Secondary Logo

Journal Logo

Where We Were, Where We Are, Where We Are Going

Epstein, Burton S., MD

doi: 10.1213/ANE.0b013e31821a6013
Ambulatory Anesthesiology: Special Article

Published ahead of print April 5, 2011

Professor Emeritus in Anesthesiology and Pediatrics, The George Washington University Medical Center, Washington, DC.

The author declares no conflicts of interest.

This work was the basis of the 2010 “Frontiers Lecture” at the Society for Ambulatory Anesthesia’s (SAMBA) 25th Annual Meeting, May 1, 2010, Baltimore, MD.

Reprints will not be available from the author.

Address correspondence to Burton S. Epstein, MD, 6704 Pawtucket Rd., Bethesda, MD 20817. Address e-mail to

Accepted March 1, 2011

Published ahead of print April 5, 2011

Back to Top | Article Outline


The Early Days

From 1958 to 1961 and 1963 to 1964, I was a resident in anesthesiology and a member of the faculty at the Hospital of the University of Pennsylvania (HUP). The chairman of the department and McNeil Professor was Robert D. Dripps. None of his trainees or faculty was allowed to use the phrase, “in my experience,” when participating in a conference. The bywords were, “show me the data!” This philosophy has greatly influenced my approach to learning, teaching, and research.

In the 1950s, general inhaled anesthesia using gas-oxygen-ether was usually used. Breathe it in through the lungs and exhale it by the same route was the preferred anesthetic technique. At the HUP, there was no ambulatory surgery, prolonged recovery was common, and nausea and vomiting were frequent complications.

In 1959, however, Egbert et al.1 compared the recovery from IV administration of methohexital (later known as Brevital) with that from thiopental. Healthy, “normal,” volunteers’ recovery reactions were studied using an American Automobile Association driving simulator. The authors of the study noted that methohexital had a shorter duration of effect than thiopental and “would be an advantage for anesthesia in outpatients.” Later, a remarkable philosophical change occurred at HUP. Dr. Dripps agreed to conduct a trial of Innovar, an IV drug consisting of droperidol and fentanyl in a ratio of 50:1 (2.5 mg/mL; 50 μg/mL). The McNeil Pharmaceutical Company wanted to field test the practical application of the combination of the hypnotic, sedative, and antiemetic properties of droperidol and the analgesic effects of fentanyl (so called “neuroleptanalgesia”). This study was done on inpatients to the virtual exclusion of gas-oxygen-ether. My early exposure to this drug and its components led to my later research.

I became a member of the faculty at the George Washington University Medical Center (GWUMC) in 1964. In 1966, at GWUMC, Levy and Coakley had opened an “In and Out Surgery” unit.2 I was not part of that development process. At the time, I was initiating a lumbar epidural service in obstetrics.

In 1972, because of my previous association with HUP, my familiarity with Innovar, and Dr. Dripps’ association with McNeil Laboratories, I was approached by their medical director with a proposal for a research study. The company wanted to test the use of fentanyl as an adjunct in the overall anesthetic management of outpatient surgery. This had not been previously attempted in that setting. Levy and Coakley agreed that I would relocate from obstetrics to the outpatient unit, and in 1973 I undertook a study to evaluate Sublimaze (fentanyl) in short surgical procedures.

Back to Top | Article Outline

The Development Years

Many highly significant events influenced the development of the field of ambulatory surgery. In 1962, Cohen and Dillon opened an outpatient surgery unit at the University of California at Los Angeles.3 GWUMC and University of California at Los Angeles were academic medical centers that provided models for the design of facilities and guidelines for care. Wally Reed visited those facilities before establishing the first successful nonhospital-based freestanding facility in Phoenix in 1970.4 Other similar units were opened shortly thereafter.

