By Don Sadler
The volume of outpatient procedures performed in ambulatory surgery centers (ASCs) has risen drastically in recent years. Over the past three decades, the number of outpatient surgeries performed in ASCs has tripled to more than 54 million each year – nearly equaling the number of surgeries performed in traditional hospital settings.
This growth is expected to continue with the ASC space projected to grow at a 7% compound annual growth rate (CAGR) over the next three years – from $36 billion today to nearly $59 billion by 2028.
Safe and Efficient Alternative
There are lots of reasons for the rise in outpatient surgeries. However, it boils down to the fact that ASCs offer a safe, efficient and cost-effective alternative to inpatient hospital surgery for appropriate cases.
“Patients are increasingly choosing the ASC environment due to its transparency and lower costs,” says Kelly Kapp, CNOR, CNAMB, the director of clinical education for SCA Health in Birmingham, Alabama.
ASCs provide upfront pricing and a streamlined experience, which ensures that patients and their families are at the center of care.
“This approach allows patients to be actively involved throughout the entire process, from financial aspects to their clinical care,” says Kapp
“For the right types of surgeries, the ASC setting makes healthcare easier to navigate and often feel more personalized,” says Renae Battié, MN, RN, CNOR, FAAN, the vice president of nursing for the Association of periOperative Registered Nurses (AORN). “Advancements in anesthesia techniques, medications and minimally invasive procedures have increased the number of surgeries that can be safely performed in this environment.”
Outpatient surgery was first introduced in the 1970s as a low-cost alternative to inpatient hospital procedures for minor, less-invasive surgeries. Its popularity surged after Medicare started covering procedures performed in ASCs in 1982.
The COVID-19 pandemic resulted in another boom in ASC growth.
“This taught everybody a big lesson in the fact that hospitals can get shut down in a pandemic and those who needed elective surgeries couldn’t get them,” says Beverly Kirchner, MSN, RN, CNOR, CNAMB, vice president of compliance with SurgeryDirect, who has helped open around 50 ASCs throughout her career. “But ASCs reopened quickly because we weren’t taking care of critically ill patients, but basically healthy patients who just needed surgery.”
This reinforced the message Kirchner has been delivering since opening her first ASC in the 1980s – “the future of surgery is outpatient,” she says.
New Procedure Codes Expand Case Mixes
ASCs are monitored and accredited by the Centers for Medicare and Medicaid Services (CMS), which continues to introduce new procedure codes for ASCs each year.
“These will enable further expansion in case mixes and make ASCs more comparable to hospital caseloads,” says Kapp. “Commercial payers are also expanding ASC coverage to contain costs, further incentivizing the shift from hospitals to ASCs.”
A wide range of different types of surgeries can now be performed in ASCs, ranging from low-acuity, minimally invasive interventions to increasingly complex surgeries.
“Advances in technology, robotics, imaging systems and AI-powered tools are enabling ASCs to handle more complex cases safely and efficiently,” says Kapp.
The most common types of surgeries performed in ASCs are GI endoscopy, cataracts, hernia repair, gallbladder removal, lumpectomy and orthopedic procedures, such as tendon and joint repairs.
“Knee, shoulder and ankle arthroscopies are the ‘meat and potatoes’ of procedures performed in ASCs,” says Kapp. “However, higher acuity cases including cardiovascular and complex spine surgeries are increasingly being performed in ASCs.”
According to Jeanine Watson, MSN, RN, CNOR(E), senior manager of the ambulatory surgery division at AORN, ASCs primarily focus on procedures that are minimally invasive, have low complication risks and allow for same-day discharge.
“The most common ASC specialties include orthopedic, ophthalmology and gastroenterology,” says Watson. “These procedures are well suited to the ASC model because they typically don’t require extended recovery or overnight hospitalization.”
Kirchner says robotics have been a real game-changer, allowing ASCs to safely perform thoracic spine surgeries that have a high complication rate. “We’ve really perfected spine surgeries in our facilities,” she says, noting that the surgery centers she oversees performed more than 1,200 spine cases last year.
“This is more than most big hospital systems,” she says. “Our spine patients did very, very well.”
Pain management is another growing area for surgery centers.
“This is bringing more spine surgeons into ASCs because some of the new spine stimulators require more than just a pain doctor,” says Kirchner.
Limitations of ASCs
Of course, there are certain surgeries that still must be performed in hospitals. These mainly include complex, high-risk and emergency cases along with trauma, cardiac and transplant surgeries.
“I don’t think we’re ever going to perform open-heart surgery or brain surgery in an ASC,” says Kirchner. “But who knows?”
Watson says there are clear limitations to what kinds of surgeries can be performed in an ASC.
“Procedures that are designated as inpatient-only by CMS or Medicare are excluded from ASC coverage,” she says. “So are surgeries that involve major blood vessels or deep invasion of body cavities, or that pose significant safety risks, such as surgeries requiring continuous medical monitoring beyond midnight. These must be performed in a hospital setting.”
Additionally, patients with complex medical histories or who are considered high-risk may not be appropriate candidates for surgery in an ASC. “These patients are better served in a hospital environment where comprehensive resources are available,” says Watson.
Patient selection plays a key role in determining whether a surgery should be performed in a hospital or ASC. “Typically, healthier patients with fewer risks and less comorbidities are good candidates for the ASC,” says Kapp.
Cindy Hess, MSN, FNP-C, CNAMB, the director of nursing at the Northeast Missouri Ambulatory Surgery Center in Hannibal, Missouri, notes that ASC patients must be discharged within 24 hours after the surgery’s completion.
