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Based on 7 years of doing locums in 20+ surgery centers, I have observations (not complaints) about the potential safety issues in surgery centers compared to hospitals. Although the performance of procedures in surgery centers has a good safety profile, with expansion of surgeries to include cardiac caths and interventional cardiac procedures, 4 level cervical discectomies, multisystem disease, and BMI patients >45, the risks appear to becoming more significant, both surgically and from the anesthetic standpoint.
Whereas many surgeons would not consider scheduling advanced surgical procedures or sicker patients in surgery centers, some (especially those with PAs that do the entire preop evaluation and schedule them at ASCs at the direction of the surgeon who may have never met the patient nor reviewed the chart until 10 minutes prior to the performance of the operation) will routinely schedule everything at the surgery center then will see what sticks. Others are insistent on performing the surgery at "their" center regardless of the risk, and will call the system medical director to override anesthesiologists that get in their way, or will replace the entire anesthesia group if there is any pushback for patient safety. Furthermore, preop info about patients is sketchy at best since ASCs generally neither have their own EMR nor can link to a hospital EMR. Patients may show up with a litany of issues they only half remember.
Surgical equipment may not be present the day of surgery and therefore the surgeon may "jerry-rig" a surgery, using equipment and implants in ways they are neither designed nor approved to be used. When the sterilization system for equipment is down, the sterilized trays may be brought from another surgery center in the back of a car, and contaminated trays have been used. One surgery performed an entire ACDF without surgical prep. Standard anesthesia equipment or medications may be completely missing, such as nerve stimulators, videolaryngoscopy, pressors, calcium channel blockers, sugammadex in centers that routinely use NMB by surgeon demand until the end of surgery (No Twitches!) and have rapid turnaround, temperature monitoring equipment or strips, and may frequently run out of oxygen or one medication after another. One admin refused to allow ephedrine at her center because it was "too expensive". At times, sevoflurane in the vaporizer must be used with very low flows given the shipment of sevo did not arrive and there are no other vaporizers or agents available. Temperature control of the centers may be non-existent with 85 degree F surgeries being performed with the walls sweating or 60 degree ORs when temperature control is being handled 1000 miles away. Water traps may be taped over and over to keep them from falling apart when it takes 3 months to acquire replacements. OR machines may be as old as Narcomed 2b, and in one OR I saw an Ohio machine. One center has an oxygen leak inside the walls, and this has existed for 6 months without repair. Another center refuses to have backup O2 tanks on the anesthesia machine, with the admin stating they are in a storage room just down the hall. Air may not be available in surgery centers performing procedures on the face and in the oropharynx. Another had mold growing inside and outside the walls and on the floors after flooding occurred. Startup centers are particularly problematic, and when anesthesiologists are assigned the night before, cannot check out the center that may have one laryngoscope blade for the enter center, and return tubing to the bag having damage preventing pressurization of the circuit. And if these sick patients get into trouble during surgery needing blood (sorry, ASCs do not carry blood nor can they get blood before the patient bleeds out), A-line, FFP, platelets, CVLs or rapid infusion systems, they are out of luck. Some surgery centers do not carry microdrip infusion tubing nor have more than one syringe pump for the entire center. Some have neither vein finders nor ultrasounds to assist with IV access in chemo patients and the dehydrated.
Running a code in a surgery center is particularly fun when using ancient defibrillators that may not have a functioning battery, inability to obtain ABGs, electrolytes, or H&H using skeleton staff and surgeons that are unfamiliar with causes or treatment of EMD/Cardiac arrest.
Surgeons also push the boundaries of what procedures they perform at the surgery center. Since they are on the board of directors, they may approve procedures for themselves for which they have no training at all, and use the rep to guide them through the procedure. Others simply engage in fraud, performing an ACDF, RF neurotomy and stem cell injection all at the same level on cases sent to them by lawyers to maximize the cost and drama of how bad the injury was since it required all these procedures. Some surgeons will bring young pediatric patients to surgery centers that have had no peds patients in a decade, with the staff lacking the experience to be handling these patients intraop or post op.