The freestanding groups were a formidable force in developing ambulatory surgery. They were very careful to adhere to safe practice models. In 1974, they formed an organization, initially known as SFAFASC (Society for the Advancement of Freestanding Ambulatory Surgical Care), later FASA (The Freestanding Ambulatory Surgical Association).5

Before considering the development of the Society for Ambulatory Anesthesia (SAMBA), one must appreciate the tension between the hospital-based and freestanding movements. The former were not only interested in providing safe care but also in education and research. The freestanding groups also maintained high standards of care and adherence to accreditation standards. FASA, however, evolved into a trade organization with major emphases on business, political, and legislative matters.5 Part of the friction between the 2 groups related to accusations by the hospital-based units that the freestanding groups were “skimming the cream off the top,” i.e., attracting the healthy patients who could undergo simple, uncomplicated procedures. Attending to only healthy patients would favor their results enabling a prompt discharge home. Because of the complexity of the patients and the more extensive surgical procedures performed at the hospital-based units, sometimes discharge was delayed or there were unplanned overnight admissions. The hospital units were accused of creating these situations to increase their charges.

Back to Top | Article Outline

The Development of SAMBA

In 1984, at an ambulatory surgery meeting sponsored by the Medical College of Virginia, Bernie Wetchler asked me and Surindar Kallar, “Should we or shouldn’t we,” … [establish a society for ambulatory anesthesia]? … “Is the time now?”a The thought process was to unite all groups dedicated to fostering safe practices in ambulatory anesthesia and to provide a forum for dialog between anesthesiologists working in a variety of settings. The goal was to develop a society that would focus on fostering research and education in ambulatory anesthesia. It would also support, encourage, and participate in the promotion of policies and programs of the American Society of Anesthesiologists (ASA) and other organizations regarding issues related to ambulatory surgery. The first organizational meeting was held October 29, 1984 at the Annual Meeting of the ASA.

In 1985, SAMBA was formally established, thanks not only to the original attendees from both sides of the aisle, freestanding and hospital-based anesthesiologists, but also because of the financial support of such visionaries as George Griffiths, Janssen Pharmaceutica, and Maria Bergamo of Roche. Janssen Pharmaceutica was interested in SAMBA from the outset and, as part of their marketing campaign, distributed our manuscript to anesthesiologists in the United States, describing the potential role of fentanyl in outpatient surgery.b Before this, many anesthesiologists in the United States were reluctant to use even a short-acting narcotic as an adjunct to inhaled anesthesia in ambulatory surgery because of the possibility of delayed recovery and complications such as nausea and vomiting.

Back to Top | Article Outline


“It has been estimated that approximately more than 80% of all surgical procedures performed in the United States are now being done on an ambulatory basis.”6 This growth could not have occurred without the initial pioneering efforts of Drs. Bernard Wetchler7 and Paul White8 who published landmark texts on ambulatory anesthesia when the field was in the early development phase. Participation of SAMBA members in educational endeavors (Table 1) and through administrative representation to national organizations (Table 2) has been extensive and vitally important to the growth of the specialty.

Table 1

Table 1

Table 2

Table 2

SAMBA also established a category “Best” Research Award in 1990, as part of its annual meeting, and an “Outcome” Research Award in 2000. The recipient of the latter that year was Lee Fleisher, MD. In 2009, Dr. Fleisher edited the second edition of the text Evidence-Based Practice of Anesthesiology.12 Many members of SAMBA were contributing authors or coauthors. Several chapters, such as those devoted to discharge criteria, office-based anesthesia, and the management of postoperative nausea and vomiting, are of particular importance in ambulatory surgery.

The problem with many of the conclusions in these chapters and in a recent textbook on the subject13 is not what is described or recommended but the variability in the availability and strength of the supporting evidence. Recommendations could only be made using the “best available” information. This problem persists in the development of the Practice Parameters, Guidelines, and Advisories of ASA and in the “consensus” Guidelines of Postoperative Nausea and Vomiting (PONV) developed by SAMBA.911

A good illustration of this issue is the ASA’s Practice Guidelines for Postanesthetic Care.14 Three of the recommendations are based on “insufficient literature”; that is, “there are too few published studies to investigate a relation (linkage) between a clinical intervention and a clinical outcome.” Nevertheless, the recommendations are generally well accepted by the ambulatory anesthesia community. They include:

  • Urination is required only in selected patients.
  • Ingestion of clear liquids without vomiting is not part of the routine discharge criteria.
  • A mandatory minimum stay in the recovery room is not required.

