Reengineering Intravenous Drug and Fluid Administration Processes in the Operating Room

† Senior Research Associate, University of California-San Diego and Veterans Medical Research Foundation.. ‡ Research Assistant, Department of Anesthesiology, University of California-Sa

Reengineering Intravenous Drug and Fluid

Administration Processes in the Operating Room

Step One: Task Analysis of Existing Processes

Deborah B Fraind, B.S

*; Jason M Slagle, M.S.†; Victor A Tubbesing, B.S.‡; Samuel A Hughes, Ph.D.†; Matthew B Weinger, M.D.§

Presented in part at the 74th Annual Congress of the International Anesthesia Research Society, Honolulu, Hawaii, March 13, 2000 Dr Weinger was a paid consultant of, and held a small equity stake in,

FluidSense Corporation (Newburyport, Massachusetts), a manufacturer of intravenous infusion therapy products.

ANESTHESIOLOGY 2002;97:139-147

Background: A reengineering approach to intravenous drug and fluid administration

processes could improve anesthesia care In this initial study, current intravenous

administration tasks were examined to identify opportunities for improved design

Methods: After institutional review board approval was obtained, an observer sat in the

operating room and categorized, in real time, anesthesia providers’ activities during 35 cases ( 90 h) into 66 task categories focused on drug/fluid tasks Both initial room

set-up at the beginning of a typical workday and cardiac and noncardiac general anesthesia cases were studied User errors and inefficiencies were noted The time required to

prepare de novo a syringe containing a mock emergency drug was measured using a

standard protocol

Results: Drug/fluid tasks consumed almost 50 and 75%, respectively, of the set-up time

for noncardiac and cardiac cases In 8 cardiac anesthetics, drug/fluid tasks comprised 27

± 6% (mean ± SD) of all prebypass clinical activities During 20 noncardiac cases, drug/fluid tasks comprised 20 ± 8% of induction and 15 ± 7% of maintenance Drug preparation far outweighed drug administration tasks Inefficient or error prone tasks

were observed during drug/fluid preparation (e.g., supply acquisition, waste disposal,

syringe labeling), administration (infusion device failure, leaking stopcock), and

organization (workspace organization and navigation, untangling of intravenous lines) Anesthesia providers (n = 21) required 35 ± 5 s to prepare a mock emergency drug

Conclusions Intravenous drug and fluid administration tasks account for a significant

proportion of anesthesia care, especially in complex cases Current processes are

inefficient and may predispose to medical error There appears to be substantial

opportunity to improve quality and cost of care through the reengineering of anesthesia intravenous drug and fluid administration processes General design requirements are proposed

* Medical Student, University of California-San Diego † Senior Research Associate, University of California-San Diego and Veterans Medical Research Foundation ‡ Research Assistant, Department of Anesthesiology, University of California-San Diego and VA San Diego Healthcare System § Director, San Diego Center for Patient Safety, Staff Physician, VA San Diego Healthcare System, and Professor of Anesthesiology, University of California-San Diego Received from the Anesthesiology Ergonomics Research Laboratory, Health Services Research Service, VA San Diego Healthcare System, San Diego, California; the San Diego Center for Patient Safety, La Jolla, California; and the Department of

Anesthesiology, University of California-San Diego, La Jolla, California.

Submitted for publication August 6, 2001

Accepted for publication February 18, 2002

Address correspondence to Dr Weinger: VA Medical Center (125A), 3350 La Jolla Village Drive, San Diego, California 92161-5085 Address electronic mail to: mweinger@ucsd.edu Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

Supported by grants from the Anesthesia Patient Safety Foundation, Pittsburgh, Pennsylvania, the National Patient Safety Foundation, Chicago, Illinois, a Howard Hughes Summer Research Scholarship, La Jolla, California (to Dr Fraind); grant No HSR&D IIR 20-0066 from the Department of Veterans Affairs, Washington, DC; and grant Nos R01-HS11375 and P20-HS11521 from the Agency for Healthcare Research and Quality, Rockville, Maryland

Impact of Unplanned Extubation and Reintubation after Weaning on Nosocomial Pneumonia Risk in the Intensive Care Unit

