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Purpose of Review: The volume of office-based surgery (OBS) has surged over the last 25-30 years, however patients with increasing comorbidities are being considered for procedures in office locations. This review focuses on office-based surgery outcomes, financial incentives driving this change, and controversies., Recent Findings: Healthcare economics appear to drive the push towards OBS with improved reimbursements, but there are rising out-of-pocket costs impacting patients. Plastic surgery has low complications, but procedures like buttock augmentation are associated with mortality. In ophthalmology, emerging controversial literature investigates the impact of anesthesia type on and whether anesthesia providers impact ophthalmology outcomes. Dental anesthesia continues to suffer occasional wrong-sided surgeries. Vascular interventions are being driven towards offices due to reimbursements, and may be safely performed. Meta-analyses of ear, nose, and throat in-office surgeries have low complication rates., Summary: The reported safety supports the proper selection of patients for the proper procedure in the right location. Anesthesiologists need to develop and implement safe and efficient systems to optimize patient outcomes in outpatient office settings. Further research and uniform standardized outcomes tracking are needed in the emerging specialties performing office-based surgery., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest Fred E. Shapiro: declares unrelated research funding and/or fees from Fresenius-Kabi and GE Healthcare, and is the founding co‑lead of the Institute for Safety in Office-Based Surgery. Richard D. Urman: declares unrelated research funding and/or fees from Merck, Medtronic and AcelRx and is the founding co‑lead of the Institute for Safety in Office-Based Surgery.

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

Office-based surgery (OBS) has emerged as a significant subspecialty of ambulatory surgery. There are few clinical trials and limited published data on patient characteristics, anesthesia, or outcomes distinguishing OBS from ambulatory surgery centers (ASCs). We examined retrospective data from a large mobile anesthesia practice for 89,999 procedures from 2016 to 2019. Data was abstracted from billing and an anesthesia-specific electronic medical record, segregating procedures performed in ASCs versus OBS. The number and breadth of procedures increased substantially. Compared to ASCs, OBS patients were more likely male (52% vs. 48%), older (61 years vs. 55 years), and to have a higher American Society of Anesthesiologists (ASAs) status (33% vs. 20% ASA 3 or higher). The procedure mix varied substantially between the two settings. The major complication rate was 0.07% for the ASCs and 0.24% for OBS (p = 0.2, confidence interval [CI] -0.15 to 0.04). Minor complications were 11.2% in OBS versus 17.3% the ASCs (p < 0.0001, 95% CI 5.2-7). The practice demonstrates a low rate of complications, and despite the limitations of this study, the organization and structure of this large mobile anesthesia practice serves as a template for effective risk mitigation and patient safety., (© 2022 American Society for Healthcare Risk Management of the American Hospital Association.)

Competing Interests: Disclosure The authors have nothing to disclose.

The growth of office-based surgery (OBS) has been due to ease of scheduling and convenience for patients; office-based anesthesia safety continues to be well supported in the literature. In 2020, the Coronavirus Disease 19 (COVID-19) has resulted in dramatic shifts in healthcare, especially in the office-based setting. The goal of closing the economy was to flatten the curve, impacting office-based and ambulatory practices. Reopening of the economy and the return to ambulatory surgery and OBS and procedures have created a challenge due to COVID-19 and the infectious disease precautions that must be taken. Patients may be more apt to return to the outpatient setting to avoid the hospital, especially with the resurgence of COVID-19 cases locally, nationally, and worldwide. This review provides algorithms for screening and testing patients, selecting patients for procedures, choosing appropriate procedures, and selecting suitable personal protective equipment in this unprecedented period., Competing Interests: Declaration of competing interest Steven Young: None declared under financial, general, and institutional competing interests Brian M. Osman: None declared under financial, general, and institutional competing interests Richard D. Urman: Declared research funding from Merck, Medtronic, Acacia, Pfizer, AcelRx and fees from Takeda and Heron. Fred E. Shapiro: None declared under financial, general, and institutional competing interests, (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs)., Methods: We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value., Results: Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325., Conclusions: Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Patient decision aids are educational tools used to assist patients and clinicians in healthcare decisions. As healthcare moves toward patient-centered care, these tools can provide support to anesthesiologists by facilitating shared decision-making., Recent Findings: Recent research has shown that patient decision aids are beneficial in the clinical setting for patients and physicians. Studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression, and decisional conflict after using patient decision aids. In addition, a structured approach for the development of patient decision aids in the field of anesthesia has been established., Summary: Patient decision aids can support patient-centered care delivery and shared decision-making, especially in the field of anesthesia. Current research involves implementing the use of patient decision aids in the discussion for monitored anesthesia care. Further development of quality metrics is needed to improve the decision aids and maximize decision quality.

