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September 16, 2014

Are surgery clinics less safe than hospitals?

Daily Briefing

The death of famed comedienne Joan Rivers has raised questions about whether it is safe for seniors to undergo surgery outside of fully equipped hospitals. 

Rivers reportedly underwent an elective endoscopy at the physician-owned Yorkville Endoscopy Center in New York. There, she went into cardiac arrest and was transferred to the hospital. Several days later, she died.

The background on Rivers' death and the questions it has raised

 There are more than 5,300 such ambulatory surgery centers in the United States. In 2012, the centers treated 3.4 million fee-for-service Medicare beneficiaries, Medicare Payment Advisory Commission data show.

According to Bloomberg's Shannon Pettypiece, the centers come in all sizes and typically are owned by physicians rather than a hospital. Some centers "almost look like an actual hospital," making it hard "for patients to tell the difference between what is a hospital, what is an outpatient surgery center," Pettypiece tells PBS's "Newshour."

Ambulatory surgery centers may soon outnumber hospitals

The clinic in Rivers' case has not been accused of any wrongdoing. However, the case has raised broader questions about the safety of the clinics.

Are outpatient clinics equipped for emergencies?

One of the main concerns about ambulatory surgery centers is whether they are properly equipped to handle major problems during surgery.

This is a particular concern for older adults, who are more likely to have multiple health issues that increase surgery risks and who are more likely to deteriorate quickly if there is an issue in surgery. "If something goes slightly wrong, it's much more likely to turn into a big problem in an older person than a younger person," says Jonathan Flacker, Emory University's chief of geriatrics.

Geriatricians say access to emergency care for older surgical patients is crucial. But ambulatory centers often must call 9-1-1 and move patients to a hospital, according to Modern Healthcare. By comparison, hospitals are staffed to handle a variety of emergencies.

Outpatient center wants to offer surgeries that require overnight stays

"If the risk is really high, somebody needs to make a decision about not doing it in a surgery center but doing it in a place that might actually better manage the patient," says Frank Federico, executive director of strategic partners at the Institute for Healthcare Improvement.

The Ambulatory Surgery Center Association says all outpatient surgery clinics that do procedures on the elderly must be prepared to handle the patients' unique care needs.

Do they have appropriate staff for surgeries that need anesthesiology?

Meanwhile, some worry that outpatient clinics are skipping necessary steps when administering anesthesia.

Last week: What happens to the patients who 'wake up' during surgery

 Jane Fitch, president of the American Society of Anesthesiologists, says that doctors must gather as much of the patients' medical history as possible, including medication history. Some say this step may be getting skipped at the clinics. "Some centers might be pushing the envelope a bit," Federico says.

Roundtable Resources
Managing the outpatient shift

Moreover, some worry that ambulatory surgery centers are performing tasking like administering anesthesia or intubation without the required expertise. "They are trying to do more, and they are trying to do it at lower costs," Federico says (Rice, Modern Healthcare, 9/13 [subscription required];
"Newshour," PBS, 9/12). 

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