They are less expensive than hospitals. But when a facility isn’t equipped to handle an emergency, the consequences can be deadly.
By Christina Jewett and Mark Alesia. From Kaiser Health News.
The surgery went fine. Her doctors left for the day. Four hours later, Paulina Tam started gasping for air. Internal bleeding was cutting off her windpipe, a well-known complication of the spine surgery she had undergone. But a Medicare inspection report says that nobody who remained on duty that evening at the Northern California surgery center could help. In desperation, a nurse did something that would not happen in a hospital: She dialed 911. By the time an ambulance delivered Tam to the emergency room, the 58-year-old mother of three was lifeless, according to the report.
If Tam had been operated on at a hospital, a few simple steps could have saved her life. But like hundreds of thousands of patients each year, Tam went to one of the nation’s 5,600-plus surgery centers. Surgery centers were created nearly 50 years ago as low-cost alternatives for minor procedures. They now outnumber hospitals, as federal regulators have signed off on an ever-widening array of outpatient surgeries in an effort to cut federal health-care costs.
Thousands of times each year, these centers call 911 when patients experience complications ranging from minor to fatal. Yet no one knows how many people die as a result of those complications, because no national authority tracks the tragic outcomes. An investigation by Kaiser Health News and the USA Today Network in March 2018 discovered that more than 260 patients have died since 2013 after in-and-out procedures done at surgery centers across the country. Dozens of people, some as young as two years old, have perished after routine procedures such as tonsillectomies and colonoscopies.
The investigation—which involved examinations of more than 12,000 state and Medicare inspection records and interviews with dozens of doctors, health-policy experts, and patients—revealed some startling trends. Chief among them: At least 14 patients of the more than 260, counting Tam, died after complex spinal surgeries. At least 25 people with a variety of underlying medical conditions left surgery centers and died within minutes or days. They included an Ohio woman with out-of-control blood pressure, a 49-year-old West Virginia man awaiting a heart transplant, and several children with sleep apnea. Medicare does require surgery centers to line up a local hospital to take their patients when emergencies arise, but in rural areas, centers can be more than 20 miles away from a hospital. Even when one is close, 20 to 30 minutes can pass between a 911 call and arrival at an ER.
Surgery carries risk no matter where it occurs, and most operations done in surgery centers go off without a hitch. Some centers have state-of-the-art equipment and highly trained staff that are better prepared to handle emergencies. But the Kaiser/USA Today study found more than a dozen cases in which the absence of trained staff or emergency equipment appears to have put spine-surgery patients in peril. And in cases similar to Tam’s, patients who had surgery on their upper spines have been sent home too soon, with the risk of suffocation looming.
In 2008, a 35-year-old Oregon father of three struggled for air, pounding the car roof in frustration while his wife sped him to a hospital. Another Oregon man began to suffocate in his living room the night of his upper-spine surgery in 2014. A San Diego man gasped “like a fish,” his wife recalled, as they waited for an ambulance on April 28, 2016.
None of them survived.
Many in the health-care field, from doctors to private insurance companies to Medicare, have dismissed the mounting deaths as medical anomalies beyond the control of physicians. Responding to lawsuits around the nation, surgery centers have argued that fatal complications were among the known outcomes of such surgeries. Two centers blamed patients for negligence in their own demises. Bill Prentice, chief executive officer of the Ambulatory Surgery Center Association, said he has seen no data proving surgery centers are less safe than hospitals. “The human body is a mysterious thing, and a patient that has met every possible protocol can walk in that day and still have something unimaginable happen to them that has nothing to do with the care that’s being provided,” he said.
However, Kenneth Rothfield, MD, a board member of the Physician- Patient Alliance for Health & Safety, said many surgery centers and physicians push the envelope on how much can be done in outpatient centers.
“Surgery centers are not hospitals,” he said. “They have different resources, different equipment.”
