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 that more and more patients are choosing surgery centers. But what about the safety of surgery centers? Should you have surgery in a surgery center? The answer – maybe not.
When did surgery centers originate?
The first 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’s the record on safety of surgery centers?
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. State regulations vary; 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 there is no rule that stops a doctor forced to resign from a hospital for misconduct from opening a nearby surgery center.
Surgery centers struggle to handle emergencies.
Surgery centers have less lifesaving equipment and staff than hospitals. These centers aren’t always prepared and sometimes struggle in a crisis, according to a review of Medicare records and more than 70 lawsuits. Health inspectors, working on behalf of Medicare, found 230 lapses in lifesaving equipment or training regulations at surgery centers since 2015. When problems arise, they often must call 911.
Surgery center doctors have limited experience with emergencies.
Doctors who work in emergency rooms treat patients with a wide range of conditions, including victims of gunshots and car accidents, and patients suffering from heart attacks and strokes. ER doctors and nurses are skilled at saving lives in emergencies. In contrast, doctors in surgery centers specialize in the procedures they commonly perform; they do not have a lot of experience saving lives in emergencies.
These centers frequently call 911.
If something goes wrong, they often must call 911, which can significantly delay treatment. Collectively, surgery centers call 911 thousands of times every year when patients have 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.
An 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 is an eye opening look at the safety of surgery centers.
How did they conduct their investigation?
This is the most extensive review of surgery center records to date. They 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.
What did the investigation find?
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.
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 can add up for operations that 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 close, it can be as much as 20-30 minutes between the time 911 is called and arrival at the 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 were fully recovered.
- 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 problems.
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, for the first time, they gathered 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. Although survey results from any particular facility will likely not be available until September 2020, they released the following findings based on aggregate data:
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).
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 to 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. 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 physician’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.
It’s not all doom and gloom.
Most operations performed in surgery centers go smoothly. All surgeries and procedures carry risks, no matter what type of facility the patient chooses. And some centers have state-of-the-art equipment and highly trained staff that are better prepared to handle emergencies.
Things to consider 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; and there is not one specified organization responsible for inspecting the centers.
Is the center 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
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?
- 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.
One last thought about the safety of surgery centers…
Keep in mind that patients with underlying health conditions may have an increased likelihood of surgery-related issues. In this case, it’s probably best to schedule all procedures in hospitals and eliminate any concerns related to the safety of surgery centers.
For more information on reducing your risk of surgical problems, read these blog 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
- What Kinds of Things Can Go Wrong During Surgery?