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8 Tips for Improving Office Surgery Safety
Here's advice on how to make office surgery safer for your patients.
Dianne Taylor
Publish Date: October 10, 2007

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.

Is Office Surgery Riskier?

During the past several years, newspapers nationwide have carried stories of patient deaths after office-based plastic surgeries. Television's Date-line profiled deaths of two patients who underwent routine procedures in their physicians' offices. A two-year comparison of office and ASC surgeries in Florida in the Archives of Surgery concluded there was an approximate 10-fold increased risk of adverse incidents and deaths in the office setting.1

But some researchers warn against drawing conclusions about office-based surgery safety because the data collected to date is mixed. Rajesh Balkrishnan, PhD, an associate professor at the University of Texas Health Sciences Center, is is among the critics calling the recent Archives study statistically flawed. He reviewed office-surgery-safety studies and found a "very low incidence of adverse events resulting from office-based surgery."2 A 2001 report by plastic surgeon Steven M. Hoefflin, MD, and colleagues at the University of California supports this. Dr. Hoefflin's 18-year study revealed no intraoperative or post-op deaths or significant complications among 23,000 consecutive office-based general-anesthesia procedures.3

Hector Vila, Jr., MD, lead author of the Archives study, believes the reason for the inconsistent findings is not statistical inexactitude but variability in the care level from one office to another. Dr. Vila says other research supports his study's office-mortality rate of 9.2 deaths per 100,000 patients.

The researchers agree, though, mandatory reporting of adverse surgical events in the office setting is needed. According to AAAASF, nine states - California, Florida, Massachusetts, Mississippi, New Jersey, North Carolina, Rhode Island, Texas and Virginia - require office-based incident reporting.

- Dianne Taylor

1. Vila H, Soto R, Cantor AB, Mackey D. Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch Surg. 2003;138:991-5.
2. Balkrishnan R, Hill A, Feldman SR, Graham GF. Efficacy, safety and cost of office-based surgery: A multidisciplinary perspective. Dermatol Surg. 2003;29:1-6.
3. Hoefflin SM, Bornstein JB, Gordon M. General anesthesia in an office-based plastic surgical facility: A report on more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthetic complications. Plast Reconstr Surg. 2001;107:243-51.

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.

N.J. Medical Examiners Require CRNA Supervision in Office

CRNAs working in the office must be supervised by anesthesiologists or physicians with anesthesia privileges, the New Jersey Board of Medical Examiners (BME) has ruled. Rule enforcement will begin Feb. 17 and apply to general and regional anesthesia, including conscious sedation, says New Jersey Association of Nurse Anesthetists (NJANA) lawyer Alma Saravia.

"The New Jersey Board of Nursing voted to recognize CRNAs as advanced practice nurses Oct. 3, and nurses are regulated by the board of nursing," says Ms. Saravia. "This is outside the BME's scope. No state mandates that CRNAs must be supervised by anesthesiologists, and the federation of state medical boards does not mandate such supervision."

The BME says the supervision rules are an effort to enhance office-surgery safety, not put New Jersey's 400 nurse anesthetists out of work. "The board has a long-standing view that doctors are responsible for what happens in their offices, and therefore should have an understanding of the services provided," says BME spokeswoman Genene Morris.

However, says Ms. Saravia, if the goal is physicians understanding an-esthesia, the BME should find a way to mandate within its scope of power. "If you want every [office surgeon] to have a basic knowledge of anesthesia, fine," she says. But to mandate that surgeons who work with CRNAs have their anesthesia knowledge approved by the BME - and that those who work with MDAs do not - creates disparity, says Ms. Saravia. The NJANA plans to fight the rule change.

- Stephanie Wasek

Consider accreditation
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.

Safety first
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.