A Prospective Multicenter Study

Arnaud de Lassence, M.D

*; Corinne Alberti, M.D.†; Élie Azoulay, M.D.‡; Eric Le Miere, M.D.§; Christine

Cheval, M.D.||; François Vincent, M.D.#; Yves Cohen, M.D.**; Mạté Garrouste-Orgeas, M.D.††; Christophe Adrie, M.D.‡‡; Gilles Troche, M.D.§§; Jean-François Timsit, M.D.||||; for the OUTCOMEREA Study Group##

ANESTHESIOLOGY 2002;97:148-156

Background: The authors prospectively evaluated the occurrence and outcomes of

unplanned extubations (self-extubation and accidental extubation) and reintubation after weaning, and examined the hypothesis that these events may differ regarding their influence on the risk of nosocomial pneumonia

Methods: Data were taken from a prospective, 2-yr database including 750 mechanically

ventilated patients from six intensive care units

Results: One hundred five patients (14%) experienced at least one episode of these 3

events; 51 self-extubations occurred in 38 patients, 24 accidental extubations in 22 patients, and 56 reintubations after weaning in 45 patients The incidence density of these

3 events was 16.4 per 1,000 mechanical ventilation days Reintubation within 48 h was needed consistently after accidental extubation but was unnecessary in 37% of self-extubated patients Unplanned extubation and reintubation after weaning were associated

with longer total mechanical ventilation (17 vs 6 days; P < 0.0001), intensive care unit stay (22 vs 9 days; P < 0.0001), and hospital stay (34 vs 18 days; P < 0.0001) than in

control group, but did not influence intensive care unit or hospital mortality The

incidence of nosocomial pneumonia was significantly higher in patients with unplanned

extubation or reintubation after weaning (27.6% vs 13.8%; P = 0.002) In a Cox model

adjusting on severity at admission, unplanned extubation and reintubation after weaning increased the risk of nosocomial pneumonia (relative risk, 1.80; 95% confidence interval,

1.15–2.80; P = 0.009) This risk increase was entirely ascribable to accidental extubation (relative risk, 5.3; 95% confidence interval, 2.8–9.9; P < 0.001)

Conclusion: Accidental extubation but not self-extubation or reintubation after weaning

increased the risk of nosocomial pneumonia These 3 events may deserve evaluation as

an indicator for quality-of-care studies

*Staff Physician, §Attending Physician, Medical ICU, Louis Mourier Teaching Hospital †Staff Physician, Department of Biostatistics, U444-INSERM, Paris 7 University, Paris France ‡Staff Physician, ICU, Saint Louis Teaching Hospital ||Staff Physician, Vascular Surgical ICU, ††Staff Physician, Polyvalent ICU, Saint Joseph Teaching Hospital #Staff Physician, Renal ICU, Tenon Teaching Hospital, Paris, France

**Professor, Medical-surgical ICU, Avicenne Teaching Hospital ‡‡Staff Physician, Polyvalent ICU, Delafontaine Hospital, Saint Denis, France §§Staff Physician, Surgical ICU, Antoine Béclère Teaching Hospital ||||Staff Physician, Medical ICU, Bichat-Claude Bernard Teaching Hospital, Paris, France

##Individuals participating in the OUTCOMEREA Study Group are listed in the Appendix Received from the Medical ICU, Avicenne Hospital, Bobigny, France; Surgical ICU, Antoine Béclère Hospital, Clamart, France; Medical and Surgical ICUs, Saint Joseph Hospital, Paris, France; Medical ICU, Louis Mourier Hospital, Colombes, France; and the Medical ICU, Saint-Louis Hospital, Paris, France.

Submitted for publication October 22, 2001

Accepted for publication February 27, 2002

OUTCOMEREA® is supported by nonexclusive educational grants from Aventis Pharma France, Paris, France, Wyeth-Lederle, Puteaux-Paris la Défense, France, and Centre National de Recherche Scientifique, Paris, France

Adress reprint requests to Dr de Lassence: Service de Réanimation Médicale, Hôpital Louis Mourier,

92701 Colombes Cedex, France Address electronic mail to: arnaud.de-lassence@outcomerea.org

Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

Anaesthesia Type Brings on Temporarily Twitchy Legs

Wed Jun 26, 5:30 PM ET

By Hannah Cleaver

BERLIN (Reuters Health) - People who have spinal anaesthesia should be warned that they may experience restless legs syndrome afterwards, but that this restlessness will disappear on its own within a few months

