The Ambulatory Surgery Center

How to select equipment, financing, and even music for your very own OR

The two significant capital costs of building an ambulatory surgery center (ASC) are the building and the surgical equipment. After you’ve spent the money, however, the asset values diverge. The building and land will likely appreciate, whereas the surgical equipment may depreciate or become obsolete. With to-day’s rapid pace of surgical advances, equipment obsolescence may occur before your accountant can depreciate the asset.

For this reason, the surgeon–investor should make careful, well-researched decisions about ASC equipment, such as whether to buy, lease, or rent. For brand-new, state-of-the-art equipment that is marketed as “must buy,” let the buyer beware. Today’s latest technological operating room (OR) gadget may be a paperweight on your desk in 3 years. That’s the bad news. The good news is that there are several financially attractive ways to reduce capital equipment costs.

The Big Four

Just four items will eat up more than 50% of your equipment budget. Despite recent increases in complexity (and cost), OR tables and lights usually have a very long, reliable life span. Some 20-year-old tables and lights are still in use today.

On the other hand, serviceability and safety compliance issues largely limit an anesthesia machine’s life span. For this reason, the manufacturer may not carry parts for anesthesia machines that are more than 15 years old. Anesthesia machines also have to be serviced and certified on an annual basis. Once support is dropped, it becomes more and more difficult to service and certify the machine.

A reliable autoclave is an often-overlooked component of the surgery center, but you cannot overestimate its importance. When a sterilizer breaks down, all of your surgeries come to a halt.

Here are some general features of these equipment categories that you should understand and appreciate.

OR Tables

The OR table is a significant expense for the practicing surgeon. It comes in three types: purely manual, purely electrical, and electrical with battery power. Each table has its advantages, disadvantages, and safety features.

Purely manual operating tables are reliable, mainly because there are few, if any, electronic components to potentially fail. But difficulty may arise when the table’s position is changed during an operation, or if secondary or tertiary attachments are needed to change its function.

Electrical operating tables are relatively user-friendly and have multiple hinges with many degrees of motion that can be easily changed during surgery. The tables have positioning-speed adjustments so that low speeds can be used during microsurgery procedures. C-arm compatibility is important if your surgery center will be used in conjunction with orthopedic or vascular procedures that require fluoroscopy.

The newer electrical op-erating tables are powered by batteries; the batteries are charged at night and run the table during the day. The advantage is that fewer cords are needed, allowing easy changing of table positions (such as during procedures of the head, neck, or face). There are also fewer cumbersome cords to become entangled and fewer obstacles beneath the surgeon’s feet.

The battery-operated table will last through approximately 50–70 procedures without requiring recharging. The cordless, battery-powered system is safe because it eliminates the possibility of fire and electrical hazards if the electrical cord comes in contact with irrigation fluids that inadvertently end up on the OR floor.

The newest modifications to OR tables include the integration of entire table systems with patient-transport systems. The operating table system consists of interchangeable tabletops docked to a fixed or mobile column base via a maneuverable transporter. The theory behind this table system is an improved workflow through parallel perioperative processing. A patient can be intubated in one room, transported to the OR, and finally moved to a postoperative recovery room without having to be moved to or from the table. This may be an advantage for high-volume centers and may obviate the need for patient transport.