Despite the ASA’s exhaustive methodical process and model, “An astonishing number of recommended practices in these (ASA) publications are based on expert consensus after our task forces have come up empty-handed in their quest for high quality evidence.”15

SAMBA has developed a less-exhaustive process for the development of guidelines. The first of these was guidelines for the management of postoperative nausea and vomiting,9 and more recently published guidelines on glucose management for the ambulatory patient.11 These guidelines were developed using a shorter time cycle with less money and have no ASA counterpart, thus adding valuable information for practicing anesthesia providers.

A very recent, provocative editorial addresses some of the problems we face today when developing guidelines, advisories, and other “authoritative statements.”16 The authors state, “… it is inevitable (we hope) that consensus statements based on opinions, however well-intentioned and thoroughly constructed, will require revision based on scientific advancement and new evidence.”

The editorial was written because of new evidence17 that calls into question a recommendation contained in the American Society of Regional Anesthesia’s consensus statement from their 2002 conference on Neuraxial Anesthesia and Anticoagulation.18

In addition, the authors of the editorial question whether many organizations, foundations, and groups should remain in the business of providing statements, guidelines, and parameters for anesthetic practice. To a great many of them, we say “cease and desist.” In part, their criticism revolves around the design of the model. They also question the size of the sponsoring organization and its ability to adequately fund the effort and to debate the initial recommendations of the final product in an open forum.

In my opinion, many of the conclusions in the preceding editorial are controversial. Yet, the fact remains that much of our practice and the advice we receive as to the “standard of care” is not based on hard data. This is not limited to the field of anesthesiology. To quote: “The poverty of our healthcare information is an embarrassment … simply try to find out how many people died from heart attacks or pneumonia or surgical complications—and you will discover that the most recent data are at least three years old, if they exist at all ….”c

Back to Top | Article Outline


There are, however, exceptions; for example, one noncardiac surgical model with ongoing data collection is the National Surgical Quality Improvement Program (NSQIP). This was established in 1994 and is a nationally validated, outcome-based, risk-adjusted, peer-controlled program analyzing 30-day morbidity and mortality in United States Veterans Administration (VA) hospitals. Their results have led to marked improvements in surgical care throughout the VA system.19

Their model has also been validated in a number of non-VA hospitals under an Agency for Healthcare Research and Quality federal grant to the American College of Surgeons (ACS NSQIP).20 An example of the application of some recently collected, published data describes the development of the use of a morbidity and mortality risk calculator for colorectal surgery.21 Unfortunately, neither NSQIP nor ACS NSQIP collects data on the conduct of anesthesia although ASA status is recorded and has been validated as a risk factor.

The NSQIP and ACS NSQIP are also very expensive to administer and are not “user-friendly.” Data from one NSQIP case consists of 163 data points per case, recorded actively by a specially trained and designated “abstractor.” This time-consuming and expensive model limits the number of cases that can be culled and the number of hospitals that are able to participate.d

Both ASA and SAMBA have recognized that it will be impossible to develop accurate and timely advice for our members without an ongoing data collection system dedicated to our specialty’s needs. These include “Benchmarkings,” “Best Practices,” “Quality Improvement,” Maintenance of Certification in Anesthesiology, as well as “Pay for Performance.”

This is the direction we must go. Fortunately, both organizations (SAMBA and ASA) have recognized the urgency of the situation. In 2008, the ASA created the Anesthesia Quality Institute (AQI).e Its task is to collect and disseminate data across the breadth of anesthesia practices in the United States, including groups from the largest universities to the smallest private practices. It will be accomplished by creation and administration of the National Anesthesia Clinical Outcome Registry. Unlike NSQIP, data will be collected by the passive capture of digitized information from anesthesia billing systems, quality management programs, hospital information technology platforms, and anesthesia information management systems.

Similar, to ASA’s efforts, SAMBA has launched the SCOR program (SAMBA Clinical Outcomes Registry). Data will be collected using a paper diary during the case to enter the data later, or on a user-friendly short form (web-based entry) during patient care. This is intended for use in any ambulatory surgery facility.