Purpose of Review: Office-based anesthesia (OBA) is rapidly growing across the world. Availability of less invasive interventions has facilitated the opportunity of offering new procedures in office-based settings to patient populations that would not have been considered in the past. This article provides a practical approach to discuss and analyze newest literature supporting different practices in the field of OBA. In addition, an update of the most recent guidelines and practice management directives is included., Recent Findings: Selected procedures may be performed in the office-based scenario with exceedingly low complication rates, when the right patient population is selected, and adequate safety protocols are followed. Current regulations are focused on reducing surgical risk through the implementation of patient safety protocols and practice standardization. Strategies include cognitive aids for emergencies, safety checklists, facility accreditation standards among other., Summary: New evidence exists supporting procedures in the office-based scenario in areas such as plastic and cosmetic surgery, dental and oral surgery, ophthalmology, endovascular procedures and otolaryngology. Different systematic approaches have been developed (guidelines and position statements) to promote standardization of safe practices through emergency protocols, safety checklists, medication management and surgical risk reduction. New regulations and accreditation measures have been developed to homogenize practice and promote high safety standards.

Over the last 25 years, with an exponential growth in the complexity of patients and procedures in the office-based setting, the topic of patient safety is becoming more fundamental. Current research efforts focus on the implementation of customizable safety checklists for both the patient and provider, and an emergency manual specifically adapted to guide providers though challenging and unexpected emergencies in this unique setting. Additional efforts are focusing on legislative changes and accreditation to standardize and ensure increased accountability and patient safety., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Patient decision aids are educational tools used by health care providers to assist patients in choosing their treatment and care. The use of anesthesia-related patient decision aids can help practitioners provide patient-centered care by facilitating shared decision-making. The benefits of these aids have been well documented, yet a structured approach for developing patient decision aids in anesthesia has not been well established. Educating patients on various anesthesia-related options is paramount in their decision-making, yet accessible and validated resources are limited. In addition, many limitations exist with current patient decision aids that must be addressed. We have reviewed multiple processes for developing decision aids and have suggested a structured approach to their creation. We address the common limitations of current patient decision aids and provide improvements to the developmental process. Improvements include increasing patient input during development, thoroughly evaluating data included in the aids, and integrating a cyclic review of the aids before and after their use. Using the provided developmental process and checklist, anesthesia providers can create evidence-based patient decision aids in a standardized manner. It is important to evaluate decision aids and measure their decision quality, or patient-centeredness, to further improve them and maximize their effectiveness. Moving forward, development of proper metrics for patient participation and decision quality are required.

There has been an exponential increase in plastic surgery cases over the last 20 years, surging from 2.8 million to 17.5 million cases per year. Seventy-two percent of these cases are being performed in the office-based or ambulatory setting. There are certain advantages to performing aesthetic procedures in the office, but several widely publicized fatalities and malpractice claims has put the spotlight on patient safety and the lack of uniform regulation of office-based practices. While 33 states currently have legislation for office-based surgery and anesthesia, 17 states have no mandate to report patient deaths or adverse outcomes. The literature on office-base surgery and anesthesia has demonstrated significant improvements in patient safety over the last 20 years. In the following review of the proceedings from the PRS Korea 2018 meeting, we discuss several key concepts regarding safe anesthesia for officebased cosmetic surgery. These include the safe delivery of oxygen, appropriate local anesthetic usage and the avoidance of local anesthetic toxicity, the implementation of Enhanced Recovery after Surgery protocols, multimodal analgesic techniques with less reliance on narcotic pain medications, the use of surgical safety checklists, and incorporating "the patient" into the surgical decision-making process through decision aids.

