Ronald E. Iverson

Mortality in outpatient surgery.

Background: The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) has reported statistics on morbidity and mortality for facilities that it accredits based on an analysis of unanticipated sequelae and surgical mortality. Data acquired through the first Internet-Based Quality Assurance and Peer Review reporting system (IBQAP) were reviewed and published in 2004. This article reports the accumulated data in the IBQAP through June of 2006, analyzing death associated with procedures performed in facilities approved by the AAAASF. With the exception of some statistics on the Medicare-aged population, there are few data reported in the literature related to deaths in outpatient surgery. Methods: The IBQAP, designed in 1999 by the AAAASF, mandates biannual reporting of all unanticipated sequelae and random case reviews by all surgeons operating in AAAASF–accredited facilities. Surgical log numbers, whose entry is required, allow for tabulation of the number of cases and procedures performed by individual reporting surgeons. Results: In this review of data collected using the IBQAP from January of 2001 through June of 2006, there were 23 deaths in 1,141,418 outpatient procedures performed. Pulmonary embolism caused 13 of the 23 deaths. Only one death occurred as the result of an intraoperative adverse event. Conclusions: A pulmonary embolism may occur after any operative procedure, whether it is performed in a hospital, an ambulatory surgery center, or a physician’s office-based surgery facility. The procedure most commonly associated with death from pulmonary embolism in an office-based surgery facility is abdominoplasty. The frequency of pulmonary embolism associated with abdominoplasty warrants further study to determine predisposing factors, understand its cause, and introduce guidelines to prevent its occurrence.

Patient safety in accredited office surgical facilities.

&NA; The medical profession is besieged by concerns about cost containment. This in turn has focused attention on the use of ambulatory surgical facilities. However, the costs of hospital outpatient surgery programs usually prevent them from being competitive when compared with the costs of using office surgical facilities. To address the question of patient safety in office surgical facilities, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) sent a questionnaire to its accredited facilities. Two‐hundred and forty‐one (57.7 percent) of the 418 accredited facilities returned the anonymous questionnaires, a very high response rate. Of interest are the following findings: 400,675 operative procedures were reported during a 5‐year period. Significant complications (hematoma, hypertensive episode, wound infection, sepsis, hypotension) were infrequent, occurring in 1 in every 213 cases. Return to the operating room within 24 hours and preventive hospitalization were less frequent. A death occurred in 1 in 57,000 cases (0.0017 percent). The overall risk is comparable in an accredited office (plastic surgical facility) and in a free‐standing or hospital ambulatory surgical facility. This study documents an excellent safety record for plastic surgery done in accredited office surgical facilities by board‐certified plastic surgeons.

Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting.

At the ASPS Annual Meeting in October of 2000, the ASPS Board of Directors convened the Task Force on Patient Safety in Officebased Surgery Facilities. The task force was assembled in the wake of several highly publicized patient deaths, increasing state legislative/regulatory activity, and a moratorium on all level II and level III office-based surgery in the State of Florida. The task force faced a daunting task. The first area the task force focused on was collecting, evaluating, and reporting the health policies, accreditation standards, state legislation/regulation activities, and publications that influence the delivery of health care in office-based surgery facilities. With the information gathered, the task force produced several documents, starting with an accreditation crosswalk table that contrasted the office-based surgery standards of the three nationally recognized accrediting agencies. The task force also built a database to track state office-based surgery regulations, which was used as a resource to draft office-based surgery model legislation/regulation. The accreditation crosswalk and model legislation/regulation were placed on-line for members and have been widely distributed to national, state, and specialty medical organizations and state medical boards. The second area the task force tackled was the development of office-based surgery guidelines. After an extensive review of the existing guidelines and scientific literature, it was determined that few materials met the scientific rigor necessary to establish clear standards of practice. Therefore, the task force determined that it would be more appropriate to develop office-based surgery practice advisories, which are defined as systematically developed reports intended to assist decision-making in areas of patient care in which scientific evidence is insufficient.1 The advisory is based on the best information available and largely reflects the collective opinion of the members of the task force. The task force included representatives from related plastic surgery organizations and the American Society of Anesthesiologists and included Ronald E. Iverson, M.D., chair; Jeffery L. Apfelbaum, M.D., American Society of Anesthesiologists representative; Jack G. Bruner, M.D., ASPS Liposuction Task Force representative; Bruce L. Cunningham, M.D., ASPS/ PSEF Joint Outcomes Task Force representative; Richard A. D’Amico, M.D., ASPS representative; Thomas Joas, M.D., American Society of Anesthesiologists representative; Victor L. Lewis, Jr., M.D., ASPS Health Policy Analysis Committee representative; Dennis J. Lynch, M.D., ASPS representative; Noel B. McDevitt, M.D., ASPS Deep Vein Thrombosis Task Force representative; Michael F. McGuire, M.D., ASAPS representative; Calvin R. Peters, M.D., Florida Ad Hoc Commission on Patient Safety representative; Robert Singer, M.D., American Association for Accreditation of Ambulatory Surgery Facilities, Inc. representative; Rebecca S. Twersky, M.D.,

Hydrofluoric Acid Burns of the Hand

Hydrofluoric acid burns, if not promptly recognized and properly treated, may produce serious injury and prolonged disability. Clinically, characteristic and specific treatment, given early, is very effective. A series of forty-five burns is reviewed and a plan of treatment is proposed which depends in part on the severity of the tissue injury and includes local injections of 10 per cent calcium gluconate.