This is the conclusion of a study on possible triggers for the condition, which often robs sufferers of their sleep as severe discomfort in their legs can only be reduced by walking around or at least moving the legs

Dr Birgit Hoegl, head of the sleep laboratory at Innsbruck University, Austria, said there also seemed to be a link between low blood iron levels and the onset of the syndrome after a spinal anaesthetic

In spinal anaesthesia, drugs are injected into the spinal area, resulting in numbness of the body below the injection point

Presenting her paper at the 12th Meeting of the European Neurological Society here Wednesday, Hoegl said her study looked at 161 patients who had never experienced restless legs syndrome (RLS) Many were pregnant women who received spinal

anaesthesia while undergoing C-sections

Fourteen of the patients developed RLS after anaesthesia Four had mild RLS, five had a moderate form of the condition, and five had severe RLS Among an additional 41 patients who already had RLS, four experienced a marked worsening of the condition

Hoegl told Reuters Health that all those who developed the condition saw it disappear again, generally within about a month, while all were free of it after 3 months

She said, "We ruled out gender, age, type of anaesthetic and dose as factors, but there does seem to be a correlation between low iron levels and development of RLS The iron factor seems to be a susceptibility factor

"The condition is not so bad, nor so long-lasting that one would recommend using a different anaesthetic But the patient needs to know that it is a possible side-effect of spinal anaesthetic and doctors treating them should also be aware so that if need be, treatment can be offered It also looks as if preoperative anaemia increases the risk of developing RLS after the operation."

Hoegl and her colleagues, chaired by Werner Poewe, now plan another study to

investigate whether RLS appears after other types of anaesthesia

Anesthestic-related Cardiac Arrest and Its Mortality

A Report Covering 72,959 Anesthetics over 10 Years from a US Teaching

Myrna C Newland, M.D

*; Sheila J Ellis, M.D.†; Carol A Lydiatt, M.D.‡; K Reed Peters, M.D.‡; John H Tinker, M.D.§; Debra J Romberger, M.D.||; Fred A Ullrich, B.S.#; James R Anderson, Ph.D.**

This article is featured in “This Month in Anesthesiology.” Please see this issue of A NESTHESIOLOGY , page 5A.

Presented in part at the annual meeting of the American Society of Anesthesiologists, San Francisco, California, October 14–18, 2000.

ANESTHESIOLOGY 2002;97:108-115

Background: A prospective and retrospective case analysis study of all perioperative

cardiac arrests occurring during a 10-yr period from 1989 to 1999 was done to determine the incidence, cause, and outcome of cardiac arrests attributable to anesthesia

Methods: One hundred forty-four cases of cardiac arrest within 24 h of surgery were

identified over a 10-yr period from an anesthesia database of 72,959 anesthetics Case abstracts were reviewed by a Study Commission composed of external and internal members in order to judge which cardiac arrests were anesthesia-attributable and which were contributory The rates of attributable and

anesthesia-contributory cardiac arrest were estimated

Results: Fifteen cardiac arrests out of a total number of 144 were judged to be related to

anesthesia Five cardiac arrests were attributable, resulting in an anesthesia-attributable cardiac arrest rate of 0.69 per 10,000 anesthetics (95% confidence interval, 0.085–1.29) Ten cardiac arrests were found to be anesthesia-contributory, resulting in an anesthesia-contributory rate of 1.37 per 10,000 anesthetics (95% confidence interval, 0.52–2.22) Causes of the cardiac arrests included medication-related events (40%), complications associated with central venous access (20%), problems in airway

management (20%), unknown or possible vagal reaction in (13%), and one perioperative myocardial infarction The risk of death related to anesthesia-attributable perioperative cardiac arrest was 0.55 per 10,000 anesthetics (95% confidence interval, 0.011–1.09)

Conclusions: Most perioperative cardiac arrests were related to medication

administration, airway management, and technical problems of central venous access Improvements focused on these three areas may result in better outcomes

* Professor, † Assistant Professor, ‡ Associate Professor, § Professor and Chair, Department of

Anesthesiology, || Associate Professor, Internal Medicine and Pulmonology, # Senior Programmer Analyst,

** Professor and Chair, Preventive and Societal Medicine Received from the Departments of

Anesthesiology, Internal Medicine and Pulmonology, and Preventive and Societal Medicine, University of Nebraska Medical Center, Omaha, Nebraska.