Objectives: Checklists are tools that are developed to complete tasks by drawing on specific and relevant knowledge and supporting communication at critical times. If checklists were designed specifically for patient use, they could promote patient engagement, potentially leading to improved quality of care. Physicians of all specialties, nurses, patients, patient advocates, and administrators can take an active role in checklist development and dissemination., Methods: Our method to investigate concepts in developing a customizable patient checklist included a literature search concerning existing checklists and resources currently available to patients. Literature containing expert opinion regarding checklists, professional organization statements, and patients and providers were consulted., Results: A template for designing a patient checklist was developed incorporating methods from previous literature and resources regarding checklists. This template includes a development, drafting, and validation phase. Sample content for inclusion in potential checklists for patients with diabetes and patients undergoing anesthesia was devised., Conclusions: Developed by physicians with input from patients and other involved health-care providers such as nurses, this relatively novel concept of a patient's checklist creates a role for the patient to ensure their own safety. With increasing attention to high-quality and cost-effective health care, patient satisfaction surveys will be assessed to rate overall health care. Further development of checklists will need to be guided by specific medical conditions and acceptance by patients and providers. Providers can use these checklists as a method to gauge a patient's understanding of an intervention, solidify the patient-doctor relationship, and improve patient safety.

Purpose of Review: The purpose of this review is to provide an update on the current knowledge about patient safety and outcomes in the office-based setting. Ambulatory procedures performed outside the hospital are steadily increasing, resulting in an increasing number and complexity of office-based procedures and patient comorbidities over the past two decades. In this review we focus on most recent outcomes studies encompassing different surgical specialties and patient populations., Recent Findings: Rates of complications in the office-based surgical (OBS) setting from the latest publications are similar to, or lower than previously reported studies. Many of the studies published were in the field of plastic surgery, with a few publications on office vascular and dental procedures. The most common complications were haematoma, infection and venous thromboembolism (VTE) and pulmonary embolism. Death was a rare finding, though when it occurred, it was often associated with VTE/pulmonary emboli and abdominoplasties., Summary: Overall, these studies contribute positively to our current understanding of the safety of office-based anaesthesia. As an increasing number of procedures migrate from the hospital setting to ambulatory and office-based environments, it will be critically important to ensure high quality and safe patient care in these settings.

The rise in office-based interventional vascular laboratories in recent years was prompted in part by expedient ambulatory patient experience and favorable outpatient procedural reimbursement. While studies have shown that clinical safety and treatment efficacy can be achieved in office-based vascular facilities, critics have raised various concerns due to inconsistent patient care standards and lack of organizational oversight to ensure optimal patient outcome. Available literature showed widely varied clinical outcomes which were partly attributable to nonuniform standards in reporting clinical efficacy and adverse events. In this report, various concerns and pitfalls of office-based interventional vascular centers are discussed. Strategies to improve patient care delivery in office-based laboratories including accreditations which serve as external validation of processes to ensure patient care and safety are also mentioned. Finally, the requirements to obtain accreditation in an office-based practice and the differences between these nationally recognized accrediting organizations are discussed herein., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Ambulatory and office-based surgery is expanding rapidly. While growth continues, there are lingering patient safety concerns. To this end, the American Society of Anesthesiologists (ASA) created the Anesthesia Quality Institute (AQI), which collected patient and procedural characteristics on 23,341,130 anesthetics from all health care settings from 2010 to 2014. Of these, 179,618 office and 4,627,379 ambulatory cases were isolated and compared. Our findings show that although both settings are often grouped together, there are statistically significant differences in patient demographics, procedure types, and reported adverse events. Among these reports, inadequate postoperative pain control and nausea/vomiting are the most common issue. More serious events such as death, cardiac arrest, and vision loss occurred but were rare., (© 2016 American Society for Healthcare Risk Management of the American Hospital Association.)

