Predicting Which Patients Will Be Hospitalized
New Patient Index Measures Risk Factors for Post-op Admission
Who are the most likely surgical outpatients to wind up being hospitalized immediately after an operation? Those who are 65 or older, receiving general or regional anesthesia, and undergoing procedures longer than two hours, according to a checklist of risk factors created by researchers at the Univer-sity of Pennsylvania School of Medicine.

The index, published in the March issue of Archives of Surgery, is based on a review of 783,558 same-day surgery patients, 95 percent of whom underwent surgery in a hospital-based facility. Of that group, 4,351 were admitted to a hospital following surgery and 19 died, equating to one death per about 50,000 patients, according to the report. The researchers excluded cardiac catheterizations, endoscopies and cataract operations.

Based on these findings, the researchers developed a summary score to identify patients at elevated risk for post-op hospitalization, assigning one point each for patients being 65 years or older; having an operating time longer than 120 minutes; cardiac diagnoses; peripheral vascular disease; cerebrovascular disease; malignancy; HIV-positive status; and regional anesthesia. Due to increased risk factors, patients receiving general anesthesia were assigned two points. Patients with an index score of three have 21 times the odds for hospital admission than patients receiving a score of zero or one. Patients with scores of four, five and six, meanwhile, have 32 times the odds of admission.

Lead author Lee A. Fleisher, MD, FACC, FAHA, chair of Anesthesia and Critical Care for the University of Pennsylvania Health System, notes that the research focused on procedures performed at hospital outpatient settings and may not reflect findings from freestanding facilities. There was no data on the patients' presurgical situation or whether some of the admissions were planned. He does believe, however, that the system can be used for enhanced patient safety and high-quality care.

"As outpatient facilities continue to push the envelope, we need to take steps to match the location of care with the risk factors of patients," says Dr. Fleisher.

- Daniel Cook

The Effects of Horizontal Violence
Study: Nurses Who Are Bullied Likely to Suffer PTSD and Endanger Patients
Nurses who are bullied by their fellow nurses and surgeons are more likely to suffer post-traumatic stress disorder, switch jobs and make errors that compromise patient safety than nurses who aren't bullied, according to an online survey of nearly 1,100 perioperative RNs.

"Horizontal violence must be stopped in the healthcare workplace by developing and enforcing a no-tolerance policy," says Beverly Kirchner, RN, BSN, CNOR, CASC, the president and CEO of Genesee Associates and the study's lead researcher. "Everyone must understand the consequences bullies will suffer in the workplace."

More than 500 RNs who answered the survey detailed patient safety breaches that occurred when horizontal violence was present in the healthcare workplace. Some likened the experience to being battered spouses.

"If you have a bully in your workplace, you will find her behavior is malicious, health-endangering and repeated," says Ms. Kirchner. "If the behavior is not stopped, the work environment can become hostile and everyone will suffer. If bullying is ignored, the entire organization is placed at risk for employee trauma, possible litigation and adverse consequences for patients."

What does a bully look like? Here is a profile:

• has low self-esteem
• needs "targets" to survive
• is an inadequate, defective, poorly developed person
• has a long history of disrespecting the needs of others
• puts her needs above anyone else's
• needs to control others; the control she seeks is humiliation and the withholding of resources

The target's profile looks like this:

• is vulnerable
• makes self-effacing statements
• carries herself poorly (looks down, avoids eye contact, slumps)
• is private
• practices self-denial, which is a form of protection
• perceives self as a target "victim"
• finds it hard to live with bullies

Knowing these traits, researchers believe they can further explore the dynamics between the bully and target. The target enters the bully relationship involuntarily. The bully has control, deciding when and where to attack, when to hold back and what audience will view the behavior. Control is the bully's ultimate goal. There are four types of healthcare workplace violence, according to bullying experts Gary Namie, PhD, and Ruth Namie, PhD. They include verbal, psychological (mix of verbal, non-verbal, and "planned" attacks), physical and sexual assault.

The three types of bullies:

• Critics nitpick at everything the target does.
• Two-headed snakes are passive-aggressive and dishonest. They pretend to be nice while actually sabotaging the target. They're masters at managing the target's image to others.
• Gatekeepers try to "one up" the target. They're masters at ordering others around as well as controlling every situation.

