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[Aether2000]

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[aneftp]

The legal team I have discussed ASC with all say this

1. As long as standard equipment is available at the ASC (video scopes, fiber optic, mh carts) for standard outpatient procedure

Than ASC are legally not held liable

That’s from attorney speak

Saying all this the asa and surgeons are very vague to set real standards such as bmi for stand a lone ASC. For one reason: money

It is up to individual medical directors to setup guidelines for the centers

1. Bmi is huge problem. You center needs to set a bmi limit for procedures and stick to it (our bmi is hard bmi 45 cut off)
2. Patients with mental health disorders like Down syndrome or combative disorder, need to set guidelines whether they are appropriate
3. Pediatrics patients. Again set some standard what is age cutoff

 

[Aether2000]

The legal team I have discussed ASC with all say this

1. As long as standard equipment is available at the ASC (video scopes, fiber optic, mh carts) for standard outpatient procedure

Than ASC are legally not held liable

That’s from attorney speak

Saying all this the asa and surgeons are very vague to set real standards such as bmi for stand a lone ASC. For one reason: money

It is up to individual medical directors to setup guidelines for the centers

1. Bmi is huge problem. You center needs to set a bmi limit for procedures and stick to it (our bmi is hard bmi 45 cut off)
2. Patients with mental health disorders like Down syndrome or combative disorder, need to set guidelines whether they are appropriate
3. Pediatrics patients. Again set some standard what is age cutoff

Unfortunately, locums have little input as to standards. One ASC has had 5 anesthesia groups over the past 4 years. Locums are neither investors nor medical directors, and are just passing through a number of surgery centers that largely establish increasingly flexible standards based on surgeons desire to do all cases in surgery centers.

 

[aneftp]

Unfortunately, locums have little input as to standards. One ASC has had 5 anesthesia groups over the past 4 years. Locums are neither investors nor medical directors, and are just passing through a number of surgery centers that largely establish increasingly flexible standards based on surgeons desire to do all cases in surgery centers.

U have input!

You leave as locums if u aren’t happy.

 

[MirrorTodd]

Biggest question I have is how the hell does anyone get through 40 GI procedures in a day if one is actually "pre-oping" (spelling?) correctly and not just shuffling people through?

 

[aneftp]

Biggest question I have is how the hell does anyone get through 40 GI procedures in a day if one is actually "pre-oping" (spelling?) correctly and not just shuffling people through?

I have covered 4 rooms
1 room peds ent tonsils ear tubes (7-10)
1 room eyeballs (30)
2 rooms gi (40-60 a day)

ASC ran 6a-7pm many days.

Probably the crappest ASC i ever covered in late 2016-2017

I did it because the market sucked back than

Preop all those patients on an iPad as well

A lot of trust in the crna. Had to call ambulance a few times to transport to hospital.

Probably worst ASC I have ever covered and thus I rarely cover those type of ASC again.

Most gi preop i saw one day by myself was 68 in that center.

The gi doc ran two shifts. 6a-12p. And second wave of of gi docs came 1230-6pm.

 

[NICMAN]

That is kinda what you signed up for as a Locums. You are a hired gun liability sponge. There is a reason people don’t want to work those places and left (especially if it is a day doc ASC job).

 

[Howard888]

Adapt. Payers will drive patients to ascs for lower costs and it’s one of the few ways surgeons can make more money these days.

Covid showed that 85 year old total joints could be done in acs and cardiac data also supports the move to ascs.

Just one example but we’ve been doing bmis of 55 for shoulder scopes in ASCs for a few years now. We just schedule them first case. To be fair they don’t have terrible hearts or lungs and younger but we’ve realized that bmi is only one criteria. The data often doesn’t support moving these cases.

Adapt or don’t work there. There are obviously many places to work. Let supply demand take its course. Enough demand and too many anesthesiologists like you and the problem will take care of itself.

 

[UscGhost]

Gotta wear your big boy pants when you go to an ASC

 

[nimbus]

Adapt. Payers will drive patients to ascs for lower costs and it’s one of the few ways surgeons can make more money these days.