Submitted for publication February 19, 2001

Accepted for publication February 13, 2002

Support was provided solely from institutional and/or departmental sources

Address reprint requests to Dr Newland: Department of Anesthesiology, 984455 Nebraska Medical Center, Omaha, Nebraska 68198-4455 Address electronic mail to: mnewland@unmc.edu Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

Eliminating Intensive Postoperative Care in Same-day Surgery Patients Using Short-acting Anesthetics

Jeffrey L Apfelbaum, M.D

*; Cynthia A Walawander, M.A.†; Thaddeus H Grasela, Pharm.D., Ph.D.‡; Phillip Wise, B.S., M.B.A.§; Charles McLeskey, M.D.||; Michael F Roizen, M.D.#; Bernard V Wetchler, M.D.**; Kari Korttila, M.D., Ph.D., F.R.C.A.††

For the list of study sites, please see Appendix 2.

This article is featured in “This Month in Anesthesiology.” Please see this issue of A NESTHESIOLOGY , page 5A.

Presented in part at the annual meeting of the American Society of Anesthesiologists, San Diego,

California, October 21, 1997.

ANESTHESIOLOGY 2002;97:66-74

Background: A multidisciplinary effort was undertaken to determine whether patients

could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria

Methods: A prospective, outcomes research study with a baseline month, an intervention

month, and a follow-up month was designed Five surgical centers (three community-based hospitals and two freestanding ambulatory surgical centers) were utilized Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period Outcome measures included PACU bypass rates and adverse events Intervention consisted of a multidisciplinary educational program and routine feedback reports

Results: The overall PACU bypass rate (58%) was significantly different from baseline

(15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4– 31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1–84.2%, P < 0.001) During the follow-up period,

the average (SD) recovery duration for patients who bypassed the PACU was

significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after

adjusting for various surgical procedures

Conclusions: This study represents a substantial change in clinical practice in the

perioperative setting Same-day surgical patients given short-acting anesthetic agents and who are awake, alert, and mobile requiring no parenteral pain medications and with no bleeding or nausea at the end of an operative procedure can safely bypass the PACU

* Professor and Chair, Department of Anesthesia and Critical Care, University of Chicago Hospitals and Clinics, Chicago, Illinois † Executive Vice President, ‡ President and CEO, Cognigen Corporation, Williamsville, New York § Former: Glaxo Wellcome, Incorporated, Research Triangle Park, North Carolina Current: Vice President, Commercial and Business Development, Ardent Pharmaceuticals, Durham, North Carolina || Former: Professor and Chair, Department of Anesthesiology, Scott & White Hospital and Clinic, Texas A&M College of Medicine, Temple, Texas Current: Senior Director, Clinical Development, Hospital Products Division, Abbott Laboratories, Abbott Park, Illinois # Former: Professor and Chair, Department of Anesthesia and Critical Care, University of Chicago Hospitals and Clinics, Chicago, Illinois Current: Dean and Vice President of Biomedical Sciences, College of Medicine, State University of New York of Upstate Medical University, Syracuse, New York ** Clinical Professor, University of Illinois College of Medicine, Chicago, Illinois †† Professor, Department of Anesthesia and Intensive Care, University of Helsinki, Women’s Hospital, Helsinki, Finland.

Submitted for publication July 25, 2001

Accepted for publication January 2, 2002

Supported in part by a grant from Glaxo Wellcome, Incorporated, Research Triangle Park, North Carolina Address reprint requests to Dr Apfelbaum: Department of Anesthesia & Critical Care, The University of Chicago Hospitals and Clinics, 5841 South Maryland Avenue MC4028, Chicago, Illinois 60637 Address electronic mail to: jeffa@airway.uchicago.edu Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

OBSTETRIC ANESTHESIA

Intrathecal Versus Intravenous Fentanyl for Supplementation of Subarachnoid Block During Cesarean Delivery

Sahar M Siddik-Sayyid, MD, FRCA, Marie T Aouad, MD, Maya I Jalbout, MD, Mirna I Zalaket, MD, Carina E Berzina, MD, and Anis S Baraka, MD, FRCA

Department of Anesthesiology, American University of Beirut, Medical Center, Beirut, Lebanon

Address correspondence and reprint requests to Anis Baraka, MD, FRCA, Department of Anesthesiology, American University of Beirut, PO Box 11-0236, Beirut, Lebanon Address e-mail to abaraka@aub.edu.lb.

