Infections and Patient Satisfaction in WALANT Hand Surgery in a Hospital Procedure Room

Abstract

Background: Wide-awake hand surgery has allowed many hand procedures to be moved out of the operating room and into minor procedure rooms while increasing efficiency, maintaining safety, and reducing both patient and hospital costs. The goal of this study was to evaluate patient satisfaction and postoperative complications of wide-awake local anesthesia with no tourniquet procedures performed in a community-based hospital procedure room. Methods: A total of 786 patients underwent 948 elective hand procedures in a hospital procedure room. At the conclusion of their surgeries, the patients were surveyed regarding their satisfaction. Following surgery, patients were evaluated for postoperative complications including infections. The trend in postoperative infection rates across 8 age groups was analyzed using a Cochran-Armitage test in R. Results: The overall infection rate was 6.2% (n = 59). All infections were superficial. Carpal tunnel had the highest number of infections (n = 25), followed by trigger finger (n = 8), and the combination trigger finger with carpal tunnel (n = 7). All infections were managed with antibiotics and/or soaks. Three patients did require a return to the operating room for irrigation and debridement. Ninety-nine percent of patients said the procedure room experience was better or the same as going to the dentist, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Conclusion: Wide-awake procedures performed in a hospital procedure room have low infection rates with high patient satisfaction.

Introduction

Wide-awake local anesthesia with no tourniquet (WALANT) or wide-awake (WA) local-only surgery has dramatically changed how surgeons practice hand surgery. Wide-awake hand surgery has allowed many hand procedures to be moved out of the operating room (OR) and into minor procedure rooms while increasing efficiency, maintaining safety, and reducing both patient and hospital costs.^{1 –3} Wide-awake local anesthesia with no tourniquet uses 1% lidocaine with epinephrine as a local anesthetic causing vasoconstriction at the operative site. With WA surgery, there is no need for a tourniquet. There is no tourniquet pain and no need for IV sedation, thereby preventing the pain associated with tourniquet use and limiting complication rates.^1,4,5 No preoperative evaluations are needed, safely saving the patient time and money.^6,7 Intraoperative monitoring, general anesthesia care, associated staff, and the hospital OR are unnecessary in WALANT, which translates to cost savings. ¹ The WA procedure is typically done under minor field sterility, described as sterile prep, a single drape, minor instrument tray, sterile gloves, mask, local anesthesia, no gown, or antibiotics. This uses fewer resources and reduces waste.^6,8,9 While not directly studied, WALANT procedures could potentially help reduce healthcare disparities by expanding surgical access to remote areas with limited OR space and resources.^10,11

Wide-awake local anesthesia with no tourniquet is gaining popularity among surgeons and results in similar outcomes to procedures performed in the hospital operating room. In a recent survey of the American Society for Surgery of the Hand members, 62% of surgeons reported using WALANT in their practice. ¹² A randomized trial comparing local-only anesthesia to sedation in patients undergoing staged bilateral carpal tunnel release found patients reported equal satisfaction scores. In 59% of the cases, they found local-only anesthesia indicated as the patient's preference. ¹³ Moreover, studies show that WALANT has low infection rates that are comparable to surgeries performed in the OR. ¹⁴

Much of the WALANT literature focuses on infection rates and patient satisfaction in smaller sample sizes, with limited procedure types, and the clinic setting. There is little information measuring patient satisfaction and infection rates across several different procedure types, with large sample sizes, or in the hospital procedure room in the United States. Our previous study focused on both patient satisfaction and postoperative complications in patients who underwent WALANT surgeries in an in-office procedure room. ¹⁵ This study fills a gap in research by focusing on a hospital-based procedure room, as opposed to an in-office procedure room. The goal of this study was to evaluate patient satisfaction and infection rates for a hospital-based procedure room, with our hypothesis being that patients would have a low infection rate with high patient satisfaction across all procedure types.

