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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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Are surgery centers safe? This column is in response the Kaiser Health News story “How a push to cut costs and boost profits at surgery centers led to a trail of deaths” published on USAToday.com this week. The article set off a firestorm of controversy in the surgery center industry. The Kaiser article cites anecdotal information and allegations from ongoing litigation cases of patients seemingly harmed by their care at outpatient ambulatory surgery centers.

The quantity of ambulatory surgery centers has greatly increased over the past forty years for three primary reasons: Technologic advances made surgery easier, anesthetic care is safer, and healthcare payment policies encourage ambulatory surgery. I’ve been the Medical Director at a busy freestanding ambulatory surgery center in Northern California for a decade and a half. I’m a Stanford University-trained anesthesiologist and internist, and I’m uniquely qualified to answer the question: Are American surgery centers safe?

Yes, they are safe.

A review of the medical literature on Pubmed shows no peer-reviewed studies or data that surgery centers provide less safe care than hospitals.

Surgery and anesthesia are never 100% safe, no matter where procedures are done. There are always risks. The roles of anesthesiologists and surgeons at surgery centers are to minimize the risks.

There are four key questions regarding safe patient care at surgery centers:

1. Is the scheduled procedure appropriate for an outpatient surgery center?
2. Is the patient healthy enough to tolerate the scheduled procedure as an outpatient?
3. Are the healthcare professionals at that center practicing at the standard of care?
4. Is the surgery center accredited by an organization such as the Accreditation Association for Ambulatory Health Care (AAAHC)?

Question #1.

The most important screening question for a surgery center is, “What is the scheduled procedure?” Knee arthroscopies, tonsillectomies, inguinal hernia repairs, and colonoscopies are standard surgery center procedures. You cannot do large cases such as craniotomies, open heart surgeries, or an aortic vascular surgeries at a surgery center. The necessary backups of an intensive care unit, a blood bank, respiratory therapy, and a clinical laboratory are lacking. The job of a Medical Director is to survey the schedule each week, and decide if any planned cases are outside the usual comfort zone for that center. If there is any question, the Medical Director must gather more information on the procedure and the patient, usually by talking directly to the surgeon, and decide whether or not to give the case a green light. If the verdict is a red light, the surgeon needs to do the case in a hospital.

In recent years, some surgery centers have expanded their scope. Procedures such spine surgeries, total joint replacements, and bariatric surgeries are performed as ambulatory or short stay procedures at some outpatient centers. As the USAToday.com article points out, one motivation is money. A surgery center can extract well-insured cases from hospitals in order to increase profits for the surgery center. Is it better for a patient to have these procedures in a freestanding facility detached from a hospital? There is a paucity of research in peer-reviewed medical literature regarding the performance of these cases outside of hospitals. The USAToday.com article lists multiple spine surgery patients who died after surgery at an ambulatory surgery center. Medicare has only approved payment for spinal surgery at ambulatory centers since 2015. To my knowledge, no one has published the overall statistics regarding complications from spinal surgery in surgery centers and compared this to the complications from similar procedures in hospital settings.

What about the claim from the USAToday.com article that 911 calls from a surgery center are a problem? If a patient unexpectedly becomes acutely ill at a surgery center, calling 911 and transferring the patient to a hospital is routine policy and appropriate medical care.

Question #2.

How does a facility decide whether a patient is fit enough to undergo a given surgery at an outpatient center? At a surgery center, it’s the Medical Director’s job to screen every patient prior to scheduling. It’s the Medical Director’s job to prevent patients who are too sick from having a procedure at a surgery center. Different systems exist for preoperative assessment. Large university hospitals staff preoperative anesthesia clinics for their patients, and patients are required to physically visit the clinic to be examined and assessed prior to inpatient surgery. This system is not always practical in outpatient community medicine. Patients are usually assessed by their primary care physicians as indicated before surgery. A typical preoperative screening protocol at a surgery center is as follows: a preoperative assessment professional from the surgery center will telephone each patient several days before surgery, ask a series of pertinent screening medical questions, and fill out a standardized form. Any outlying answers are referred to the Medical Director, who decides if the patient is fit for the surgery. If the patient is too sick, the Medical Director will cancel the case, and tell the surgeon that the surgery needs to be done in a hospital.

Question #3.

When a complication occurs, anesthesiologists and surgeons in the operating room have a responsibility to correctly diagnose the problem and apply the correct therapy. The legal term for this is that physicians must adhere to the “standard of care.” The standard of care is defined as “what a reasonably trained physician would do in the same circumstance.” Deviating from the standard care is called negligence, and is part and parcel to medical malpractice lawsuits. If a bad outcome occurs in a surgery center because of negligence, i.e. malpractice, this is not a fault of the surgery center system. This concept is a central flaw in the USAToday.com article. The article cites multiple bad outcomes from surgery center cases, and in many of these cases the central issue seems to be negligent, below the standard of care decisions and actions by the health care professionals involved. Negligence is not specific to surgery centers.

Question #4.

Most surgery centers provide care to Medicare patients, and must meet standards approved by the federal government. To obtain Medicare certification, a surgery center must have an inspection conducted by a representative of an organization that the government has authorized to conduct that inspection, such as the Accreditation Association for Ambulatory Health Care (AAAHC). Inspectors will physically visit the surgery center to verify that the center meets established standards. Most surgery centers have passed such an inspection. The surgery center I work at is recertified every three years. If you’re uncertain whether your local surgery center is safe, request documentation that the facility has been certified by an organization such as AAAHC.

Nearly 60% of all surgical procedures in the United States are performed as outpatient surgery. Tens of millions of Americans receive care in ambulatory surgery centers each year. I’ve personally had two arthroscopic surgeries and three colonoscopies, and I chose to have all five procedures at a freestanding outpatient surgery center. The USAToday.com article cited anecdotal adverse outcomes from patients who were cared for at outpatient ambulatory surgery centers. Adverse outcomes will occur, but the frequency of these events (adverse events vs. total number of cases) is extraordinarily small. America’s surgery centers are by and large very safe. I reaffirm that no peer-reviewed data documents that ambulatory surgery centers are unsafe.

The key issues regarding surgery center safety will always be the four questions posed above. Is a given procedure safe and appropriate for an outpatient surgery center? Is a given patient fit enough to have their particular procedure in an outpatient surgery center? Are the healthcare professionals at that center practicing at the standard of care? And is the surgery center accredited by an organization such as the AAAHC?

In the overwhelming majority of America’s surgery centers, the answers to these three questions will be “Yes, yes, yes, and yes.”