Statement on ​Outcome Indicators for Office-Based and Ambulatory Surgery

Developed By: Committee on Ambulatory Surgical Care
Last Amended: October 26, 2022 (Original Approval: October 16, 2013)

Effective, accurate, and consistent monitoring of the quality-of-service delivery is central to an organization’s ability to maintain and improve standards of care. Failure to monitor quality has been linked to well-publicized, adverse clinical events. Both internal and external entities should contribute to monitoring Ambulatory surgical centers to guarantee high-quality services are being provided to patients. 

Clinical indicators are norms, criteria, standards, and other direct qualitative and quantitative measures used in determining health care quality. Outcome indicators should be implemented to ensure a safe, effective, and efficient environment for patients receiving same-day surgeries and procedures. The committee on ambulatory surgical care suggests that outcome indicators should aid facilities in making improvements in healthcare delivery by providing data regarding patient or procedure trends. 

This document is meant to serve as a framework of key indicators that can be selected based on a facility's needs, and utilized by ambulatory surgery centers, office-based settings, and accreditation bodies to enact internal and systemwide improvements. National comparison of these indicators can lead to the development of best practices and continuous quality improvement across facilities. Available resources and cases performed will guide each facility’s selection of appropriate indicators to monitor. In addition, committee members recommend that all measures should be normalized for comparison. Benchmarking at each center or office will be individualized to each facility’s procedural capabilities and specified time frames.

Patient safety and quality of care:
Safety involves the delivery of services in absence of preventable adverse events. Medical errors, adverse events, falls, wrong sites/side/patients are well documented in healthcare delivery and must be monitored. 

Acute kidney injury (AKI) 
Anesthesia equipment problems causing cancellation, delay, or resulting in injury
Intraoperative awareness 
Mortality 
NPO status violation causing cancellation, delay, or resulting in injury (e.g. aspiration pneumonitis)
Operating room fire 
Other unanticipated trauma
Patient burns 
Patient falls inside the facility
Postoperative infection (surgical site, systemic)
Retained objects
Skin injuries 
Unplanned electric shock 
Unplanned transfusion 
Wrong patient 
Wrong procedure 
Wrong site / side surgery

Perioperative efficiency and cost of care:
These are directly related and help measure patient selection, surgeon selection, procedure selection, discharge, and processes within a facility. Cost indicators measure the cost of care relative to the care delivered. A productive and efficient facility should not suffer from chronic and substantial waste. 

Arrival to facility, timeliness, accuracy
Cancellation pre-induction & reasons
Cancellation post-induction & reasons
Cost of care delivered
COVID & other virus status, vaccination, infection prevention protocols 
Delay over 30 minutes (including PACU delays)
Discharge without escort or Against Medical Advice (AMA)
First case on-time starts (FCOTs)
Median wait times in admissions, pre-op holding areas
Patient preparation, translator, capacity 
Presence of IV placement protocol 
Procedure booking accuracy, issue
Percentage of patients who received a preanesthetic assessment 
Return to operating room 
Turn-over times (TAT) 
Unplanned admission or escalation to a higher level of care

Facility sustainability and greening the operating room:
As presented in the 2021 House of Delegates, it is our responsibility, as leaders of our organizations to monitor and improve our facility’s sustainability. Refer to https://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-equipment-and-facilities/environmental-sustainability/greening-the-operating-room

Anesthetic equipment choices

Environmental impact of anesthetic choices

Fresh gas flow

Total inhalational anesthesia agent used

Waste stream management & recycling

Medication safety:

Adverse drug reactions, anaphylaxis

Administration of expired medication

Biohazards, USP 800

Delayed emergence from anesthesia

Emergency drug availability

Errors d/t look alike medication

Clinical care and complications:

Airway

Airway soft tissue trauma
Aspiration
Dental injury
Inability to ventilate 
Inadvertent extubation
Unplanned reintubation
Unanticipated difficult airway
Lack of availability of airway equipment

Respiratory

Airway obstruction
Aspiration pneumonitis
Bronchospasm
Diaphragmatic paresis leading to respiratory failure, or distress
Hypoxia
Laryngospasm
Pneumothorax 
Postoperative intubation/ reintubation
Pulmonary edema
Respiratory failure or arrest

Cardiovascular

Acute coronary syndrome
Clinically significant arrhythmia or cardiac arrest
Clinically significant hypotension
Embolism: fat, air, venous thromboembolism
Hemorrhage
Clinically significant hypertension
Vascular access injury

Central Nervous System

Adult delirium
Central neurologic injury caused by regional anesthesia, e.g., hematoma, infection, spinal cord injury, unintended dural puncture, high spinal, retained catheter, wrong medication injection, failed block
Cerebrovascular accident: Transient Ischemic Attack (TIA), stroke, bleed 
Cognitive dysfunction 
Eye injury, including corneal abrasion
Pediatric delirium
Post-dural puncture headache
Seizures
Visual loss

Peripheral Nerves

Failed peripheral nerve block (PNB)
Falls after PNB
Nerve injury, neuropraxia
Other PNB complications
Positioning related neuropraxia
Wrong site or wrong sided block

Post-Anesthesia Care Unit events:

Extended PACU stay: delayed discharge due to medical reasons including obstructive sleep apnea (OSA)
Extended stay for unplanned social reasons: ride, lack of responsible adult at discharge
Inadequate pain control
Post-operative and post-discharge nausea and vomiting (PONV)
Postoperative urinary retention 
Prolonged neuromuscular block

Consent obtained
Equipment maintenance
Presence or absence of language line / translation
Patient, family, care-taker complaints
Patient satisfaction and complaints
Surgeon complaint
Timeout performed for any surgery or procedure

Outcome events:

Follow-up on postop within 24 h
Postoperative follow-up after 30-days
Unplanned Post-procedural Treatment in physician’s office or emergency department within 7 days after discharge.
Unplanned Admission to hospital or acute care facility within 7 days after discharge from facility

Some facilities may choose to monitor the financial viability of the facility or specific service line as part of their outcomes process, however, these are beyond the scope of this document.

This document has been developed by the ASA Committee on Ambulatory Surgical Care in collaboration with SAMBA. The recommendations are designed to promote quality patient care but do not guarantee specific outcomes. Recommendations are subject to revision as dictated by evolution of technology and practice. (Revised June 2022.)