Purpose: To implement and measure the effect of a surgical safety checklist on the prevention of serious medical errors (never-events)., Setting: Boston Eye Group, Boston, Massachusetts, USA., Design: Retrospective cohort study., Methods: A safety checklist incorporating 28 sources of error was designed and implemented in December 2011 at the Boston Eye Group's refractive surgical center. Consecutive patients who had primary or enhancement laser vision correction (LVC) between July 2009 and February 2014 were included in this study. Before that date, a general checklist fashioned around the World Health Organization time-out procedure was used. The latter subjects were recruited as controls. The perioperative characteristics of both groups were retrospectively compared., Results: The study comprised 2951 consecutive patients who had primary or enhancement LVC between July 2009 and February 2014; of these, 1417 patients (2744 eyes) had LVC after the implementation of a presurgical safety checklist. The general checklist fashioned around the World Health Organization time-out procedure was used for 1534 patients (2969 eyes). Both groups were comparable in patient age. The most common surgical procedures were laser in situ keratomileusis (78%) and laser-assisted subepithelial keratectomy with mitomycin-C (16%). Although there were 2 (0.07%) serious errors in the prechecklist cohort, none occurred following implementation of the safety checklist protocol (P = .23). The medical errors involved wrong refractive aim in 1 patient and wrong person-wrong procedure-wrong aim in another., Conclusions: Multiple potential sources of error exist in refractive surgery. The broad-scale implementation of a detailed presurgical safety checklist was helpful in minimizing and preventing serious errors (never-events) during LVC., Financial Disclosure: Drs. Shapiro and Urman are members of the Institute for Safety in Office-Based Surgery, a nonprofit organization whose aims are to implement safety checklists for office-based surgery. No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Although checklists are used as tools for providers, they have not been adequately explored as tools for patients. The purpose of this study was to survey the stakeholders on the usefulness of an ambulatory surgical checklist for patients. We performed a cross-sectional study through a survey designed to include both patients and providers. Descriptive analysis of the data was performed based on responses from 35 patients and 52 providers. Overall, 94% of patients and 83% of providers thought the checklist would be beneficial for patients. In addition, 37% of providers indicated potential barriers to checklist implementation, including fear of confusing the patient, making patients doubt the care they were receiving, taking too much time, and lack of resources. Based on survey responses, the study suggests that the ambulatory surgical checklist can potentially facilitate patient education, enable more active patient participation, increase patient satisfaction, and decrease patient anxiety., (Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights reserved.)

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Safe office-based anesthesia practices dictate proper patient and procedure selection, appropriate provider qualifications, adequately equipped facilities, and effective administrative infrastructure. Analysis of patient outcomes can help reduce mortality and morbidity by identifying high-risk patients and procedures. We analyzed data from the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry. Analysis included patient demographics and outcomes, procedure and anesthesia type and duration, and case coverage by provider. Increased regulation and standardization of care, such as the use of checklists and professional guidelines, can advance safe practices. There is increasing emphasis on continuous quality improvement, electronic health records, and outcomes data reporting., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Simulation-based interventions and education can potentially contribute to safer and more effective systems of care. We utilized in-situ simulation to highlight safety issues, regulatory requirements, and assess perceptions of safety processes by the plastic surgery office staff., Methods: A high-fidelity human patient simulator was brought to an office-based plastic surgery setting to enact a half-day full-scale, multidisciplinary medical emergency. Facilitated group debriefings were conducted after each scenario with special consideration of the principles of team training, communication, crisis management, and adherence to evidence-based protocols and regulatory standards. Abbreviated AHRQ Medical Office Safety Culture Survey was completed by the participants before and after the session., Results: The in-situ simulations had a high degree of acceptance and face validity according to the participants. Areas highlighted by the simulation sessions included rapid communication, delegation of tasks, location of emergency materials, scope of practice, and logistics of transport. The participant survey indicated greater awareness of patient safety issues following participation in simulation and debriefing exercises in 3 areas (P < 0.05): the need to change processes if there is a recognized patient safety issue (100% vs 75%), openness to ideas about improving office processes (100% vs 88%), and the need to discuss ways to prevent errors from recurring (88% vs 62%)., Conclusions: Issues of safety and regulatory compliance can be assessed in an office-based setting through the short-term (half-day) use of in-situ simulation with facilitated debriefing and the review of audiovisual recordings by trained facilities inspectors.