“Surgeries that require specialized resources and equipment the ASC may not have, or surgeries involving patients with higher risk comorbidities, should be evaluated to make sure a hospital setting would not be more appropriate,” says Hess. “It’s extremely important to evaluate the surgery and patient to make sure they are an appropriate candidate for the ASC setting and do not require a hospital stay.”
Battié agrees.
“Outpatient surgery may not be the best option for patients undergoing complex procedures or patients with chronic conditions, limited home support or a history of surgical complications,” Battié says. “In these situations, an inpatient setting is often preferred because it provides broader expertise along with around-the-clock care and emergency support.”
Benefits and Drawbacks of Outpatient Surgery
Outpatient surgery offers a number of patient benefits, assuming that the patient and type of procedure are appropriate for an ASC. Battié lists five specific benefits.
“First, patients are able to return home more quickly to recover in a familiar and comfortable environment,” she says. “Second, outpatient surgery is generally less expensive because there is no overnight stay or additional facility fees. Third, patients face a reduced risk of hospital-acquired infections since there is less exposure to acutely ill patients and a shorter stay in a less acute setting.”
“Fourth, there’s less disruption to daily life so patients can return to normal activities sooner, take fewer days off work and more easily navigate the smaller healthcare setting,” says Battié. “And finally, ASCs often provide more personalized and efficient care by specializing in specific procedures, streamlining processes, reducing wait times and ensuring access to focused expertise and equipment.”
According to Kapp, ASCs offer patients lower cost, fast scheduling, shorter wait times and a culture of safety.
“Overall lower costs and facility fees usually make ASCs a more affordable option for patients,” she says, noting studies that have shown outpatient procedures performed in ASCs can cost 30 percent to 60 percent less than the same procedures performed in hospitals.
“Also, the quality of care provided in an ASC is often considered superior to that of hospitals,” says Kapp. “For example, there tend to be lower infection rates due to high-quality standards, fast turnovers and efficient procedures.”
A misconception among some patients is that ASCs are less safe than hospitals. “ASCs are accredited and licensed by the CMS so they maintain the same high-quality standards as hospitals,” says Kapp. “Procedures are performed on carefully selected patients to minimize complications.”
Despite these benefits, there are potential risks and drawbacks to outpatient surgeries performed in ASCs. One of the biggest drawbacks is the limited ability to respond to medical emergencies during surgery.
“ASCs are not equipped with intensive care units or emergency departments,” says Kapp. “So, if patients experience serious complications during or after surgery, they must be transferred to a hospital, which can delay critical care. This is why patient selection is so critically important.”
According to an article published by KFF Health News, ASCs dial 911 thousands of times each year for emergency assistance when patients experience post-op complications, ranging from minor to fatal.
A joint investigation by Kaiser Health News and USA Today revealed more than 260 patient deaths linked to routine outpatient surgeries between 2013 and 2018. According to the investigation, some ASCs are expanding their business by performing riskier surgeries that have sometimes proven fatal.
While Medicare requires ASCs to make arrangements for a local hospital to take patients when emergencies arise, these hospitals can be many miles away from the facility in rural areas. Even when the hospital is nearby, vital minutes waiting for emergency personnel and in transport can result in severe complications and even patient deaths.
Key Differences Between ASCs and Hospitals
While the surgical procedures themselves are essentially the same in ASCs and hospitals, there are a number of key differences between the two environments that affect how perioperative nurses perform their jobs. “Hospitals and ASCs provide different types of professional experiences that can align with a nurse’s personality, goals, lifestyle and interests,” says Battié.
For starters, ASCs tend to offer more predictable schedules since most operate Monday through Friday with no nights, weekends or holidays. “This is compared to hospitals where on-call shifts, emergency cases and a wider range of procedures are common,” says Battié. “Also, ASC teams are typically smaller, which fosters close collaboration and trust, and there are often more opportunities for cross training.”
In contrast, hospitals provide exposure to a wider range of surgical cases that can enhance skill development and offer greater networking and mentoring opportunities. “Larger teams and specialty areas in hospitals support complex procedures and emergencies, creating more opportunities for growth, specialization, education and management,” says Battié.
According to Hess, the culture of an ASC requires clinical staff, administration and office staff to perform multiple roles. “This improves efficiency, teamwork and continuity of care,” she says. “There aren’t as many layers in an ASC, which results in faster decision making and more direct communication.”
On the other hand, perioperative nurses who want more defined roles (e.g., being on the heart, ortho or transplant team) are likely to find these in a hospital setting.
Hess asked her team members to describe the pros and cons of working in an ASC: “Some said the ASC offers more of a ‘family setting’ and they feel more connected to coworkers, surgeons and management here. And some said they feel more ‘invested’ in the surgery center and its success.”
Some ASC drawbacks mentioned by Hess’ staff were that they may be asked to fulfill multiple roles and help out in other areas during downtime, and they may not be able to work on more complex cases.
“ASC nurses appreciate the predictable work schedule – this work-life balance makes positions in an ASC very appealing to many OR nurses,” says Kapp. “Due to the structure of the ASC, nurses develop a broader skill set and establish strong relationships with patients and surgical teams. As a result, they may experience greater job fulfillment and lower levels of burnout.”
Hess says her facility frequently receives comments from patients stating that the staff made them feel comfortable and at ease. “Having been a patient recently myself in both a hospital setting and an ASC, I completely agree with what our patients have stated in these surveys,” she says.
