BOSTON—Pediatric ambulatory surgery centers are fast-paced, high-volume places with many of the ingredients that can contribute to safety concerns, a patient safety expert from Children’s National Medical Center (CNMC) said at the 2010 Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), held here Sept. 26-29.
Those concerns make it especially important for physicians to be aware of safety pitfalls and establish guidelines that fit each center, said Rahul Shah, MD, a pediatric otolaryngologist at the CNMC and co-chair of the Patient Safety and Quality Improvement Committee of the AAO-HNS.
Dr. Shah was part of a panel on safety in pediatric ambulatory surgery centers that asked, “Is the bar too low?” The panel generally agreed that the bar is probably set correctly, because safety statistics show otolaryngology procedures at ambulatory centers are generally safe.
Ambulatory procedures in the U.S. have been on the rise: A 300 percent jump in procedures from 1996 to 2006 was almost entirely the result of increased volume in ambulatory centers, according to data presented by Ellis Arjmand, MD, PhD, medical director of the Ear and Hearing Center at Cincinnati Children’s Hospital Medical Center.
In pediatrics, otolaryngology traditionally accounts for a large number of pediatric ambulatory procedures, due largely to the high number of ear procedures, tonsillectomies and adenoidectomies performed on children. A 2006 national survey found that pediatric adenotonsillectomy was the second most common ambulatory procedure, behind myringotomy (Laryngoscope 2010;120:821-825).
A study on national safety data recorded for all types of procedures at all facilities (Ear Nose Throat J. 1996;75:710-714) gives some guidance for pediatric ambulatory centers, Dr. Shah said. It’s clear that several factors that have been found to contribute to safety problems are inherent at pediatric ambulatory centers, he said, even if they have been handled well according to safety statistics.
One of those factors is haste, he said. “We all know, perhaps by definition, that there is some haste in a surgery center,” he said.
In addition, because ambulatory centers tend to be smaller, problems may arise in situations requiring more resources than are available, he said.
“What happens if your cautery goes out? What happens if your anesthesia machine goes out?” Dr. Shah said. “Many facilities, including our own, have two anesthesia machines running [in] two rooms, so if you lose an anesthesia machine, that could be a problem.”
Then there are “automatic behavior arrays,” he explained, which can occur when several procedures performed in succession are all the same, leading to the risk of falling into a habit. “It’s a paradigm of thought that you go through when you have seven tonsillectomies, and your eighth case is a tonsillectomy and a tube removal,” Dr. Shah said. “It’s very easy to forget about that.”
Certain error types, identified in a 2004 study in The Laryngoscope that involved an anonymous retrospective survey of 2,500 AAO-HNS members (114(8):1322-1335), specifically apply to ambulatory centers. One is surgical management, which accounted for 61 percent of the errors identified in the study, Dr. Shah said. These are errors that involve things like poor planning and mistakes related to equipment, and they can lead to problems like operating on the wrong side of the body.
“Every time I operate in my surgery center I get a little bit nervous because the pace is fast—it’s built that way—and I don’t help the system when I keep adding on cases,” Dr. Shah said. “But this is a big zone of risk when you talk about wrong patient, wrong organ, wrong side or incomplete surgery.”
That study cited two errors due to “wrong facility.” “These were done at surgery centers, and surgeons wish they would have done them at the main hospital,” Dr. Shah said.
Still, a review by the American Association for Accreditation of Ambulatory Surgery Facilities found one unanticipated sequela for every 299 procedures, a rate of just 0.33 percent.
And a 2008 review of 4,977 cases performed at the ambulatory center of the CNMC found only nine unanticipated outcomes, a rate of 0.2 percent.
Overall, Dr. Shah said, “ambulatory surgery is extremely safe within otolaryngology.”
Dr. Shah said safety data allow for benchmarking opportunities. “It allows you folks to go back to your practices, have your administrator run those numbers and give you a rough idea of where you are. If you’re at 5 [or] 6 percent of unanticipated outcomes, it poses a question as to why.”
At the ambulatory center on the Liberty Campus of the Cincinnati Children’s Hospital Medical Center, a review found no unexpected events out of 275 cases at the center, compared to nine unexpected events out of 211 cases at the main hospital, said Dr. Arjmand, the facility director. That facility has the capacity for short-term admissions, but there is limited specialty physician coverage, no emergency surgery is performed and there is no blood bank.
At the Children’s Hospital Boston at Waltham satellite facility, there is a small inpatient unit that allows for overnight stays if necessary and a pharmacy on site, along with radiology services and a hospitalist. The hospitalist is available 24 hours a day Monday through Saturday for both patient care and emergencies and can be reached, along with the anesthesia staff, via a stat-call system with special two-way SpectraLink phones.
Constance Houck, MD, clinical director of the hospitalist program at Children’s Hospital Boston at Waltham and a member of the panel, said many surgery cases are now transferred to the Waltham facility. She added that this approach is possible at other institutions as well.
“An increasing amount of pediatric ORL surgery seems feasible in an ambulatory or satellite setting if careful attention is paid to patient selection, the ability to rescue, pediatric-specific PACU [post anesthesia care unit] care and family education,” she said.
Not all surgery centers, however, have the same tools available, Dr. Arjmand pointed out. “These facilities vary quite a bit in terms of their resources,” he said. “Some have imaging on site, have a pharmacy, maybe have emergency blood available. There’s a lot of variability in what the facility offers.”
Everyone on the panel stressed the importance of patient selection and not doing more than the facility allows.
“You have to know what’s appropriate to do at the facility and what the resources are,” Dr. Arjmand said. “And have some guidelines, and develop and follow them.”