The utility of preoperative electrocardiograms in the ambulatory surgical patient.

To determine the utility of preoperative screening electrocardiograms (ECGs) among ambulatory surgery patients, we reviewed the charts of 751 consecutive adult patients who underwent ambulatory surgery. Data were collected on demographic characteristics, coexisting medical problems, American Society of Anesthesiologists physical status score, preoperative ECG results, adverse intraoperative cardiovascular events, and postoperative cardiovascular complications. In our study population of relatively healthy outpatients, preoperative ECGs were abnormal in 42.7% of patients. Age, increased physical status score, and male gender were associated with a greater incidence of abnormal preoperative ECGs. There were 12 adverse cardiovascular perioperative events among the 751 patients (1.6%), and the preoperative ECG may have been clinically useful in six of these 12 patients. Neither preoperative ECGs nor results of preoperative screening questionnaires were predictive of adverse cardiovascular perioperative events. These findings question the utility of preoperative ECGs in the ambulatory surgery setting, especially among younger, relatively healthy patients.

Arthroscopic surgery of the knee under local anesthesia.

This report delineates the efficacy of local anesthesia in the performance of arthroscopic surgery of the knee. A retrospective review of 500 cases revealed that only three required administration of general anesthesia to successfully complete the procedure. A prospective study comparing fentanyl, midazolam, and fentanyl/midazolam combinations as intravenous supplements was performed. Meticulous surgical technique combined with local anesthesia and some form of intravenous sedation in minimal therapeutic dosage will provide satisfactory conditions to perform surgical arthroscopy of the knee.

Unanticipated admission to the hospital following ambulatory surgery.

We conducted a case-control study to identify clinical and demographic risk factors for admission to the hospital following ambulatory surgery. Of 9616 adult patients who underwent ambulatory surgery at a university-affiliated hospital between 1984 and 1986, one hundred were admitted. The most common reasons for admission were pain (18), excessive bleeding (18), and intractable vomiting (17). The mean age (+/- SD) of patients who were admitted was 37 +/- 13 years, and 96% had American Society of Anesthesiologists' physical status scores of 1 or 2. Factors that were independently associated with an increased likelihood of admission were general anesthesia (odds ratio, 5.2), postoperative emesis (odds ratio, 3.0), lower abdominal and urologic surgery (odds ratio, 2.9), time in the operating room greater than 1 hour (odds ratio, 2.7), and age (odds ratio, 2.6). Our results indicate that the likelihood of unanticipated admission is related more to the type of anesthesia and surgical procedure rather than to the patient's clinical characteristics.

Examining nursing personnel costs: controlled versus noncontrolled oral analgesic agents.

To date, few evaluations have focused on nursing personnel costs generated by practices of other clinicians. The authors used traditional industrial engineering and cost accounting techniques to determine nursing personnel costs generated by the use of controlled versus noncontrolled oral analgesic agents. The findings indicate that additional nursing labor costs are generated for drug administration and inventory activities for controlled agents when compared with noncontrolled agents. On an annual basis, the additional costs for drug administration generate approximately +34,000 in hospital expenses for the three nursing units included in this evaluation. This type of interdisciplinary investigation may be valuable as nursing departments face increasing pressures to decrease costs by reducing overtime and eliminating positions.

Hospital resources used for inpatient and ambulatory surgery.

New hospital and physician payment schemes encourage physicians to participate actively in efforts to minimize hospital resource use. As an example of the type of evaluations anesthesiologists may conduct, we examined hospital resources used for comparable groups of inpatients (INPTs) and day surgery unit (DSU) patients. Although INPTs and DSU patients undergoing surgical arthroscopy of the knee or diagnostic laparoscopy were similar with regard to age, physical status, and staff surgeon, more preoperative tests were performed for INPTs than for DSU patients (P less than .05). Hospital costs for these tests were four times greater for INPTs than for DSU patients. Operating room time was from 20 to 45 min longer for INPTs than for DSU patients (P less than .05). Recovery room time was from 25 to 52 min longer for DSU patients (P less than .05). Per patient nursing labor costs paralleled operating and recovery room times. These kinds of analyses are important in identifying opportunities to improve resource use, in assessing institutional costs for surgical care, and in designing strategies that allow institutions and physicians to respond to cost containment pressures.

Savings from outpatient antibiotic therapy for osteomyelitis. Economic analysis of a therapeutic strategy.

Clinical, economic, and epidemiologic data were used to compare the costs of conventional inpatient care of osteomyelitis with the costs of early-discharge treatment using a once-daily parenteral antibiotic at home. Estimated expenses included inpatient medical care, outpatient visits, supplies, child care, home care, transportation, and lost productivity. Early-discharge treatment was associated with lower medical direct, non-medical direct, and indirect expenses than conventional inpatient treatment. Estimated savings per patient ranged from $510 to $22,232 (demonstrating the wide differences in estimated savings when different sources of data on hospital costs are used). These savings are due to large decreases in inpatient costs, which are partially offset by increased outpatient costs. However, because outpatient costs are more often borne by patients than are inpatient costs, early-discharge treatment could be more expensive from the patient's perspective, despite its savings for the hospital and for society as a whole.

Teaching cost-effective diagnostic test use to medical students.

The purpose of this project was to develop and evaluate a program to teach medical students how to order diagnostic tests in a cost-effective manner. The 1-month educational program included a seminar, a simulated patient-care exercise, special case presentations by students, newsletters about diagnostic tests, and concurrent review of patients' bills. Content analysis of answers to open-ended questions and pretests and posttests were used to measure differences in the study and control groups. Although students said the program was useful, no significant differences were found in students' knowledge, attitudes, or simulated test-ordering behavior. The authors conclude that the lack of improvement in objective measures limits the potential effectiveness of restricted efforts such as this one and that the discrepancy between the subjective and objective measures reinforces the need for more rigorous evaluations of programs that teach cost-effective diagnostic test use.

Screening for chest disease in college students: policies of student health services regarding the use of routine screening chest radiographs and tuberculin skin tests.

We conducted a survey of college health services to determine their policies regarding the use of screening chest radiographs and tuberculin skin tests. Pre-enrollment chest radiographs are prescribed for all incoming students by 24 per cent of the 531 respondents and for health professions students, foreign students, and intercollegiate athletes only by an additional 20 per cent, 19 per cent, and 6 per cent, respectively. Periodic chest radiography is conducted for all students by 7 per cent of the respondents and for health professions students, foreign students, and intercollegiate athletes only by an additional 22 per cent, 16 per cent, and 8 per cent, respectively. Pre-enrollment tuberculin skin tests are prescribed for all incoming students by 52 per cent of the respondents and for health professions students, foreign students, and intercollegiate athletes only by an additional 48 per cent, 29 per cent, and 9 per cent, respectively. Periodic tuberculin skin testing is conducted for all students by 27 per cent of the respondents and for health professions students, foreign students, and intercollegiate athletes only by an additional 48 per cent, 23 per cent, and 16 per cent, respectively. We estimate from these data that 723,000 incoming students in the United States received screening chest radiographs in 1979 with estimated charges totaling between $7 million and $27 million. There may be 0.05 to 0.33 induced cases of lung cancer, leukemia, thyroid cancer, and female breast cancer over a 20-year period among this group of students exposed to ionizing radiation.