Is ambulatory surgery crossing the line with patients and procedures?

SAMBA web survey: 40% have pushed envelope of patient safety

(Editor’s note: In this first part of a two-part series on patient safety, we discuss how safety can be compromised in outpatient surgery and how anesthesiologists and surgeons can agree on limits. In next month’s issue, we discuss the source of the pressure to handle more types of patients and procedures as outpatient cases.)

A 400-pound patient comes to an outpatient surgery department. The patient has obstructive sleep apnea, diabetes, and heart disease.

"I take one look at the patient and say to the surgeon, Do you think this patient is really going home today?’" says Scott R. Springman, MD, professor of anesthesiology and director of ambulatory anesthesia services and the preoperative clinic at the University of Wisconsin Clinical Sciences Center in Madison. "He winks at me and says, probably not.’ Surgeons play a game where they’re pushing the envelope, but they’re waiting to see if we [anesthesiologists] push back."

From the beginning of the field, outpatient surgery has explored the outer boundaries of patient selection and procedures. Has it gone too far? This concern is evident in an Internet survey conducted by the Society of Ambulatory Anesthesia (SAMBA) in Park Ridge, IL. In that survey, 40% (21) of 53 respondents said they agree or strongly agree with the statement, "My practice pushes the envelope of patient safety by performing outpatient surgery on patients with serious pre-existing conditions." (See graph, below left.) When asked whether they push the envelope in terms of performing complex or lengthy surgical procedures on outpatients, 35% (18) of 52 respondents said they agree or strongly agree. (See graph, below right. For information on how to access the survey, see "Sources and resource" at the end of this article.)

"I am not sure it is less safe to perform a longer or more complicated case in an ASC [ambulatory surgery center] as long as all of the tools or supplies that are needed are available," says J. Lance Lichtor, MD, professor at The University of Iowa Department of Anesthesia in Iowa City. "A much more common issue would be what happens to patients after the surgery. Should they go home or be admitted to a hospital? If they are admitted to the hospital, was it appropriate to perform the surgery in the ASC?"

Where do anesthesiologists feel the pressure coming from in outpatient surgery? Mostly surgeons — according to the results of the survey. When asked the source of the greatest pressure, 43% (22) of 51 respondents said surgeons, 25% (13) said "myself," 20% (10) said administrators, 6% (three) said patients, and 6% (three) said colleagues. When asked how much of their practice is devoted to performing ambulatory anesthesia, 55% (27) of 49 respondents said 67% to 100%, and 33% (16) of respondents said 34% to 66%. Another 10% (five) said they devote 1% to 33% of their practice to ambulatory anesthesia, and 2% (one) said none of their practice is ambulatory.

"One of the things you don’t want to do is to be pushed into doing things by other people — administrators, other colleagues, surgeons — when you don’t feel it’s safe to do," Springman says. "Surgeons are probably the biggest drivers of taking patients that otherwise you wouldn’t take."

In general, surgeons tend to be risk takers, and anesthesiologists are usually conservative, he says. Surgeons are performing more complex procedures than previously, taking longer to perform the procedures, and in addition, they’re "lumping" procedures together under the same anesthetic, he says. The problem is that with a longer procedure, there’s a greater risk of hemodynamic instability and often a greater need for fluid replacement, because of the trauma to the tissue, Springman says.

Pushing the envelope isn’t always bad, however, says Barbara S. Gold, MD, president of SAMBA and associate professor in the Department of Anesthesiology at the University of Minnesota in Minneapolis. In fact, it is that "pushing" that has allowed outpatient surgery to achieve widespread popularity today, she emphasizes. In the early years of the field, patients with underlying diseases were treated cautiously on an outpatient basis. "Given early successes, the eligible outpatient population was expanded," she says. Pressure from third-party payers accelerated this process, Gold adds. "So, pushing the envelope can be beneficial and can be innovative, especially when sound medical judgment and the welfare of the patient guide decision making."

Gold is quick to point out, however, that outpatient surgery can be pushed too far. For example, in some cases, "system issues — i.e., schedule, reimbursement, staffing, etc. — rather than medical judgment or patient welfare drives decisions, and the concern is that the patient’s best interests are not primary," she says. "In anesthesia, this can have significant consequences."

Consider these suggestions for addressing patient and procedure selection in outpatient surgery:

Do research before you decide whether a procedure should be performed outpatient. Look at the data, urges Ross Musumeci, MD, vice president of Anaesthesia Associates of Massachusetts in Westwood. "We look at what the complication rates are for certain procedures and make our decisions based on that," he says.

