Day care anaesthesia: Overview

Abstract
Importance: Identification of factors associated with variation in outpatient surgery may further quality improvement efforts to safely reduce postoperative hospital length of stay nationally.

Objectives: To explore variation in the use of outpatient surgery, incorporating patient, geographic, and hospital factors.

Design, setting, and participants: This retrospective cross-sectional study used deidentified administrative claims data from OptumLabs Data Warehouse. Participants included adults who underwent 1 of 10 general, urological, or gynecological operations between January 1, 2015, and June 30, 2021, in the US. Patients who underwent combined procedures or reoperations or had at least 15 Elixhauser comorbidities were excluded. Data were analyzed from July 26 to December 16, 2023.

Exposure: Inpatient or outpatient surgical procedures.

Main outcomes and measures: Multilevel logistic regression assessed variation in the use of outpatient surgery rates by hospital characteristics (bed size, presence of trainees, and rural referral center status) and hospital census division, adjusting for patient factors (age, sex, number of Elixhauser comorbidities, year, and rural-urban commuting area). This multilevel model allowed for the sources of variability to be quantitatively attributed to patient characteristics, geography, and hospital characteristics.

Results: A total of 330 424 (72.3%) of 456 954 included patients underwent outpatient surgery. The median age was 54 (IQR, 41-67) years, and of those with data available, most patients were female (268 692 of 414 193 [64.9%]). The likelihood of outpatient surgery varied significantly by hospital census division for all 10 operations (eg, MIS salpingo-oophorectomy range, 29.6%-58.8%; P < .001). Variation in hospital census division contributed most to outpatient surgery for 8 of 10 operations compared with other patient and hospital characteristics. Hospital census division contributed the greatest degree to the variation in outpatient simple mastectomy (20.6%) and the least to outpatient open ventral hernia repair (0.7%). Multivariable analysis showed that the odds of outpatient surgery for patients from metropolitan areas were higher for minimally invasive salpingo-oophorectomy (odds ratio [OR], 1.62; 95% CI, 1.34-1.95) and open ventral hernia repair (OR, 1.16; 95% CI, 1.09-1.24). Hospitals with 400 or more beds were independently associated with decreased odds of outpatient surgery compared with hospitals with 50 to 199 beds for 4 of 7 operations (MIS paraesophageal hernia repair [OR, 0.58; 95% CI, 0.47-0.71; P < .001]; MIS cholecystectomy [OR, 0.73; 95% CI, 0.68-0.78; P < .001]; open ventral hernia [OR, 0.51; 95% CI, 0.46-0.57; P < .001]; MIS ventral hernia repair [OR, 0.66; 95% CI, 0.56-0.77; P < .001]). The presence of a residency training program was independently associated with increased odds of outpatient surgery for simple mastectomy (OR, 1.35; 95% CI, 1.16-1.58; P < .001) and mastectomy with reconstruction (OR, 1.50; 95% CI, 1.27-1.77; P < .001) and decreased odds of outpatient surgery for minimally invasive cholecystectomy (OR, 0.96; 95% CI, 0.92-1.00; P = .04), open ventral hernia repair (OR, 0.93; 95% CI, 0.86-1.00; P = .04), and total thyroidectomy (OR, 0.84; 95% CI, 0.71-1.00; P = .04).

Conclusions and relevance: In this cross-sectional study, significant variation existed in the use of outpatient surgery in the US and appeared to be driven primarily by hospital geography. Addressing these variations may improve the use of resources.

Abstract
Purpose of review: While the demand for nonoperating room anesthesia (NORA) care expands, anesthetic care in NORA settings continues to be associated with unique challenges and hazards. Simulation has been recommended as an effective patient safety tool promoting interprofessional communication and crisis response in this setting. The aim of this review is to examine the current literature on simulation in NORA, focusing specifically on interprofessional in situ simulation (ISS).

Recent findings: ISS is best practiced in an interprofessional setting and involves simulation of clinical scenarios in the environment where clinical care is delivered. Several recent studies across NORA settings have investigated the impact of interprofessional ISS on team dynamics. These studies have concluded that the implementation of ISS improves patient safety and is associated with improvement in interprofessional communication, understanding of team members' roles, and coordination during crisis management. Most studies to date have focused on qualitative analysis of simulation participant experiences.

Summary: Interprofessional ISS represents a promising strategy to address the unique challenges and hazards faced in NORA settings. Future research on this topic is needed, with a focus on the sustainability and scalability of interprofessional ISS programs and their impact on long-term provider learning and patient outcomes.