection. Plast Reconstr Surg 2002 Dec;110(7):1785-90. [4 references]

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • November 6, 2013 – Low Molecular Weight Heparins External Web Site Policy: The U.S. Food and Drug Administration (FDA) is recommending that health care professionals carefully consider the timing of spinal catheter placement and removal in patients taking anticoagulant drugs, such as enoxaparin, and delay dosing of anticoagulant medications for some time interval after catheter removal to decrease the risk of spinal column bleeding and subsequent paralysis after spinal injections, including epidural procedures and lumbar punctures. These new timing recommendations, which can decrease the risk of epidural or spinal hematoma, will be added to the labels of anticoagulant drugs known as low molecular weight heparins, including Lovenox and generic enoxaparin products and similar products.

Scope

Disease/Condition(s)
  • Any condition which may be treated by ambulatory surgery
  • Complications associated with ambulatory surgery
Guideline Category
Evaluation
Management
Prevention
Risk Assessment
Clinical Specialty
Anesthesiology
Plastic Surgery
Surgery
Intended Users
Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings
  • To identify several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and to provide recommendations for how best to minimize these complications
  • To update, combine, and expand on two prior practice advisories issued by the American Society of Plastic Surgeons in 2002: one detailing patient selection in the office-based surgery setting and another detailing procedures in the office-based surgery setting
Target Population

Any patient undergoing plastic surgery in the ambulatory surgery setting

Interventions and Practices Considered

Risk Assessment/Evaluation

  1. Patient selection
    • Preoperative patient history including assessment of risk factors
    • Physical examination, including body mass index determination, respiratory status, American Society of Anesthesiologists (ASA) physical classification status, cardiovascular status assessment (including electrocardiogram and evaluation and treatment of active cardiac conditions)
    • Complete blood count/blood chemistries
    • Additional tests as appropriate
  2. Assessment of risk of thrombosis or embolism
  3. Assessment of ASA physical classification status

Management/Prevention

  1. Cardiovascular monitoring
    • Noninvasive blood pressure measurement
    • Heart rate
    • Electrocardiography
    • Pulse oximetry
    • Respiratory rate
    • Additional specialized monitoring as needed
  2. Management of specific patient populations
    • Obese patients (including obese patients with respiratory abnormalities and other comorbid conditions)
    • Patients with obstructive sleep apnea
    • Patients with cardiac conditions
  3. Thromboprophylaxis (implemented according to risk rating)
    • Patient education
    • Early and frequent ambulation (continued at home)
    • Flexion/extension of ankles (continued at home)
    • Graduated compression stockings (may be used at home)
    • Intermittent pneumatic compression (IPC)
    • Low-molecular-weight heparin (LMWH)
    • Venous foot pumps
    • Longer term prophylaxis with warfarin
    • Patient positioning on the operating room table
  4. Chemoprophylaxis (LMWH, fondaparinux, idraparinux, direct thrombin inhibitors) as indicated
  5. Management of physiologic stresses associated with surgical procedures
    • Strategies for hypothermia
    • Strategies for anticipated intraoperative blood loss
    • Choice of anesthesia type and monitoring anesthesia
    • Duration of procedure
    • Combining multiple procedures
    • Preventing unanticipated admission
Major Outcomes Considered

Morbidity and mortality associated with surgery and anesthesia

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

PubMed and the Cochrane Library were searched. The search terms used were: patient selection, preoperative assessment, ambulatory surgery, outpatient surgery, office-based surgery, surgical procedures, physical examination, medical history, risk factors, comorbidity, age, deep vein thrombosis (DVT), pulmonary embolus (PE), body mass index (BMI), obesity, obstructive sleep apnea (OSA), heart disease, stroke, hypertension, American Society of Anesthesiologists (ASA) Status, hypothermia, anesthesia, malignant hyperthermia, multiple procedures, duration of operation/procedure/surgery, unanticipated admission. No limits were set on publication dates in the searches. The searches included all types of published articles. However, articles that were critically appraised and rated for level of evidence were limited to systematic reviews, meta-analyses, randomized controlled trials (RCTs), clinical trials, comparative studies, case series and case reports.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The supporting literature was critically appraised for study quality according to criteria referenced in key publications on evidence-based medicine. Depending on study design and quality, each reference was assigned a corresponding level of evidence (I through V) with the American Society of Plastic Surgeons (ASPS) Evidence Rating Scales, and the evidence was synthesized into practice recommendations. (see "Rating Scheme for the Strength of the Evidence").

