Since 1982, Medicare has covered surgical procedures provided in freestanding or hospital-based ambulatory surgery centers (ASCs). In 1999, the California legislature increased the regulatory requirements applicable to all outpatient surgery settings in which moderate sedation or higher levels of anesthesia are provided to their patients.¹

ASCs are separate and freestanding from acute care facilities. There has been a substantial increase in the number of procedures performed in ASCs over the last two decades. It is estimated that over 63 percent of all outpatient surgery is now conducted in these settings.² The most common procedures performed are cataract removal and lens replacement, endoscopies, mastectomies, orthopedic and urology procedures, hernia repairs, and plastic surgery procedures.³ Pressures to reduce costs, physician dissatisfaction with hospital-run operating rooms, and convenience to patients helped fuel the increase in the number of ASCs.

When analyzing patient safety and risk management data, it is commonly not the procedure that causes problems, but the complication from the procedure. The human condition known as “compliance drift” comes into play when more medically complex patients are treated in an ASC. Compliance drift is the belief that it’s okay to perform more procedures on more complex patients in an ASC because adverse outcomes rarely happen.

Lee A. Fleisher, MD, et al., developed an outpatient surgery admission index that provides an evidence-based guide used in assisting the clinician to identify patients at higher risk of immediate hospitalization. The index uses the patient’s variables of age, operating time, cardiac diagnoses, peripheral vascular disease, cerebrovascular disease, malignancy, seropositive findings for human immunodeficiency virus, and whether regional or general anesthesia will be used.⁴ Another analysis found that the strongest predictor of complications requiring hospital admission as the result of surgery performed in an ASC was hospitalization within the previous six months.⁵

The Case
A 65-year-old male had a laparoscopic ventral hernia (recurrent) repair done by the surgeon at a freestanding ambulatory surgery center. This patient had several previous hernia repairs and was obese (over 300 pounds) with a history of hypertension.

He was discharged the day of surgery despite having an increased heart rate, temperature, no bowel sounds, and the need for supplemental oxygen to maintain his oxygen saturation above 92 percent.

Twenty-four hours after discharge, the patient’s wife called the surgeon’s office to report that her husband had a fever and abdominal pain but that he was refusing to go to the surgeon’s office. The surgeon called in a prescription for antibiotics. The following day, the patient was seen and the surgeon diagnosed cellulitis of the abdominal incision area. The wife called the surgeon’s office twice in the following days to voice concern over her husband’s recovery.

Eight days post-op, the patient was admitted to the hospital with continual complaints of abdominal pain. A CT scan of the abdomen showed large gas fluid collection. A CT-guided drain was placed. The surgeon planned to take the patient back to the operating room, but before they could return to the OR, the patient coughed and the abdominal incision opened, draining brown and foul-smelling fluid. The surgeon found peritonitis with involvement of the mesh used in the repair surgery and perforation in the distal ileum, secondary to a tear from one of the tacks used to attach the mesh.

The patient had a problematic postoperative course with many complications, including renal failure, respiratory failure requiring mechanical ventilation and tracheostomy, upper GI bleeding, septic shock, stroke, seizures, and encephalopathy. He required an additional laparotomy (performed by a different surgeon per request of the family) and remained hospitalized for an extended period prior to being admitted to a rehabilitation hospital.

Using the criteria previously described, this patient may have been better served by having his surgery in a hospital. The physician should have used the patient’s clinical criteria—his past surgical history, obesity, and hypertension—in choosing the facility.

Although the original surgeon had extensive laparoscopic surgical experience, he did not hold credentials or privileges for this particular laparoscopic procedure, nor was there a second physician with appropriate privileges and credentials in the operating room. An administrator conceded during pretrial discovery that the privileges list was not properly checked by the nursing staff prior to the surgery. As hospitals have extensive experience with credentialing and privileging, this particular error most likely would not have been an issue.

The Commentary
A review of patient safety and risk management issues from ASC closed claims reveals that certain precautions may lessen the likelihood of adverse outcomes. This case illustrates some of these factors. The following issues are frequently cited in ASC cases:

Patient Assessment

• Failure to establish a differential diagnosis. The surgeon diagnosed cellulitis of the abdominal incision area as the cause for pain without considering other diagnoses, such as possible bowel perforation.
• Failure to rule out an abnormal finding. When the patient continued to complain of pain, there were no further studies done.
• Failure to respond to patient concerns. Both the wife and patient repeatedly voiced concerns that the surgeon did not follow up, possibly contributing to the poor outcome.

Selection and Management of Therapy

• Surgical/invasive procedures. Considering the patient’s past history of abdominal surgeries and the likelihood of adhesions, performing the surgery in an ASC was not considered to be the most appropriate location for the situation, and it allegedly contributed to the poor outcome.
• Medication inappropriate for medical condition. The surgeon prescribed an oral antibiotic without adequately evaluating the patient.

Communication Between the Patient/Family and Provider

• Poor patient rapport. A poor relationship between the patient and provider may have contributed to the patient’s inclination to file suit.
• Inadequate consent for surgical procedures. The patient was not informed of the surgeon’s lack of experience in the procedure during the informed-consent process.

Patient Factors

• Patient factors. The possibility of adhesions developing and the obesity of the patient contributed to the poor outcome.

Patient Safety Tips

• Practice in an ASC that has been accredited, or encourage the ASC administration to seek accreditation.
• Develop criteria for the length of surgeries and types of patients to be treated in an ASC.
• Do not “drift” regardless of personal experience. Assess the patient using established clinical criteria when determining his or her suitability for a procedure in the ASC.
• Develop a good rapport with the patient and family, and use established communication techniques. One suggested technique is “Ask Me 3.” For an overview of this technique, read our article “Rx for Patient Safety: Ask Me 3” at www.thedoctors.com/askme3.
• Develop a plan to deal with emergencies or crises, such as ACLS certification for staff and physicians.
• Ensure all equipment is maintained.
• Be aware that bleeding is the most common complication and reason for subsequent hospital admission. Make sure patients receive specific instructions outlining what to do when bleeding occurs and how to evaluate the amount of bleeding.⁶
• Provide patients and family with comprehensive discharge instructions that include a list of prescribed medications, diet and activity restrictions, and side effects related to surgery and anesthesia with an emphasis on symptoms and complications associated with the specific procedure. Defining the time parameters related to surgical complications may help to ensure that the patient understands when to contact the physician.⁷

We are here to help if you have questions or need assistance. Please contact us at
(800) 421-2368, extension 1243, or at patientsafety@thedoctors.com.