Although this effort will be directed toward the massive population of anesthesiologists who provide care in a variety of ambulatory surgical settings, the success of both AQI and SCOR relies on sharing and interpreting data. “Establishing connections between an anesthesia registry and emerging registries in organizations such as our subspecialty societies … is demanding but critical.”15 Fortunately, the leadership of SCOR and AQI is working on a means to share data collected by both groups and to have a single report of these data generated by SAMBA that will be shared with participating groups and hospitals.

a Memo from the desk of Bernard V. Wetchler, MD, 1984 (undated).
Cited Here...

b Epstein BS, Levy ML, Thein MH, Coakley CS. Evaluation of fentanyl as an adjunct to thiopental–nitrous oxide–oxygen anesthesia for short surgical procedures. Anesthesiol Rev 1975;2:24–9.
Cited Here...

c Gawande A. Testing, testing. The New Yorker. December 14, 2009.
Cited Here...

d Dutton RP. Counterpoint: out with the old, in with the new! ASA Newsletter 2010;74:18–9.
Cited Here...

e Dutton RP. Data exchange in the information age: creation of the Anesthesia Quality Institute. AUA update 2009. Winter: pp 3, 8.
Cited Here...

Back to Top | Article Outline


1. Egbert LD, Oech SR, Eckenhoff JE. Comparison of the recovery from methohexital and thiopental anesthesia. Surg Gynecol Obstet 1959; 109: 1–4
2. Levy ML, Coakley CS. Survey of “in and out” surgery: first year. South Med J 1968; 61: 995–8
3. Cohen DD, Dillon JB. Anesthesia for outpatient surgery. JAMA 1966; 196: 98–100
4. Ford JL, Reed WA. The surgicenter: an innovation in the delivery of medical care. Ariz Med 1969; 26: 801–4
5. Wong HC, Epstein BS. United States. In: White PF ed. Ambulatory Anesthesia and Surgery. Philadelphia: WB Saunders, 1997:779–84
6. Pasternak LR. Preanesthesia evaluation and testing. In: Twersky RS, Philip BK eds.Handbook of Ambulatory Anesthesia. 2nd ed. New York: Springer, 2008:1
7. Wetchler BV. Anesthesia for Ambulatory Surgery. Philadelphia: JB Lippincott, 1985
8. White PF. Outpatient Anesthesia. New York: Churchill Livingstone, 1990
9. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramer MR, Watcha M. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003; 97: 62–71
10. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Habib AS, Hooper VD, Kovac AL, Kranke P, Myles P, Philip BK, Samsa G, Sessler DI, Temo J, Tramer MR, Kolk CV, Watcha M. Society for ambulatory anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2007; 105: 1615–28
11. Joshi GP, Chung F, Vann MA, Ahmad S, Gan TJ, Goulson DT, Merrill DG, Twersky R. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg 2010; 111: 1378–87
12. Fleisher LA. Evidence-Based Practice of Anesthesiology. 2nd ed. Philadelphia: Saunders Elsevier, 2009
13. Twersky RS, Philip BK eds, Handbook of Ambulatory Anesthesia. 2nd ed. New York: Springer, 2008
14. Silverstein JH, Apfelbaum JL, Barlow JC, Chung FF, Connis RT, Fillmore RB, Hunt SE, Joas TA, Nickinovich DG, Schreiner MS. Practice guidelines for postanesthetic care. Anesthesiology 2002; 96: 742–52
15. Hannenberg AA, Warner MA. The registry imperative. Anesthesiology 2009; 111: 687–9
16. Butterworth JF, Rathmell JP. Standard care, standards for care, or standard of care? Anesthesiology 2010; 112: 277–8
17. Benzon HT, Avram MJ, Benzon HA, Kirby-Nolan M, Nader A. Factor VII levels and international normalized ratios in the early phase of warfarin therapy. Anesthesiology 2010; 112: 298–304
18. Horlocker TT, Wedel D, Benzon H, Brown DL, Enneking KF, Heit JA, Mulroy MR, Rosenquist RW, Rowlingson J, Tryba M, Yuan CS. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28: 172–97
19. Khuri SF, Daley J, Henderson WG. The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Arch Surg 2002; 137: 20–7
20. Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA Jr, Fink AS, Mentzer RM Jr, Neumayer L, Hammermeister K, Mosca C, Healey N; Principal Investigators of the Patient Safety in Surgery Study. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery Study. Ann Surg 2008; 248: 329–36
21. Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an American College of Surgeons National Surgical Quality Improvement Program: morbidity and mortality risk calculator for colorectal surgery. J Am Coll Surg 2009; 208: 1009–16
© 2011 International Anesthesia Research Society