Study Suggests VA Outpatient Surgery May Be More Risky than Previously Considered

BACKGROUND:
Outpatient surgeries are frequently performed and considered relatively safe; however, research on adverse events (AEs) in this setting has been limited. Moreover, as more high-complexity surgeries move to the outpatient setting, clinicians, quality managers, and policymakers may not have complete information about AEs to direct quality improvement efforts. This study sought to characterize the nature and severity of AEs among outpatient surgical cases performed from FY2012 through FY2015 at 111 VA hospitals and 20 ambulatory surgery facilities. Investigators identified 1,185 cases with a high likelihood of adverse events and 1,073 cases with a low likelihood of adverse events based on post-operative healthcare use. Using a chart review tool developed specifically for this study, which included established AE definitions and validated harm and severity scales, investigators assessed the median days to the adverse event, harm ratings, and severity scores by type of AE.

FINDINGS:

• Among VA outpatient surgeries selected based on the likelihood of an adverse event, nearly 40% of identified events carried more than minimal patient harm, suggesting that outpatient surgery is relatively less safe than previously thought.
• Adverse events were found in 51% (n=608) of high-likelihood surgeries and 12% (n=261) of low-likelihood surgeries.
• While 63% of all AEs involved minimal harm, 28% required hospitalization, and 9% were severely harmful, including 8 adverse events that required intervention to sustain life – and 2 deaths.
• Among 1,010 unique adverse events, the most common were wound issues (26%), urinary retention (23%), and urinary tract infections (12%).
• The median number of days to an AE was 5, with 18% of AEs occurring the day of the outpatient surgery and 75% occurring outside the VA facility after the outpatient surgery occurred.

IMPLICATIONS:

• Potentially preventable AEs such as wound dehiscence (rupture along incision) and urinary retention may be useful targets for quality improvement.

LIMITATIONS:

• This study was unable to reliably define 20% of the AEs that were identified; however, this creates an opportunity for future research to explore and standardize the different types of outpatient surgical AEs, particularly those related to post-operative pain.

AUTHOR/FUNDING INFORMATION: Dr. Mull was supported by an HSR&D Career Development Award (CDA 13-270). Drs. Mull, Charns, Rivard, and Rosen are part of HSR&D's Center for Healthcare Organization and Implementation Research (CHOIR) in Boston, MA.

Mull H, Itani K, Charns M, Pizer S, Rivard P, Hawn M, Rosen A. The Nature and Severity of Adverse Events in Select Outpatient Surgical Procedures in the Veterans Health Administration. Quality Management in Health Care. July-September 2018;27(3):136-144.