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations
Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The guideline was approved by the American Society of Plastic Surgeons Executive Committee on January 10, 2009.

Recommendations

Major Recommendations

Definitions for the levels of evidence (I–V) and the grades of the recommendations (A–D) are provided at the end of the "Major Recommendations" field.

    Recommendations Supporting Evidence Grade
    Patient Selection

    Preoperative tests

    • Order pertinent tests based on the patient's preoperative history and physical examination results:
      • Electrocardiogram in patients older than 45 years
      • Electrocardiogram at any age when known cardiac conditions are present
      • Complete blood count/blood chemistries, as needed, for detailed evaluation of specific diagnosis
      • Additional tests as appropriate

    Expert opinion

    D

    Age

    • Patients older than 60 years can be considered for ambulatory surgery but may be at increased risk for cardiac events, other complications, and unanticipated admissions.
    • Cardiovascular monitoring is important; however, the level of monitoring depends on the patient's overall health, the presence and severity of cardiovascular disease, and the nature of the surgical procedure.
    • Standard monitoring should include
      • Noninvasive blood pressure
      • Heart rate
      • Electrocardiography
      • Pulse oximetry
      • Respiratory rate
    • Additional specialized monitoring may be needed (see Fleisher et al., 2007)

    Custer & Trinkaus, 2002; Mandal et al., 2005; Aldwinckle & Montgomery, 2004; George et al., 2004; Fleisher et al., 2007; Chung, Mezei, & Tong, "Adverse events," 1999

    B

    Body mass index (BMI)

    • Ambulatory surgery can be considered for patients with:
      • BMI 18.5–24.9 (normal weight)
      • BMI 25–29.9 (overweight)
      • BMI 30–34.9 (moderately obese)
    • A hospital setting should be considered for patients with:
      • BMI 35–39.9 (severely obese)
    • A hospital setting is recommended for patients with:
      • BMI ≥40 (morbidly obese)

    Mandal et al., 2005; Kempers, Foote, & DiFlorio-Brennan, 2000; Atkins, White, & Ahmed, 2002; Chacon, Viehweg, & Ganzberg, 2004

    D
    • General management of obese patients:
      • Consider histories/comorbidities that may complicate patient management.
      • Consider prophylaxis against deep vein thrombosis (DVT) (i.e., with low-dose heparin, sequential compression devices, and postoperative ambulation).

    Nielsen et al., 2005; Samama, 2000; Chacon, Viehweg, & Ganzberg, 2004; Friedman, Chung, & Wong, 2004

    B
    • Management of obese patients with respiratory abnormalities:
      • Ensure proper patient positioning and monitoring.
      • Use a semiupright position in a chair for patients under sedation.

    Chung, Mezei, & Tong, "Pre-existing," 1999; Myles et al., 2002; Chacon, Viehweg, & Ganzberg, 2004

    B
    • Consider supplemental oxygen.
    • Carefully sized airway adjuncts (e.g., oral/nasal pharyngeal airways, endotracheal tubes, laryngeal mask airways) should be immediately available for patients under moderate sedation or general anesthesia.
    • Consider intravascular monitoring of arterial pressure (or other approaches) if blood pressure measurements and auscultation of the heart and lungs is difficult to obtain.
    • Pharmacologic approaches to sedation and pain management in obese patients:
      • Use a catheter-over-needle system to prevent loss of intravenous access.
      • Short operation times and lighter levels of sedation are recommended.
      • Consider a hospital setting if deeper anesthesia is required.
      • Calculate initial doses of pharmacologic agents based on ideal body weight (as a reflection of lean body mass) rather than actual body weight.
      • Consider possible drug interactions.
        • Exercise caution for patients taking appetite suppressants or other medications.
        • Consider avoiding opioids, especially in patients with diagnosed or suspected obstructed sleep apnea (OSA); consider nonopioid analgesics and moderate sedation with reversible agents.