Anesthesia Machine Obsolescence
Lack of any of these essential safety features
Safety Feature	Rationale
Minimum oxygen-ratio device on a machine that can deliver nitrous oxide Oxygen-failure safety device Oxygen supply pressure failure alarm Vaporizer interlock device     Pin index safety system   Noninterchangeable, gas-specific connectors on the gas-pipeline inlets	Hypoxia has been a major cause of patient death or severe brain injury during anesthesia. An anesthesia machine that cannot deliver oxygen must automatically be rendered incapable of delivering nitrous oxide as well. Anesthesia machines unable to signal a depleted oxygen supply (usually from an exhausted cylinder) can result in the delivery of a hypoxic mixture. This event can occur even with piped-in gases. An oxygen-failure safety device prevents this hazard by stopping the flow of nitrous oxide when there is a loss of oxygen supply. Whereas the supply of oxygen from a pipeline system or cylinders is usually very reliable, interruptions in that supply can occur. Given the critical nature of oxygen delivery, the operator of an anesthesia machine should immediately be made aware of the failure of the central oxygen supply so that appropriate remedial measures (such as opening a cylinder, reducing the use of oxygen, or obtaining additional cylinders) can be taken. Turning on two vaporizers at the same time can result in the delivery of dangerously high anesthetic vapor concentrations and contamination of the downstream vaporizer. This system is needed to prevent mounting a cylinder on an incorrect yoke. These connectors are needed to prevent the attachment of an incorrect gas-delivery hose to the machine.
Presence of any of these unacceptable features
Unacceptable Feature	Rationale
Measured flow (flowmeter-controlled) vaporizers More than one flow-control knob for a single gas delivered to the common gas outlet of the machine Vaporizer with rotary concentration dials such that the anesthetic vapor concentration increases when the dial is turned clockwise	These vaporizers have not been manufactured for some time, and servicing is no longer available. Many anesthesia providers are not sufficiently familiar with them to use them correctly, which may result in delivery of inadequately low or dangerously high anesthetic vapor concentrations. Some of these vaporizers lack the side-fill feature needed to prevent accidental overfilling and spilling of liquid anesthetic into the breathing system. Having more than one flow-control knob for a gas may result in the delivery of an unintended high or low flow of gas. Parallel flowmeters may cause ambiguity because on all recently manufactured machines, flowmeters are in series, with one flow-control knob for each gas delivered to the machine’s common gas outlet. All vaporizers manufactured in recent years are designed to deliver increased vapor concentration when the dial is turned counterclockwise. Uniformity in vaporizer controls prevents errors and increases safety.
Adequate maintenance is no longer possible
Connection(s) in the scavenging system of the same diameter (such as 15 mm or 22 mm) as a breathing-system connection The manufacturer or certified service personnel will not or cannot service the machine with acceptable replacement parts so that it performs within the tolerances to which it was originally designed	Having 15- or 22-mm-diameter connections in the scavenging system can result in incorrect connections between the breathing system and the scavenging system, potentially resulting in negative or high pressure in the breathing system. Current standards mandate 30-mm (preferred) or 19-mm connections in the scavenging system. Rationale: A machine that cannot be serviced or for which replacement parts are not available cannot be maintained according to the standards and specifications to which it was originally designed, and is therefore dangerous.
Adapted from the American Society of Anesthesiologists’ guidelines for determining anesthesia machine obsolescence. Developed by the ASA Committee on Equipment and Facilities.

Anesthesia Machines

Patient safety is of paramount importance, and a reliable anesthesia machine is necessary for every surgical center. It is the responsibility of the anesthesia provider and the surgery center’s operating officers to determine whether a machine’s failure to meet newer standards represents a sufficient threat to patient safety and renders the machine obsolete. Integral monitors (such as electrocardiograph, oxygen monitor, blood pressure monitor, pulse oximeter, and carbon dioxide monitor) are essential components for safe anesthesia delivery, but are not components of the vapor-delivery system contained in the anesthesia machine.

The American Society of Anesthe­siologists has developed criteria for determining whether an anesthesia machine is obsolete, as shown in the table on the left. Before you purchase an anesthesia machine, it is important for you to understand the anesthesiology requirements for the common operations of the center. It will be the responsibility of the anesthesiologists and the technicians to update, troubleshoot, and re-evaluate the machine.

OR Lighting

OR lights are of paramount importance for the surgeon, and are often insufficient. We believe that a significant proportion of the initial surgery center cost should be allocated to OR lighting. 