Materials and Methods

We used a similar method to that which was previously described by McKnight et al, this time focusing on hospital-based procedure rooms instead of in-office procedure rooms. ¹⁵

All patients seen in the clinic were given the option of doing their surgery in the hospital procedure room (Figure 1) with local anesthesia or in the hospital OR for their surgery with local/monitored anesthesia care (MAC) anesthesia. All patients who were seen and scheduled for surgery and agreed to undergo WA surgery were included in this study. There were 2 contraindications to WA surgery: a history of vasospastic disease (Raynaud’s) and fixed-vessel disease, such as calciphylaxis (calcific uremic arteriolopathy). ¹⁶ During the study period, no patients were excluded based on these criteria. No preoperative laboratory tests or medical examinations were done. Procedures were performed by 1 fellowship-trained orthopedic surgeon between March 2019 and December 2020.

Figure 1.

Hospital-based procedure room.

Anesthesia was obtained using the local injection technique described by Lalonde and Wong using 1% lidocaine with 1:100 000 epinephrine. ¹⁷ Injections occurred approximately 25 minutes prior to moving the patient into the hospital procedure room. Patients did not change into hospital gowns or stop their medications, including oral anticoagulants. All WA procedures were performed with minor field sterility and minimal instrumentation. The surgical team included a hand surgeon, surgical assistant, and a nurse. The extremity was prepped and draped using one drape with a designated arm hole. No prophylactic antibiotics were used. A pulse oximeter was used for cardiovascular monitoring. Phentolamine was available for epinephrine-induced digital ischemia.

The patients were surveyed after the surgery regarding their experience, using a questionnaire (Figure 2). Those who did not provide survey responses while in the hospital were excluded from this study. Charts were reviewed for survey responses and complications, including erythema, drainage, swelling, or other signs of infection after surgery. Infections were recorded at follow-up appointments. If patients had any signs or symptoms of infection, it was recorded along with management plans. All infections were included in our complication rate.

Figure 2.

Patient satisfaction survey.

The Institutional Review Board granted an exemption from approval since the data was de-identified and stored in the RedCap database. Using Current Procedural Terminology codes and a premade database, a retrospective chart review was performed on 786 patients (total of 948 procedures) who underwent WALANT surgery in our hospital procedure room.

Statistical Methods

The data exported from RedCap database included demographics (age and gender), procedure type, number of procedures, survey responses, and infections. We evaluated the trend in proportion of patients with an infection across 8 age classifications (13-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80+) using a Cochrane-Armitage test performed using the “prop.trend.test” function in program R. ¹⁸ We set the significance level at α=0.05.

Results

A total of 786 patients (336 men, 450 women; mean age 58.7 years, range = 13-93 years) elected to undergo a minor hand surgery under WALANT in a hospital procedure room. The most common procedures were carpal tunnel release (440 procedures), mass removal (81), Dupuytren’s excision (57 procedures), and deQuervain’s release (51 procedures; Table 1).

Table 1.

Infections by Procedure Type for WALANT Hand Surgeries in the Hospital Procedure Room From 2019-2020.