    Chacon, Viehweg, & Ganzberg, 2004

    D

    OSA

    • Patients with OSA can be considered for ambulatory surgery; however, careful patient assessment is necessary.
    • For patients without a prior diagnosis of OSA, inquire about the following symptoms:
      • Airway obstruction during sleep
      • Loud and frequent snoring
      • Frequent arousal from sleep, especially with choking sensation
      • Daytime somnolence or fatigue
      • Falling asleep in nonstimulating environments (e.g., watching television, reading, driving)
    • Also consider interviewing family members as to whether they have seen telltale OSA symptoms in the patient (e.g., apneic events, restless sleep, vocalizations)
    • The physical examination should include an evaluation of the following:
      • The airway
      • Nasopharyngeal characteristics
      • Tonsil and tongue size
      • Neck circumference
      • BMI
    • For patients with suspected OSA, consider referring the patient for additional tests (e.g., sleep studies, more extensive airway assessment) and OSA treatment prior to surgery.
    • Factors to be considered in determining whether outpatient surgery is appropriate for patients with OSA:
      • Sleep apnea status
      • Anatomical and physiologic abnormalities
      • The status of coexisting diseases
      • The nature of the surgery
      • The type of anesthesia
      • The need for postoperative opioids
      • Patient age
      • Adequacy of postdischarge observation
      • Capabilities of the outpatient facility (availability of emergency difficult airway equipment, respiratory care equipment, radiology facilities, clinical laboratory facilities, and a transfer agreement with an inpatient facility)
    • Discharge criteria for patients with OSA:
      • Patients can be discharged from the recovery area to an unmonitored setting (i.e., the home, unmonitored hospital bed) when they are no longer at risk for postoperative respiratory depression.
      • Because of the propensity to develop airway obstruction or central respiratory depression, OSA patients may require a longer stay as compared with non-OSA patients undergoing similar procedures.
      • Document the adequacy of postoperative respiratory function by observing patients in an unstimulated environment (preferably while asleep) to establish that they are able to maintain their baseline oxygen saturation while breathing room air.

    Friedman, Chung, & Wong, 2004; Sabers et al., 2003; "Practice guidelines," 2006

    D

    Cardiovascular conditions

    • Patients with a history of cardiovascular conditions can be considered for ambulatory surgery; however, the surgery location depends on the severity of disease. Patients with moderate to severe cardiovascular disease may not be appropriate candidates for surgery outside of the hospital setting.

    Custer & Trinkaus, 2002; George et al., 2004; Friedman, Chung, & Wong, 2004

    D
    • General management of patients with cardiovascular conditions:
      • Evaluate the risk of bleeding and thromboembolism.
      • Adjust medications such as aspirin, warfarin, or clopidogrel bisulfate accordingly.
      • Refer patients to their cardiologist, hematologist, or internist for preoperative evaluation and treatment.

    Custer & Trinkaus, 2002; George et al., 2004; Kirkorian et al., 2007; Broad et al., 2007; Ardekian et al., 2000; Dhiwakar, Khan, & McClymont, 2006; Bartlett, 1999; Partridge, Campbell, & Alvarado, 2008; Chassot, Delabays, & Spahn, 2007; Burger et al., 2005; Szalat, Erez, & Leitersdorf, 2007; Inman, Michla & Partington, 2007

    B

    Risk for thrombosis or embolism

    • Assess risk factors:
      • Patient history, including the use of contraceptives and hormone replacement, stillbirth, preterm delivery, and possibly recurrent miscarriage
      • Family history, including past episodes of thrombosis or embolism
      • Genetic disposition to clotting disorders (e.g., factor V Leiden, prothrombin G20210A)
      • Edema, swelling, or other signs of venous insufficiency in the lower extremities

    Samama, 2000; Reinisch et al., 2001; Spring & Gutowski; 2006; Keyes et al., 2008; Wu et al., 2006; Wu et al., "Oral contraceptives," 2005; Kocher et al., 2007; Sottilotta et al., 2006; Jauniaux et al., 2006; Wu et al., "Thrombophilia," 2005

    B

    Thromboprophylaxis

    Implement thromboprophylaxis according to risk rating:

