Background: Outpatient thyroid surgery is gaining popularity as it can reduce length of hospital stay, decrease costs of care, and increase patient satisfaction. There remains a significant variation in the use of this practice including a perceived knowledge gap with regards to the safety of outpatient thyroidectomies and how to go about implementing standardized institutional protocols to ensure safe same-day discharge. This review summarizes the information available on the subject based on existing published studies and guidelines. Methods: This is a scoping review of the literature focused on the safety, efficacy and patient satisfaction associated with outpatient thyroidectomies. The review also summarizes and editorializes the most recent American Thyroid Association guidelines. Results: In total, 11 studies were included in the analysis: 6 studies were retrospective analyses, 3 were retrospective reviews of prospective data, and 2 were prospective studies. The relative contraindications to outpatient thyroidectomy have been highlighted, including: complex medical conditions, anticipated difficult surgical dissection, patients on anticoagulation, lack of home support, and patient anxiety toward an outpatient procedure. Utilizing these identified features, an outpatient protocol has been proposed. Conclusion: The salient features regarding patient safety and selection criteria and how to develop a protocol implementing ambulatory thyroidectomies have been identified and reviewed. In conclusion, outpatient thyroidectomy is safe, associated with high patient satisfaction and decreased health costs when rigorous institutional protocols are established and implemented. Successful outpatient thyroidectomies require standardized preoperative selection, clear discharge criteria and instructions, and interprofessional collaboration between the surgeon, anesthetist and same-day nursing staff.

/pdf/feasibility-and-safety-of-outpatient-thyroidectomy-a-3n6y2utp06.pdf

Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review

The American Society of Anesthesiologists Physical Status Classification (ASA) is used for communication of patient health status, risk scoring, benchmarking and financial claims. Prior studies using hypothetical scenarios have shown poor concordance of ASA classification among healthcare providers. There is a paucity of studies using clinical data, and of clinical factors or patient outcomes associated with discordant classification. The study aims to assess ASA classification concordance between surgeons and anesthesiologists, factors surrounding discordance and its impact on patient outcomes. This retrospective cohort study was conducted in a tertiary medical center on 46,284 consecutive patients undergoing elective surgery between January 2017 and December 2019. The ASA class showed moderate concordance (weighted Cohen's κ 0.53) between surgeons and anesthesiologists. We found significant associations between discordant classification and patient comorbidities, age and race. Patients with discordant classification had a higher risk of 30-day mortality (odds ratio (OR) 2.00, 95% confidence interval (CI) = 1.52-2.62, p < 0.0001), 1-year mortality (OR 1.53, 95% CI = 1.38-1.69, p < 0.0001), and Intensive Care Unit admission > 24 h (OR 1.69, 95% CI = 1.47-1.94, p < 0.0001). Hence, there is a need for improved standardization of ASA scoring and cross-specialty review in ASA-discordant cases. 

/pdf/discordant-american-society-of-anesthesiologists-physical-2e31vn50.pdf

Discordant American Society of Anesthesiologists Physical Status Classification between anesthesiologists and surgeons and its correlation with adverse patient outcomes

In ureterorenoscopy, anaesthesiologists are preferring regional anaesthesia to avoid postoperative complications, while surgeons are preferring general anaesthesia to avoid ureteral trauma. China h...

Comparison of the effects of general, spinal and epidural anesthesia on ureter access and surgical outcomes during flexible ureterorenoscopy for transurethral single stone removal surgeries: a monocentric retrospective study.

