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Safety at outpatient surgery centers: A spine surgeon’s perspective
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With the rapid growth of outpatient surgery centers, patient safety in this setting has come under increased scrutiny. Outpatient surgery centers have provided patients with a convenient and cost-effective alternative to a hospital setting with a minimal risk of complication. With technological and medical advances, procedures in many disciplines that were once thought to be unsuited for the outpatient arena are being increasingly adapted for use in this environment, thereby favorably bending the health care cost curve.
The benefits of outpatient surgery are substantial. Outpatient surgery centers are more easily accessed than large hospital facilities, and the streamlining of services at these centers allows for maximum efficiency and minimal wait times. These advantages have led to outpatient surgery centers achieving an overall patient satisfaction rate of 92%. In addition, outpatient surgery is cost-effective, with $2.6 billion in annual savings to Medicare alone. As outpatient surgery centers employ a specialized staff, these centers can focus on providing the highest quality and level of care for patients.
Extensive management plan
Regardless of the operative setting, a surgeon must always be prepared for potential complications. This is particularly important in the outpatient setting where the resources of a full hospital are not always available. In this setting, the management plan must be more extensive to ensure all necessary equipment is on hand and staff members are prepared and capable of handling any potentially life-threatening complications. In fact, extensive preoperative preparation to ensure the best care possible and minimize the risk of complications should be the practice of hospital-based surgeries, as well. Furthermore, physicians who operate in the outpatient setting must have an action plan designed to expedite hospital transport at the first sign of impending harm. Calling 911 so a patient can be transferred to a hospital from an outpatient surgical center does not always mean something went wrong. This is often a precautionary action that ensures there will be continued close monitoring and an emphasis on patient safety during transit.
An article in USA Today by Christina Jewett from Kaiser Health News and Mark Alesia from the IndyStar brought attention to an uncommon complication after cervical spine surgery: a cervical hematoma. A cervical hematoma can develop within the first few hours of the surgery and, without emergent drainage, can lead to death. Patients in the outpatient setting are monitored closely during the period following cervical spine surgery so emergent treatment can be initiated, if needed. Outside of that time frame, cervical hematomas are exceedingly rare. Patients are typically allowed to go home with instructions to seek emergent care if they develop concerning symptoms. This is true even for patients who undergo surgery in a hospital facility. Although the consequences can undoubtedly be tragic, the development of this complication at home is no more likely to occur after surgery done in an ASC than in a hospital-based OR.
Low complication rates
Although the anecdotal evidence discussed in the USA Today article is concerning, reports of such surgical complications should not be regarded as common occurrences. In a 2016 article, McClelland and colleagues analyzed complication rates after outpatient cervical spine fusions among all published reports from 1996 to 2016. Among a total of 2,448 patients, the overall complication rate was 1.8% and the mortality rate was 0.1%. Notably, these complication rates are much lower than those reported for hospital-performed procedures, which can be as high as 5%. One investigation of outpatient surgery safety reported a 0.095% adverse event rate among 244,297 outpatient procedures. Other studies have reported rates of major perioperative morbidity ranging from 0.09% to 0.6% for common outpatient procedures.
Concerns are often expressed over the impact of physician ownership of outpatient surgery centers, yet most operating rooms where outpatient surgery is performed are owned and operated by hospitals or health systems. Regardless of financial incentive, it is the obligation of the surgeon to prioritize patient safety above all else. Surgeons must rigorously assess a patient’s eligibility for outpatient surgery. Pre-existing medical conditions may put patients at a greater risk for complications. These factors alert the clinical care team about any patients who require closer monitoring postoperatively and they often prevent patients from being eligible for outpatient surgery.
Patients considering outpatient surgery should employ due diligence to ensure they are being treated at a center that is compliant with safety standards. Furthermore, they are encouraged to communicate any concerns to their surgeon and share with their surgeon pertinent information regarding any medical conditions they may have, as well as medications they are taking. A proficient surgeon who employs responsible patient selection can perform many surgical procedures safely in an outpatient center while favorably reducing overall costs to society. Excellent outcomes and high patient satisfaction combined with lower costs represents improved health care value. Many patients can safely experience this kind of value despite having numerous tenuous conditions, including cervical spine disease and other musculoskeletal problems.
- References:
- Engbaek J, et al. Acta Anaesthesiol Scan. 2006;doi:10.1111/j.1399-6576.2006.01090.x.
- Jewett C, et al. How a push to cut costs and boost profits at surgery centers led to a trail of death. USA Today. March 2, 2018. https://www.usatoday.com/story/news/2018/03/02/medicare-certified-surgery-centers-safety-deaths/363172002/. Accessed April 5, 2018.
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- For more information:
- Kern Singh, MD, can be reached at Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite #300, Chicago, IL 60612; email: kern.singh@rushortho.com.
Disclosure: Singh reports ownership in ASCs.