Find out what’s causing unplanned admissions
Research shows the reasons why
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
Hospitals have seen a tremendous increase in the number of surgical procedures performed in the outpatient setting. This change in practice has implications for patient care quality and hospital resource use. Does ambulatory surgery negatively affect quality? Are strict controls on resource use resulting in unexpected hospital inpatient admissions? Can hospital and medical staff control quality problems while improving utilization? Do case managers need to be involved in preadmission assessments of outpatient surgery patients?
The medical staff may routinely review admissions following outpatient surgery to identify potential quality problems. It is unlikely this type of subjective case-by-case assessment will yield significant findings. Overnight stay is usually the appropriate action because of intraoperative findings or the patient’s postoperative clinical condition. Selective peer review of individual cases will not provide the information needed for trend and pattern analysis. A longitudinal criteria-based study is much more effective at identifying practice patterns or organizational issues that are affecting unplanned admission rates.
By reviewing all inpatient admissions following ambulatory surgery, the medical staff and the institution can identify structural or practice variations that could adversely affect patient care quality, patient satisfaction, and resource use. In seeking an explanation for your hospital’s ambulatory surgery inpatient admission rate, several factors must be considered:
• patient or disease-related factors such as socioeconomic class of patient population, age, patient comorbidities, and patient noncompliance;
• organizational/management factors such as lack of sufficient holding or observation beds, payer reimbursement policies, scheduling of ambulatory surgery, staffing problems, unavailability of necessary equipment, and availability of psychosocial resources;
• practitioner or staff-related factors such as adequacy of preoperative assessment, availability of case managers in the outpatient surgery area, medical management and judgement, surgeon’s technical skills, and patient selection.
To undertake a study of the reasons for hospital admission following ambulatory surgery, the medical staff and affected hospital departments must identify the data elements to be collected and the definitions. Some of the data elements that require further clarification include:
• Admission following ambulatory surgery.
Will the study include only patients admitted to the ambulatory surgery unit, or will it include patients admitted for any procedure in which they are expected to leave the hospital the same day, e.g., endoscopy patients seen only in the endoscopy lab, medical admissions for diagnostic procedures, etc.?
• Post-procedure retention.
Should a total hospital stay of less than 24 hours be deemed an unplanned admission if the patient stayed beyond the midnight hour? Or will the study only include those patients who stayed beyond 24 hours post-procedure? What about patients unexpectedly admitted as observation patients post-procedure? Are these patients counted as unplanned admissions? There are no right answers to these questions, but it’s important to clarify the definitions before embarking on the study.
• Reason for unplanned retention.
During data collection, the reasons for the unplanned extended stay post-procedure will be gathered. These reasons can later be categorized for better analysis of the study results. For example, the reasons for extended stay can be broken down into five categories:
1. the number of patients who remained in the hospital for continued observation of post-surgical effects (noncomplications);
2. the number of patients who remained in the hospital for continued observation of perioperative complications;
3. the number of patients who remained in the hospital because of the need for more extensive surgery not anticipated at the time of admission for outpatient procedure;
4. the number of patients who remained in the hospital because of personal request (documented patient/family request for continued stay);
5. the number of patients who remained in the hospital for other reasons.
Collect additional information about the variables that might have affected post-procedure admissions, such as:
• preoperative American Society of Anesthesiologists (ASA) classification (a patient risk variable);
• type of anesthesia administered;
• surgeon/anesthesiologist;
• service (i.e., orthopedics, ophthalmology, etc.);
• patient age and payment source;
• patient’s participation (or lack of participation) in preadmission education classes.
Data collection tool facilitates improvement
A data collection tool can be completed by unit nurses when patients are admitted following outpatient surgery. (See data collection tool, p. 127.) This tool also could be used by staff in the case management department or health information management department to conduct retrospective reviews.
By capturing well-defined and meaningful data about unplanned admissions following outpatient surgery, the medical staff and hospital departments can identify areas for potential improvement. Trends of admissions in certain services and inpatients receiving specific types of anesthesia may be overlooked when extended stays are only examined on a case-by-case basis.
It is important for hospitals to assess their post-ambulatory-surgery admission rates in these times of resource control. Physicians may unknowingly subject patients to a day-stay experience because of managed care pressures when a planned inpatient admission would have been more appropriate. Patients and families may need education regarding post-surgical symptomatology with the understanding that post-discharge supportive care must be arranged. The nursing units must be staffed adequately to ensure timely discharge of patients. Patients who are considered high-risk for post-surgical complications (preoperative ASA categories 3-4) might not be candidates for some outpatient procedures. Consideration might be given to decreasing reliance on general anesthesia in those procedures where straight local or nerve block anesthesia could be substituted satisfactorily. Studies such as this post-ambulatory surgery retention evaluation will aid the medical staff and the institution in identifying areas for both cost control and quality improvement.
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