How ASC Facilities Turn Their Smaller Operations Into Safer Operations

An ASC leader and orthopedic surgeons share their success strategies for conducting safe invasive procedures at ASCs.

Ambulatory surgery centers (ASCs) are on the frontline of efforts to shift healthcare outside the hospital walls in several specialties, including endoscopy, ophthalmology, and pain management. And within those efforts, physician leaders are reinforcing the safety advantages of ASCs for invasive procedures, according to an ASC leader, surgeons, and scientific data.

Amid questions and concerns that ASCs could be less safe than hospitals, several physician leaders share successful strategies they use to make their ASCs safer.

"The advantage we have in the ASC environment is that we are smaller. That helps us be closer with our employees, and we communicate with them daily," says Rebecca Craig, RN, CEO of Harmony Surgery Center and Peak Surgical Management in Fort Collins, Colorado.

Asheesh Gupta, MD, MPH, an orthopedic surgeon at Bethesda, Maryland-based Centers for Advanced Orthopaedics, agrees that ASCs have an advantage: "I think it's safer for the patient."

"I can do hip arthroscopy surgery in an hour to an hour and 15 minutes. At the hospital, the exact same procedure takes two to two-and-a-half hours because nobody knows the setup, and they don't have the same staff every day. It's like I'm doing the procedure for the first time every time, and that leads to more complications for the patient because they are under anesthesia longer and have longer traction time," Gupta says.

Research published earlier this year in the Journal of Health Economics found ASCs on average provide higher-quality care than hospital outpatient departments (HOPDs):

• After a procedure, ASC patients are less likely to visit an emergency room or have a hospital inpatient admission than HOPD patients.
   
• ASC patients have fewer ER visits because of adverse events compared to HOPD patients. On the day of surgery, 0.1% of ASC patients visited an ER. From one to seven days after surgery, 0.52% of ASC patients visited an ER. From eight to 30 days after surgery, 1.41% of ASC patients visited an ER.
   
• Data indicates that reduced medical complications is a possible reason why ASC-based procedures result in fewer ER visits than HOPD-based procedures. On the day of surgery, 0.02% of ASC patients visited an ER for a medical complication. From one day to seven days after surgery, 0.07% of ASC patients visited an ER for a medical complication. From eight days to 30 days after surgery, 0.17% of ASC patients visited an ER for a medical complication.
   
• The relatively low number of hospital visits after ASC-based procedures applies to both low-risk and high-risk patients, indicating even high-risk patients can be treated safely in the ASC setting.

5 elements of ASC facility safety
 

Craig, who is the immediate past president of the Ambulatory Surgery Center Association, says there are five primary elements that underpin ASC safety:

1. There are fewer patients with dangerous infections such as MRSA in ASCs, she says.

"If you are having a knee replacement, a gall bladder removal, or a hernia repair, you don't want to be anywhere near the superbugs that a hospital has to deal with. So, that is probably the most significant infection control difference," she says.

2.  Small staff size and procedure specialization fuels care coordination in the ASC setting, Craig says.

"We work very closely with all team members, passing along pertinent patient information at every point of care and hand-off transition.  Whether the ASC is a large multispecialty facility center with 100 employees or a two-procedure room endoscopy ASC with 25 employees, it is a finely orchestrated flow centered on the patient," she says.

3. Well-run ASCs adhere to a wide range of safe surgery checklists, industry guidelines, and regulations, Craig says.

Safety-related best practices for ASCs include guidance from the Association of periOperative Registered Nurses, the Society of Gastroenterology Nurses and Associates, and the American Society of PeriAnesthesia Nurses, she says.

4. ASCs have the potential to retain a high percentage of their perioperative staff, Craig says. "One of the advantages in the surgery center environment is we don't have weekend or holiday shifts. We don't work on call or come back to work for emergency cases in the middle of the night. So, that is a staffing advantage."

5.  Procedure specialization drives efficiency in the ASC setting, she says.

"In the ASC environment, we are nimble, which allows us to quickly address any roadblock in our process that could cause us to be inefficient or could be a potential patient safety issue. We utilize patient satisfaction, physician satisfaction, employee satisfaction, turn-over time, on-time starts, and many other benchmarks to drive our quality assurance and performance improvement," Craig says.

ASC surgical safety practices
 

Gupta, and Barry Waldman, MD, an orthopedic surgeon at Centers for Advanced Orthopaedics, say safety practices are key in patient selection, and preoperative, perioperative, and postoperative care.

1. Patient selection
 

Some patients are not appropriate for surgery in an ASC, with medical, surgical, and motivational considerations.

"First and foremost, the patient has to get medical clearance, which can include clearance from other specialists such as cardiologists or pulmonologists, depending on what other disease processes they have. Based on those processes, other specialists may recommend an inpatient setting for closer monitoring and follow up," Gupta says.

High-risk medical conditions often disqualify a patient for surgery at an ASC, he says. "If someone has coronary artery disease and high-risk factors related to the heart, instead of sending a patient home the same day of surgery they may want to monitor them overnight or two nights."

Several medical factors can disqualify a patient for ASC care, Waldman says. "You don't want anyone who has a high-end seizure risk, someone who is obese, someone who is going to have trouble with physical therapy, or someone with a lot of comorbidities."

2. Preoperative care
 

"Traditionally, outpatient total joint replacement—hip and knee—was performed in the inpatient setting. Patients would stay in the hospital for two to five days. Now, we have to change those expectations. You can go home the same day, and the outcomes are the same if not better. You don't have the germs that are in hospitals, which potentially seed the wound," Gupta says.

Planning is an important part of the preoperative phase of care at ASCs to ensure the patient's well-being, he says.

"We share what time to show up, what time the surgery is, how long the surgery will be, how long you will be in recovery, and when you are going to go home. We also discuss whether the patient will need an assistive device and whether someone will be at the center to take the patient home," he says.

3. Perioperative care
 

On the day of surgery, mobility and medications are top concerns to ensure safety for the patient, Waldman says.

"With anesthesia, you need to make sure that patients can get up and walk. You need to make sure patients can urinate after surgery, and make sure they are on their antibiotics; sometimes we have to do IV doses in the center before the regular doses at home. We also have a physical therapist at the center to make sure patients are walking correctly."

4. Postoperative care
 

Postoperative care is more intense for ASC patients compared to hospital patients, Waldman says.

"We do physical therapy more often with our outpatient cases. Patients will work with a therapist five days a week for five days straight. We also see them back in the office sooner; for a lot of patients, I will see them three to five days after surgery. I will check the wound and make sure there are no complications. We want to be much more on top of them than the hospital patients because they are not being watched in a hospital."

Gupta makes sure patients set up their postoperative appointments.

"I also give patients a physical therapy referral, so they can schedule that along with their postoperative visit. I try to take care of as many questions and issues that I can preoperatively; so that postoperatively, patients can hit the ground running."