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When the wear and tear on Richard Merrell’s shoulder finally became too painful to bear this past fall, the Virginia-based firefighter opted to forgo a hospital visit. He turned instead to an outpatient medical facility in suburban Maryland where a surgeon shaved down his frayed cartilage, connected some tissue to the shoulder socket and drilled a few holes in the bone to stimulate the growth of new cartilage. Within hours of the operation, Merrell was free to go home. Six months later, he is pain-free, with no apparent side effects.
Success stories like Merrell’s have prompted thousands of Americans to schedule outpatient procedures at ambulatory care centers throughout the country. Patients can get anything from eye operations to biopsies at such sites. As with any surgery, however, operations at these facilities do come with a finite risk of infection. Unfortunately, no one knows how significant the problem might be because outpatient surgical centers, unlike hospitals, are not required to track health care–associated infections.
Experts are clearly worried about the potential for harm. Beth Bell, director of the National Center for Emerging and Zoonotic Infectious Diseases, raised the issue in testimony before Congress in September. “These days there are a lot more—and more complicated—surgeries that are taking place in ambulatory surgery centers, and so this sort of clean break between the hospital and the ambulatory surgery center is perhaps not as clean as it once was,” she said. “We don’t have very good estimates about [infections in] ambulatory surgery centers.”
She added, “We’ve had many years now of work in hospitals to reduce health care–associated infections, and we’ve shown progress, for example, in reducing surgical-site infections in hospitals. We don’t have the same history in ambulatory surgery centers,” she said. Right now, in fact, the U.S. health care system rarely tracks potentially worrisome infections linked to such care.
An infection after surgery does not always mean that a health care facility offered substandard care. Some infections happen when patients fail to follow wound-care instructions, for example. But lack of tracking on such infections could mean that persistent problems in the medical system may be missed. For decades the vast majority of operations happened only in hospitals, which is why Congress mandated tracking of certain hospital-based infections nearly a decade ago. The collection of that data and patient follow-up is viewed as so essential that neglecting it is punished with a hefty stick: Failure to comply means that hospitals will not receive full reimbursement for Medicare-funded procedures.
Operations at freestanding outpatient clinics were first offered on a small scale in the 1970s. More targeted anesthetics and less invasive surgical approaches like laparoscopy have helped fuel their more recent surge in popularity, and the interest is only expected to grow. There are now more than 5,000 of these outpatient surgical centers in the U.S.
Usually, such operations have positive results. After all, patients approved for surgeries outside the hospital are generally healthier than most—free of concerning heart conditions and other risk factors that might cause complications in surgery. Moreover, at least so far, only relatively straightforward operations occur at these ambulatory care facilities—reducing the risk of infection. But more patients are coming to ambulatory care settings for the same procedures that would be otherwise tracked in the hospital—such as colon operations and hysterectomies—and there is still no similar tracking provision for ambulatory care facilities. Nor is there a federal recording mechanism for such data.
Although ambulatory surgery centers that receive Medicare funding are required to have someone on staff tasked with infection prevention in general, that person is required merely to have received some training, no formal certification. Often, the job is tacked onto a health professional’s other duties. And how, or if, they may track infections after surgeries—following up with patients who may be receiving aftercare at hospitals or elsewhere—may differ.
At the Massachusetts Avenue Surgery Center, the Bethesda, Md.–based facility where Merrell had his operation, for example, a registered nurse is charged with splitting her time between acting as a postanesthesia care unit nurse and acting as the facility’s infection control manager. Katie Crean tracks new employees’ vaccination status, leads staff efforts to promote hand-washing at the facility and also makes sure that patients get a phone call two days after surgery to insure they are not having unexpected side effects—especially ones that might indicate an infection such as fever or swelling. Such reports prompt a follow-up call from her and a notation in her records of potential infection.
