Joan Rivers' death highlights risks for seniors in outpatient surgery

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 actually 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 performed. 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.

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