The Ins & Outs of Ambulatory Surgery Centers

By Don Sadler

Perioperative nurses have two main options when it comes to the type of operating room environment where they can work: a traditional hospital OR or an ambulatory surgery center (ASC). While there are some clear differences in these two environments, there are also many similarities.

The biggest similarity is the fact that the surgical procedures themselves are the same, regardless of whether they are performed in a hospital OR or an ASC.

“Surgical processes don’t really differ in hospital ORs and ASCs,” notes Sandy Berreth RN, BS, MS, CASC.

“Standards and regulations dictate how hospital ORs and ASCs are structured and maintained, and both have rigorous standards,” Berreth adds. “Our benchmarks are the same — ultimately, it’s about outcomes, accountability and goals to produce and maintain high quality-of-care standards.”

More Outpatient Surgeries

Betty Bozzuto, RN, MBA, a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC), notes that as recently as a decade ago, ASCs were mostly reserved for less-complicated surgical cases.

“But not anymore,” says Bozzuto. “More complicated surgeries are now being done on an outpatient basis due to restrictions by many insurers in paying for overnight hospital stays.”

Bozzuto says that about 60 to 70 percent of all surgery is now done on an outpatient basis.

“So the equipment in an ASC is pretty much the same now as the equipment in a hospital OR. Almost any procedure that’s done outpatient in a hospital OR can now be done in an ASC,” she says.

According to Berreth, if an ASC is planning on having Medicare as a payor, it must be evaluated by Medicare surveyors for quality, infection control, patient safety, governance and physician oversight.

“Only after rigorous screening is an ASC given its certification to proceed with scheduled cases,” she says.

“Many ASCs go even further,” Berreth adds, pointing out that they ask to be surveyed by an outside accrediting organization like The Joint Commission, the AAAHC, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) or the American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP). “While acute care ORs are monitored by The Joint Commission, ASCs are monitored by the Centers for Medicare and Medicaid Services (CMS), these accrediting organizations and a variety of other national and state regulatory bodies.”

While surgical procedures themselves are essentially the same in hospital ORs and ASCs, there are many other things that are different between the two environments.

“Perioperative nurses working in ASCs usually have to wear many different hats,” says Jan Davidson, MSN, RN, CNOR, CASC, the director of the Ambulatory Surgery Division of the Association of periOperative Registered Nurses (AORN).

“Nurse responsibilities in an ASC might include assuming the role of employee health nurse, quality management coordinator, infection prevention specialist and facility risk manager, to name just a few,” says Davidson. “While this might stretch nurses outside of their comfort zone, it also helps broaden their skills and abilities.”

Judy Harless, MBA, CASC, the administrator at SMI Surgery Center in San Diego, Calif., adds that due to their size, hospitals are compartmentalized and assign individuals to a specific set of responsibilities and duties.

“Ambulatory surgery centers optimize staff by cross-training and being team focused,” she says. “Team members are able to jump in where needed, rather than depending on a particular individual to complete a task.”

“This dynamic also lends itself to the team having a broad perspective of what is happening with the case,” Harless continues, “rather than being solely focused on a particular function.”

“In the ASC environment, our teams are smaller so our communication with each other is steady and constantly flowing,” says Rebecca R. Craig, RN, CNOR, CASC, CPC-H, the CEO of Harmony Surgery Center LLC and Peak Surgical Management LLC in Fort Collins, Colo. “Not only does this create a tight-knit team, but it also helps ensure that everyone is kept up-to-speed about the daily events, including patient and physician needs.”

Pros and Cons

Perioperative nurses who have worked in hospital ORs and ASCs are quick to point out some of the pros and cons of each of the different environments.

One of the biggest advantages of working in an ASC is the fact that most ASCs are only open Monday through Friday and are closed on holidays.

“Not having to work weekends or holidays or be on call results in higher nurse satisfaction,” says Craig.

“The work flexibility offered by an ASC is excellent,” says Terresa Roulhac, an OR technician at SMI Surgery Center who has worked in ASCs and hospital ORs. “There are days when cases start earlier, which allows staff to arrive and leave early. Also, with the smaller size of the ASC, staff members become well-rounded and experienced in more than one aspect of the operating room and surgeries.”

However, Roulhac adds that caseloads in ASCs fluctuate and hours are not guaranteed.

“This can be an issue for those who prefer set hours. In a hospital, the caseload is usually set day to day and the hours are more consistent,” she says.

Amy Herbert, an OR RN at SMI Surgery Center who has also worked in both ASCs and hospital ORs, says she likes the fact that ASCs usually provide more continuity of care for patients.

“The surgical nurse has the ability to float into the pre-op and the post-anesthesia care unit,” says Herbert. “The ASC’s smaller size affords the opportunity for nurses to check in with their previous patients while they are in the recovery room.”

In addition, the surgical team members routinely work together in the ASC.

“In a hospital, you may constantly be put with new or less familiar team members, which can be challenging,” says Herbert. “It’s sometimes easier to work within a team when everyone is familiar with each other and their preferences and expectations, since each nurse, surgeon, tech and anesthesiologist has his or her particular way of doing things.”

However, the closeness of the working relationship between team members in the ASC makes it imperative that all team members maintain professional and positive relationships, Herbert adds.

The pace of work is another big difference between the two environments.

“There might be 20 cases in a day in an ASC, compared to just two or three cases in a hospital OR,” says Davidson. “The ASC is a very fast-paced environment, where strong critical thinking and patient assessment skills are required.”

At the same time, though, the hospital OR environment can be more exciting, says Bozzuto, since the focus is often on dealing with emergencies and saving lives.

“This usually doesn’t happen in an ASC, where most of the surgeries are elective and scheduled well in advance,” she says.

“Some OR nurses may miss the rush of being involved in emergency and trauma cases,” adds Herbert.

There is also a heavier administrative component to working in an ASC, Davidson adds. AORN offers a three-day ASC Boot Camp to provide admin training to perioperative nurses working in an ASC for the first time. The boot camps will be offered in April, June and November 2015.

Cruise Liner or Speed Boat?

Berreth says she once worked with a CEO who compared his hospital to a cruise liner.

“It takes a long time to turn a cruise liner — similarly, change in a hospital can take weeks, if not months. But an ASC is more like a speed boat: If something needs to be changed, this can often happen on the spot,” she says.

“In an ASC, processes are constantly being challenged for improvement and communication is essential,” Berreth adds. “As a result, communication between front-line players and management is often optimized in an ASC.”