Stupid ASC Article by Michael Gorback MD
The Joan Rivers debacle resulted in heightened media attention regarding the safety of ASCs (ambulatory surgical centers). I have heard some people claim that they will now have procedures done only in hospitals. When I ask them if that means dental care too, they just stare at me. I then tell them about the time I was on the receiving end of an accidental intravascular injection of lidocaine and epinephrine in the dentist’s office and had a major reaction. Ever since then I always take diazepam before dental work, not for anxiety but to raise seizure threshold. Then they say yes, they would have dental work done at a hospital.
Good luck with that!
It therefore came as no great surprise to run across an idiotic article in Kaiser Health News about whether ASCs are more dangerous than hospitals for outpatient surgery.
After a long discussion of the issue, the article concluded . . . . not a whole lot. It did manage to kick up a lot of dust in the ASCs’ direction but in the end it was all heat and no light.
We have this criticism from Lisa McGiffert, director of Consumers Union’s Safe Patient Project: “There’s not much known about what happens within the walls of these places by regulators or by the public.”
Actually, we know quite a bit. These facilities have to undergo periodic inspections just like hospitals do (and we all know how meaningful those inspections are). In addition, the ASC Quality Collaboration has been collecting ASC morbidity and mortality data for the past 8 years. The Kaiser article relates the results of the 2013 University of Michigan study on ASC complications and then another, un-cited, study about the rate at which ASC patients require postop transfer to a hospital. Naturally, the critical question is, “How does this compare with a hospital setting?”. Well, it turns out that you can’t answer that question because, as the Kaiser article states,”Comparable statistics could not be obtained for hospitalized patients. . . ”
McGiffert also recommended asking the ASC staff questions such as “How are you going to make sure I don’t get an infection?”. Ok, I’m just guessing here, but maybe the answer would be, “The usual way”. Is there any doctor who feels they have a lower chance of infection at a hospital than an outpatient center?
Kenneth Rothfield, chairman of anesthesiology at St. Agnes Hospital in Baltimore, put the icing on the cake with a slap in the face to his colleagues. “Rothfield said that when one of his children underwent surgery in an ambulatory center several years ago, he brought his own resuscitation equipment and, as a precaution, sat in a corner during the uneventful procedure . . . “. Excuse me Dr. Rothfield – may I ask why you agreed to have the surgery done at the perilous ASC to begin with instead of making yourself a walking cartoon?
Unless and until we have comparable data, it is absurd to talk about the relative safety of an ASC vs a hospital. The data simply aren’t there. Meanwhile the Bullshit Parade marches on with baton leaders like McGiffert and Rothfield.
Of course the ASC is the only place the MD’s still have some power – not an inconsequential detail in understanding why this story is running as it is.
While I agree with many of your comments, I do have a bone or two to pick.
First, I’m not sure that the underlying issue is ASC vs. hospital so much as it is making sure that appropriate personnel and equipment are available (same facility, same building, same unit…whatever) when patients are under sedation. Many hospitals struggled with this a decade or two ago, and some probably still do. There is always an inclination to think “I don’t need it just this once.” Or “I can do it here just this once.” It works until it doesn’t.
And the main point shouldn’t be comparison so much as a dedication to reliable safety, including credentialing of professionals. I hesitate to believe the tabloid press, but it sounded like there were some issues around that in Ms. Rivers’ case. It also sounded like they expanded the scope of her procedure while she was sedated, which denied her the right to decide if she wanted the more extensive work done in the ASC or at all.
And while there are many surgeons who work professionally and ethically at ASC’s, I have also known some to move into that environment to avoid the rules they don’t like at hospitals. I guess patients have to decide how they feel about that.