Are outpatient Surgery Centers Safe?

With the recent death of Joan Rivers from a cardiac arrest during what appears to be a routine endoscopy procedure, many are questioning the safety of outpatient or ambulatory surgery centers (ASCs).

Background: ASCs first appeared in 1970 and have been growing steadily due to reduction in health costs; less invasive procedures; physicians specializing in certain procedures; better anesthesia; patients preference; and shorter waiting times. A total of 5,357 ambulatory surgery centers treated 3.4 million fee-for-service Medicare beneficiaries in 2012, and the Medicare program and its beneficiaries spent $3.6 billion on ASC services, according to a report from the MedicarePayment Advisory Commission. 

Accreditation Requirements: According to the Ambulatory Care Association, Forty three states and the District of Columbia currently require ASCs to be licensed in order to operate. The remaining seven states have some form of regulatory requirements for ASCs, such as Medicare certification or accreditation by an independent accrediting organization. Each state determines the specific requirements ASCs must meet for licensure and most require rigorous initial and ongoing inspection and reporting....All ASCs serving Medicare beneficiaries must be certified by the Medicare program....In addition to state and federal inspections, many ASCs choose to go through voluntary accreditation by an independent accrediting organization. Accrediting organizations for ASCs include The Joint Commission, the Accreditation Association for Ambulatory Health Care (AAAHC), the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF) and the American Osteopathic Association (AOA). 

Many hospitals offer same day surgery suits, which are different then free standing ASC facilities, as the hospital licensure requirements cover the surgical center.

The majority of ASCs are accredited by one of the four agencies listed above. However, this is not true for small practices, where one or two doctors perform surgery in their offices.

To find out what your state’s requirements are, go to the AAAASF website. 

Safety: According to Richard Dutton, chief quality officer for the American Society of Anesthesiologists, “Deaths in outpatient surgery are extremely rare. It should be less than one in one million in healthy patients.” Further, there is “no published literature that I know of that suggests any difference in outcomes” between doctor-owned and hospital-based outpatient surgery clinics.” 

In almost 250,000 outpatient surgeries examined in a study published in December, 232 patients had major complications within 72 hours, including 21 who died. The report, which appeared in the journal Anesthesiology, said common risk factors found in the patients with severe adverse events included obesity, prior cardiac surgery and history of a stroke. Bloomberg News

A study in the journal Surgery  found of the nearly 4 million patients who were sent home after having a procedure, an estimated 1 out of every 31 (3.2%) were admitted to the hospital or visited an emergency room for follow up care within seven days of being discharged, and the need for visits varied widely depending on the procedure. ...Those receiving a diagnostic cardiac catheterization ended up at the hospital later, either in the emergency room or admitted for care, at the highest rate—1.9%. Other procedures with much smaller but still-high hospitalization rates included noncardiac vascularization (0.17%); replacement or removal of pacemakers and defibrillators (0.18%); and bunionectomies (0.16%). Those who had a breast biopsy were the least likely to be sent to the hospital.

Interestingly, but not surprising, ACS’s have significantly lower infection rates than hospitals.

Rivers situation highlights the fact that ASCs can be riskier for older patients, since:  they tend to have multiple health issues; are more likely to deteriorate rapidly, particularly if they have to wait for emergency responders; and have difficulty coping with the stress of surgery. In addition, not all ACSs are staffed to handle a crisis.

Before Having Surgery at an ACS: If you are being referred to an ACS for surgery or another procedure consider the following:

• Do the research:

- Is the facility part of a hospital? Is it accredited? If yes, by whom?

- What hospital would you be taken to in the event of an emergency? How equipped is the ASC to handle a crisis?

- Have there been any issues with this ACS in the past? If so, how have they been resolved?

•    It is important that the doctor performing the surgery/procedure knows your health history and current status. Be sure they know all the medications, including supplements and over the counter medications, you are taking as well as any you’ve had an allergic reaction to.

•    Call your doctor if: you experience any changes in your health between your most recent visit to your physician and the day of your procedure, even minor ones like a temperature, cough or a cold; or you think you might be pregnant.

• Make sure you that you, your doctor and your surgeon all agree on exactly what will be done. Because people with chronic conditions often have multiple health issues, make sure someone, your primary doctor coordinates your care.

• Choose an ACS and surgeon where many patients have had the procedure or surgery you need.

While ACSs are convenient and preferred by patients and doctors alike, keep in mind that age as well as pre existing conditions could be an important reason why a hospital may be the safer choice. Regardless of where your care is being delivered, follow Be S.A.F.E.R and avoid medical errors.