    • Low risk
      • Patient education
      • Early and frequent ambulation (continue at home)
      • Flexion/extension of ankles (continue at home)
      • Optional: graduated compression stockings (GCS) (may be used at home)

    Reinisch et al., 2001; Young & Watson, "The need for," 2006; Michot et al., 2002

    D
    • Moderate risk
      • Same as low risk, plus
      • Intermittent pneumatic compression (IPC) if anticoagulation is not an option (continue until good ambulation)
      • Low-molecular-weight heparin (LMWH) (30–40 mg subcutaneously [SQ] once daily [qd]; initial dose 2 hr before surgery or 12 hr after; continue until patient is fully ambulatory and evaluate need for longer prophylaxis) or low-dose unfractionated heparin (LDUH) (every [q] 12h until patient is fully ambulatory)

    Handoll et al., 2002; Wille-Jørgensen et al., 2003; Urbankova et al., 2005

    A
    • High risk
      • Same as low risk, plus
      • IPC and/or GCS (until good ambulation)
      • LMWH (40 mg SQ qd; initial dose 2 hr before surgery or 12 hr after; continue for 5–10 days) or fondaparinux (2.5 mg SQ qd; initial dose 6–8 hr after surgery; do not give <6 hr postoperatively; continue for 5–10 days)

    Handoll et al., 2002; Urbankova et al., 2005; Amaragiri & Lees 2000; Turpie et al., 2002; Turpie et al., 2007

    A
    • Very high risk
      • Same as low risk, plus
      • IPC and/or GCS (until good ambulation)
      • LMWH (40 mg SQ qd; initial dose 2 hr before surgery or 12 hr after; continue for 7–12 days and seriously consider longer prophylaxis) or fondaparinux (2.5 mg SQ qd; initial dose 6–8 hr after surgery; do not give <6 hr postoperatively; continue for 7–12 days and evaluate need for longer prophylaxis)
      • Longer term prophylaxis with warfarin or convert to warfarin at international normalized ratio (INR) 2–3 (if patient risk factors indicate the need for other vitamin K antagonist long-term prophylaxis)

    Handoll et al., 2002; Urbankova et al., 2005; Amaragiri & Lees 2000; Turpie et al., 2002; Turpie et al., 2007

    A

    Mechanical prophylaxis

    • Methods recommended for patients with a high risk of bleeding or as an adjunct to chemoprophylaxis:
      • GCS
      • IPC devices
      • Venous foot pumps (VFP)
    • IPC devices or VFP are recommended for any procedure that lasts >1 hr, and for all patients receiving general anesthesia; begin 30–60 min before surgery.
    • Also consider patient positioning on the operating room table.
      • Flex the patient's knees at 5 degrees or
      • Reposition the patient's legs at regular intervals throughout a procedure.

    Reinisch et al., 2001; Young & Watson, "The need for," 2006; Michot et al., 2002

    D

    Chemoprophylaxis

    • Use chemoprophylaxis (e.g., LMWH, fondaparinux, idraparinux, direct thrombin inhibitors) in patients undergoing:
      • Abdominoplasty
      • Circumferential body contouring
      • Thighplasty
      • Combined procedures
      • Procedures lasting >4 hr
      • Surgery requiring open-space dissection
      • Transverse rectus abdominus musculocutaneous (TRAM) flap procedures
      • Surgical procedures likely to contribute to venous stasis or compression
    • Recognize the increased risk of bruising or hematoma and the possible need for blood transfusion when using chemoprophylaxis; bleeding incidence is strongly associated with dosage.

    Reinisch et al., 2001; Young & Watson, "The need for," 2006; Michot et al., 2002

    D

    American Society of Anesthesiologists (ASA) status

    • Patients categorized as ASA class 1–3 can be considered for ambulatory surgery; however, the setting should be determined by the ASA class, the type of procedure, and the type of anesthesia.

    George et al., 2004; Friedman, Chung, & Wong, 2004; Fortier, Chung, & Su, 1998; Ansell & Montgomery, 2004

    B
    • ASA class 4 patients can be considered for ambulatory surgery; however, the setting is dependent on the type of procedure and type of anesthesia.
    • Office-based procedures:
      • ASA class 1 and 2 patients are generally considered the best candidates for ambulatory surgery and reasonable candidates for the office-based surgery setting.