Effects of German chamomile on symptoms and healing after mandibular third molar surgeries: A triple-blind split-mouth randomised controlled trial

Previous studies showed mixed results for patient satisfaction by supplementing the preanesthetic assessment with written or audio-visual materials. We hypothesize that an audio-visual aid or a brochure in addition to face-to-face interview, leads to improved patient satisfaction and shortens the preanesthetic assessment duration.We randomly assigned 1051 patients scheduled for preanesthetic assessment to three different groups: face-to-face preanesthetic interview alone (Group 1), videos before the interview (Group 2), and brochure before the interview (Group 3). All patients were asked to complete a postinterview questionnaire assessing patient satisfaction, knowledge gain, prior experience with anesthesia, and quality of supplementary media.The use of additional materials immediately before the preanesthetic interview did increase the overall patient satisfaction (F<inf>(2, 1003)</inf> = 3.10, P<0.05, ƞ2=0.006) but not the interview satisfaction (F<inf>(2, 1011)</inf> = 0.756, P>0.05) nor information gain (procedure explanations F<inf>(2, 987)</inf> = 0.400, P>0.05) or quality of answered questions (F<inf>(2, 1029)</inf> = 0.769, P>0.05). A statistically significant effect on interview satisfaction (F<inf>(13,996)</inf> = 5.15, P<0.01., ƞ2=0.063), overall satisfaction (F<inf>(13,988)</inf> = 4.25, P<0.01., ƞ2=0.053) and given explanations (F<inf>(13, 972)</inf> = 3.132, P<0.001, ƞ2=0.04) was associated with the explanation of different anesthetic techniques by the provider. No differences of response quality between the anesthesiologists was found (F<inf>(13, 1014)</inf> = 1.494, P>0.05).Additional information imparted in the form of an educational brochure or videos immediately before the preanesthetic assessment and interview does not lead to higher patient satisfaction. 

A comparison of face-to-face, brochure- and video-assisted anesthesia interviews: a qualitative randomized survey study

A successful anesthesia pre-assessment clinic needs to identify patients who need further testing, evaluation, and optimization prior to the day of surgery to avoid delays and cancelations. Although the ASA Physical Status Classification system (ASA PS) has been used widely for over 50 years, it has poor interrater agreement when only using the definitions. In 2014, ASA-approved examples for each ASA physical status class (ASA PS). In this quality improvement study, we developed and evaluated the effectiveness of institutional-specific examples on interrater reliability between anesthesia pre-anesthesia clinic (APAC) and the day of surgery evaluation (DOS). A multi-step, multi-year quality improvement project was performed. Step 1, pre-intervention, was a retrospective review to determine the percentage agreement of ASA PS assignment between APAC and DOS for adult and pediatric patients. Step 2 was a retrospective review of the step 1 cases where the ASA PS assignment differed to determine which medical conditions were valued differently and then develop institutional-specific examples for medical conditions not addressed by ASA-approved examples. Step 3 was to educate clinicians about the newly implemented examples and how they should be used as a guide. Step 4, post-intervention, was a retrospective review to determine if the examples improved agreement between APAC and DOS ASA PS assignments. Weighted Kappa coefficient was used to measure of interrater agreement excluding chance agreement. Having only ASA PS definitions available, APAC and DOS agreement was only 74% for adults (n = 737) and 63% for pediatric patients (n = 216). For adults, 20 medical co-morbidity categories and, for pediatric patients, 9 medical co-morbidity categories accounted for > 90% the differences in ASA PS. After development and implementation of institutional-specific examples with ASA-approved examples, the percentage agreement increased for adult patients (n = 795) to 91% and for pediatric patients (n = 239) to 84%. Weighted Kappa coefficients increased significantly for all patients (from 0.62 to 0.85, p < .0001), adult patients (from 0.62 to 0.86, p < .0001), and pediatric patients (from 0.48 to 0.78, p < .0001). ASA-approved examples do not address all medical conditions that account for differences in the assignment of ASA PS between pre-anesthesia screening and day of anesthesia evaluation at our institution. The process of developing institutional-specific examples addressed the medical conditions that caused differences in assignment at one institution. The implementation of ASA PS examples improved consistency of assignment, and therefore communication of medical conditions of patients presenting for anesthesia care.

/pdf/improving-agreement-of-asa-physical-status-class-between-pre-afzibai3dj.pdf

Improving agreement of ASA physical status class between pre-anesthesia screening and day of surgery by adding institutional-specific and ASA-approved examples: a quality improvement project

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Improving agreement of ASA physical status class between pre-anesthesia screening and day of surgery by adding institutional-specific and ASA-approved examples: a quality improvement project