Ambulatory Surgery Center or Hospital for Surgery
Article by Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
Much has been written by the popular press concerning the safety of operations performed in outpatient surgery centers, usually introduced by the story of a catastrophe that provoked the inquiry in the first place. From these vignettes, there may be the impression that surgery is more safely performed in the hospital. After all, the staffs are large and all of the latest and sophisticated equipment is there. Outpatient surgery centers don’t have intensive care units and armies of specialists on the premises. In certain cases, this reasoning is true. But in a different population of patients, actually the opposite is the case.
First, we have to define what we mean by an outpatient surgery center. Many procedures are done in doctors’ offices that are not accredited. This is not the setting referred to in this article. The safety record of outpatient centers discussed now pertains to facilities that are accredited and licensed. For reasons of brevity, the specifics of accreditation and licensure will not be addressed here. But the significance of these two terms is essential to the assessment of safety for operations performed “off-campus”, meaning away from the operating room of a big hospital.
One of the dirty secrets of large hospitals is the issue of acquired infections. In a big hospital, a certain number of patients are on long term antibiotic therapy. There develops a microbiologic “atmosphere” in the hospital that is very much the product of the patients, their diseases, and the treatment they receive. One by-product of the centralization of diseased patients undergoing antibiotic treatment is the emergence of bacteria that are resistant to conventional antibiotics. Although hospitals try to quarantine these dangerous strains of bacteria, the fact of the matter is, they can’t. They are everywhere. For that reason, perhaps the most unsafe environment for a healthy person is in a hospital.
Studies have now been published examining the safety of procedures performed in outpatient facilities (defined as properly credentialed and licensed). It is clear that surgical outcomes are better, infection rates are lower, and patient satisfaction rate considerably higher when compared to in-hospital operations. One must remember that certain operations have to be performed in a hospital because of the magnitude of the procedure. Discussed here are only those operations that can logistically be supported by an outpatient facility.
Outpatient centers are also more efficient. The services are more specialized and the bureaucracies are customarily much smaller. Patients benefit because of lower costs and savings of time and trouble. Add to this the safety benefits and it’s hard to understand why more procedures are not completed in outpatient centers.
One opponent of independent outpatient surgery centers, as you might imagine, is the big hospital industry. Outpatient centers are direct competitors. The outpatient operating rooms also have the advantage of being able to pick their customers. Large hospitals, on the other hand, more or less take all comers regardless of how much they will pay. There are inequities in the system, but that’s just the way it is. For patients looking out for themselves, in most instances the free-standing outpatient surgery center (provided it is properly inspected and licensed) is the best choice for safety, service, and economy.
Finally, there is a growing trend towards specialty hospitals. In states where it is permitted, even centers specializing in angioplasty and cardiac bypass surgery have opened. It is no surprise that they more efficient and post better outcomes than larger full service hospitals. This new direction in medical care is developing and it will be interesting to see where it leads.