From the Top
ASCA President Kathy Bryant Discusses the Merger, Medicare and How to Make an Impact
The Ambulatory Surgery Center Association's "ASCs 2008" conference last month in San Antonio, the group's first outing as the industry's sole representative body, marked a milestone while strengthening ASCs' voices, says association President Kathy Bryant.

The Night in Pictures
Outpatient Surgery Hosts Dinner Party @ "ASCs 2008" Meeting in San Antonio
Outpatient Surgery hosted a group of readers and advertisers at the Dashiell House in San Antonio's historic La Villita district during last month's "ASCs 2008" conference.

"There was not a difference between AAASC and FASA in terms of mission or who was served," she says. But unifying their leadership and efforts — from education to political support and from data collection to regulatory interpretation — defused the possibility that a future difference of opinions would derail or dilute the industry's impact with policymakers. In her view, the success of the Texas conference in joining the two groups has "closed the books on the merger."

"It's been a great industry to represent," says Ms. Bryant, 54, who led FASA since November 1998. "We're much further ahead than we were 10 years ago."

But Ms. Bryant, who previously directed the American College of Obstetricians and Gynecologists' government relations for 13 years and who worked for the American Medical Association and the Iowa State Senate following her graduation from the University of Iowa School of Law, maintains that the Alexandria, Va.-based ASCA's influence is not limited to her dialogues with federal and state officials, state outpatient surgery associations, reporters and members.

"As much as I am the visible spokesperson for this organization, the organization is more than me," she says. There's also the influence of the executive committee; the board of directors, which includes members originating from both FASA and AAASC; 23 staffers, who cover issues such as lobbying, state legislatures, reimbursement and quality initiatives; and, of course, ASCA's members, which include 2,400 ASCs (and their employees) as well as 600 vendors and other outpatient surgery supporters.

Ms. Bryant admits that it's not always easy for the organization to show its results. "I think that's always a struggle for any association," she says. "It's impossible to say, ???Here's what would have happened without us.' And we're not operating in a vacuum. But we can point out what's going on and what we're going to do about it."

Granted, outpatient surgery facilities took a high-profile hit from the seismic shifts in Medicare's reimbursement rates that began this year. "CMS proposed 62 percent. We got it up to 65 percent. It's not what the ASCs wanted, and not what they deserved," she says. "But I know that a 3 percent change between a proposed rule and a final rule is the result of strong advocacy."

Visibility is the name of the game in political impact. "I can't always demonstrate the positive impact of this," she says. "But with more legislative sponsors supporting this year's bill than last year's, or with one of our members serving on a panel, or standing on the podium with the president of the United States, I think we demonstrate that we can make our case, even if we can't guarantee we're going to win on any given issue."

Ever-increasing visibility is one of Ms. Bryant's visions for creating a more favorable climate for ASCs. Besides the letter-writing to federal and state officials she promotes at association meetings, Ms. Bryant also urges facility administrators to schedule community open houses, host or visit lawmakers when they're in town and network with community leaders met through school functions or other community events.

"One of the things that sets our industry apart is, our organizations have great stories to tell," she says. "We're just keeping quiet way too often. How do we get to tell those stories?"

— David Bernard

MRSA's Mutations
Its name reflects its tenacity - when Staphyloccus aureus first became impervious to a common antibiotic, it was dubbed "methicillin-resistant S. aureus" (MRSA). For 50 years, vancomycin has been the most frequently used antibiotic against MRSA. But recently, these extraordinarily adaptable organisms show a startling trend. Two new strains, VRSA (vancomycin-resistant S. aureus) — already documented in eight cases — and VISA (vancomycin-intermediate S. aureus) reflect vancomycin's decreasing effect.

Experts at a May 1 press conference in New York City called MRSA's mutations a public health crisis, citing its widening impact. By 2005, after the number of invasive MRSA infections in the U.S. had tripled in five years, 94,360 Americans contracted it and 18,650 died — more than that year's deaths from AIDS or influenza. The CDC found that MRSA as the cause of any staph infection rose from 2 percent in 1974 to 63 percent in 2004.

MRSA is increasing alarmingly among otherwise healthy people, with outbreaks reported by sports teams, health clubs, day care centers and prisons, for example. "Community-acquired" MRSA appears to be a more virulent strain than the familiar hospital-acquired type, accounting for nearly two-thirds of skin infections in emergency rooms, compared to 2 percent in 1973.

MRSA's growing incidence is expected to affect more outpatients, so it's urgent to watch for symptoms. Co-morbidities are common. Infected patients are likely to have a complex medical history or prior hospitalization, says Alpesh Amin, MD, MBA, chief of the division of internal medicine at the University of California at Irvine. Typical symptoms include:

• cellulites;
• "spider-bite" look-alike;
• bacterial endocarditis; and
• thin plaque-like vegetation on tricuspid valve.

Up to one in three people may carry the MRSA pathogen asymptomatically, says Alan Tice, MD, associate professor at John Burns School of Medicine at the University of Hawaii. He's found it to cause sores, skin disease, pneumonia or sepsis. "Beware of underlying risk factors that raise the potential for serious infection: influenza, heart disease and prosthetic joints. Distinguish between colonization and infection. Just because a patient has staph in the nose doesn't mean it's MRSA," says Dr. Tice.

