Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
As of 2020, approximately 80% of surgeries were performed in outpatient surgical centers.1,2 Ambulatory surgery centers are strictly regulated for patient safety, and patients are carefully selected to reduce risk. However, there are cases in which a patient undergoing a procedure in a surgery center needs to be transferred for observation to a facility with more resources for higher level care.
There are no current guidelines which explicitly state the indications for transfer, but generally, when the needs of the patient being observed in the surgical center become greater than what the surgical center is able to provide, it is best to transfer the patient to an inpatient status, where enhanced observation and immediate management are possible. This article will review common clinical situations in which the needs of the patient may outweigh the capacity of the surgical center to deliver timely and optimal care.
Prolonged hemodynamic instability is a notable clinical situation for which clinicians should consider inpatient patient transfer for a higher level of care.3 While each situation is patient-specific and context-dependent, when the patient’s systolic blood pressure is less than 90 mmHg despite adequate fluid resuscitation and necessitates vasopressor or inotropic support, the clinician should consider transferring the patient. Furthermore, signs of inadequate end organ perfusion (e.g., urine output less than 0.5 mL/kilogram of ideal body weight over 3 hours, altered mental status, and lactate >4) should also prompt consideration of transfer.3
Respiratory failure—hypoxemia or hypercarbia—requiring advanced respiratory support (e.g., invasive positive-pressure ventilation or extra-corporeal membrane oxygenation), should initiate prompt transfer to appropriate inpatient centers.3 Additionally, uncontrolled post-operative symptoms at a severe level may be best monitored and treated in the inpatient setting.4
New, life-threatening medical complications are another reason for a surgery center patient to be transferred. Examples include the acute onset of life-threatening cardiac complications (e.g., suspected myocardial infarction, aortic dissection, or blunt aortic trauma). A chronic obstructive pulmonary disease exacerbation threatens adequate ventilation and indicates inpatient-level care. If there is a suspected thromboembolic event (e.g., pulmonary embolism or arterial occlusive event), transfer to the emergency department should happen promptly to facilitate rapid treatment.4,5
Generally, patients should be transferred when the readily available resources of the outpatient surgery center do not adequately meet the immediate or anticipated needs of the patient. While these needs and available resources vary by patient and surgical center, clinical situations associated with increased risk of inadequate resources in the surgical center include prolonged hemodynamic instability, respiratory failure, and acute life-threatening complications—including exacerbations of pre-existing conditions. While this list is not exhaustive, it provides a framework within which the clinician can further execute clinical judgement.
References
1. Carey K, Morgan JR. Payments for outpatient joint replacement surgery: A comparison of hospital outpatient departments and ambulatory surgery centers. Health Serv Res. 2020;55(2):218-223. doi:10.1111/1475-6773.13262
2. Janeway MG, Sanchez SE, Chen Q, et al. Association of Race, Health Insurance Status, and Household Income with Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States. JAMA Surg. 2020;155(12):1123. doi:10.1001/jamasurg.2020.3318
3. American College of Surgeons. Optimal Resources for Emergency General Surgery: 2022 Standards. 2022. https://www.facs.org/media/evyh55dj/optimal-resources-for-emergency-general-surgery.pdf
4. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery–a prospective study. Can J Anaesth J Can Anesth. 1998;45(7):612-619. doi:10.1007/BF03012088
5. Brown CR, Ghenbot S, Magnussen RA, Harangody S, Flanigan DC, Miller TL. Unplanned Emergency Visits and Admissions After Orthopaedic Ambulatory Surgery in the First 2 Years of Operation of a University Ambulatory Surgery Center. Am J Sports Med. 2021;49(2):505-511. doi:10.1177/0363546520976626