Today’s lighting systems are much more than simply a light source: They are tailored to accommodate specific surgical procedures, and they contain a wealth of features, including liquid-crystal display (LCD) screens and digital video cameras. Because many imaging centers are recording images on CD-ROM, these LCD displays eliminate the need for a light box in the OR because they can display preoperative images. With the right in-office mainframe computer, photos may be displayed during rhinoplasties, rhytidectomies, and other body-contouring procedures.

Driven by a variety of technologies, major surgery lights are designed to produce soft, high-intensity white light that provides true color with minimal heat, shadows, and glare. Options include single-, double-, and triple-lighthead configurations that are avalable with wall, ceiling, and stand mounts. Illumination of 100,000 lux at a distance of 1 m from the light source is the minimum required by the Illumination Engineering Society of North America; some lights provide considerably more illumination than that.

It is important to consider a light’s rotation capabilities—many rotate 360° at the lighthead axis. Look for lights made of lightweight, yet durable materials that provide drift-free capabilities. Newer lighting uses a technology called “gas-discharge lighting.” Instead of heating a filament, the electric current ionizes a canister of gas to emit light. One advantage is that there are no physical parts to fail because of heating and cooling. More important, gas-discharge lights use only 70 W to generate the optimum illumination of 160,000 lux with very little heat. A conventional 150-W bulb is needed to generate the same illumination.

Sterilizers

Before you purchase a sterilizer, you should determine your requirements. Will it run only a few days per week, or will it run 24/7? What is your turnover time? What types of equipment will you be sterilizing? Stainless steel? Endoscopes? Ceramics?

Every surgery center should be equipped with an excellent sterilizer. The vast majority of OR sterilizers are steam-based. Steam has been an excellent method of sterilization, and has withstood the test of time, but some newer OR devices are not compatible with steam sterilization and require a second sterilizer.

Before you purchase a steam sterilizer, it is important to know your surgery center’s capability to produce the steam. Does it have a steam boiler system, or will a self-contained steam generator be needed? Ceramic tools, electronic equipment, minimally invasive surgical instruments, and plastic devices such as sterile Doppler ultrasound probes and endoscopes cannot withstand the high temperature and moist environment of steam sterilization. The purchase of a sterilizer requires knowledge of frequently used equipment and its appropriate sterilization methods.

The latest sterilizer technologies use steam, ethylene oxide, ozone, peracetic acid, gamma radiation, or vaporized hydrogen peroxide as sterilizing agents. Ethylene oxide has been used for sterilization for some time. It obviates the need for large quantities of heat for sterilizing instruments, but it and its byproducts are toxic—a situation that we recommend avoiding.

The new ozone sterilizers show a good deal of promise. Ozone is toxic, but it is consumed as rapidly as it is generated and its major breakdown products are oxygen and water. The concept appears to be both effective and safe, but it is new and has not been widely tested.

Sterilization speed is also very important in sterilizer selection. Rapid sterilization can improve OR turnover time and often requires the surgeon to stock only a limited number of instruments. A significant overhead cost for surgery centers is employee time to sterilize and package equipment, so reducing turnover time can provide considerable cost savings.

As with any significant purchase, the vendor of the sterilizer should be able to provide references, guides, and manuals, and should support the equipment by offering parts and repair service.

Used Equipment?

Unlike building costs, there are several ways to dramatically reduce capital outlays for ASC equipment. High-quality refurbished OR equipment can save you 50% or more compared with new equipment. There is a large trade in used medical equipment, but again, let the buyer beware. You may find the best price for a used anesthesia machine on eBay, but it may not have been refurbished. Even worse, service and parts support for some older models of anesthesia machines may no longer be available. As a result, your bargain on eBay may be a bust.

For the novice buyer in the used ASC equipment market, the safest search should start with these questions for the seller:

• Do you refurbish and repair the used equipment you sell?

• Do you provide a warranty on the used equipment? If so, how long is the warranty valid? 90 days? 5 years?

• What does the warranty cover? Parts? Labor?

• Will you repair it if it breaks? On-site?

• Will you provide a “loaner” while the equipment is being repaired?