Forty-eight healthy parturients scheduled for elective cesareandelivery were randomly allocated to receive intrathecally either12 mg of hyperbaric bupivacaine plus 12.5 µg of fentanyl(n = 23) or bupivacaine alone (n = 25) In the latter group,IV 12.5 µg of fentanyl was administered immediately afterspinal anesthesia We compared the amount of IV fentanyl requiredfor supplementation of the spinal anesthesia during surgery,the

intraoperative visual analog scale, the time to the firstrequest for postoperative analgesia, and the incidence of adverseeffects Additional IV fentanyl supplementation amounting

toa mean of 32 ± 35 µg was required in the IV Fentanylgroup, whereas no supple- mentation was required in the IntrathecalFentanyl group (P = 0.009) The time to the first

request forpostoperative analgesia was significantly longer in the IntrathecalFentanyl group than in the IV Fentanyl group (159 ± 39min versus 119 ± 44 min; P = 0.003) The

incidence ofsystolic blood pressure <90 mm Hg and the ephedrine requirementswere significantly higher in the IV Fentanyl group as comparedwith the Intrathecal Fentanyl

group (P = 0.01) Also, intraoperativenausea and vomiting occurred less frequently in the IntrathecalFentanyl group compared with the IV Fentanyl group (8 of 23vs 17 of 25; P =

0.02)

IMPLICATIONS: Supplementation of spinal bupivacaine anesthesiafor cesarean delivery with intrathecal fentanyl provides a betterquality of anesthesia and is associated with a decreased incidenceof side effects as compared with supplementation with the samedose of IV fentanyl

Anesth Analg 2002;95:214-218

© 2002 International Anesthesia Research Society

REGIONAL ANESTHESIA

New Landmarks for the Anterior Approach to the Sciatic Nerve Block: Imaging and Clinical Study

Alain C Van Elstraete, MD * , Claude Poey, MD , Thierry Lebrun, MD * , and

Frédéric Pastureau, MD *

Departments of *Anesthesiology and Radiology, Saint-Paul Medical Center, Fort de France, Martinique, France

Address correspondence and reprint requests to Alain C Van Elstraete, Département d’Anesthésiologie, Centre Médico-Chirurgical Saint Paul, Clairière, 97200 Fort-de-France, Martinique, France Address e-mail

to alainvanel@hotmail.com.

In this study, we assessed the reliability of the inguinal creaseand femoral artery as anatomic landmarks for the anterior approachto the sciatic nerve and determined the optimal position ofthe leg during this approach An imaging study was conductedbefore

the clinical study The sciatic nerve was located twicein 20 patients undergoing ankle or foot surgery, once with theleg in the neutral position and once with the leg in the

externallyrotated position The patient was lying supine A 22-gauge,150-mm insulated b-beveled needle connected to a nerve stimulatorwas inserted 2.5 cm distal to the

inguinal crease and 2.5 cmmedial to the femoral artery and was directed posteriorly and laterally with a 10°–15° angle relative to thevertical plane The sciatic nerve was located

in all patientsat a depth of 10.6 ± 1.8 cm when the leg was in the neutralposition and 10.4 ± 1.5 cm when the leg was in the externallyrotated position (not significant) In the neutral positionand in the externally rotated position, the time needed to identify

anatomic landmarks was 28 ± 15 s and 26 ± 14 s,respectively (not significant), and the time needed to locatethe sciatic nerve was 79 ± 53 s and 46 ± 25 s(P < 0.006),

respectively We conclude that the inguinalcrease and femoral artery are reliable and effective anatomiclandmarks for the anterior approach to the sciatic nerve andthat the optimal position of the leg is the externally rotatedposition