Rekhaben Shah, 67, had gone to Oak Tree Surgery Center in Edison, New Jersey, for a simple colonoscopy. After receiving the standard anesthetic, she stopped breathing. The anesthesiologist, Yoori Yim, MD, later testified that she came up empty-handed when she tried to find the right-sized airway tube for Shah, according to an ongoing lawsuit.
Dr. Yim tried a variety of methods to help Shah breathe, with limited success. Paramedics responding to the center’s 911 call ultimately had to use a video GlideScope, equipment the surgery center didn’t have, to see inside Shah’s throat, according to court testimony. What’s more, paramedics testified that Dr. Yim refused to move away from Shah and allow them to attempt life-saving measures. An expert for the surgery center said Shah’s airway was obstructed and was cleared around the time the paramedics arrived. He said the GlideScope is not required in New Jersey, nor would it likely have made a difference. Shah’s family has settled its lawsuit against the center—which denied wrongdoing—under confidential terms.
An expert for Dr. Yim, however, said that her actions were appropriate and if a GlideScope had been at the center, “we would probably not be discussing this case at all.” Instead, from the moment Shah stopped breathing on the operating table, 33 minutes passed before a paramedic effectively inserted a breathing tube, according to medical and EMS records. By then, the family claims, it was too late. Shah was removed from life support at a nearby hospital two days later. She died on Christmas Day 2015.
The explosive growth of surgery centers—which receive $4.3 billion a year from Medicare—has taken place under circumstances some medical experts consider unseemly. Federal law allows surgery-center doctors, unlike others, to steer patients to facilities they own rather than to the full-service hospital down the street. In some cases, doing so could increase the risk to a patient but double a physician’s profits: Doctors who own a share of a center can earn their own fee plus a cut of the facility’s fee, a meaningful sum for operations that can cost $100,000 or more. Prentice said physician ownership of surgery centers is a good thing. “The physicians who practice there are responsible for everything that happens in that surgery center from the moment the patient walks out of their car in the parking lot to the moment they leave,” he said.
But several studies have shown that surgery-center doctors who are owners perform operations more frequently than those who aren’t owners. And in lawsuits across the country, surgery-center doctors have been accused of taking risks with patients.
Larry Teuber, MD, a South Dakota neurosurgeon who worked as an executive in the surgery-center industry for 22 years, said he has watched surgery-center owners take on increasingly complex—and lucrative—orthopedic and spinal surgeries, undercutting a nearby hospital’s profits for their own gain. “The money overshadows everything,” Dr. Teuber said.
The first surgery center in the United States opened in Phoenix in 1970. In 1982, Medicare began paying for procedures at these centers, which helped drive their expansion.
Today, there are more than 5,600 Medicare-certified centers. The expansion has come despite lingering safety concerns. In 2007, Medicare noted that surgery centers “have neither patient safety standards consistent with those in place for hospitals, nor are they required to have the trained staff and equipment needed to provide the breadth and intensity of care.” Some procedures are “unsafe” to be handled at surgery centers, the report concluded.
While the thrum of a hospital continues through the night, some centers’ doctors keep bankers’ hours. That means patients whose surgeries end later in the day are sometimes left in the care of one or two nurses for up to 23 hours.
Medicare advised the centers to transfer patients to hospitals when emergencies arise. Only a third of surgery centers participate in a voluntary effort to report how often that happens. They sent at least 7,000 patients to the hospital in the year that ended in September 2017, a Kaiser Health News analysis shows.
One of the saddest cases reviewed in the investigation happened in 2016 at West Lakes Surgery Center in Iowa. The paramedics arrived as staff tried to revive 12-year-old Reuben Van Veldhuizen after he experienced complications during a tonsillectomy, according to a Medicare inspection report. One paramedic told state inspectors she had to ask who was in charge of the resuscitation efforts. No one replied, the report says. The boy made it to the hospital 37 minutes after the surgery-center staff called 911. There, he was pronounced dead.
The family filed suit, alleging that the center and anesthesiologist erred in giving the boy an anesthetic that carries a warning about cardiac arrest risk in young boys. In court filings, the surgery center and anesthesiologist said Van Veldhuizen’s death was a result of “pre-existing conditions, acts of others, or conditions over which (Defendants) had no control or responsibility.”
