This Just In

Unsafe Offices?
Controversial Study Indicts Office Surgery Safety
The risk of death and injury resulting from a surgical procedure may be 10 times higher when performed in physicians' offices than in ambulatory surgery centers, according to a Florida-based study in the September Archives of Surgery likely to re-ignite national debate about office surgeries.

The study examined all adverse-incident reports to the Florida Board of Medicine from April 2000 to April 2002 and found adverse incidents occur in 66 of every 100,000 office procedures, compared to 5.3 per 100,000 ASC surgeries. The death rate per 100,000 office procedures was 9.2 (13 deaths in 141,404 cases) and 0.78 (18 in over 2,300,000 cases) in the ASC. The study concludes: "If all office procedures had been performed in ambulatory surgery centers, approximately 43 injuries and 6 deaths per year could have been prevented." Other key findings:

• Only 38 percent of the office surgery suites reporting adverse incidents were accredited.
• Eighty-four percent of the physicians involved in the adverse office events were board-certified and held active hospital OR privileges.
• The office surgery deaths had both anesthesia-related causes as well as procedural problems, such as an endoscope perforating a colon or an esophagus.

In September 2000, the Florida Medical Board placed a 90-day moratorium on all office-based general anesthesia procedures. Study critics note there were five office surgery deaths (including two general anesthesia procedures) in 2000 before the moratorium, which may skew the analysis. They also note that previously published data, looking at 400,000 procedures in 250 accredited facilities, found comparable safety to ASCs and HOPDs, including the Mayo Clinic's.

In February 2002, the Florida Board of Medicine enacted office surgery regulations, including procedural limitations, office accreditation, surgeon credentialing, anesthesia-provider qualifications and mandatory adverse-incident reporting. Hector Vila, MD, the study's lead author, says, "the office surgery outcomes problem exists nationwide," particularly in unaccredited facilities in the 28 states that do not have laws or regulations for office surgery. He says problems arise when doctors perform operations outside their expertise, do multiple procedures per session and accept patients who shouldn't have been office surgery candidates.

Inside the Numbers

• 1,263 Number of anesthesiology residency graduates in the United States in 2002, up 37 percent from 2000 (919 graduates), but down 42 percent from 1995
• 1,129 Number of newly certified CRNAs in 2001
• $204,850 National mean salary for anesthesiologists employed by ASCs 2002
• $101,825 National mean salary for CRNAs employed by ASCs in 2002
• 5.4% Percentage of all registered nurses who are men
• 45% Percentage of nurse anesthetists who are men
• 12 Average 2002 profit by cents on the revenue dollar by 101 ASCs in Pennsylvania
• 2 Average 2002 profit by cents on the revenue dollar by community hospitals in Pennsylvania

SOURCES: AMGA, FASA, U.S. Department of Health and Human Services, AANA, PHC4.

British ASCs
American-Style Outpatient Surgery Comes to the UK
Two obstacles blocked the paths of would-be participants in the British National Health System (NHS) and Department of Health's experiment to open 24 ambulatory surgery centers across Great Britain. The first challenge: standing out from the other bidders. Mission accomplished for Johns Hopkins Medical International (JHMI). The second task is even larger: working to revise a British system of surgical care that greatly limits the list of outpatient procedures.

"There was a feeding frenzy to participate in the program when the British government started accepting bids," says JHMI CEO Steve Thompson. "We had an edge, perhaps, because we already have an established reputation of exporting intellectual capital of medical knowledge overseas and we have a well-known surgical program in the States."

The British government selected six management entities for the 24 planned centers. JHMI was assigned to a group headed by a management consortium, Nations Healthcare. JHMI's partners in the venture include the Harvard School of Public Health, Chicago-based Same Day Surgery, a British diagnostics firm and an Aus-tralian provider of specialized eye care. Nations' two centers will be in Bradford and Burton.

The ASCs have yet to be built; the management team has yet to determine what specialties they'll service. The British government is collecting input from the participants about expanding the list of approximately 20 permitted outpatient procedures, further lengthening already-long waiting lists for surgery.

"Developing an expanded list is our next big task, then we can begin to formulate a strategic plan to become single or multi-specialty centers," says Mr. Thompson. "British outpatient surgery is ... a work in progress, but from the American perspective, it's a great chance to adapt a proven model of care to an eager market that has a need for it."

Nosocomial Infections
Six Steps for Lower Infection Rates
Here are six steps Genesis Medical Center in Davenport, Iowa, took to minimize the risk of surgical site infections, says Lisa Caffery, MS, RN, BC, CGRN, an epidemiology specialist and the administrator of the SSI-reduction program:

Remove razors from the OR and replace them with clippers. "Our neurosurgeons in particular were not happy at first about the switch, but when we showed them several types of clippers, they all found one they really liked," she says.