Given that a surgery center may have 10 different anesthesiologists/CRNAs over 5 days, there may be no consistency in enforcement of surgery center policies nor in patient selection.
Have others had similar observations making them question surgery center safety?
Whereas many surgeons would not consider scheduling advanced surgical procedures or sicker patients in surgery centers, some (especially those with PAs that do the entire preop evaluation and schedule them at ASCs at the direction of the surgeon who may have never met the patient nor reviewed the chart until 10 minutes prior to the performance of the operation) will routinely schedule everything at the surgery center then will see what sticks. Others are insistent on performing the surgery at "their" center regardless of the risk, and will call the system medical director to override anesthesiologists that get in their way, or will replace the entire anesthesia group if there is any pushback for patient safety. Furthermore, preop info about patients is sketchy at best since ASCs generally neither have their own EMR nor can link to a hospital EMR. Patients may show up with a litany of issues they only half remember.
Surgical equipment may not be present the day of surgery and therefore the surgeon may "jerry-rig" a surgery, using equipment and implants in ways they are neither designed nor approved to be used. When the sterilization system for equipment is down, the sterilized trays may be brought from another surgery center in the back of a car, and contaminated trays have been used. One surgery performed an entire ACDF without surgical prep. Standard anesthesia equipment or medications may be completely missing, such as nerve stimulators, videolaryngoscopy, pressors, calcium channel blockers, sugammadex in centers that routinely use NMB by surgeon demand until the end of surgery (No Twitches!) and have rapid turnaround, temperature monitoring equipment or strips, and may frequently run out of oxygen or one medication after another. One admin refused to allow ephedrine at her center because it was "too expensive". At times, sevoflurane in the vaporizer must be used with very low flows given the shipment of sevo did not arrive and there are no other vaporizers or agents available. Temperature control of the centers may be non-existent with 85 degree F surgeries being performed with the walls sweating or 60 degree ORs when temperature control is being handled 1000 miles away. Water traps may be taped over and over to keep them from falling apart when it takes 3 months to acquire replacements. OR machines may be as old as Narcomed 2b, and in one OR I saw an Ohio machine. One center has an oxygen leak inside the walls, and this has existed for 6 months without repair. Another center refuses to have backup O2 tanks on the anesthesia machine, with the admin stating they are in a storage room just down the hall. Air may not be available in surgery centers performing procedures on the face and in the oropharynx. Another had mold growing inside and outside the walls and on the floors after flooding occurred. Startup centers are particularly problematic, and when anesthesiologists are assigned the night before, cannot check out the center that may have one laryngoscope blade for the enter center, and return tubing to the bag having damage preventing pressurization of the circuit. And if these sick patients get into trouble during surgery needing blood (sorry, ASCs do not carry blood nor can they get blood before the patient bleeds out), A-line, FFP, platelets, CVLs or rapid infusion systems, they are out of luck. Some surgery centers do not carry microdrip infusion tubing nor have more than one syringe pump for the entire center. Some have neither vein finders nor ultrasounds to assist with IV access in chemo patients and the dehydrated.
Running a code in a surgery center is particularly fun when using ancient defibrillators that may not have a functioning battery, inability to obtain ABGs, electrolytes, or H&H using skeleton staff and surgeons that are unfamiliar with causes or treatment of EMD/Cardiac arrest.
Surgeons also push the boundaries of what procedures they perform at the surgery center. Since they are on the board of directors, they may approve procedures for themselves for which they have no training at all, and use the rep to guide them through the procedure. Others simply engage in fraud, performing an ACDF, RF neurotomy and stem cell injection all at the same level on cases sent to them by lawyers to maximize the cost and drama of how bad the injury was since it required all these procedures. Some surgeons will bring young pediatric patients to surgery centers that have had no peds patients in a decade, with the staff lacking the experience to be handling these patients intraop or post op.
Given that a surgery center may have 10 different anesthesiologists/CRNAs over 5 days, there may be no consistency in enforcement of surgery center policies nor in patient selection.
Have others had similar observations making them question surgery center safety?