Covid showed that 85 year old total joints could be done in acs and cardiac data also supports the move to ascs.

Just one example but we’ve been doing bmis of 55 for shoulder scopes in ASCs for a few years now. We just schedule them first case. To be fair they don’t have terrible hearts or lungs and younger but we’ve realized that bmi is only one criteria. The data often doesn’t support moving these cases.

Adapt or don’t work there. There are obviously many places to work. Let supply demand take its course. Enough demand and too many anesthesiologists like you and the problem will take care of itself.

Guess I’m not desperate enough to adapt. I’m sure you can get away with it most of the time but I’m not doing any 55 BMIs at a freestanding surgicenter. If I had a loved one who was 55 bmi, no way I’d let them have a procedure at a surgicenter. Seems like in some areas of the country, we have lost control of our own specialty or sold control in exchange for money.

 

[T-burglar]

This is why I hide in high volume heart and vascular centers. I’ve worked in community hospitals taking care of extremely ill patients and had no access to the kind of drugs or equipment most people leaving training would consider necessary for safety .

And I hated it.

 

[UscGhost]

This is why I hide in high volume heart and vascular centers. I’ve worked in community hospitals taking care of extremely ill patients and had no access to the kind of drugs or equipment most people leaving training would consider necessary for safety .

And I hated it.

Hospitals should have everything, as they take care of the stuff that ASCs won't.

ASCs just need the basics

 

[ucladoc2b]

Adapt. Payers will drive patients to ascs for lower costs and it’s one of the few ways surgeons can make more money these days.

Covid showed that 85 year old total joints could be done in acs and cardiac data also supports the move to ascs.

Just one example but we’ve been doing bmis of 55 for shoulder scopes in ASCs for a few years now. We just schedule them first case. To be fair they don’t have terrible hearts or lungs and younger but we’ve realized that bmi is only one criteria. The data often doesn’t support moving these cases.

Adapt or don’t work there. There are obviously many places to work. Let supply demand take its course. Enough demand and too many anesthesiologists like you and the problem will take care of itself.

Those two examples sound like bad ideas.

 

[cchoukal]

The OPs situation sounds just terrible, and I can’t imagine continuing to work in a place where medication’s and supplies are available so tenuously. our group staffs a couple of surgery centers and a couple of Plastics offices, and even there, the quality of supplies and equipment is good. I work locum at an outside surgery center, and they are certainly receptive to locum’s physicians opinions about safety and supplies, but to be honest, they don’t really need to up their game. Regarding patient selection criteria, I am with Aneftp; somewhere there has to be a written piece of paper that says what the criteria are, and somebody needs to stand up for themselves and enforce it. It may be interpersonally difficult to say no, but it’s not like they can force you to do the case.

 

[TheLoneWolf]

The OPs situation sounds just terrible, and I can’t imagine continuing to work in a place where medication’s and supplies are available so tenuously. our group staffs a couple of surgery centers and a couple of Plastics offices, and even there, the quality of supplies and equipment is good. I work locum at an outside surgery center, and they are certainly receptive to locum’s physicians opinions about safety and supplies, but to be honest, they don’t really need to up their game. Regarding patient selection criteria, I am with Aneftp; somewhere there has to be a written piece of paper that says what the criteria are, and somebody needs to stand up for themselves and enforce it. It may be interpersonally difficult to say no, but it’s not like they can force you to do the case.

I worked at one of those. Published exclusion criteria routinely ignored, making for very difficult situations. BMI 58 for elective shoulder replacement, 90 year old for total shoulder replacement with a recent failed stress test, nonfasted morbidly obese for elective TKA. Pulmonary HTN for a total shoulder, 20+ allergy morbidly obese for an elextive joint? Oh man I don't miss those encounters.

No, the orthos won't see your concerns as valid. They will run to admin and scream murder.

Told them I won't do an unfasted mac spinal for a morbidly obese TKA, they cussed me out and tried with 2 other anesthesiologists. Both said no. They kept shopping it until they found someone willing to do it under those conditions. Orthos felt vindicated when nothing untoward happened.

Patient selection criteria is cool, but is it enforced?

