By Joy Daughtery Dickinson
Executive Summary
Following the death of Joan Rivers, the national media raised questions about the safety and emergency response capability of freestanding surgery centers.
• Define what types of patients are appropriate for your facility.
• Consider the patient’s American Society of Anesthesiologists score, Mallampati score, and the degree of sedation when deciding whether to have an anesthesiologist present.
• Designate a nurse to monitor patient, and have a crash cart, staff trained about the crash cart, and CO2 monitoring. Have a transfer-of-care agreement with a hospital.
From The New York Times to The Dr. Oz Show, it seems that everyone in the national media became an armchair quarterback in the weeks following the unexpected death of comedian Joan Rivers on Aug. 18. A loud, critical unified voice was aimed at outpatient surgery providers, particularly freestanding facilities.
Rivers died several days after going into cardiac arrest during an undisclosed procedure at Yorkville Endoscopy in New York City. Consider these publicized comments:
The New York Times described Yorkville Endoscopy as a "for-profit center" and said that the management structure of outpatient surgery centers "is often explicitly designed to maximize profits for doctors, who are typically the majority owners."1 The news article said that the management company, Frontier Healthcare, is run by three persons, including an ex-salesman, an ex-investment banker, and a gynecologist. It said that Frontier’s web site refers to their taking advantage of "favorable reimbursement market trends."
An article by Bloomberg News said that outpatient surgery centers are "created by physicians to attract patients and higher revenues from routine procedures and minor surgeries."2
Another article by Bloomberg News said that River’s death was a rare event but that "an aging population could boost the numbers at such outpatient centers in the future."3
On The Dr. Oz Show, Mehmet Oz, MD, vice-chair and professor of surgery at Columbia University, New York City, questioned what would have been handled differently if Rivers’ surgery had been conducted in a hospital.4 One of his physician guests touted the immediate availability of emergency care and emergency personnel in a hospital. Jonathan Aviv, MD, author and ear, nose, and throat physician, suggested that patients ask these questions: Is the facility licensed and accredited in that state? Is the facility affiliated with a hospital? Does the physician have privileges at that hospital? Oz added that patients also should ask about their risk of heart attack, and if they are determined to be at high risk, they should have their surgery in a hospital.
The publicity following River’s death has focused on whether a freestanding center was an appropriate surgery setting, especially considering her age and her admitted history of heart arrhythmia and bulimia. Rivers’ death is under investigation by the New York City Office of Chief Medical Examiner and the New York State Health Department, as well as the facility’s accrediting agency: the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
The attention given to her death, due to her celebrity status, is likely to result in increased scrutiny for you from patients and the media, and potentially regulators and accreditors. For that reason, outpatient surgery managers must ensure they have taken essential steps to provide the best possible patient outcomes. Such preparation will help ensure your program can withstand the sudden attention that comes with the news coverage and/or potential liability resulting from an unexpected outcome. Beyond being compliant with your state and accreditation requirements, leading experts interviewed by Same-Day Surgery emphasize these points:
Spell out for what types of patients your facility will include.
Accreditation agencies typically require statements as to what specific types of patients are appropriate for your facility, says Jane C.K. Fitch, MD, president of the American Society of Anesthesiologists (ASA). "For example, extremes of age aren’t well-suited for outpatient and ambulatory and office-based procedures," Fitch says.
ASA offers guidelines and standards on safe ambulatory anesthesia (http://bit.ly/1mr3U3b) (and safe office-based anesthesia http://bit.ly/1mr40YF). "They should guide anesthesiologists and others in making the best decisions for patient in terms of the correct place to have surgery," Fitch says. "A young, healthy 21-year-old is quite different from someone who’s 81, who might have heart, lung, or kidney disease."
Some surgery centers have criteria that say they won’t perform surgery on children under age 13 or patients who are over a certain body mass index (BMI), says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, patient safety & risk management consultant, The Kicklighter Group in Tamarac, FL. "It carries some inherent risk," Kicklighter says.
Any patient with comorbidities should have clearance from their primary care physician and a specialist to have surgery, she says. "Any patient who has comorbidities should be evaluated first by the surgeon as to the risks and whether the risks would be better dealt with in an acute care setting or ambulatory setting, before they ever schedule it," Kicklighter says. Secondly, a specialist, such as a cardiac specialist for a patient with heart issues, should provide clearance, she says.
Consider a patient’s overall health when making decisions about having an anesthesiologist present.