    Expert opinion

    D
    • ASA class 3 patients may also be reasonable candidates for office-based surgery facilities when local anesthesia, with or without sedation, is planned and the facility is accredited.
    • ASA class 4 patients are appropriate candidates for the office-based surgery setting only when local anesthesia without sedation is planned.

    Expert opinion

    D

    If a free-standing ASC or office-based setting is chosen, it should be accredited with appropriate hospital transfer arrangements.

    Expert opinion

    D
    Management of Physiologic Stresses Associated with Surgical Procedures

    Hypothermia

    • General strategies:
      • Equip the ambulatory surgery suite so that temperatures can be adequately monitored and adjusted.
      • Have equipment available (e.g., Bair Huggers [Arizant Healthcare, Inc., Eden Prairie, Minn.]), forced-air arming blankets, intravenous fluid warmers] to warm the patient, as necessary, especially during more extensive procedures.
      • When no hypothermia prevention measures are available, the procedures performed should be of short duration (1–2 hr) and limited to no more than 20% of the body surface area.
    • Recommended protocol for hypothermia prevention during general or regional anesthesia:
      • Actively prewarm patients.
      • Monitor core temperature throughout administration of general and regional anesthesia.
      • Cover as much body surface area as possible with blankets or drapes to reduce radiant and convective heat loss through the skin.
      • Actively warm patients intraoperatively with a forced-air heater or resistive-heating blanket to prevent heat loss and add heat content; rearrange covers every time the patient is repositioned to warm as much surface area as possible.
      • Minimize repositioning time as much as possible so that the active warming method can be quickly continued.
      • Warm intravenous fluids and/or infiltration fluids if large volumes are used.
      • Warm incision irrigation fluids.
      • Aggressively treat postoperative shivering with a forced-air heater or resistive-heating blanket and consider pharmacologic intervention.

    Fossum, Hays, & Henson, 2001; Smith et al., 1998; Agrawal et al., 2003; Cavallini, Baruffaldi Preis, & Casati, 2005; Negishi et al., 2003; Robles-Cervantes, Martinez-Molina, & Cárdenas-Camarena, 2005; Vanni et al., 2003; Ng et al., 2003; Young & Watson, "Prevention," 2006

    B

    Intraoperative blood loss

    • Procedures performed on the average-size adult patient in which blood loss >500 cc is anticipated should be performed only in facilities where adequate blood and blood components are readily available.

    Junger et al., 2001

    D

    Type of anesthesia

    • General anesthesia, moderate sedation, and local anesthesia can be used safely in the ambulatory setting. The type of anesthesia administered depends on the invasiveness of the procedure, the health status of the patient, and the preference of the physician and patient. The physician should discuss anesthetic options with the patient and determine the most appropriate regimen.

    George et al., 2004; Fleisher et al., 2007; Perrott et al., 2003; Hoefflin, Bornstein, & Gordon, 2001; Bitar et al., 2003; Ersek, 2004; Shirakami, Teratani, & Fukuda, 2006; Shirakami et al., 2005; Liu, 2004; Marcus et al., 1999; Sungurtekin, Sungurtekin, & Erdem, 2003; Cinnella et al., 2007

    B
    • The ASA and American Association of Oral and Maxillofacial Surgeons (AAOMS) recommends the following measures for patients undergoing deep sedation/general anesthesia:
      • Continuous use of pulse oximetry
      • Recording of blood pressure every 5 min
      • Continuous cardiovascular monitoring with an electrocardioscope
      • Use of supplemental oxygen throughout the anesthesia period
      • Ventilatory monitoring should include auscultation of breath sounds and
      • ≥1 of the following:
        • Observation of the chest wall
        • Observation of the reservoir bag
        • Monitoring the color of skin, nails, mucosa, and the surgical site
        • Capnography
      • Additional monitoring should include either auscultation of heart sounds or palpation of peripheral pulses.
      • Capnography—end tidal carbon dioxide when endotracheal anesthesia or laryngeal mask airway (LMA) is inserted.

