How Safe are Surgery Centers?

The thought of surgery, or any invasive procedure, is scary for most people. And hospitals can be intimidating places, with infections and other dangers lurking. Add to that the high costs of hospital procedures and a possible long drive. It’s no wonder more and more patients are choosing surgery centers. However, surgery centers do not have the same resources and equipment as hospitals. Can you trust the safety of surgery centers? Should you have a procedure in a surgery center? It depends.

When did surgery centers originate?

The first surgery center opened in 1970 in Phoenix, by two doctors who didn’t think patients should be hospitalized for minor surgeries. Performing procedures outside of hospitals reduced the cost for patients and insurers, since these centers don’t require the same level of staffing and lifesaving equipment as hospitals.

How common are these centers?

There are over 8,000 surgery centers in the US, outnumbering hospitals.

Who owns and operates these centers?

There are two kinds of surgery centers – ambulatory surgery centers (ASCs) and hospital outpatient surgery departments (HOPDs). As the name implies, hospitals own and operate HOPDs. However, the ownership structure varies for ASCs – most are for-profit entities owned by doctors, with or without management companies. A few are jointly owned by doctors and hospitals.

Why have they become so common?

The federal government has played a role in the expansion of these centers:

• The government has allowed a growing list of procedures to be performed in an outpatient setting, in an effort to cut federal healthcare costs.
• In 1982, Medicare began paying for procedures at these centers, driving an expansion of surgery centers.
• In 1993, Congress encouraged doctors to open surgery centers by exempting these centers from the second Stark Law, which bans doctors from steering patients to other businesses they own.

Other reasons for the increase in surgery centers:

• Doctors who have a financial stake in surgery centers encourage their patients to try this option.
• Hospitals are opening their own off-site surgery centers.
• Insurers are getting involved – UnitedHealth Group bought a chain of surgery centers recently.
• Patients like the convenience and cost savings.

What are the safety issues in surgery centers?

Providing safe care should always be the top concern for doctors, surgery center owners, and the government. Unfortunately, there is much room for improvement.

Regulations and reporting requirements are lax.

A 2018 investigation by Kaiser Health News and USA Today Network revealed that these centers do not face the same scrutiny as hospitals. For starters, regulations vary by state. Alarmingly, 17 states don’t even require surgery centers to report deaths or serious injuries.

And the top surgery center accreditation body has no guideline encouraging centers to report unexpected deaths. This lack of reporting makes it impossible for the federal government, and for potential patients, to learn about dangerous centers.

Even centers that have faced the toughest sanctions by federal regulators can still operate on patients. And importantly, there is no rule that stops a doctor forced to resign from a hospital for misconduct from opening a nearby surgery center.

Anesthesia may be more dangerous in surgery centers.

Is it safe to receive anesthesia in a surgery center?

A 2009 analysis of claims data from the American Society of Anesthesiologists suggests that anesthesia at remote locations* poses a significant risk for patients. In fact, they found that procedures involving anesthesia in remote locations had a significant increase in deaths compared to cases performed in an operating room. Additionally, they found that respiratory damage and inadequate oxygenation were more common in cases performed in remote locations.

*Note that “remote locations” refers to any location that is not a hospital operating room. This includes surgery centers, as well as hospital-based procedure areas, such as centers for cardiac catheterization, interventional radiology, or colonoscopies.

Surgery centers struggle to handle emergencies.

Clearly, surgery centers do not have the same facilities as hospitals, such as labs and ICUs. Additionally, compared to hospitals, surgery centers have less lifesaving equipment and fewer (if any) staff trained to handle emergencies.

Unsurprisingly, surgery center doctors specialize in the procedures they commonly perform but have limited experience saving lives in emergencies. In contrast, ER doctors routinely treat patients with a wide range of conditions including gunshots, car accidents, heart attacks, and strokes. Simply put, ER doctors and nurses have the skills and experience to save lives in emergencies.

But, due to a lack of experience and equipment, surgery centers can struggle to handle problems that can arise during or after procedures.

How big a problem is this? Researchers who reviewed Medicare records and over 70 lawsuits found 230 lapses in lifesaving equipment or training regulations at surgery centers since 2015.

These centers frequently call 911.

If something goes wrong, they often must call 911, which can significantly delay treatment. Every year, surgery centers collectively call 911 thousands of times, for patient complications ranging from minor to fatal.

Unfortunately, there is no official tracking of complications and deaths, so no one knows how many people have died from complications at surgery centers.

Government inspections reveal widespread issues regarding the safety of surgery centers.

The HHS Office of the Inspector General released a report in September 2019 highlighting findings from the most recent inspections of surgery centers.

Unfortunately, inspectors found that 77% of surgery centers had at least one violation, and 25% of them had serious deficiencies. Issues found, and the percent of centers in violation, include:

• 55% were deficient in infection control.
• 37% had deficiencies in pharmaceutical services.
• 33% had issues with environmental conditions.
• 30% fell short on patients’ rights.
• 28% had deficiencies related to admission, assessment and discharge.