• Add antibiotic prophylaxis reminders to OR preference cards. This reminds staff to re-administer antibiotics after two hours during long procedures.
• Maintain ambient room temperatures in the OR.
• Use tympanic monitoring instead of another method.
• Give oxygen via face mask in PACU unless contraindicated.
• Add SSI-reduction procedures to nurse orientation.

"Staff buy-in is better when you focus on SSI reduction as a patient-safety initiative," says Ms. Caffery, "rather than a quality improvement program."

Safety Resources
10 New Posters
Joint Commission Resources, an affiliate of JCAHO, is offering 10 staff-education posters focusing on patient-safety issues. "These 10 colorful posters help hospitals, ambulatory care and long-term care organizations keep essential patient safety issues a top priority among members of the health care team," says JCAHO. The posters are 18 inches by 24 inches and cost $95 per set. To order, call JCR at 877-223-6866 or visit www.jcrinc.com.

Reimbursement
CMS Extends Acceptance of Non-HIPAA-compliant Transactions
If your facility is still not quite ready for the Oct. 16 deadline to code and bill only with HIPAA-compliant electronic transaction sets, you can rest easy awhile. With less than 20 percent of providers complying, CMS announced it will accept older claim formats after the deadline. CMS did not announce an end date for non-compliant transaction amnesty but said it would regularly evaluate the readiness of facilities to switch from legacy transaction forms.

Judie English, the vice president of business operations for Fort Myers, Fla.-based Surgery Center Billing, LLC, says about half of third-party payers are not ready to process HIPAA transactions, further complicating the process of facilities adopting a single coding standard.

"When our facilities sent test HIPAA transactions out to payers, many couldn't respond or they responded incorrectly," says Ms. English. "Even if you're HIPAA compliant, I'd estimate there could be a three- to four-month delay for getting paid by non-HIPAA-compliant payers."

Nurse Recruitment
Wanted: More Male Nurses
"Are You Man Enough?" the Oregon Center for Nursing poster campaign that encourages men to apply to nursing school, attempts to dispel gender stereotypes by depicting real male nurses from a variety of backgrounds.

The poster reflects a trend of focusing on male nurse candidates, a strategy deemed necessary by 70.29 percent of nurses responding to a recent online poll by NurseWeek. Other campaigns focus on the high demand for nurses and the salaries offered to fill vacant positions.

"Anything that degenders nursing and recruits qualified applicants is a positive step. We need a lot more men and women in nursing," says Gene Tranbarger, EdD, RN, the president of the American Assembly for Men in Nursing.

While most nurses are women, many male nurses become nurse anesthetists. While 5.4 percent of RNs are men, according to U.S. Depart-ment of Health and Human Services data, men comprise 45 percent of CRNAs, according to the American Association of Nurse Anesthetists.

• Nellcor's new half-pound, battery-operated hand-held pulse oximeter is designed to monitor SPO2 and pulse-rate values during transport from the OR to the PACU...
• The Maryland Health Care Commission is studying the way other states regulate ambulatory surgery - specifically regarding the state's one-OR exemption that lets a physician open an ASC, as long as it has only one OR. Currently, though, "there is no proposal to change the way ambulatory surgery is regulated," says Pam Barclay, the MHCC deputy director of health services...
• The American Society of Anesthesiologists has developed anesthesia machine obsolescence guidelines to help facilities decide whether to update their gas delivery systems. Download them at www.asahq.org/ publicationsandservices/machineobsolescence.pdf...
• The California Legislature passed a workers' compensation reform bill that includes a fee schedule capping ASC workers' comp reimbursements at 120 percent of Medicare. The law also lets insurance companies ask for audits, which can delay payment by six months...
• StabilEyes, an endocapsular tension ring by Ophtec and AMO, has been given expedited pre-market approval review status by the FDA. The device is designed to stabilize the capsular bag during cataract surgery...
• AAASC is offering members $200 grants for physician-owned ASCs to assist physicians and nurses to attend AAASC's 25th Annual Conference, March 3-6, at the Peabody Hotel in Orlando, Fla. Download information and applications at www.aaasc.org/ education...
• ASC development firm AmSurg Corp., which acquires and manages ASCs with surgical and group practices, ranks 39th on Fortune's annual 100 Fastest Growing Companies in America. AmSurg owns a majority interest in 107 surgery centers and ranks 10th in total investment return.