Joan Rivers’ death high­lights risks in out­pa­tient surgery for se­niors

Modern Healthcare - - NEWS - By Sabriya Rice

In the wake of co­me­dian Joan Rivers’ death fol­low­ing an am­bu­la­tory surgery pro­ce­dure, pa­tient-safety lead­ers and some physi­cians are call­ing on out­pa­tient surgery cen­ters to more care­fully se­lect el­derly pa­tients for surgery and are urg­ing pa­tients to scru­ti­nize the qual­i­fi­ca­tions of physi­cians in th­ese cen­ters.

Older adults are more likely to have mul­ti­ple health con­di­tions that el­e­vate their surgery risks. If some­thing goes wrong, they’re likely to de­te­ri­o­rate more rapidly, so hav­ing im­me­di­ate ac­cess to emer­gency ser­vices is es­sen­tial, geri­a­tri­cians say. Not all am­bu­la­tory surgery cen­ters are staffed to han­dle a cri­sis. In a hos­pi­tal, emer­gency teams can re­spond rapidly while out­pa­tient cen­ters of­ten need to call 911 and trans­fer the pa­tient to a hos­pi­tal.

“If some­thing goes slightly wrong, it’s much more likely to turn into a big prob­lem in an older per­son than a younger per­son,” said Dr. Jonathan Flacker, chief of ge­ri­atrics at Emory Univer­sity.

Rivers, 81, re­port­edly un­der­went an elec­tive en­doscopy re­quir­ing anes­the­sia at the physi­cian-owned Yorkville En­doscopy Cen­ter in New York City be­fore suf­fer­ing car­diac ar­rest and be­ing rushed to a nearby hos­pi­tal. She re­port­edly had a his­tory of bu­limia and heart ar­rthymia. The New York State Health Depart­ment said it’s re­view­ing med­i­cal records and con­duct­ing in­ter­views with staff at the clinic.

Hos­pi­tals are staffed to man­age a va­ri­ety of crises while surgery cen­ters tend to have a nar­rower ex­per­tise, said Frank Fed­erico, ex­ec­u­tive di­rec­tor of strate­gic part­ners at the In­sti­tute for Health­care Im­prove­ment. “If the risk is re­ally high, somebody needs to make a decision about not do­ing it in a surgery cen­ter but do­ing it in a place that might actu- ally bet­ter man­age the pa­tient.”

More than 5,300 am­bu­la­tory surgery cen­ters treated 3.4 mil­lion fee-for-ser­vice Medi­care ben­e­fi­cia­ries in 2012, and the Medi­care pro­gram and its ben­e­fi­cia­ries spent $3.6 bil­lion on th­ese ser­vices, ac­cord­ing to the Medi­care Pay­ment Ad­vi­sory Com­mis­sion. The CMS re­quires am­bu­la­tory surgery cen­ters to re­port on five qual­ity mea­sures: pa­tient burns; pa­tient falls; wrong-site or wrong-pa­tient pro­ce­dures; hos­pi­tal ad­mis­sion and trans­fer; and pro­phy­lac­tic IV an­tibi­otic tim­ing for all am­bu­la­tory sur­gi­cal cen­ters. In 2013, the cen­ters also were asked to re­port on use of safe-surgery check­lists and vol­umes for cer­tain pro­ce­dures. A fa­cil­ity that fails to re­port can have its Medi­care pay docked by 2%.

Be­cause many of the high-vol­ume pro­ce­dures at am­bu­la­tory surgery cen­ters are pro­ce­dures that se­niors un­dergo, out­pa­tient cen­ters that per­form them should be fully pre­pared for the med­i­cal needs of the el­derly, ac­cord­ing to the Am­bu­la­tory Surgery Cen­ter As­so­ci­a­tion.

A re­cent study on out­pa­tient surgery care in the jour­nal Surgery found that of the nearly 4 mil­lion pa­tients who were sent home after hav­ing a pro­ce­dure in three states be­tween July 2008 and Septem­ber 2009, about 3.2% were ad­mit­ted to the hos­pi­tal or vis­ited a hos­pi­tal emer­gency depart­ment within seven days of be­ing dis­charged. The rate var­ied sharply by type of pro­ce­dure, with di­ag­nos­tic car­diac ca­theter­i­za­tion show­ing a par­tic­u­larly high rate. About half of the to­tal pop­u­la­tion of pa­tients stud­ied were 60 and older, with 22% 60 to 69, 18% 70 to 79, and 10% 80 or older.

Ex­perts say the keys to safety are thought­ful as­sess­ment of risks and ben­e­fits to out­pa­tient surgery pa­tients, and en­sur­ing that the right clin­i­cal staffers are present when the pro­ce­dure is per- formed. If anes­the­sia is in­volved, it’s crit­i­cal to know as much about the pa­tient’s med­i­cal his­tory as pos­si­ble, in­clud­ing their med­i­ca­tions, said Dr. Jane Fitch, pres­i­dent of the Amer­i­can So­ci­ety of Anes­the­si­ol­o­gists.

Some worry that is not al­ways hap­pen­ing. “Some cen­ters might be push­ing the en­ve­lope a bit,” Fed­erico said. As am­bu­la­tory surgery cen­ters ex­pand their scope of pro­ce­dures, clin­i­cians may be per­form­ing tasks such as ad­min­is­ter­ing anes­the­sia or in­tu­ba­tion with­out hav­ing spe­cial­ized ex­per­tise. “They are try­ing to do more, and they are try­ing to do it at lower costs,” he said.

Joan Rivers, who was re­port­edly un­der­go­ing an en­doscopy, went into car­diac ar­rest at an am­bu­la­tory surgery cen­ter in New York and died sev­eral days later.

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