 

[UscGhost]

I worked at one of those. Published exclusion criteria routinely ignored, making for very difficult situations. BMI 58 for elective shoulder replacement, 90 year old for total shoulder replacement with a recent failed stress test, nonfasted morbidly obese for elective TKA. Pulmonary HTN for a total shoulder, 20+ allergy morbidly obese for an elextive joint? Oh man I don't miss those encounters.

No, the orthos won't see your concerns as valid. They will run to admin and scream murder.

Told them I won't do an unfasted mac spinal for a morbidly obese TKA, they cussed me out and tried with 2 other anesthesiologists. Both said no. They kept shopping it until they found someone willing to do it under those conditions. Orthos felt vindicated when nothing untoward happened.

Patient selection criteria is cool, but is it enforced?

Sounds like a bad anesthesia culture.

 

[<(^_^)>]

I try to emphasize it’s not about whether things will go sideways, it’s about how screwed you will be legally if things go sideways. That seems to make them care a bit more for whatever reason.

 

[TheLoneWolf]

I try to emphasize it’s not about whether things will go sideways, it’s about how screwed you will be legally if things go sideways. That seems to make them care a bit more for whatever reason.

*when*, not if

 

[pgg]

Told them I won't do an unfasted mac spinal for a morbidly obese TKA, they cussed me out and tried with 2 other anesthesiologists. Both said no. They kept shopping it until they found someone willing to do it under those conditions. Orthos felt vindicated when nothing untoward happened.

I hate it when anesthesiologists do that to each other.

The group should work on educating or getting rid of the collaborateur. That shouldn't be tolerated.

If a partner cancels a case, it's canceled. If surgeons are dumb and unprofessional enough to go shopping, partners should (1) not undermine their partners, and (2) aggressively tell surgeons not to play that game.

 

[Arch Guillotti]

I hate it when anesthesiologists do that to each other.

The group should work on educating or getting rid of the collaborateur. That shouldn't be tolerated.

If a partner cancels a case, it's canceled. If surgeons are dumb and unprofessional enough to go shopping, partners should (1) not undermine their partners, and (2) aggressively tell surgeons not to play that game.

Yeah that guy is a scumbag.

 

[castafari]

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?

Worked at 5 different surg centers and the last one was fairly out of control. Was one of the reasons I switched jobs. Asa 4s daily. Surgeon doesn’t have hospital privileges and schedules every case at surg center. Push back from ortho who wants that facility fee on the bmi 48 difficult airway that I cancelled. Some sketchy stuff going on. Filthy guy (homeless?) for acdf and the lawyer is driving him home late at night two counties away. What is going on here? Oh, and the video scope is glidescope rip off that fogs up and can make a difficult airway damn near impossible.

 

[UscGhost]

I hate it when anesthesiologists do that to each other.

The group should work on educating or getting rid of the collaborateur. That shouldn't be tolerated.

If a partner cancels a case, it's canceled. If surgeons are dumb and unprofessional enough to go shopping, partners should (1) not undermine their partners, and (2) aggressively tell surgeons not to play that game.

Depends a bit

Some are notorious for cancelling cases for nonsense reasons. K 5.6 in a dialysis patient...wants cardiac clearance for a hip fx just because patient is old..high BMI in an ASC..and recently with the GLP1 because they are 6 days out and not 7

Especially if it's an addon, late afternoon case, etc.

 

[ucladoc2b]

Depends a bit

Some are notorious for cancelling cases for nonsense reasons. K 5.6 in a dialysis patient...wants cardiac clearance for a hip fx just because patient is old..high BMI in an ASC..and recently with the GLP1 because they are 6 days out and not 7

Especially if it's an addon, late afternoon case, etc.

How high of a BMI?

At ours, we go to 45. Any higher in an ASC seems risky.

 

[Iso4ane]

Depends a bit

Some are notorious for cancelling cases for nonsense reasons. K 5.6 in a dialysis patient...wants cardiac clearance for a hip fx just because patient is old..high BMI in an ASC..and recently with the GLP1 because they are 6 days out and not 7

Especially if it's an addon, late afternoon case, etc.