Introduction: The analysis of malpractice claims can provide risk managers with a detailed view of patient mortality and morbidity. The data comes from many institutions, encompasses a diverse group of practitioners and practice settings, and contains detailed clinical information. Analysis can help identify patterns of injury, risk factors, and rare and sentinel events., Methods: We examined most recent anesthesia closed claims data collected by The Doctors Company, a large national malpractice insurer. We analyzed data from claims closed between 2007 and 2012. Each claim underwent a review by physician and nurse experts, and was then coded using the Comprehensive Risk Intelligence Tool. Injury distribution and association between the injury and patient comorbidity were also examined., Results: A total of 607 claims were analyzed. Most frequent injuries were teeth damage (20.8%), death (18.3%), nerve damage (13.5%), organ damage (12.7%), pain (10.9%), and arrest (10.7%). Obesity was most frequently identified as a contributing factor leading to a claim. Injury-to-claim rates were highest in hospitals with fewer than 100 beds, while ambulatory surgery centers had the lowest death-to-claim rate (12%). Average indemnity for an anesthesia claim was $309 066, compared to $291 000 for all physician specialties., Conclusions: The most frequent claims were death and nerve damage when teeth damage was excluded. Obesity impacted anesthesia outcomes more frequently than did other comorbidities. Although there were fewer claims from the smaller hospitals, those claims had higher rates of mortality and nerve damage compared to larger-size hospitals. Further analysis is needed to evaluate these trends as well as impact of specific patient comorbidities on anesthesia outcomes., (© 2014 American Society for Healthcare Risk Management of the American Hospital Association.)

Background: Patient safety is critical for the patients, providers, and risk managers in the office-based procedural setting, and the same standard of care should be maintained regardless of the healthcare environment. Checklists may improve patient safety and potentially decrease risk. This study explored utilization of checklists in the office-based setting and the potential barriers to their implementation., Methods: A cross-sectional prospective study was performed by using a 19-question anonymous survey designed with REDCap®. Medical providers including physicians and nurses from 25 different offices that performed procedures participated, and 38 individual responses were included in the study., Results: Only 50% of offices surveyed use safety checklists in their practice. Only 34% had checklists or equivalent protocol for emergencies such as anaphylaxis or failed airway. As many as 23.7% of respondents indicated that they encountered barriers to implementing checklists. The top barriers identified in the study were no incentive to use a checklist (77.8%), no mandate from a local or federal regulatory agency (44.4%), being too time consuming (33.3%), and lack of training (33.3%). Reasons identified that would encourage providers to use checklists included a clear mandate (36.8%) and evidence-based research (26.3%)., Conclusions: Checklists are not being universally utilized in the office-based setting. There are barriers preventing their successful implementation. Risk managers may be able to improve patient safety and decrease risk by encouraging practitioners, possibly through incentives, to use customizable safety checklists., (© 2014 American Society for Healthcare Risk Management of the American Hospital Association.)

Purpose of Review: Office-based practice is distinct from other ambulatory practices and has unique considerations for an effective administrative structure to support its operations., Recent Findings: National guidelines have been promulgated by various entities addressing both management and clinical care aspects of the practice. Specific regulations vary by practice location, and practitioners need to comply with the pertinent accreditation and licensing requirements. Anesthesiologists have been at the forefront of promoting the culture of safety in the office-based setting. Specific practice considerations include provider credentialing, maintenance of documentation, quality assessment, professional liability, facility safety, patient health information, billing, and finance. Although there is emerging literature linking office accreditation to improved patient outcomes, more work is needed in this area., Summary: Office-based practice will continue to evolve with the national emphasis on patient safety, cost reduction, value-based care, and outcomes measurement and reporting. Each practice must comply with the state and national regulations that could limit the types of procedures being performed and who can administer sedation or anesthesia, and require the facility to be accredited by a nationally recognized accrediting agency.