IMPLICATIONS: This new anterior approach to the sciatic nerveusing the inguinal crease and femoral artery as landmarks isan easy and reliable technique

Anesth Analg 2002;95:133-143

© 2002 International Anesthesia Research Society

ANESTHETIC PHARMACOLOGY

The Efficacy and Safety of Transdermal Scopolamine for the Prevention of Postoperative Nausea and Vomiting: A

Quantitative Systematic Review

Peter Kranke, MD * , Astrid M Morin, MD, DEAA , Norbert Roewer, MD, PhD * , Hinnerk Wulf, MD, PhD , and Leopold H Eberhart, MD

*Department of Anesthesiology, University of Würzburg; and Department of Anesthesiology, University

of Marburg, Germany

Address correspondence and reprint requests to Peter Kranke, MD, Department of Anesthesiology, University of Würzburg, Josef-Schneider-Str 2, D-97080 Würzburg, Germany Address e-mail to

peter.kranke@mail.uni-wuerzburg.de.

The role of scopolamine administered via transdermal therapeuticsystems in the

prevention of postoperative vomiting, nausea,and nausea and vomiting is unclear We performed a systematicsearch for full reports of randomized comparisons of transdermal scopolamine with inactive control Dichotomous data were extracted.In the

meta-analysis, relative risks and numbers-needed-to-treat/harmwere calculated with 95% confidence intervals (CI) In 23 trials,979 patients received transdermal scopolamine, and

984 patientsreceived placebo Sensitivity analyses were performed usingrestricted data for truncated control event rates (40%–80%)and for large trials With these data, the relative risks forpostoperative vomiting (five reports), nausea (five reports),nausea and

vomiting (eight reports), and rescue treatment (threereports) were 0.69 (95% CI, 0.58– 0.82), 0.69 (95% CI,0.54–0.87), 0.76 (95% CI, 0.66–0.88), and 0.68 (95%CI, 0.54– 0.85), respectively This means that of 100 patientswho receive transdermal scopolamine, approximately 17 will notexperience postoperative vomiting who would have done so hadthey all received a placebo However, 18 of 100 patients willhave visual

disturbances, eight will report dry mouth, two willreport dizziness, one will be classified

as being agitated,and 1–13 patients who are prescribed transdermal scopolaminewill not use it correctly The timing of application does notalter efficacy

IMPLICATIONS:Of 100 patients who receive transdermal scopolamine,approximately

17 will not vomit in the postoperative periodwho would have done so had they all

received a placebo However,18 of 100 patients will have visual disturbances, and eight will report dry mouth Incorrect use further limits its efficacy

Anesth Analg 2002;95:78-82

© 2002 International Anesthesia Research Society

AMBULATORY ANESTHESIA

Development of an Appropriate List of Surgical Procedures of a Specified Maximum Anesthetic Complexity to Be Performed at a New Ambulatory Surgery Facility

Franklin Dexter, MD, PhD * , Alex Macario, MD, MBA , Donald H Penning, MS,

MD , and Patricia Chung, MHA

*Division of Management Consulting and Department of Anesthesia, University of Iowa, Iowa City; Department of Anesthesia, Stanford University, Stanford, California; Department of Anesthesia,

Sunnybrook and Women’s Health Sciences Centre; Department of Anaesthesiology, University of Toronto, Ontario, Canada; and Decision Support, Hospital Administration, Sunnybrook and Women’s Health Sciences Centre, Toronto, Ontario, Canada

Address correspondence and reprint requests to Franklin Dexter, Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, IA 52242 Address e-mail to

Franklin-Dexter@UIowa.edu.

A common but difficult task for a hospital when it decides toopen a freestanding

ambulatory surgery facility is how to decidewhich surgical procedures should be done at the new facility.This is necessary in order to determine how many operating roomsto plan for the new facility and which ancillary services areneeded on-site In this case study, we describe a novel methodologythat we used to develop a comprehensive list of procedures tobe done at a new ambulatory facility The level of anestheticcomplexity of

a procedure was defined by its number of ASA Relative Value Guide basic units Broad

categories of procedures (e.g.,eye surgery) were defined according to the International Classificationof Diseases, Ninth Revision, Clinical Modification We identified22 categories that are of a type that every procedure in thecategory has no more than seven