Is that one patient or three?

 

[pgg]

Some are notorious for cancelling cases

That's a problem with your group that should be addressed internally. It's not a problem to be solved by surgeons shopping around.

I suppose it gets trickier if you're employees of the hospital or an AMC, and how well the place functions is not your problem. And it's not your partner, but just some guy who happens to work at the same place you do.

 

[AppTrail]

Depends a bit

Some are notorious for cancelling cases for nonsense reasons. K 5.6 in a dialysis patient...wants cardiac clearance for a hip fx just because patient is old..high BMI in an ASC..and recently with the GLP1 because they are 6 days out and not 7

Especially if it's an addon, late afternoon case, etc.

Yeah this gets annoying...examples:
- Hip fx gets posted for 5pm. My partner decides at 4:30 that they need cards clearance. Could have easily done a chart review and requested cards clearance at 8am instead of waiting til the hour before. Looks bad on us
-Pt comes in for MAC foot case. K is 2.9. Same partner cancels case. Pt comes in a week later, K is still 2.9. I order IV potassium and move pt to later in the day so we can replete and recheck K.

 

[Norepi]

I have seen it too, OP. The constant pushing of boundaries as shrinking reimbursements force surgeons to try to up their numbers at sites of service where they have more horses in the race. What does this mean? Earlier starts, later finishes, pushing of boundaries of medicolegal appropriateness.

Surgeon doesn't have privileges at hospital but has privileges at surgery center, then posts a case with time sensitivity (ortho trauma, hand cases), now what? It becomes a political minefield arguing with administrators and surgeons that they may very well have to relinquish care of a patient completely to another system and surgeon because of the swiss cheese that led to these poorly optimized patients landing in the surgery center. What's more, some of these surgeons want to push 23 or 24+ hr Observation for some of these patients in surgical centers, relying on a revolving door of fly by night nursing staff.

Same day, 2 hour discharge gastric sleeves, BMI 40+, ACDFs, multi level fusions, obese patients, "just this one time" CKD patients, vasculopaths getting diagnostic and therapeutic angiographies, heart caths, ICD and pacer procedures in surgical centers. I only see this getting worse as the surgeons don't want to give up the sweet candy they had before. Don't even get me started on the team of ambulance chasing personal injury mafiosos that cart in their captive, clueless patients in for a round of money extraction-go-round.

I'm not sure what the answer is aside from WRITING some hard no guidelines - otherwise the purpose of using locums becomes a feature, not a bug. If you have enough anesthesiologists that rotate just infrequently enough to be just clueless enough to feel pressured to proceed because, surely the system has figured it out before them, well you can continue to squeeze the rag.

Same austere conditions - no fiber scope, no infusion pumps, ancient vents. Occasional pipeline failure. No wall room air, shoddy nurses, shoddy surgeons, old equipment that nobody is qualified to investigate or vigorous enough to report. No anesthesia techs, no central lines (do we do this anterior fusion or multi level fusion in this building with a bag of reds we called in the night before and no blood bank? By the way there is no ultrasound machine or central line kits so have fun and don't say no!)

 

[NumTacos]

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?

Jesus, are you working in Afghanistan?

 

[Aether2000]

Jesus, are you working in Afghanistan?

Florida. Not much different at times.

 

[HemeOncHopeful19]

Florida.

 

[2Fast2Des]

As someone who is looking to do Locums work, is this typical? The ASCs I go to are not like this in my full time place so that sounds super sketch if the rest of the places are like this

 

[Aether2000]

As someone who is looking to do Locums work, is this typical? The ASCs I go to are not like this in my full time place so that sounds super sketch if the rest of the places are like this

The issues I list are not all within one ASC. Over the past 7 years, I have been a locums in at least 20 ASCs, but the past 3 years in particular has seen an definite increase in patient ASA status, class 3 obesity, holes in equipment availability, surgery centers cutting corners or engaging in overtly dangerous practices, and surgeon-owners that are performing risky procedures (some of which they never did previously) in surgery centers.