Coccidioidomycosis Tenosynovitis in the Hand

A patient with disseminated coccidioidomycosis with acute palmar tenosynovitis is presented. Early synovectomy followed by amphotericin B therapy was carried out and is recommended for treatment of coccidioidomycosis tenosynovitis. The association of an exacerbation of coccidioidomycosis in a patient with a history of coccidioidomycosis treated with immunosuppressive drugs is described. Prophylactic amphotericin B therapy is recommended for such patients.

MOC-PS(SM) CME article: liposuction.

Learning Objectives: After studying this article, the participant should be able to: 1. Adequately evaluate a patient preoperatively for liposuction. 2. Formulate a surgical treatment plan to safely perform liposuction. 3. Postoperatively diagnose immediate, early, and late complications and formulate a treatment plan for the complications. 4. Classify the anesthesia status of a potential liposuction patient and select the appropriate type of anesthetics to be used. 5. Understand large-volume liposuction and the added risks inherent in this type of liposuction procedure. Summary: The purpose of this liposuction article is to provide a broad overview of the procedure, currently one of the most common operations performed by plastic surgeons. The important medical history that must be obtained, including comorbidities and conditions that increase the risk of deep venous thrombosis, is discussed. Specifics of the physical examination are highlighted. Anesthesia for liposuction is an extremely important factor for the success and safety of the procedure. The anesthetic agents and the wetting solutions used in liposuction are explained to promote safety and good results. A surgical treatment plan for a successful outcome, including the types of lipoplasty, is presented. Outcomes of the procedures, including potential complications, are covered. The rare complication of intestinal or organ perforation from the cannula is discussed to increase the surgeons level of awareness of the problem and its avoidance. Deep venous thrombosis, associated with pulmonary embolism and death, is the most frequent serious complication of liposuction. This and other sequelae of liposuction are discussed so that the surgeon can evaluate his or her surgical outcomes to improve the results and promote patient safety. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery.

Summary: Despite the many benefits of ambulatory surgery, there remain inherent risks associated with any surgical care environment that have the potential to jeopardize patient safety. This practice advisory provides an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings. In conjunction, this advisory identifies several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and provides recommendations for how best to minimize these complications.

Cross-finger Pedicle Flaps in the Hand

The cross-finger pedicle flap technique provides good functional and cosmetic reconstruction to loss of volar digital tissue. A high degree of sensory rehabilitation including two-point discrimination is the usual end result.

Keratoacanthoma is frequently a dangerous diagnosis

Summary One hundred and two cases of keratoacanthoma were reviewed. Fourteen cases were selected for brief reports to demonstrate the danger in the diagnosis of keratoacanthoma. The danger lies in the treatment of keratoacanthoma as benign when it is probably premalignant and closely associated with squamous cell carcinoma. This has influenced us to recommend wide excision as the primary treatment of all cases of keratoacanthoma.

Sedation and Analgesia in Ambulatory settings

At the ASPRS Annual Meeting in October of 1998, the ASPRS Board of Directors convened the Task Force on Sedation and Analgesia in Ambulatory Settings. This task force was called to address, in detail, concerns that had been identified by many plastic surgery organizations about sedation in outpatient surgery settings. The concern about safety and sedation in outpatient surgery facilities is also a major focus for many state legislatures and medical boards. The task force has provided guidelines that, if followed, will provide safe sedation and analgesia for plastic surgery patients in all types of outpatient surgery settings. The statement from the task force represents an extensive review of the literature and existing guidelines and a critical analysis of clinical experience. The task force members were the following: Ronald Iverson, M.D., Chair; Julio Garcia, M.D., Lipoplasty Society representative; Thomas Joas, M.D., Medical Board of California; Brian Kinney, M.D., ASAPS representative; Dennis Lynch, M.D., ASPRS representative; Charles McLeskey, M.D. (Chair, Anesthesiology, Scott and White Clinic, Temple, Texas); and Robert Singer, M.D., AAAASF representative. I would like to thank the members of the task force for the insights that they brought to this process. The final document represents their significant contributions to these efforts.