A Kaiser Health and USA Today Network investigation finds frightening conditions.

A 2018 investigation by Kaiser Health News and the USA Today Network is reported in an aptly titled article “As Surgery Centers Boom, Patients Are Paying With Their Lives“.

Their research discovered that more than 260 patients have died since 2013 after undergoing “in-and-out” procedures at surgery centers in the US. Dozens of people – some only 2 years old – died after routine procedures such as colonoscopies and tonsillectomies. The article provides an eye-opening look at the safety of surgery centers.

This is the most extensive review of surgery center records to date. The team examined autopsy records, legal filings and more than 12,000 state and Medicare inspection records. They interviewed dozens of doctors, health policy experts and patients throughout the industry.

The investigation found some scary and disturbing facts related to the safety of surgery centers which should make us all think twice before scheduling procedures for ourselves or a family member.

Here are the highlights of their findings:

Increasingly risky surgeries pose dangers for patients.

Surgery centers have steadily expanded their business by taking on increasingly risky surgeries. Even though the dangers of performing risky surgeries outside of a hospital can be great, the financial reward for doctors is significant.

Doctors who own a share of a surgery center not only earn their own fee; they also receive a cut of the facility’s fee. This fee can add up quickly since operations can cost $100,000 or more.

The time to transport a patient to an ER can be significant.

To protect patients, Medicare requires surgery centers to have arrangements with local hospitals to take their patients when emergencies arise. However, in rural areas centers can be 15 or more miles away from the nearest hospital.

Even when the hospital is nearby, it can be up to 20-30 minutes between the time 911 is called and the patient arrives at an ER.

Some centers ignore high risks.

Some surgery centers are accused of ignoring high-risk health problems and treating patients who experts say should be operated on only in hospitals, if at all. The research found that at least 25 people with underlying medical conditions were released from surgery centers and died within minutes or days.

Some centers don’t have ample training or lifesaving equipment.

Some surgery centers put patients’ lives at risk by skimping on training or lifesaving equipment. Other centers send home patients before they fully recovered.

Some examples:

• In some surgery centers staff didn’t have the tools to open a difficult airway or skills to save a patient from bleeding to death.
• The oxygen tanks in a California center were empty.
• One Arkansas center performing procedures on children didn’t have a pediatric tracheotomy set to restore breathing; another lacked pediatric defibrillator pads to restore children’s hearts to a normal rhythm.

The investigation discovered a wide range of safety problems at surgery centers.

The investigation uncovered examples of the kinds of serious problems, including death, patients can face in surgery centers:

• Family members driving patients home from surgery centers were shocked to find their loved ones were on the verge of death, not merely asleep.
• One 60-year-old spinal surgery patient lost more than a quart of blood during the procedure, struggled to breathe after surgery, and died on the way home, according to his family. A spine surgeon acting as expert witness in the family’s lawsuit against the surgery center says if the patient was “observed in a hospital overnight, his death would not have occurred.”
• A 67-year-old woman died after a simple colonoscopy. She stopped breathing, and doctors tried various methods to help her breathe, only with limited success. 33 minutes passed from the moment she stopped breathing until a paramedic inserted a breathing tube. The family took her off life support 2 days later.
• A 58-year-old woman had spinal surgery on 2 discs in her upper spine. These dangerous surgeries involve a risk of suffocation. After her surgery, the only doctor on-site was a digestive health specialist. Four hours after the procedure, she complained to a nurse that the collar felt too tight; and then stated she couldn’t breathe. The nurse called a “code blue”. Instead of removing the staples in her neck that is standard procedure in these situations, the staff repeatedly tried and failed to insert a breathing tube. No one attempted the standard last-ditch remedy to help her breathe – punching a hole in the front or her throat. After calling 911, it took 24 minutes for the patient to arrive at the ER; but it was too late. According to experts, this kind of delicate surgery should never be performed outside of hospitals.

Leapfrog Group investigates the safety of surgery centers.

For 20 years, Leapfrog group has gathered and reported data on hospital’s performance and patient safety. In 2019, they started gathering information on ambulatory surgery centers (ASCs) and for hospital outpatient departments (HOPDs).

Data gathered includes information on the medical, surgical and clinical staff; volume and safety procedures; patient safety practices; and patient experience. As of October 2021, you can find their survey results on some, but not all, surgery centers.

The Leapfrog group released the following findings based on aggregate data:

Training gaps.

There are gaps in the education, training and national certifications of clinicians in ASCs and in HOPDs. Both ASCs and HOPDs showed gaps in ensuring all providers performing surgery or anesthesia were board certified. And, not all facilities had clinicians certified for Pediatric Advanced Life Support (PALS).

Communication gaps.

