The Pennsylvania Patient Safety Authority developed and administered a statewide survey to inform its ambulatory surgical facility (ASF) collaboration that examines presurgical screening and assessment processes and the frequency of ASF cancellations and transfers. The results identified that 37.4% of facilities have implemented an electronic health record and 41.7% receive medical forms electronically. Secretaries and schedulers are the primary contact person 11.7% of the time for preoperative screening and 20.5% of the time for preoperative instructions. The 2010 ASF transfer rate was 1.16 per 1,000 completed procedures, and cardiac conditions were the most frequent reason for an ASF transfer. The 2010 ASF cancellation rate was 18.09 per 1,000 completed procedures, and medical conditions were the most frequent reason for an ASF cancellation. The baseline ASF prescreening activities, transfer rates and reasons, and cancellation rates and reasons obtained in this survey provide direction for the Ambulatory Surgical Facility Preoperative Prescreening and Assessment Collaboration.
In 2010, Pennsylvania ambulatory surgical facilities (ASFs) reported 3,648 events to the Pennsylvania Patient Safety Authority; 66% (n = 2,403) of these events were reported as “Incidents” and 34% (n = 1,245) of these events were reported as “Serious Events.” Of the reported serious events, 34% (n = 423 out of 1,245) indicated that the patient was transferred from the ASF to an acute care hospital. ASFs also reported 335 cancellations of procedures on the day of surgery in 2010. Transfers from an ASF to an acute care hospital may represent good patient care but may also be the result of insufficient rigor in patient or procedure selection.1,2,3 Similarly, cancellations on the day of surgery may be an indicator that practice patterns or patient selection criteria are in need of review. The Authority initiated a northeast Pennsylvania regional ASF collaboration in January 2012 to examine presurgical screening and assessment processes and the frequency of ASF transfers and cancellations. In order to understand the factors related to transfers and cancellations, a statewide survey of ASF presurgical screening and assessment practices and transfer and cancellation information was conducted.
The survey evaluated freestanding ASFs as defined by the Pennsylvania Department of Health4 and was made up of 37 questions:
- 13 organizational characteristic questions
- 10 patient characteristic questions
- 7 history and physical questions
- 3 cancellation questions
- 2 preoperative screening questions
- 2 transfer questions
The questions focused on ASF activities that occurred during the 2010 calendar year. Not all respondents answered all of the questions, so non-responses were removed from the analysis with the percentages calculated based on the actual responses for each question. The 10 patient characteristic questions focused on gender, insurance status, and physical health status. Questions about patient gender mix and insurance status accounted for 7 of the 10 questions. Because response rates for the gender and insurance status questions were less than 25%, which limited the reliability of this data, these questions were removed from the analysis. The unit of analysis was the ASF facility.
An e-mail invitation was sent to 260 Pennsylvania ASFs. Excluding 13 e-mails that were undeliverable, there were a total of 247 delivered invitations. The response rate was 46.5% (n = 115 out of 247).
Over half (63.5% [n = 73 out of 115]) of the responding ASFs are owned by physicians. The remaining ASFs are owned by hospitals or healthcare systems (16.5% [n = 19 out of 115]), corporations (11.3% [n = 13 out of 115]), and partnerships or joint ventures between physicians and hospitals (8.7% [n = 10 out of 115]).
Ninety-seven percent of the responding ASFs are accredited, four ASFs are not accredited, and two ASFs have accreditations with two different organizations. The majority of ASFs, 66.9% (n = 77 out of 115), are accredited by the Accreditation Association for Ambulatory Health Care, 20.8% (n = 24 out of 115) are accredited by the Joint Commission, 9.5% (n = 11 out of 115) are accredited by the American Association for Accreditation of Ambulatory Surgical Facilities, and 0.9% (n = 1 out of 115) is accredited by a magnet organization. ASF size, as indicated by the number of operating rooms and/or procedure rooms, ranged from 1 to 20 rooms per facility, with an average of 3.56 rooms per facility. Three facility responses were removed from the analysis because these facilities opened in 2011; therefore, they did not match the 2010 survey time frame. The majority of responding facilities (59.3% [n = 64 out of 108]) identified themselves as providers of specialty surgical or diagnostic services. The remaining 40.7% (n = 44 out of 108) of facilities identified themselves as providers of general surgical or diagnostic services.
Ninety-nine percent (n = 83 out of 84) of responding ASFs provide ongoing patient safety educational programs or activities for their staff, and 42.3% (n = 33 out of 78) of responding ASFs participated in a culture of safety survey.
The Pennsylvania Department of Health classifies patients based on physical status. A Class 1 patient has no organic, physiologic, biochemical, metabolic, or psychiatric disturbance.5 A Class 2 patient has a mild or moderate systemic disturbance that is either controlled or has not changed in severity for some time. A Class 3 patient suffers from significant disturbance, although the degree to which it limits the patient’s functioning or causes disability may not be quantifiable. ASFs were asked to identify the class of patients that they served the majority of the time. Class 1 patients were the most commonly treated group in 17% (n = 17 out of 102) of ASFs, Class 2 patients were the most commonly treated group of patients in 71% (n = 73 out of 102) of ASFs, and Class 3 patients were the most commonly treated group in 12% (n = 12 out of 102) of ASFs.