Office-based surgery continues to grow as more procedures are being performed in the outpatient setting. With this exponential growth, there is an increasing emphasis on safe and effective patient care. Current research shows both gaps in safety and opportunities for improvement. Practice managers, clinicians, and other personnel should be cognizant that office procedures are coming under intense regulatory scrutiny. Effective strategies to maintain quality and patient safety include the use of checklists, obtaining office accreditation, encouraging board-certification and proper credentialing of proceduralists, and appropriate patient and procedure selection. There is increasing regulation of ambulatory surgery on state and national levels that will likely affect the financial and care quality aspects of office-based practice. Socioeconomic and political forces will continue to shape the future of office-based surgery.

The migration of gynecologic procedures to office-based settings provides numerous advantages for patients and providers alike, including reduced patient expenses, improved scheduling convenience, favorable provider reimbursement, and enhanced continuity of care and patient satisfaction. With rising health care costs-a major concern in health care-procedures will continue to shift to practice environments that optimize care, quality, value, and efficiency. It is imperative that gynecologic offices ensure that performance and quality variations are minimized across different sites of care; physicians should strive to provide care to patients that optimizes safety and is at least equivalent to that delivered at traditional sites. The gynecologic community should nonetheless heed the Institute of Medicine's recommendations and embrace continuous quality improvement. By exercising leadership, office-based gynecologists can forge a culture of competency, teamwork, communication, and performance measurement.

Over the past decade, the number of procedures performed in office-based settings by a variety of practitioners-including surgeons, gastroenterologists, ophthalmologists, radiologists, dermatologists, and others-has grown significantly. At the same time, patient safety concerns have intensified and include issues such as proper patient selection, safe sedation practices, maintenance of facilities and resuscitation equipment, facility accreditation and practitioner licensing, and the office staff's ability to deal with emergencies and complications. An urgent need exists to educate practitioners about safety concerns in the office-based setting and to develop various educational strategies that can meet the continued growth of these procedures. This review outlines educational needs and possible solutions such as simulation exercises and education during residency training.

Purpose of Review: Office-based anesthesia is a new and growing subspecialty within ambulatory anesthesia. We examine major developments in office-based anesthesia and how patient safety can be maintained., Recent Findings: The emergence of office-based anesthesia as a subspecialty of ambulatory anesthesia is a result of economic and social factors, and is also due to the development of better surgical techniques and anesthestic drugs. There is still a dearth of primary literature that addresses patient safety in the office-based setting. Some existing literature points to increased risk in the office, although others suggest that proper provider credentialing, qualifications, and appropriate facility accreditation can improve patient outcomes compared to surgicenters and inpatient facilities. There is a lack of state and federal oversight of office-based facilities. Increased regulation and standardization of care, such as the use of check lists and professional society guidelines, can help promote safer practices., Summary: There is no uniform standard of care for performing procedures in the office-based setting. Healthcare providers are facing the challenge of creating a safer, efficient, cost-effective and patient-centered environment. Available data show that the office-based practice can be as safe as any ambulatory surgicenter or hospital, as long as patients, regulators, and physicians become educated advocates of safer practices. In addition, procedures can be performed safely with general anesthesia or conscious sedation, provided that there are properly trained personnel and adequate equipment and facilities. Moreover, physicians should be credentialed to perform the same procedure in a hospital that they perform in an office.