"Cultures of any suspicious wounds or sores or infected areas may be helpful in identifying if it is MRSA, which can be devastating if introduced into a fresh wound," says Dr. Tice. "The tissue destruction and blood are excellent food for staph and allow them to grow and produce further destruction through [their] toxins and enzymes."

With evidence of any significant skin infection — including boils, abscesses, ulcers, eczema and cellulites — especially anywhere near the operative site, "generally, elective surgery should be postponed," he advises.

For a patient with MRSA, "the optimal antimicrobial regimen is one that has low potential to induce resistance," says Dr. Amin. Vancomycin is inexpensive, and still has some activity against MRSA, but its effectiveness is weakening, says Stan Deresinski, MD, clinical professor of medicine at Stanford University. "Against natural instinct, diminishing activity may not be overcome by increasing the dose," he says. "There's some evidence that as we push the dose, we may be seeing increased toxicity, including kidney toxicity."

Since it's hard to tell which organism has affected a patient, clinicians often prescribe a massive initial antibiotic dose, then de-escalate as clinical and microbial information arrives. "Use them carefully," says Dr. Tice. "The first dose is the most important."

Choices include daptomycin, the first available agent in a new antibiotics class (cyclic lipopeptides) active against organisms resistant to methicillin and vancomycin. The combination of quinupristin and dalfopristin is active in vitro against MRSA. Cost has curtailed use of one effective agent, linezolid, says Dr. Deresinski. Awaiting FDA approval are three semisynthetic glycopeptides: oritavancin, dalbavancin and televancin. Tigecycline, a glycylcycline, has shown promise in a dose-comparison study. Doctors speculate that while a newer antibiotic may be best for a particular patient, clinicians are hesitant to prescribe them for fear of developing resistance.

Make patients aware of possible MRSA symptoms following surgery, says Dr. Tice. Clearly explain the conditions that should prompt a patient to call your office at once. To help prevent infection at your facility, clean and disinfect frequently. "Studies still show that healthcare workers don't wash their hands 40 to 50 percent of the time," says Dr. Amin. "That has to change."

— Carol Milano, Contributing Editor

Briefly Noted

• STATIONED In Sherwood Forest Hospitals NHS Foundation Trust in Nottinghamshire, England, life-size cardboard nurses (above) that play an electronic message reminding all who walk past them to wash their hands.
• PLED Guilty to three counts of misdemeanor assault involving several nurses at the Midtown Surgery Center in Memphis, Tenn., orthopedic surgeon Bret Sokoloff, MD. Dr. Sokoloff exposed himself to or attempted to rape three nurses between August 2005 and February 2008 at the surgery center, according to court records. Prosecutors dismissed charges of attempted rape, sexual battery and indecent exposure. Dr. Sokoloff was placed on probation for three years. Prosecutors say his accusers approved of the settlement.
• OFFERED A women-only colonoscopy clinic, one morning a week, at the University of Colorado Hospital for women who are hesitant to see a male physician for colon-related health issues. The physician doing the procedure and the nurse in the endoscopy room are both women. At least one study suggests that most women prefer the idea of a female colonoscopist and will wait longer and even pay more to have their procedure done by a woman.
• SETTLED A wrongful death lawsuit that faulted a North Carolina anesthesiologist for allowing a surgical patient to remain conscious but paralyzed — an experience that reportedly prompted the patient to take his own life two weeks later. The lawsuit, which has been settled confidentially, claimed the patient was paralyzed but fully aware for 16 minutes after the first incision during an exploratory laparotomy and gall bladder removal at Raleigh General Hospital in January 2006.
• DRIVEN From Dover, Del., to the ASCA exhibit hall in San Antonio, Texas, this mobile anatomic path lab. V. Raman Sukumar, MD, president and medical director of Doctors Pathology Services, says his mobile intraoperative consultation service eliminates some of the hassles associated with lab consultations by bringing pathologists and their equipment right to the point of care. That proximity also fosters better working relationships, says Dr. Sukumar. "It's the pathologist's chemistry with the surgeon that makes the difference."

Government Survey Reveals a 10-Year Surge in Outpatient Visits
The number of visits to ambulatory surgery facilities, including hospitals and ASCs, rose by about 70 percent between 1996 and 2006, with freestanding ASCs getting the lion's share of the industry's growth, a new government survey shows. The preliminary findings of the first National Survey of Ambulatory Surgery since 1996 show visits to freestanding ASCs rose by more than 300 percent between 1996 and 2006, compared with an increase of about 14 percent at hospital-based outpatient surgery departments. HOPDs performed slightly more ambulatory procedures than ASCs, but freestanding facilities took a much larger piece of the pie than they did 10 years before, the 2006 NSAS reveals.

Data combined from both types of facilities show endoscopies of the large and small intestines were the most common ambulatory procedures performed in 2006, far outpacing cataract removal, which topped the list in 1996.

Researchers from the U.S. Census Bureau collected data from a sample of 696 facilities and 52,233 visits to both HOPDs and ASCs. More information on the survey is available at the National Center for Health Statistics Web site (www.cdc.gov/nchs/nsas.htm), where the final data will be available in August.

— Irene Tsikitas