Sometimes, complications are unavoidable during surgery. Other times, problems can cascade into serious events because staff are unqualified or unprepared, equipment malfunctions or recovering patients go unattended. To help prevent problems in the office setting, surgeons offer this advice.
Don't take every case
"The No. 1 thing: Turn down cases you shouldn't do," says Max Gouverne, MD, a plastic surgeon in Aesthetic Associates in Corpus Christi, Texas. Dr. Gouverne won't do combined procedures, such as abdominoplasty and liposuction, on a patient with a high body mass index in his office suite. "The complication rates for combined procedures is more than the simple sum of the complication rates for each," he says.
Some argue no hard clinical data supports this observation, but there is little doubt combined procedures are riskier, says Ronald E. Iverson, MD, FACS, past president of the American Association for Ac-creditation of Ambulatory Sur-gery Facilities (AAAASF). Add-ing liposuction to abdominoplasty, for example, may compromise blood flow to the surgical area. Combined procedures can also increase blood loss and fluid and electrolyte shifting. Prolonged surgery stresses patients physiologically, especially those with pre-existing risk factors, and combined procedures can increase pain and lengthen recovery.
Don't stack the schedule
When surgeons push themselves too hard, error potential increases, says Daniel Daube, MD, of the Gulf Coast Facial Plastics and ENT Center in Panama City, Fla. "If I have to slow down, I don't care how long it takes." He likens surgery to aviation: If you fly too many hours, safety suffers. Dr. Daube admits it's not best for profits but, "We haven't had any significant problems here in nine years," he says.
Consider routine medical clearance
"The best measures we can take are preventive," says Steven K. Palumbo, MD, an AAAASF inspector and plastic surgeon with Palumbo Plastic Surgery in Quogue, N.Y. He orders platelet counts, CBC, electrolytes and tests requested by the internist and anesthetist for every patient over 40. He says this finds problems warranting cancellation or rescheduling in about 4 percent of patients with clean medical histories. In one case, an internist diagnosed a previously undetected pericardial effusion. In another, a woman with a low post-menstruation hematocrit count donated her blood pre-op, just in case.
Perform regular intraop monitoring
Consider routine pulse oximetry or EKG monitoring, says James W. Northington, MD, of Northington P.C., in Florence, Ala. He performs pulse oximetry on every patient and EKG monitoring on most, depending on age and cardiac history. In fact, Dr. Northington once halted plans for surgery due to an abnormal cardiac beat that surfaced in the OR. The surgical plan was resumed only after the patient received treatment to control the condition. "So many people have some sort of cardiac issue, it simply makes sense," he says.
Be mindful of potential problems
Remember, perioperative problems do occur. "If you do enough surgery, you will see every complication," warns Dr. Northington. So be prepared. Dr. Northington ensures each of his staffers is ACLS certified and that emergency supplies like the defibrillator, supplemental oxygen and medications for treating malignant hyperthermia are within reach. "I also emphasize credentialing; any surgery I do here is surgery for which I have privileges at the hospital," he says. "As phys-icians, 80 percent of our training is learning how to take care of problems, and privileges ensure we have this training."
Preparation pertains to equipment as well. Four years ago, when his Bovie stopped working, Dr. Palumbo realized he was lucky the procedure was a breast augmentation and not a breast reduction, which can produce significant blood loss. "I thought, what if the same thing happens to my oxygen source or the antiembolic cuffs or the liposuction machine. It's not like the hospital, where we can run to the next room for a replacement," he says. "So, I purchased backups of all critical pieces of equipment." Dr. Palumbo says he spent about $5,000 on the extra hardware, which he feels is negligible considering the risk of operating without it.
Have an emergency-transfer protocol
Should a serious complication develop, an emergency-transfer protocol with your local hospital will help ensure that you get the patient the care he needs as quickly as possible. These protocols not only guide the staff in case of emergency but ensure the lines of communication with the hospital will be open when needed. Says Dr. Gouverne: "Building a relationship with the hospital is critical. If I need to call the emergency nurses about a patient, they will speak with me right away."
Protocols also ensure the surgeon has hospital privileges for the procedures done in the office. Implementing such a protocol will help you realize how much time will likely lapse between an emergency call and an ambulance's arrival. "Every now and then, we place a call to the ambulance service to see how fast they get to our place," says Dr. Northington. "This is a good precautionary measure."
Never leave recovering patients unattended
Occasionally leaving recovering patients unattended or watching them through a window or one-way mirror may be fairly common, but you shouldn't do this. "It takes two minutes for a patient to get nauseous, vomit and aspirate, for the IV to stop working or for a hyper- or hypotensive episode to begin," warns Dr. Palumbo. Rather, do whatever is necessary - including paying an extra person to oversee recovering patients on surgery days - to ensure continuous patient monitoring. Many untoward reactions manifest before and after, not during, surgery.
Dr. Northington also advises surgeons to remain in the facility until all patients are discharged, even if they are not directly overseeing patients. Finally, adds Dr. Palumbo, follow up after discharge, because patients are not out of the woods just because they go home. "We call every patient on the first post-op night and again the next morning to do a careful assessment," he says.
Although, as Dr. Daube says, "accreditation will not turn a bad surgeon into a good surgeon," it is an outline of everything you can do to protect patients from undue harm, say the surgeons we interviewed. For example, you can ensure proper credentialing and privileging, implement emergency transfer protocols, get ACLS/BLS certifications, and ensure continuous patient management during recovery. "When I read the manual, I realized it addressed so many things we don't always think about," says Dr. Palumbo, "like backup generation and ACLS certification."
Hector Vila, Jr., MD, anesthesiologist at the H. Lee Moffitt Cancer Center and Research Institute's Department of Interdisciplinary Oncology in Tampa, Fla., and lead author of an Archives of Surgery study of office-surgery safety, says accreditation addresses many of the issues that underlie the events and deaths evaluated in his study. These issues include an unqualified surgeon, poor-quality anesthesia services, lack of emergency-transfer agreement, lack of peer review and an unqualified nursing staff.
Surgeons who aren't required or ready to pursue accreditation should at least try to evaluate and duplicate the standard of care that exists in their ASC market, says Dr. Vila, especially because standards vary by region. For example, some ASCs may be able to transfer a patient to the hospital in 10 minutes whereas others might be 30 minutes from a hospital.
Following these tips may help protect office-surgery patients from complications. "When we practice safe office surgery, we like to think of the risk of a significant complication as less than that of the patient being in a fatal accident on the day of surgery," says Dr. Daube.