    Perrott et al., 2003; American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists, 2002

    D

    Multiple procedures

    • The presumed benefits of combining procedures, particularly liposuction, must be weighed against the possibility of adverse events.
    • Liposuction can be performed safely in the ambulatory setting when performed in accordance with American Society of Plastic Surgeons (ASPS) recommendations to limit the total aspirant (supernatant fat and fluid) to ≤5000 cc.
    • Combining large-volume liposuction with certain other procedures (e.g., abdominoplasty) should be avoided because of the possibility of serious complications.

    Stevens, Vath, & Stoker, 2004; Stevens et al., 2006; Kim & Stevenson, 2006; Simon, Thaller, & Nathan, 2006; Stokes & Williams, 2007; Cárdenas-Camarena, 2005; Cárdenas-Camarena & Paillet, 2007; Stevens et al., 2005

    B

    Duration of procedures

    • Long procedures should be scheduled sufficiently early in the day to allow for adequate recovery time before discharge.
    • If possible, surgery should be completed by 3 pm to allow adequate time for recovery and discharge.
    • The overall duration of the procedure(s) should ideally be completed within 6 hr.
    • Attention to patient selection, intraoperative management, and postoperative care is of particular importance when procedures of longer duration are to be performed in the ambulatory setting.

    Fleisher, Pasternak, & Lyles; 2007; Mandal et al., 2005; Fortier, Chung, & Su, 1998; Shirakami et al., 2005; Mattila et al., 2005; Gordon & Koch, 2006

    B

    Preventing unanticipated admission

    • Control of pain, nausea/vomiting, dizziness, and postoperative bleeding is essential to postoperative recovery and discharge.
    • Pain management should be correlated to BMI and the procedure being performed, and the patient should be sent home with sufficient medication to control pain and with adequate instructions on the use of this medication.
    • Recommendations regarding the duration of procedure(s) also apply.

    Mandal et al., 2005; Fortier, Chung, & Su, 1998; Shirakami et al., 2005; Tham & Koh, 2002

    B

    Definitions:

    Evidence Rating Scale for Studies Reviewed

    Level of Evidence Qualifying Studies
    I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
    II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
    III Retrospective comparative study; case-control study; or a systematic review of these studies
    IV Case series
    V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"

    Scale for Grading Recommendations

    Grade Descriptor Qualifying Evidence Implications for Practice
    A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
    B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
    C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
    D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
    Clinical Algorithm(s)

    None provided

    Evidence Supporting the Recommendations

    References Supporting the Recommendations
    Type of Evidence Supporting the Recommendations

    The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

    Benefits/Harms of Implementing the Guideline Recommendations

    Potential Benefits

    Appropriate patient selection and improved patient safety in the ambulatory surgery setting

    Potential Harms

    Risks inherent with ambulatory surgery, which can be minimized through appropriate patient selection and adherence to recommended practices

    Qualifying Statements

    Qualifying Statements
    • Practice advisories are strategies for patient management, developed to assist physicians in clinical decision-making. This practice advisory, based on a thorough evaluation of the present scientific literature and relevant clinical experience, describes a range of generally acceptable approaches to diagnosis, management, or prevention of specific diseases or conditions. This practice advisory attempts to define principles of practice that should generally meet the needs of most patients in most circumstances. However, this practice advisory should not be construed as a rule, nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the appropriate results. It is anticipated that it will be necessary to approach some patients' needs in different ways. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of all the circumstances presented by the patient, the diagnostic and treatment options available, and available resources.
    • This practice advisory is not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all the facts or circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance, and as practice patterns evolve. This practice advisory reflects the state of knowledge current at the time of publication. Given the inevitable changes in the state of scientific information and technology, periodic review and revision will be necessary.

    Implementation of the Guideline

    Description of Implementation Strategy

    An implementation strategy was not provided.

    Institute of Medicine (IOM) National Healthcare Quality Report Categories

    IOM Care Need
    Getting Better
    Living with Illness
    IOM Domain
    Effectiveness
    Safety

    Identifying Information and Availability

    Bibliographic Source(s)
    Haeck PC, Swanson JA, Iverson RE, Schechter LS, Singer R, Basu CB, Damitz LA, Glasberg SB, Glassman LS, McGuire MF, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):6S-27S. [101 references]
    Adaptation

    Not applicable: The guideline was not adapted from another source.

