Surgeries that were once performed only in a hospital or surgery center are becoming more common in converted examining rooms, surgical suites in physicians' offices or outpatient surgery centers.

Many of these procedures require general anesthesia or intravenous (IV) sedation. Yet, in most states, there are no standards, regulations, or accreditation requirements for surgeries performed in physician offices.

"It used to be that the only [procedures] done in physician offices were dermatologic or plastic surgery, primarily under a local anesthetic," says Rebecca Twersky, MD, a New York-based anesthesiologist who helped write the American Society of Anesthesiologists' guidelines for office-based anesthesia. "Now we're seeing oral surgery, orthopedics, podiatry, and general surgery."

Safety Concerns

Dr. Twersky warns that without the same safety regulations as hospital surgery, office-based surgeries could cause serious complications. There have already been reports of deaths resulting from the following situations:

  • Staff was unprepared and untrained to manage cardiac arrest or breathing problems.
  • Staff called 911 too late or not at all, for fear of reporting.
  • Drugs and/or equipment were outdated.
  • Lengthy surgery in medically unfit patients.

Why Have Surgery in the Office?

The trend toward office-based surgery is driven by several factors, including:

  • Patients' wishes for privacy and convenience
  • Flexibility in scheduling
  • Wider availability of smaller patient monitors and other surgical and anesthesia equipment
  • Newer anesthetics that work faster and wear off more quickly

But the biggest reason for the increasing popularity of office-based surgery may be cost.

A procedure performed in an outpatient surgery setting costs up to half of what it costs in the hospital, says Ronald E. Iverson, MD, a plastic surgeon in Pleasanton, California, and former president of the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF). Performing surgery in the doctor's office saves even more money. Physicians also like scheduling their own surgeries on their own time, according to Dr. Iverson.

Standards Are Needed

What worries Twersky, Iverson, and others is the lack of state or federal oversight of office surgeries. Dr. Iverson says that these procedures should be governed by the same standards as those performed in ambulatory care centers.

Hospitals and surgery centers must meet strict state and federal licensing and accreditation guidelines. They also have medical boards that oversee practitioners' qualifications and credentials. Inconsistent standards exist for office-based surgery. Some states (ie California, Florida, New Jersey, Pennsylvania, Rhode Island and Texas) have addressed the issue of office based surgery and implemented regulatory requirements while others are relatively unregulated.

The Anesthesia Factor

The type of anesthesia used in surgery is an important safety concern, Dr. Iverson explains. Once you move from local anesthesia to IV sedation or general anesthesia, the risk for complications such as respiratory distress or heart attack increases. In rare cases, patients can even have a life-threatening reaction to local anesthesia, says Dr. Twersky.

Who Should Not Have Surgery in a Doctor's Office?

Regardless of how minor the surgery, certain patients, particularly those with serious health conditions, such as diabetes, heart disease, or uncontrolled high blood pressure, shouldn't have surgery in a physician's office, says Dr. Twersky.

Be Informed

Before you have surgery in a doctor's office, the American Society of Anesthesiologists recommends that you ask the following questions:

  • Is the office accredited for surgery and anesthesia? [Note: The following organizations accredit physician office surgery suites: American Association for the Accreditation of Ambulatory Surgery Facilities, Accreditation Association for Ambulatory Health Care, Inc., and the Joint Commission on Accreditation of Healthcare Organizations. There is also state and medicare certification of outpatient surgery centers.
  • Does the doctor have credentials to perform the surgery in a hospital or outpatient surgery center?
  • Will a qualified anesthesiologist or certified registered nurse anesthetist (supervised by an anesthesiologist or other qualified physician) give the anesthesia? (You should meet this person before your surgery, and he or she should remain with you until you wake up.)
  • Is the anesthesia equipment equivalent to that used in a hospital or ambulatory surgical facility?
  • Does the doctor have the necessary equipment and drugs to handle any emergencies?
  • Which hospital will you be admitted to if complications occur?
  • Will qualified and trained staff monitor your recovery?
  • Is the recovery area equipped similarly to one in a hospital or ambulatory surgery facility?
  • Will a physician decide if you're ready to be discharged? (A nurse could follow a doctor's orders based on objective criteria.)
  • Is someone in the office certified in advanced cardiac life support (ACLS)?
  • If a child is having the surgery, is someone trained in pediatric life support? Are equipment and drugs specifically for children available?

"We're not saying don't have the surgery in a physician's office," says Dr. Twersky. "But be aware of the risks involved and make sure that you're safeguarding yourself."