History and Physical
The quality of systems and processes used to obtain a completed history and physical (H&P) for an ASF was evaluated. Three-quarters of ASF respondents (75.7% [n = 87 out of 115]), have a policy in place requiring a completed H&P prior to the actual day of surgery; the other 24.3% (n = 28 out of 115) of ASFs do not have a policy in place requiring a completed H&P prior to the actual day of surgery. The time a completed H&P is received prior to the surgery date varied from one week to one month. ASFs completing the H&P on the day of surgery reported that the time frame was inapplicable. See Table 1.
|1 to 7 days prior to surgery date||68||61.3%|
|8 to 14 days prior to surgery date||16||14.4%|
|15 to 21 days prior to surgery date||2||1.8%|
|22 to 30 days prior to surgery date||11||9.9%|
|No specified time frame||14||12.6%|
The survey also evaluated the number of facilities that had an electronic health record (EHR) and whether a facility receives any medical forms electronically. Fewer than half (37.4% [n = 43 out of 115]) of ASFs have implemented an EHR and 41.7% (n = 48 out of 115) of ASFs receive medical forms electronically.
See Table 2.
|Implemented an EHR system|
|Receive medical forms electronically (i.e., fax, electronic mail, EHR) from other office practices|
In assessing how ASFs received the H&P, EHR transmission was the fourth-most common method. Fifty-four percent (n = 60 out of 112) of facilities indicate two or more means of receiving the H&P information. See Table 3.
Method Of Delivery||
|Faxed from provider||79||69.9%|
|Delivered by patient, family member, or caregiver||35||31.0%|
|Mailed by provider||28||24.8%|
|Electronic health record transmission||23||20.4%|
|History and physical performed at
|Unidentified delivery method||6||5.3%|
|Total number of responding facilities||113|| |
* Facilities could choose more than one item|||||
Out of 74 facilities that perform their own H&P, 95.9% (n = 71) rely heavily on information from the patient, family member, or caregiver; 47.3% (n = 35) indicated that they obtain H&P information from medical records; 31.1% (n = 23) noted that they obtain H&P information from diagnostic tests; and 8.1% (n = 6) indicated that they obtain H&P information from a provider physical assessment or phone call.
ASFs were asked to identify which healthcare provider completed the H&P the majority of the time. According to the survey, surgeons complete the H&P 50.5% (n = 55 out of 109) of the time; referring physicians 23.8% (n = 26 out of 109) of the time; non-surgeon physicians 8.3% (n = 9 out of 109) of the time; nurse practitioners, certified registered nurse anesthetists (CRNAs), or physician assistants 7.3% (n = 8 out of 109) of the time; primary care physicians 6.4% (n = 7 out of 109) of the time; and registered nurses and anesthesiologists 3.7% (n = 4 out of 109) of the time. In addition to the regular H&P, 60.4% (n = 67 out of 111) of facilities also require a separate history form from the patient, family member, or caregiver.
Preoperative screening, including preoperative testing, was another part of the H&P process to evaluate. For the survey, ASFs identified the primary patient contacts for preoperative screening. Nurses are by far the primary patient contact for any preoperative screening, serving in this role for 63.9% (n = 71 out of 111) of responding ASFs. Nurse practitioners, physician assistants, and surgical and non-surgical physician offices are the primary patient contact for preoperative screening at 12.6% (n = 14 out of 111) of facilities, followed by secretaries and ASF schedulers, who were noted as the primary patient contact for preoperative screening at 11.7% (n = 13 out of 111) of responding ASFs. The remaining 11.7% (n = 13 out of 111) of facilities do not have a primary patient contact for preoperative screening.
Based on 56 facility responses, the ASF survey revealed a 2010 cancellation rate of 18.09 per 1,000 completed surgeries or procedures (95% CI: 17.5 to 18.68). The cancellation rates ranged from 0 to 144.22 cancellations per 1,000 completed surgeries or procedures performed. There was great variation in the reported number of cancellations. The range of ASF cancellations for 2010 was from 0 to 650 cancellations. The average number of cancellations was 64.88, with a standard deviation of 127.66, median of 96.27, and mode of 5.
ASFs were asked to identify when the majority of their same-day patient cancellations occurred: prior to admission, after admission, or after anesthesia. In this survey, out of 100 facilities, 56% indicated that the majority of their same-day patient cancellations occurred prior to admission, 31% indicated the majority of their same-day cancellations occurred after admission, 13% did not know when the majority of their same day cancellations occurred, and none indicated that the majority of their same day cancellation occurred after anesthesia. See Table 4 for the reasons for patient cancellations.