"In a social setting - work is a social setting - a target can feel isolated, betrayed or abandoned by co-workers," says Ms. Kirchner. "Financially, we can suffer due to loss of job or simply by having to take days off to avoid the bully."

- Dan O'Connor

Break Out Your Yardsticks
Do Your ORs Measure Up?
Two changes of note from the AIA's 2006 Construction Guidelines, which are updated and published every five years.

• Class C operating rooms (the most common) remain at 400 net square feet, but that square footage is now exclusive of any permanent cabinetry or fixtures. In other words, your ORs will have to be 400 square feet plus whatever square footage you need for cabinetry and writing surfaces, for example.
• Recovery beds must be 48 inches from walls and 60 inches (an increase over 48 inches) from each other.

"The problem with these two changes is that once the facility is designed and constructed, it's nearly impossible to make the adjustments necessary without compromising the revenue-generating ability of the surgery center," says Wade Taylor, AIA, of Wade Taylor and Associates Architects in Milwaukee, Wis.

- Dan O'Connor

Benchmarking Snapshot
Nobody Likes Cancellations
Be they after admission or after anesthesia induction, cancellations create a cascade effect on your patients, your physicians and your surgical department. The AAASC Clinical Benchmarking report shows that 0.69 percent of the average facility's cases are canceled after admission and 0.02 percent after induction. The result of cancellations?

• Patients are inconvenienced and upset when they have to rearrange their day. Their anxiety increases when their procedure is postponed or rescheduled to another day.
• Patients' family members may have to make changes in their schedule, causing undue stress.
• The surgery center could lose money on supplies if the procedure is cancelled and the operating room staff has already opened the supplies.
• The surgery center also faces a potential loss on the salary cost for the OR team scheduled to do the procedure.

In the Know

• Arizona Looks to Restrict Office-based Procedures. Arizona would become the 23rd state to restrict office-based procedures if the state medical board's new rules on office-based surgery with sedation are accepted. Among the proposed rules:
• Physicians who use general anesthesia in an office or other outpatient setting that isn't part of a licensed hospital or ASC must obtain a healthcare institution license.
• Staff who assist or participate in office-based surgery using sedation must have sufficient education, training and experience, and if applicable a current license certificate to perform the duties.
• Patients must read and sign an informed consent form concerning the risks of undergoing the procedure in an office rather than in a hospital or a licensed ASC.
• Physicians who administer moderate or deep sedation must monitor oxygenation levels.
• Someone trained in advanced cardiac life support must remain to respond to an emergency until the patient is discharged.
• The office must have a reliable oxygen source with resuscitation equipment, a cardiac monitor and patient monitoring equipment.
• HealthSouth Divests ASCs. HealthSouth is selling its 139 outpatient surgery centers and three surgical hospitals to TPG (Texas Pacific Group) for about $945 million. HealthSouth will have an equity stake in a newly formed company, which will be among the nation's largest providers of outpatient surgical services. HealthSouth, still trying to recover from a $2.7 billion accounting fraud, will focus solely on post-acute care.
• Indiana Pushing for Mandatory ERs in Specialty Hospitals. Legislation that would require specialty hospitals to provide emergency services passed the Indiana House by a 60-37 vote last month and is now being considered by the Senate. If passed, all hospitals licensed in the state must contain an "emergency medical service facility." The bill's sponsor says he'd be willing to go back to the original form of the bill, which simply prohibited facilities from using the term "hospital" unless they provided emergency care.
• Inhaled Anesthetics Could Lead to Early Alzheimer's. Common inhaled anesthetics increase the number of amyloid plaques in the brains of animals, which might accelerate the onset of such neurodegenerative diseases as Alzheimer's, say researchers at the University of Pennsylvania's School of Medicine in a study published in the March 7 online edition of Neurobiology of Aging.
• Study OKs Cell Phone Use in Hospitals. The use of cellular phones in a healthcare facility has no noticeable impact on the performance of patient care equipment or other medical devices, according to Mayo Clinic researchers. The finding, researchers suggest, should make facility administrators reconsider their bans or restrictions on the use of mobile electronics. For a study appearing in the March issue of Mayo Clinic Proceedings, researchers at the clinic's Rochester, Minn., institute conducted 300 tests gauging the effects of two different cellular technologies on 192 medical devices over a five-month period last year. They didn't detect a single incident of the phones' interference with the equipment.