Springman researches the procedure that’s planned. "Am I the first kid on the block to be doing this, or have others being doing it safely for years?" he asks. "What’s their experience? What are their techniques? How are they handling potential complications?" Additional factors that affect whether a procedure can be performed outpatient include the surgeon’s skill level, the anesthesiologist’s skill level, the type of anesthesia, and the patient’s pre-existing medical conditions, Springman says. "If you have surgeons that are slick and fast and can do a procedure specifically under a local or a regional, your outcomes may be entirely different from another ASC where surgeons are slower, results are not as good, and you have to do a general anesthetic on the same type of patient for the same procedure," he says.

Establish a goal to make outpatient surgery as safe as inpatient surgery. "Administrators should look at surgery centers and ask, What can I do to make it equivalent to a hospital without going broke?’" says Ervin Moss, MD, executive medical director of the New York State Society of Anesthesiologists in Verona. For example, use nurses in the post-anesthesia care unit who have been trained in recovery, he urges. In addition, put your credentials in order, and update your equipment, Moss adds.

Have open lines of communication between anesthetists and surgeons. Anesthetists should be facilitators, not obstructionists, Musumeci says. Obstructionists cancel cases and insist on having their way, he says. Facilitators align their interests with those of the facility and surgeons, Musumeci explains. "If you are perceived as doing that, you tend to have a lot less trouble saying no when you need to and look out for patients’ well-being," he says.

If anesthetists take every case that surgeons bring to them, surgeons will assume they are comfortable with it, Springman says. Anesthetists periodically should communicate with surgeons about what types of patients are acceptable for your facility, he says. "If surgeons and anesthesiologists have differences, that’s a good opportunity for them to sit down and discuss them, and come up with reasonable compromise," Springman says. As a general rule of thumb, Springman says, if an anesthetist feels comfortable 100% of the time, he or she is being too conservative. "But you don’t want to feel 100% uncomfortable all the time," he says. The point of a "happy medium" isn’t clear, Springman adds.

Set up mechanisms to ensure adequate patient review before the day of surgery. In the SAMBA web survey, 10 (19%) of 52 respondents said they agree or strongly agree with the statement that they never cancel ambulatory cases for inadequate preoperative evaluations. Eight (15%) agreed or strongly agreed that they never cancel ambulatory cases for noncompliance with NPO guidelines. Adequate patient review is critical to ensure good patient outcomes, Musumeci emphasizes. At the day surgery centers which he works, morbidly obese patients and patients with abnormal EKGs have to be reviewed by an anesthesiologist in advance. This review prevents pressure on the day of surgery and allows clinicians to make the right decisions, he says.

Aim for being efficient, not simply fast. "We feel strongly that efficiency in the operating room and delivery of care doesn’t have to mean decline in quality of care," Musumeci says. "It can go hand in hand with improvement in quality of care."

If you’re efficient, you’re fast, Springman acknowledges. "But if you simply aim for being fast, you get into situation where overall, you end up being less efficient, complications increase, patient satisfaction may go down, and you have a whole host of adverse outcomes," he says. Concentrate first on being efficient, and speed will follow, he advises. For example, the University of Wisconsin Clinical Sciences Center formerly spent a lot of time interviewing and preparing patients when they arrived on the day of surgery. To address the problem, many of the questions were moved to the pre-op telephone call, and any concerns were addressed ahead of time. "We could reduce the amount of time patients wait prior to surgery," says Springman, who says 15-20 minutes was saved per patient.

As more procedures and patients move to the outpatient surgery setting, managers continually will have to evaluate where to draw the line, Springman says. "And [all] anesthesiologists [have] their own point at which they feel they’ve stepped over that line," he adds.

Expect scrutiny if your complications rates aren’t low, Musumeci warns. "My advice to anyone who asks is, don’t push the envelope," he says. Give anesthesiologists adequate information to make the right decision "without a surgeon breathing down their neck and without surgeons having to look at a day of wasted time because the case got cancelled," he says. "This isn’t an area worth pushing the envelope, in my opinion."

Sources and resource

For more information on quality of care in outpatient surgery, contact:

Ervin Moss, MD, 11 Robert Court, Verona, NY 07044. Telephone: (973) 744-8158. Fax: (973) 857-7137. E-mail:

Ross Musumeci, MD, Vice President, Anaesthesia Associates of Massachusetts, 690 Canton St., Westwood, MA 02090. Telephone: (781) 407-7771.

Scott R. Springman, MD, Professor of Anesthesiology, Director of Ambulatory Anesthesia Services and Preoperative Clinic, University of Wisconsin Clinical Sciences Center, F6-281 CSC, 600 Highland Ave., Madison, WI 53792.

To access the web survey by the Society of Ambulatory Anesthesia, go to and click on "SAMBA Survey" on right side of page.