Most Frequent Reason For ASF Cancellations||
|Patient (e.g., no show, changed mind about surgery)||27||27%|
|Failure to follow protocol (e.g., incomplete history and physical, failure to maintain nothing by mouth status, failure to stop medications, no ride home)||24||24%|
|Other (e.g., unsuccessful completion of all conditions for the procedure, no one main reason (i.e., multiple reasons), no cancellations, unsure, data unavailable)||5||5%|
ASFs were asked who the primary patient contact was for any preoperative instructions. Out of 112 facilities, 70% have a nurse as the primary contact; 20.5% have a scheduler, secretary, or technician as the primary patient contact; and 8% designate the primary patient contact as a nurse practitioner, CRNA, physician assistant, clinical staff member, or non-ASF physician. One facility indicated that they do not have a primary patient contact for preoperative instructions.
ASF transfer rates were calculated using the 74 facility responses that provided answers to the questions asking for the total number of ASF transfers to the inpatient setting in 2010 and the total number of completed surgeries and/or procedures in 2010. Responses such as “unknown” or “unavailable,” those using the percentage of transfers rather than the number, and responses that were inconsistent (e.g., transfer rates greater than number of completed surgeries or procedures) were removed from the calculations. The transfer rate was 1.16 transfers per 1,000 completed surgeries or procedures (95% CI: 1.04 to 1.29).
The 2010 ASF number of transfers range from 0 to 50 with a median of 2, mode of 0, and average of 4.35. These numbers were deemed to be statistically valid. Twenty facilities had no transfers in 2010, and seven facilities had 11 or more transfers in 2010. A detailed analysis of the transfers and facility organizational characteristics was performed and revealed that the 20 facilities with no transfers were facilities that provided services for four or fewer medical specialties. Six of the seven facilities with 11 or more transfers in 2010 were generalists that provided services for six or more medical specialties. ASF facilities were then divided into two groups based on the number of medical specialties they provided (i.e., one to four medical specialties and five or more medical specialties). Transfer rates were recalculated for each group. See Table 5 for a comparison of transfer rates based on medical specialty designation.
Asf Medical Specialty Grouping||
Transfer Rate Per 1,000 Completed Surgeries And/Or Procedures|
|All ASF medical specialties combined (n = 74)||1.16 (95% CI: 1.04 to 1.29)|
|ASFs that offer 4 or fewer medical specialties (n = 55)||0.75 (95% CI: 0.63 to 0.87)|
|ASFs that offer 5 or more medical specialties (n = 19)||2.06 (95% CI: 1.76 to 2.36)|
Facilities were asked to identify the most frequent reason their facility transferred their patients to a hospital setting. Cardiac conditions (e.g., arrhythmias, chest pain), which 52.8% (n = 37 out of 70) of facilities reported as the most frequent reason for an ASF transfer to a hospital. Table 6 provides a breakdown of the facility-level reasons for transferring patients to the hospital.
Most Frequent Reason |
|Cardiac (e.g., arrhythmias, chest pain)||37||52.9%|
|Unspecified surgical complications||6||8.6%|
Hospital-based ASFs were not included in this survey, which limits the results to freestanding ASFs. Hospital-based ASFs may have different presurgical screening and assessment processes, as well as different cancellation and transfer information and rates. Many of the ASF facilities indicated that some of the information requested for this survey (e.g., number of male and female patients, number of patients with specific types of insurance coverage) was not routinely collected, which limited their ability to answer some of the questions. The other set of questions with a high percentage (>75%) of missing data focused on the type of anesthesia. The missing data prevented the analysis of these patient characteristics and their potential association with ASF transfers.
This survey of freestanding ASFs came from facilities that were physician-owned, accredited by the American Association for Ambulatory Health Care, and providers of patient safety education programs and activities. The results uncover variation in how H&P information is obtained and collected. Seventy percent of facilities receive H&Ps by fax and 20.4% by EHR transmission. While less than half of the ASFs have implemented an EHR system, the number of ASFs transmitting information with an EHR is expected to rise as more ASFs implement an EHR system. The information provided in this survey provides a starting point to address ASF transfers and cancellations and will help guide the Authority’s ASF collaboration in Pennsylvania’s northeast region.
Denise Martindell, RN, JD, Pennsylvania Patient Safety Authority and Megan Shetterly, RN, MS, Pennsylvania Patient Safety Authority, contributed to the development of the ambulatory surgical facility survey.
Haeck PC, Swanson JA, Iverson RE, et al. Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery.
Plast Reconstr Surg 2009 Oct; 124(4 Suppl):6S-27S.
Gupta A. Preoperative screening and risk assessment in the ambulatory surgery patient.
Curr Opin Anaesthesiol 2009 Dec; 22(6):705-11.
Fleisher LA, Pasternak RL, Lyles A. A novel index of elevated risk of inpatient hospital admission immediately following outpatient surgery.
Arch Surg 2007 Mar; 142(3):263-8.
28 Pa. Code § 551.31 (1999). Also available:
28 Pa. Code Ann. A § 551.3 (1999). Also available: