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Defining Outpatient Surgery Using a Consensus Approach in the Veteran’s Health Administration (VA)
Mull HJ, Rosen AK, Rivard PE, Itani K. Defining Outpatient Surgery Using a Consensus Approach in the Veteran’s Health Administration (VA). Presented at: VA Association of Surgeons Annual Meeting; 2015 May 3; Miami, FL.
Outpatient surgeries are increasing compared to surgeries performed in inpatient setting. Few studies have examined outpatient surgical adverse events (AEs); this lack of a standard definition of "outpatient surgery" has hindered progress in this area. We conducted a survey with a multidisciplinary panel of VA surgical staff to reach consensus on a uniform definition of outpatient surgery for the purposes of AE detection.
We employed a modified-Delphi approach with a convenience sample of VA surgical staff. We surveyed participants regarding which of 41 outpatient surgery criteria (based on VA infrastructure guidelines, literature review and expert opinion) should be used in the definition of outpatient surgery. Participants rated categories of procedures, settings, providers, anesthesia, and incisions on a scale of 1-5 (1 = must include, 5 = must exclude) over 3 survey rounds. We defined consensus as an interquartile range 2 among responses; we excluded criteria from the definition of outpatient surgery if the median rating was 2.
Participants from seven VISNs (three Chiefs of Surgery, four surgeons, three nurses, two anesthesiologists, and two surgical residents) rated criteria. We achieved consensus on 51% of items after Round 1, 54% after Round 2, and 63% after Round 3. Participants agreed to exclude procedures performed 1) by gastroenterologists, 2) in prosthetic/orthotic or non-OR anesthesia procedure clinics, or 3) under local anesthetic, from the definition of outpatient surgery. Consensus was not reached on procedures performed by dermatologists or in certain clinics (e.g., thoracic surgery).
There is wide variation in the criteria surgical stakeholders chose to include in the definition of outpatient surgery - only 2/3 of the criteria presented in the Delphi process reached consensus. While our work lays the foundation for development of a standard definition of outpatient surgery, additional work is needed before AE detection in this setting can be systematically conducted.