But postoperative infections can happen as long as a month following a surgery, not just in the first couple of days, so potential infections may go unreported. To get at that issue, the executive director at Massachusetts Avenue Surgery, Randy Gross, says surgeons at his ambulatory care facility submit regular reports to him. Surgeons who perform operations at that center are told to track their patients and note if infections occurred in the month following the procedure. If an infection happens, which the surgeons would hopefully hear about during follow-up care visits, they note it in the report that is shared with Gross.
As at other ambulatory care sites, that type of report does not go to any central reporting entity. And although a patient may see that same surgeon to get stitches removed or make follow-up care plans, it would fall to the surgeon to ask about infections and file that report. If a patient made an emergency visit to the hospital for the infection, for example, that incident may not necessarily make its way back to the surgeon. Even when the facility does learn of an infection, that data may never go anywhere. It could alert that one facility to a problem they could address—such as a sterilization issue—but does not allow policy makers to assess if there are large-scale issues.
Infections arise
Myra Gross, no relation to Randy, knows too well how seriously ambulatory surgery can go awry. She arrived at a New Jersey–based center in 2012 for a routine colonoscopy. All went according to plan during the procedure, she said in an interview with Scientific American, but several days later she developed an infection. Further testing from the facility revealed it was caused by the organism Clostridium difficile, a strain of bacterium particularly resistant to antibiotics.
The facility where she received the procedure, the Cooper Digestive Health Institute, declined to comment on specifics of this incident, citing patient privacy laws. But in a statement sent by its legal office it said, “There are no required external or voluntary reporting mechanisms for infection with respect to colonoscopy procedures.” And when asked about if they follow up with patients in any standardized way to track infection, their legal office wrote in a statement that the facility calls a patient “within 24 hours of the procedure to screen for any complications and answer any questions” and patients are also instructed to call with any follow-up concerns. Unfortunately, infections that occur in the days or weeks following a procedure could be missed if follow-up lasts for only 24 hours.
Certainly, once a patient goes home it can be tricky to track if she has negative side effects, regardless of where she received the operation. The challenge, however, is particularly amplified at an ambulatory surgery setting. “When getting surgery at an ambulatory surgical center you’re leaving in a matter of hours, so clearly you won’t be developing signs and symptoms of infection before you leave,” says Daniel Pollack, surveillance branch chief in the U.S. Centers for Disease Control’s Division of Healthcare Quality Promotion. The Ambulatory Surgery Care Association, an industry association representing such centers, says it does not collect such information because there is no standard way of reporting it. And so it is not possible for patients to know if a particular facility, or type of operation, could be risky.
When it comes to tracking these infections, “It’s an area we recognize as a gap in our knowledge of understanding,” says Arjun Srinivasan, CDC’s associate director for Healthcare Associated Infection Prevention Programs. Part of the problem is the way the U.S. health care systems does its tracking on the subject. Although CDC and several states have recently started keeping records on community-associated infections, they do not record the data in a way that would let someone connect a particular infection to a specific outpatient procedure or vice versa.
Without robust data pinpointing any infection trends, it is difficult to convince anyone of the need to act. “We have no problem,” says Massachusetts Avenue Surgery’s Gross. “Why make more bureaucracy for a problem we don’t have?” he asks. In addition, CDC’s Pollack says he is not sure that a system mirroring hospitals’ tracking would necessarily be the best way to address this issue. “That’s a question that I think is still open to an ongoing exploration,” he says. “To date, I think that experience suggests the yield [for infections] will be fairly low for those procedures that would be included.”
On a bright April morning, hours after undergoing a knee operation performed by the same surgeon who operated on her husband’s shoulder, Lori Moore-Merrell was resting in the ambulatory center’s recovery room. “This is hands-down better than a hospital,” she said. “There are no long waits alone and this appears to be more efficient,” she added, leaning back against one of the four cushy, beige-colored reclining chairs. “It’s not a hospital experience,” Merrell agreed.
Going forward, policy makers will have to decide if that’s a good thing.