Objective: To implement a customizable checklist in an interdisciplinary, team-based plastic surgery setting to reduce surgical complications., Methods: We examined the effects on patient outcomes and documentation of a customizable, office-based surgical safety checklist. On the basis of the World Health Organization Surgical Safety Checklist, we developed a 28-element, perioperative checklist for use in the office-based surgical setting. The checklist was implemented in an office-based plastic surgery practice with an already high standard of care. We recorded baseline, prechecklist rates for each checklist item and postoperative adverse outcomes via a retrospective chart review of 219 cases. After an education program and 30-day run-in period, a prospective, post-checklist implementation chart review was initiated (n = 184), with outcome data compared to the baseline., Results: The total number of complications per 100 patients decreased from 15.1 to 2.72 after checklist implementation (P < .0001), for an absolute risk reduction of 12.4. The proportion of patients with one or more complications decreased from 11.9% to 2.72% (P = .0006). Site and side marking increased from 69.9% prechecklist to 97.8% (P < .0001). Medical optimization increased from 90.9% to 99.5% (P < .0001). Emergency medical services (EMS) policy confirmation, case-specific equipment availability, anticipation of estimated blood loss, and verbal confirmation of local anesthetic toxicity precautions increased from 0% to 90.0% (P < .0001), 92.4% (P < .0001), 82.1% (P < .0001), and 91.3% (P < .0001), respectively. Assessment of patient satisfaction increased from 57.1% to 90.8% (P < .0001)., Conclusions: Implementation of a customizable checklist was associated with a reduction in surgical complications in an office-based plastic surgery practice with an already high standard of care.

Purpose of Review: American Society of Aesthetic Plastic Surgery statistics show outpatient cosmetic procedures increased from 3 to 11 million (1997-2007), an increase of 457%, and $13 billion was spent. Exponential growth, complexity of cases and patients, and media attention to high-profile untoward events are accompanied with concerns for patient safety and development of safer anesthesia practices., Recent Findings: Improved safety and efficacy in aesthetic facial surgery include oral sedation and local anesthesia, addition of dexmedetomidine to intravenous anesthesia, and defining the 'safest' dose of lidocaine with epinephrine. A nasopharyngeal tube can be used to deliver a concentration of oxygen commensurate with recent American Society of Anesthesiologists Task Force Practice Advisory for the prevention and management of operating room fires. Analgesia for breast surgery including instillation of bupivicaine, paravertebral block, and combination dexamethasone with nonsteroidal anti-inflammatory drugs can decrease narcotic requirement and recovery time. Risks of combined gynecologic and plastic surgical procedures are not greater than those seen with either procedure alone. A coordinated team approach for patient management is essential. Pulmonary embolism remains the greatest cause of mortality., Summary: The methods presented improve patient safety. The number of cosmetic procedures will continue to grow exponentially and evolve additional patient safety concerns. This larger population is the foundation for prospective trials to develop evidence-based anesthesia for cosmetic surgery.

Background: Dexmedetomidine is an alpha2-agonist anesthetic with several properties that are advantageous in aesthetic facial surgery. By attenuating sympathetic nervous system activity, it induces sedation and analgesia while lowering blood pressure and preventing pain-induced hemodynamic fluctuations. It spares the respiratory drive and decreases the need for supplemental oxygen, thus reducing the fire risk of electrocautery. It decreases narcotic use, thereby further improving respiratory safety and decreasing postoperative nausea and vomiting. This retrospective study evaluated the safety and efficacy of dexmedetomidine in rhytidectomy., Methods: Records were reviewed for 155 consecutive face lifts performed under sedation by one surgeon over 3.5 years. Intraoperative and postoperative parameters and outcomes were compared for 78 patients sedated with dexmedetomidine (dexmedetomidine group) and 77 sedated without dexmedetomidine (no-dexmedetomidine group)., Results: Intraoperatively, the dexmedetomidine group had lower mean systolic and diastolic blood pressures and heart rate (p < 0.001). Fewer dexmedetomidine group patients had oxygen desaturation below 92 percent (p < 0.05) and fewer required antihypertensives (p < 0.01), although more required vasopressors (p < 0.01). The dexmedetomidine patients needed less midazolam (p < 0.01) and fentanyl (p < 0.001). Postoperatively, the dexmedetomidine group again had lower mean systolic and diastolic blood pressures and heart rate (p < 0.001). In addition, fewer patients in this group needed postoperative antiemetics (p < 0.05). Immediate postoperative hematomas occurred in two patients in the dexmedetomidine group and one patient in the no-dexmedetomidine group., Conclusions: Dexmedetomidine lowered blood pressure, decreased the frequency of oxygen desaturations, and reduced narcotic, anxiolytic, and antiemetic use. When compared with conventional sedation, dexmedetomidine appears to improve anesthetic safety and efficacy for rhytidectomy patients.