    Date Released
    2002 Oct (revised 2009 Oct)
    Guideline Developer(s)
    American Society of Plastic Surgeons - Medical Specialty Society
    Source(s) of Funding

    American Society of Plastic Surgeons

    Guideline Committee

    American Society of Plastic Surgeons Patient Safety Committee

    Composition of Group That Authored the Guideline

    Committee Members: Phillip C. Haeck, M.D. (Chairman); Stephen B. Baker, M.D., D.D.S., Georgetown University Hospital, Washington, D.C.; Charles W. Bailey, Jr., M.D., J.D., Austin, Texas; C. Bob Basu, M.D., M.P.H., Center for Advanced Breast Restoration and Basu Plastic Surgery, Houston, Texas; Lynn A. Damitz, M.D., University of North Carolina, Chapel Hill, North Carolina; Felmont F. Eaves, III, M.D., Charlotte Plastic Surgery, Charlotte, North Carolina; Paul D. Faringer, M.D., Kaiser Permanente, Honolulu, Hawaii; Scot Bradley Glasberg, M.D., Lenox Hill Hospital and Manhattan Eye Ear and Throat Hospital, New York, New York; Lawrence S. Glassman, M.D., Nyack Hospital, Nyack, New York; Karol A. Gutowski, M.D., North Shore University Health System and University of Chicago, Evanston, Illinois; Elizabeth J. Hall-Findlay, M.D., private practice, Banff, Alberta, Canada; Ronald E. Iverson, M.D., Stanford University Medical School, Palo Alto, California; Linda J. Leffel, M.D., Bend, Oregon; Dennis J. Lynch, M.D., retired, Scott and White Healthcare, Texas A&M University, Temple, Texas; Noel B. McDevitt, M.D., Pinehurst Surgical, Pinehurst, North Carolina; Michael F. McGuire, M.D., David Geffen UCLA School of Medicine, Los Angeles, California; Patrick J. O'Neill, M.D., Medical University of South Carolina, Charleston, South Carolina; Neal R. Reisman, M.D., J.D., St. Luke's Episcopal Hospital and Baylor College of Medicine, Houston, Texas; Gary F. Rogers, M.D., Children's Hospital Boston, Boston, Massachusetts; Loren S. Schechter, M.D., Morton Grove, Illinois; Maria Siemionow, M.D., Ph.D., D.Sc., Cleveland Clinic, Cleveland, Ohio; Robert Singer, M.D., University of California, San Diego, La Jolla, California; Gary A. Smotrich, M.D., Lawrenceville Plastic Surgery, Lawrenceville, New Jersey; Rebecca S. Twersky, M.D., M.P.H., SUNY Downstate Medical Center, Brooklyn, New York; Amy G. Wandel, M.D., Mercy Medical Group, Sacramento, California; Ronald H. Wender, M.D., Cedars-Sinai Medical Center, Los Angeles, California; and James A. Yates, M.D., Grandview Surgery Center, Vista Surgery Center, Plastic Surgery Center, and Holy Spirit Hospital, Camp Hill, Pennsylvania

    Financial Disclosures/Conflicts of Interest

    The authors have no financial interests related to this article.

    Guideline Status

    This is the current release of the guideline.

    This guideline updates two previous versions: Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg 2002 Oct;110(5):1337-42. [14 references]

    Iverson RE, Lynch DJ. Patient safety in office-based surgery facilities: II. Patient selection. Plast Reconstr Surg 2002 Dec;110(7):1785-90. [4 references]

    Guideline Availability

    Electronic copies: Available in Portable Document Format (PDF) from the American Society of Plastic Surgeons Web site External Web Site Policy.

    Print copies: Available from the American Society of Plastic Surgeons, 444 East Algonquin Road, Arlington Heights, IL 60005-4664

    Availability of Companion Documents

    None available

    Patient Resources

    None available

    NGC Status

    This NGC summary was completed by ECRI on July 7, 2005. This NGC summary was completed by ECRI Institute on June 17, 2010. The information was verified by the guideline developer on August 31, 2010. This summary was updated by ECRI Institute on March 7, 2014 following the U.S. Food and Drug Administration advisory on Low Molecular Weight Heparins.

    Copyright Statement

    This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

    Copyright ©2009 by the American Society of Plastic Surgeons

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