 

[Howard888]

The issues I list are not all within one ASC. Over the past 7 years, I have been a locums in at least 20 ASCs, but the past 3 years in particular has seen an definite increase in patient ASA status, class 3 obesity, holes in equipment availability, surgery centers cutting corners or engaging in overtly dangerous practices, and surgeon-owners that are performing risky procedures (some of which they never did previously) in surgery centers.

Again get with the times. This is where surgeries are moving too. Payers are incentivizing ascs because the cost of care is much less in ASCs than hospitals. This is where surgeries are moving. Now…improper equipment is a big problem but the rest-

1. Total joints and spines have increased exponentially in ASCs. Spines even more so in ASCs with 23 hour observation. We did over 1000 total joints in 2 ASCs last year. Zero reservations about doing them in ASCs. It’s only going up this year with govt total shoulders approved. Did 2 80 year old total shoulders last week. Did great. We do 2 level lumbar and cervical spines. Likely going to do 3 levels in healthier patients. No issues

2. We do same day hysterectomies. I’ve heard of ascs in midwest now doing robotic prostates and other urology procedures.

3. Read beckers sometime. Cardiac and vascular ascs are the largest area of growth forecast by industry leaders and growing rapidly. Most of these cases are done with just conscious sedation and don’t involve us but we do some peritoneal dialysis placement and would do fistulas if asked at one of our centers

4. BMI-our cutoff is 55 but anyone over 50 gets reviewed. Why? Because looking at hospital data all those bmi 53 knee scopes, foot or hand cases, even shoulders in younger patients do fine and never spend the night. Zero regrets doing these in ASCs. Just do earlier in day,

Again. This is where surgeries are moving. Technology has made surgery much safer-robotics, equipment, minimally invasive techniques. Do bad things still happen? Of course. But I can tell you our transfer rates are less than national average and in reviewing transfers the last few years it was never a sicker, bigger patient or a bigger surgery. It was typically healthier patients in smaller surgeries where unexpected things happen

Payers will only drive more cases to ascs. You don’t have to work there of course but this is where the cases are going

 

[Aether2000]

Again get with the times. This is where surgeries are moving too. Payers are incentivizing ascs because the cost of care is much less in ASCs than hospitals. This is where surgeries are moving. Now…improper equipment is a big problem but the rest-

1. Total joints and spines have increased exponentially in ASCs. Spines even more so in ASCs with 23 hour observation. We did over 1000 total joints in 2 ASCs last year. Zero reservations about doing them in ASCs. It’s only going up this year with govt total shoulders approved. Did 2 80 year old total shoulders last week. Did great. We do 2 level lumbar and cervical spines. Likely going to do 3 levels in healthier patients. No issues

2. We do same day hysterectomies. I’ve heard of ascs in midwest now doing robotic prostates and other urology procedures.

3. Read beckers sometime. Cardiac and vascular ascs are the largest area of growth forecast by industry leaders and growing rapidly. Most of these cases are done with just conscious sedation and don’t involve us but we do some peritoneal dialysis placement and would do fistulas if asked at one of our centers

4. BMI-our cutoff is 55 but anyone over 50 gets reviewed. Why? Because looking at hospital data all those bmi 53 knee scopes, foot or hand cases, even shoulders in younger patients do fine and never spend the night. Zero regrets doing these in ASCs. Just do earlier in day,

Again. This is where surgeries are moving. Technology has made surgery much safer-robotics, equipment, minimally invasive techniques. Do bad things still happen? Of course. But I can tell you our transfer rates are less than national average and in reviewing transfers the last few years it was never a sicker, bigger patient or a bigger surgery. It was typically healthier patients in smaller surgeries where unexpected things happen

Payers will only drive more cases to ascs. You don’t have to work there of course but this is where the cases are going

Yes, you can roll the dice how ever many times you feel lucky, but eventually it will bite you in the ass. Surgery centers are simply not as safe as hospitals when things go wrong. Anesthesia itself is very safe- most of the time. We are doing 3 and 4 level ACDFs in surgery centers with patients staying until 9 pm at night along with the anesthesiologist due to the surgeon's obligatory 6 hour post op stay requirement and the center's mandatory anesthesiology presence prior to patient discharge.