The Hospital V The Ambulatory Surgical Center

An article published in a small New Jersey rag called the Star Ledger on December 20th 2014 entitled ‘Feds penalize 23 NJ hospitals for infections, errors’ describes the unacceptably high rate of hospital acquired infection observed in certain hospitals in the state of New Jersey. A report from the US Department of Health and Human Services assessed a penalty of 1 percent of the hospitals annual Medicare payment. This newly implemented federal policy is a key part of the efforts of the Affordable Health Care Act to reduce the excessive costs associated with the high incidence of nosocomial(hospital acquired) infections which have been conservatively demonstrated to add 5 percent to the overall annual health budget.

Included on the list are some of the most prestigious and largest hospitals in the state, which maintain aggressive marketing programs detailing their ranking on national lists.

The issue of hospital acquired infections has been a contentious issue in the NJ as a part of the battle between the corporations that own the hospitals and the less organized ambulatory surgical centers, a significant number of which are owned by physician groups. From 2000 to 2009 there had been a rapid increase in the number of ambulatory surgical centers which diverted business away from the large hospital corporations who in turn used their political and financial clout to lobby the politicians in Trenton to enact a piece of legislation in 2009 that prevented the issuance by the state of any further licenses for the development of ambulatory surgical centers unless they had a hospital partner. This unfortunate but purely political piece of business skullduggery brought down the drawbridge on an innovative and cost effective model of healthcare delivery that is now being demanded within the remits of the AHA.

The investigation by the Department of Human and Health Services is a damning report of the quality of one of the most critical indices of care a clinical institute delivers. The poor ratings given to the largest hospital corporations in the state support the main thrust of the argument between their institutions and the ambulatory surgical centers which includes the following three points:

  • The ASC has a lower infection rate than the hospital

  • The ASC is a more cost effective healthcare delivery model

  • The ASC has a lower mortality rate than the hospital

These facts that are widely supported in the medical literature are clinically consistent with the difference in patient flow and system mechanics of the hospital versus the ambulatory surgical center. The main fact that accounts for the markedly reduced infection rate in the ASC is the limited time that the patient spends in the institution which minimizes their exposure to pathogens from other patients. The ability to discharge patients in a much shorter time frame has evolved over the last decade due to improved anesthetics and the emergence of minimally invasive surgical technologies. These advances reduce the level of post operative pain and blood loss thus allowing the patient to safely discharged within a 12 hour period which essentially prevents almost any interaction with foreign pathogens. The number of infection related surgical re-operations in the ASC is approximately a tenth of that observed in hospitals, which partly explains the reduced cost of performing a particular surgery in either type of facility.

The ASC model is very likely going to be the model of most future healthcare delivery as minimally invasive techniques and portable imaging devices evolve, that have lower energy requirements and cost when compared to a hospital. The cumbersome ventilation systems of most hospitals are centrally involved in the ease with which infective pathogens spread between patients, particularly the immune-compromised populations, while the ventilation configuration of an ASC is far simpler and easier to maintain with regular inspections.

The science and medicine of the numerous clinical advantages of the ASC are well documented in the medical literature, and so one can only assume that the odd state of affairs in NJ with the passing of pieces of legislation hostile to the ASC model has nothing to do with logical scientific thought but everything to do with money.

However the state has, I believe, done its citizens a great disservice in acquiescing to the political and financial muscle that the hospital and the auto insurance companies flexed in Trenton over the last decade. The insurance companies, without question, have no concern other than their financial bottom line, and should not be involved in the clinical decision making process, which with the recent issue of infection in NJ hospitals confirms their disregard for the most important part of healthcare, which is the patient. The ASC community in NJ had a proven decade long track record of superior clinical outcomes, lower costs and patient satisfaction surveys that outshone even the most highly regarded NJ hospitals, a number of which have appeared on the HHS list

To illustrate the marked difference in hospital v ASC infection rate an article published in the Bergen Record in 2011 describes the 0 percent infection rate of a Medicare certified, AAAHC accredited ambulatory surgical center in Pompton Lakes New Jersey. This statistic is evidence of the clinical effectiveness of the outpatient surgical model and as the US moves further into the implementation of the AHA it will undoubtedly seek guidance from the experts with the knowledge and history of administering 0 percent facilities

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