Such tragedies rarely find their way into the discussion when Medicare decides whether to approve new procedures at surgery centers. For instance, until 2015, Medicare wouldn’t pay for spinal operations at surgery centers. Then the industry’s trade association urged the agency to make a change and encouraged its members to start a campaign.
Letter writers included Alan Villavicencio, MD, who said he’d been doing such surgeries for 12 years and found that his patients “appreciate the convenience and cost savings.” He did not mention that James Long, 56, had died three weeks earlier after spinal surgery at a Lafayette, Colorado, surgery center where he is an owner, health department and medical board records show.
United Surgical Partners International, a surgery-center chain, urged the approval of even more procedures, not mentioning a patient death hours after a spine surgery at one of its affiliate centers several months before, according to court records and securities filings. The chain said in a statement that it stands behind its comments in support of the proposal.
Such letters carry weight with Medicare, which approves procedures in surgery centers based on the invasiveness and complexity of the surgery and on input from stakeholders.
But Robert Beatty-Walters, an attorney based in Portland, Oregon, who has represented the families of three people who died after spine procedures at surgery centers, said Medicare’s decision-making process is not evenhanded.
“The stakeholders—they call them—during these regulatory proceedings are the profit makers, not the people who are being provided the service,” he said.
Medicare approved ten spine-surgery procedures to be billed at surgery centers starting in 2015 and added more in 2017. In an e-mail, a spokesperson for Medicare said that it had received no comments suggesting the procedures would pose a threat to patients.
And yet in 2014, Paulina Tam had died after a spinal procedure at Fremont Surgery Center. Tam had finished careers as a nurse and as an educator and planned to travel the world with her husband of 32 years. “She was the driving force of the family, the spirit,” said her son, Eric Tam, MD, of New York City. “We didn’t expect the worst to happen.”
Pain from a car crash had bothered Tam for years. Her doctor scheduled her for a procedure to replace two disks in her upper spine on April 7, 2014. Any such surgery—entering the front of the neck to address pain in the spine—comes with a risk of suffocation, according to the Medicare inspection report.
About four hours after her procedure, Tam told a nurse that her surgical collar felt too tight. Then she said she couldn’t breathe. With her surgeon and anesthesiologist already gone for the day, the only doctor on-site was a digestive health specialist, the inspection report shows. A nurse called a code blue just after 6:30 p.m., records say.
Medical experts say the first step in helping such patients is removing the surgical staples so the pooled blood can disperse, allowing the patient to breathe. In Tam’s case, staff repeatedly tried and failed to insert a breathing tube through her mouth and into her airway, the inspection report shows. A last-ditch remedy would have been to punch a hole through the front of her throat to restore breathing, but the gastroenterologist later told an inspector that he “wasn’t prepared” to do so.
The inability to perform the suffocation-rescue maneuver, the inspection report says, amounted to the center’s “failure to ensure patient safety.”
From the time a nurse called 911, it took 24 minutes to get Tam to the nearest hospital, EMS records show. She arrived without a pulse and remained on life support overnight, as her children raced to her bedside to say goodbye.
Tam’s surgeon filed pleadings in court saying Tam’s “carelessness and negligence” caused her death. It’s unclear what the defense meant by negligence. The case reached a confidential settlement. After Tam’s death, the center told Medicare inspectors that a qualified doctor would stay on-site overnight after all upper-spine cases.
Nancy Epstein, MD, chief of neurosurgical and spine care at New York University Winthrop Hospital, said surgery centers’ doing delicate work near the spinal cord, windpipe, and esophagus in a same-day procedure is “pretty revolting.” But she said the centers are making so much money—“reeling it in hand over fist”—that the potential dangers are being ignored.
“Medically, it should not be tolerated,” she said, “but it is.”
Editor’s Note: In November 2018, Medicare completed a review of 38 procedures at surgical centers and determined to keep its approval in effect.
Feb. 1, 2019