ASC and HOPD patients may experience gaps in communication before and after procedures. Both types of facilities could improve their proactive contact of patients by phone within 24 hours of discharge.

Additionally, patients would benefit from having the surgical and anesthesia consent forms before they arrive, giving them time to think carefully and ask their doctor questions before a procedure.

Patient safety gaps.

ASCs are not as good as HOPDs in implementing best practices for patient safety. Very few ASCs have an antimicrobial stewardship program in place. Additionally, ASCs are less likely to adopt infection prevention practices such as monitoring for hand hygiene compliance.

All facilities performing same-day surgery should comply with best practices for infection prevention, hand hygiene and medication safety.

What should you do if you need surgery?

Think long and hard before agreeing to a procedure at a surgery center. Consider the surgery center safety issues discussed in this article.

And don’t blindly follow your doctor’s recommendation for a surgery center. Federal law allows surgery center doctors to steer patients to facilities they own, rather than to a full-service hospital. In some cases, doing so could increase the risk to a patient, but double a doctor’s profits.

Keep in mind that several studies have shown that surgery center doctors who are owners perform operations more frequently. Additionally, in lawsuits across the country, patients and families have accused surgery center doctors of taking risks with patients.

Finally, the investigation by Kaiser Health News and the USA Today Network found over 12 cases where the lack of trained staff or emergency equipment appears to have put patients in danger.

Despite the doom and gloom presented here, most procedures performed in surgery centers go smoothly. And some centers have state-of-the-art equipment and highly trained staff who are better prepared to handle emergencies.

And all surgeries and procedures carry risks, no matter what type of facility you choose.

Do you have risk factors that could increase your risk of harm?

Unsurprisingly, some patients face an increased risk of harm at surgery centers and should therefore always have their procedures at hospitals. Before deciding if a surgery center is right for you, consider this list of health conditions that create higher risks of complications and deaths at surgery centers:

• Overweight or obesity.
• Chronic obstructive pulmonary disease.
• History of transient ischemic attacks/stroke.
• Hypertension (high blood pressure).
• Previous cardiac surgical intervention.

Additionally, research shows that patients undergoing longer procedures have increased risk of harm in surgery centers.

Think carefully before choosing a surgery center.

If you really want to use a surgery center, do your homework! It can be hard to learn everything you should know before you decide. Government regulations do not require most surgery centers to report infections or other complications. Plus, there is not one specified organization responsible for inspecting the centers.

Find out if the center is certified and accredited.

• Is it certified by Medicare?
• Has one or more of the following organizations given accreditation to the center?
  • The Joint Commission
  • The Accreditation Association for Ambulatory Health Care
  • The American Association for Accreditation of Ambulatory Surgery Facilities
  • The Healthcare Facilities Accreditation Program

Research safety records.

You can look up quality and safety information for surgery centers using The Leapfrog Group’s website. Search by center name, region, or procedure to find information on several metrics, including:

• Preventing and responding to patient harm.
• Healthcare-associated infections.
• Medication safety.
• Quality of care.

Question your surgeon.

In addition to all the questions you would normally ask your surgeon before scheduling a procedure, I suggest you ask the following questions about the surgery center:

• Am I a good candidate for a procedure at a surgery center? Anything I should worry about? If you have a condition on the above list of conditions that can increase risk of harm, ask your doctor how your condition could impact your experience.
• Is the anesthesiologist board certified?
• What is the plan for emergencies?
• What types of lifesaving equipment does the surgery center have on hand? How do they make sure the equipment is in good working order? How often do inspectors evaluate equipment?
• What kind of training for emergencies does the staff receive? How often?
• What types of doctors and nurses will be physically present in the period between the procedure and discharge?
• Do they use safety checklists to prevent patient harm? Which ones?
• What is the infection rate?
• Where is the nearest hospital? How long would it take an ambulance to get from the center to the ER?
• Have any patients died at the center, or within 48 hours of leaving? What happened?
• How many emergencies, including non-life-threatening ones, has the center had in the last few years?
• What would necessitate a transfer to a hospital during or after the procedure? How often has that happened in the last few years for the procedure I am having? For other procedures at the center?
• Do you (the surgeon) have a financial stake in the center? If your doctor owns the center, or a share of the center, beware! He/she might be recommending the center for his/her own financial gain.

Did you have a problem at a surgery center?

If so, you can file a complaint with your regional Medicare (CMS) office. Find contact information for your region’s CMS office on their website.

Learn more tips related to the safety of surgery centers.

Every surgical procedure carries risk, whether done in a hospital or surgery center. For more information on reducing your risk of surgical problems, read these posts:

• What is the Best Time of Day for Medical Care?
• Recover Faster After Surgery.
• Questions Seniors Should Ask Before Surgery.
• Questions to Ask Before Surgery.
• You Can Improve Your Surgical Outcome.
• How to Recover Faster After Surgery.
• Surgical Dangers – What You Need to Know.