Procedure	Number of procedures	Infections	Procedure	Number of procedures	Infections	Procedure	Number of procedures	Infections
2 × Mass	1	0	Dupuytren's, 3 × trigger finger, mass	1	0	Tendon repair	1	0
2 × Trigger finger	34	2	Dupuytren's, amputation	2	0	Tendon transfer	1	0
2 × Trigger finger, mass	1	0	Dupuytren's, carpal tunnel	2	0	Tenosynovectomy	3	0
3 × Mass	1	0	Dupuytren's, deQuervain's	1	0	Trigger finger	174	8
3 × Trigger finger	6	1	Dupuytren's, mass	1	0	Trigger finger, 2 × mass	1	0
4 × Trigger finger	3	0	Dupuytren's, trigger finger	3	0	Trigger finger, mass	11	0
Amputation	8	1	Extensor tendon repair	3	0	Trigger finger, neurectomy	1	1
Carpal tunnel	376	25	Extensor tenolysis	1	0	Grand total	948	59
Carpal tunnel, 2 × trigger finger	3	0	Flexor tendon repair	1	1
Carpal tunnel, 4 × trigger finger	2	0	Foreign body	3	1
Carpal tunnel, deQuervain's	5	1	Hardware removal	1	0
Carpal tunnel, injection	1	0	Hardware removal, tenolysis	1	0
Carpal tunnel, mass	1	0	Irrigation and debridement	18	1
Carpal tunnel, tenosynovectomy	1	0	Intersection syndrome	2	0
Carpal tunnel, trigger finger	47	7	Laceration repair	1	0
Cubital tunnel	1	0	Lacertus syndrome, carpal tunnel	1	0
Cubital tunnel, carpal tunnel	1	0	Mass	69	2
Cubital tunnel, carpal tunnel, trigger finger	1	0	Nail ablation	5	0
deQuervain's	49	1	Neurectomy	6	2
deQuervain's, injection	1	0	Pronator	6	0
deQuervain's, mass	1	0	Pronator, carpal tunnel	16	3
deQuervain's, trigger finger	3	0	Pronator, carpal, trigger	1	0
deQuervains, intersection	1	0	Pronator, trigger finger	1	0
Dupuytren's	57	2	Sagittal band reconstruction	2	0
Dupuytren's, 2 × trigger finger	1	0	Scar revision	2	0

Note. WALANT, wide-awake local anesthesia with no tourniquet.

Infections were identified during chart review at postoperative follow up appointments. Fifty-nine patients with infections were identified, for a 6.2% infection rate. All infections were superficial infections. All infections were treated with antibiotics and/or soaks. Three patients required a return to the OR for irrigation and debridement. There were no hospital admissions. Carpal tunnel release totaled the most infections (25), followed by trigger finger release (8), and then patients with both carpal tunnel and trigger finger release (7). Phentolamine rescue was not used in this series.

Infection rate increased with age. We found a significant increasing trend between the proportion of infections and age categories (χ² = 4.462; P = .035). The infection rate was approximately 5% for patients 20 to 29 years old and increased to approximately 10% for patients greater than 80 years of age (Figure 3).

Figure 3.

Proportion of patients with infection by age group, with the number of patients in each group given above each bar.

The survey response rate was 99.4%. Six respondents did not complete the survey in 2019, but survey response was 100% in 2020. Of those that responded, 80% (n = 757) compared their experience as better than going to the dentist, 19% (n = 178) said it was the same, and 1% (n = 7) said it was worse (Table 2).

Table 2.

Percentage Agreement for Survey Responses by Year, Where the Number of Patients Is Given in Parentheses.

Survey responses	2019	2020	2021
Better than the dentist	77% (240)	80% (270)	84% (247)
Same as the dentist	22% (70)	19% (65)	15% (43)
Worse than the dentist	1% (2)	1% (2)	1% (3)
Would recommend to friend/family member	99% (310)	99% (335)	100% (292)
Would not recommend to friend/family member	1% (2)	1% (2)	0% (1)
Would do another procedure under WALANT	99% (310)	99% (335)	100% (292)
Would not do another procedure under WALANT	1% (2)	1% (2)	0% (1)

Note. WALANT, wide-awake local anesthesia with no tourniquet.

Over 99% (n = 937) would recommend a procedure done in the hospital procedure room under wide-awake anesthesia to a friend or family member (Table 2). Over 99% (n = 937) would do another procedure in the hospital procedure room under wide-awake anesthesia (Table 2). One hundred and twenty-four patients did return for a second procedure during the study.

Discussion

Our findings suggest that WALANT procedures in a hospital-based procedure room are safe and have high patient satisfaction. Our overall infection rate of 6.2% is comparable to other WALANT studies. Existing literature demonstrates low complication rates for elective hand operations in the procedure room with no statistical difference between the procedure room and the hospital OR.^{8,14,19 –22} A recent review suggests that hand surgery should be moved out of the main OR and into minor procedure rooms because the risk of postoperative infections is not reduced in the main OR.^3,17 Rellán et al demonstrated that no greater risk of infection was observed with WALANT procedures when compared to their MAC counterparts for carpal tunnel syndrome and trigger finger release surgeries. ²³ In a retrospective chart review of 424 patients who underwent WALANT procedures conducted by Reynolds et al, the complication rate for all procedures was 2.8% with a total infection rate of 9% for first dorsal compartment release, 5.5% for extensor tendon repairs, 4% for mass excision, and 2.5% for AI pulley release. ²⁴ Reynolds et al found no complications with carpal tunnel release and foreign body removal, in contrast to our infection rate for carpal tunnel release (7%) and foreign body removal (33%). ²⁴