Chronological age has become less of an issue than a patient’s overall health condition, when looking at the need for anesthesia staff, says Brian Dunkin, MD, FACS, president elect of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The ASA classification system provides a good basis for decision-making, Dunkin says. Consider having an anesthesiologist present for patients who are ASA 3 or higher, he advises.
A patient who has had heart arrhythmia for years that’s well-controlled might not be an indication to have an anesthesiologist present, Dunkin says. However, you would want to make sure the patient has a heart rhythm that is expected, he says.
A potentially difficult airway might be a reason to discuss the case beforehand with an anesthesiologist, he says. A patient who has a Mallampati score, which measures the potential difficulty of an airway, of 3 or 4 typically means an anesthesiologist should be present, he says. "If there’s trouble, the airways are likely to be difficult to get access to," Dunkin says.
Whether an anesthesiologist should be present depends on the degree of sedation required, Fitch says. "Any time you get into the realm of deep sedation or general anesthesia or regional anesthesia, that’s when it becomes critical. You need physician anesthesiology oversight," she says.
The capability of an outpatient surgery provider should be a determining factor in location of a procedure.
Whether a procedure is done in a freestanding or hospital-based outpatient surgery program isn’t so much a matter of location as is the capability of that location, Dunkin says.
"For example, I’ve working in a freestanding endoscopy unit that had anesthesiologist-administered sedation," he said. "They had a full code cart and a person who can intubate. That’s probably not a lot different than in a hospital." He also has worked in office-based surgery programs that didn’t have any of that type of emergency assistance available.
If an elderly patient has a problem during a scope procedure, the problem usually is respiratory, Dunkin says. "You must be prepared in your setting," he emphasizes.
Ensure you have the equipment and staff who are trained to respond to an emergency.
Fitch says, "You can never be too well-educated or too well-trained."
Members of your professional staff, including your physicians, should be certified in advanced life support (ALS), Kicklighter says, and if you have pediatric patients, they should be certified in pediatric ALS (PALS), she says.
Have one nurse designated to monitor the patient and communicate with the physicians during a procedure, Dunkin says. "The physician may be directing sedation, but the person performing [the scope procedure] is not the one to monitor vital signs," he says
Also, ensure you are using CO2 monitoring, not just a pulse oximeter, for moderate or deep sedation, as recommended by the ASA, he says. A patient’s oxygen level, as measured by pulse oximetry, can remain high even though the patient isn’t breathing, "then you fall off a cliff" when the oxygen goes down, Dunkin says.
Have emergency equipment available to manage respiratory or cardiac events during the procedures, he says. "Essentially, have a code cart available and personnel who know how to use things on that code cart," Dunkin says. Also, have medication readily available that can quickly reverse the sedation, he says.
"You need to have availability of emergency personnel that can take [care] to the next level if there’s a problem," Dunkin says.
Have processes set in place for transfer of care, Fitch says. "If there is something that happens, there is seamless transfer to an inpatient facility," she says.
- Hartocollis A and Goodman JD. At Surgery Clinic, Rush to Save Joan Rivers’s Life. The New York Times; Sept. 9, 2014. Accessed at http://nyti.ms/1sV7hN0.
- Gilblom K, Pettypiece S. Surgical center that treated Joan Rivers is part of outpatient push. Bloomberg News. Sept. 6, 2014. Accessed at http://bit.ly/1v0koje.
- Langreth R, Gilblom K. Death of Joan Rivers spotlights risks for elderly at centers. Bloomberg News. Sept. 12, 2014. Accessed at http://buswk.co/1ue764R.
- The Dr. Oz Show. Investigating Joan Rivers’ Final Battle, Pt 1. Accessed at http://bit.ly/1rhx5Vr.
For more information on endoscopy safety, consider the following resources:
The American Society for Gastrointestinal Endoscopy (ASGE) has issued Guidelines for safety in the gastrointestinal endoscopy unit. These guidelines were published in GIE: Gastrointestinal Endoscopy online. To read the guidelines, go to http://bit.ly/1lqFpyu. (Editor’s note: The April 2014 issue of Same-Day Surgery newsletter covers these guidelines and includes 10 safety tips. See "Guidelines address safety in GI endoscopy unit" on p. 43. )
The Society of Gastroenterology Nurses and Associates (SGNA) has a Statement on the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting. To access the SGNA statement, go to http://bit.ly/ZD8HEt.
