Patient Selection for Adult Ambulatory Surgery

A Narrative Review

Niraja Rajan, MD; Eric B. Rosero, MD, MSc; Girish P. Joshi, MBBS, MD, FFARCSI


Anesth Analg. 2021;133(6):1415-1430. 

In This Article

Social Factors and Patient Selection

Social factors that play a role in patient selection include availability of a responsible individual to receive discharge instructions, transport the patient to and from the ASC, and provide any necessary postdischarge care. Although this is outside the focus of this review, the debate regarding the need for a responsible escort is ongoing, as the evidence regarding the safety of discharging a patient home alone is equivocal.[21–23]

The American Society of Anesthesiologists (ASA) recommends that a responsible individual receive discharge instructions and escort the patient who has received sedation or general anesthesia.[24,25] Likewise, regulatory agencies such as Accreditation Association for Ambulatory Healthcare (AAAHC) and The Joint Commission (TJC) recommend that the patient who has received moderate/deep sedation or general or regional anesthesia be discharged in the company of a designated responsible individual unless exempted by the attending physician. According to the Medicare conditions of participation, the ultimate decision rests with the attending anesthesiologist and surgeon.[25]

Poor health literacy of the patient and caregiver is an important consideration because it has been shown to influence compliance with postoperative instructions and is associated with higher rates of acute care visits or readmission to the hospital.[26,27] Thus, these patients may not be suitable for certain types of outpatient procedures that require patient and caregiver investment in the recovery process. Similarly, patients' living conditions can impact postoperative care. Social factors need to be considered when determining where to schedule a patient for surgery (ie, inpatient versus outpatient setting). A large database study of 1,328,708 procedures performed in 86 freestanding ASCs in South Carolina from 2006 to 2013 found that Medicaid insurance and lowest median household income were associated with the highest postoperative acute care use within 7 days.[28] This study highlights the importance of clear communication regarding postoperative follow-up. Although not within the scope of this review, postdischarge disposition (home versus nonhome discharge) may play a role in decision-making as it might influence postoperative outcomes and costs.[29,30]