Studies have demonstrated high satisfaction with elective hand operations performed in a procedure room or clinic setting.^{1,2,9,15,20,25,26} In this study we that found that 99% of patients rated the hospital procedure room as the same as or better than a dental visit, the same finding as McKnight et al found from the in-office procedure room study. ¹⁵ Recall bias may have impacted patient responses in the in-office procedure room study, since 110 patients were called for survey responses after their surgeries instead of being asked prior to surgery discharge. In a study by Choukairi et al, 95% of patients stated that WALANT procedures were better than they had expected preoperatively, and 95% said they would recommend WALANT to a friend. The majority found it better or equivalent to a dental procedure and limited postoperative pain management was necessary, using acetaminophen or acetaminophen and codeine. Only 3 patients in their study required stronger analgesics. ²⁶ Rabinowitz et al demonstrated that patients treated in the procedure room for trigger finger release were significantly more satisfied than patients treated in the OR and had better functional postoperative disabilities of the arm, shoulder and hand scores. ¹⁴

In our study, patients over 80 years of age were reported as the decade with most infections while maintaining high patient satisfaction. Similarly, Lech et al reported high patient satisfaction in both WALANT and IV regional anesthesia with a tourniquet procedure for patients over 80 years of age. They found that immediate postoperative discharge did not increase complications for this patient population. Furthermore, they found significantly less postoperative pain compared to procedures using tourniquets. ²⁷ In another study, despite the small sample size of 13, Castro Magtogo and Alagar, and other corroborating studies, found that the lack of tourniquet did not result in excessive bleeding and led to a significant reduction in postoperative pain.^4,14 Perceived pain was not an outcome of our research but is an important metric when evaluating patient satisfaction and is identified as an area for future research.

Wide-awake procedures reduce cost and decrease our carbon footprint.^{9,28 –31} Recent literature shows that by using procedure rooms, the ORs can gain hours and prioritize surgeries that require traditional anesthesia. ³² Starr et al demonstrated that 808 in-office procedures freed up 821 h of ambulatory surgery center time. They also found that hospitals increased their net margins if they were to replace 808 minor hand surgeries with sports procedures, complex orthopedic hand procedures, and adult reconstruction, increasing profit margins by $629 852, $746 939, or $3 917 537, respectively. ³²

The methodology in this study relied on retrospective chart review, so there is a risk for self-selection bias. All patients seen in the practice were given the choice of having the procedure in the procedure room or the hospital OR, regardless of comorbidities. The only exclusion criteria were history of vasospastic disease (Raynaud’s) or fixed vessel disease. A control group was not available for this study nor were patient outcome measurements collected. The decision was made to only use the data from 1 trained surgeon to eliminate recall bias. As such, carpal tunnel surgery was the most common procedure analyzed and had the highest rate of infections. The survey was collected immediately after the operation in the same building as the professionals who performed the surgery, which may have influenced survey responses. It is possible that not all charts accurately reflected infections, as some patients received follow-up care at other facilities. All patients who had signs of infection or were prescribed antibiotics were recorded as infections.

Conclusions

This study shows that WALANT surgery done in a community-based hospital procedure room is safe with high patient satisfaction and minimal complications. The findings corroborate our institution's sister-study that demonstrated low infection rates (4.3%) and high patient satisfaction in the in-office WA procedure room. ¹⁵ The use of WA surgery principles reduces costs to the hospital, patient, and the environment. Shifting minor hand surgeries to the procedure room may be a viable option for health system rural expansion or re-evaluating sustainability initiatives.