• How long have you been in business?

• Can you provide several references whom I can call?

• Do you offer discounts for “package purchases” (equipment for the whole OR)?

• Will your company bid competitively for the equipment purchase?

New Equipment?

There are other considerations if you decide that you want new equipment. Several OR-equipment manufacturers have begun to develop new equipment-financing options that are based on equipment use. These creative solutions allow you to pay as you use new equipment. For this reason, you should ask yourself these questions before you purchase new OR equipment:

• How often will I use the new equipment? OR tables are used for every surgery, but a laser may be used only once per month.

• If the equipment is used infrequently, can I set up a “pay-as-you-use” plan with the seller?

• How much up-front capital cost can I save with an equipment lease? Do I have the option to buy, return, or replace the equipment at the end of the lease?

• How much longer will the new equipment last compared with used equipment?

• Is the equipment likely to become obsolete? Examples might be lasers, computers, and electronic video equipment.

• Will the new equipment save OR turnover time compared with older models of the same equipment?

• Will the new equipment save employee costs, such as equipment-cleaning time, record-keeping time, and workers’ compensation costs?

• Will the new equipment improve safety? Examples might be reducing patient falls and Bovie burns, and employee back injuries.

• Will the new equipment reduce hazardous biological waste and help comply with mandated federal waste-reduction laws? If it does, how much money will this reduction save?

• Is the new equipment compatible with other equipment platforms? Examples might be fiber-optic light sources, cords, lighted retractors, and endoscopes.

Sharing the Space

We all enjoy performing surgery, but patients need to be accurately assessed and evaluated in preoperative and postoperative office visits. On the days when you are seeing patients in your office, the surgery center is not being amortized, but the monthly bills for surgical equipment are accruing. Many surgeons in your community may wish to use the space and equipment in your surgery center.

Centers designed for plastic surgeons can be used by otolaryngologists and head and neck specialists who often require the same endoscopes and surgical instruments. Limited vascular procedures such as vein stripping or harvesting may be a nice accompaniment to the center. The use of the facility by these surgeons can help pay for equipment overhead; also, they won’t have to invest in their own equipment.

A center equipped with sophisticated endoscopes may be suitable for gastroenterology endoscopists, but separate rooms should be allocated at all times to reduce the risk of infection. Therefore, we advocate sharing individual rooms only with specialists who perform Class I operations.

Music in the OR

In our experience, surgeons and other OR personnel are more productive, enthusiastic, and happy when music is being played in the OR. Often, patients who are under local anesthesia or light sedation request music during the operation. It is essential that the music is adjusted so that it is not too loud or distracting for the surgeons. Also, it shouldn’t interfere with the staff’s ability to hear anesthesia-machine alarms, such as pulse oximeters or blood-pressure alarms.

On many occasions during long reconstructive cases, the OR staff have thanked us for playing music on our portable MP3 players. Many surgery centers choose to install sound systems with multiple CD players or portable boom boxes. In our experience, we have found portable MP3 players and their docking stations to be an excellent accompaniment to the surgery center. For ambulatory surgery centers, a portable MP3 docking system can be kept in each OR for little cost. The surgeon, anesthesiologist, and staff members can bring in their portable MP3 players.

Expensive, but Worth It

The capital equipment costs required for an ambulatory surgery center are significant and are often daunting for surgeons with little or no experience with these facilities. A fundamental knowledge of the four most expensive components of an ambulatory surgery center is essential for overall patient outcome, patient safety, and surgery center efficiency.

The ambulatory surgery center’s work environment should be pleasant, healthy, and productive. In our experience, meticulous attention to detail and proper OR construction can ensure a healthful and enjoyable work environment for everyone. Thorough consideration for the OR setup  and careful construction allow all involved  in the surgery center to spend more time operating and less time repairing and organizing. PSP

James P. Watson, MD, is an associate clinical professor in the Division of Plastic and Reconstructive Surgery of the University of California—Los Angeles David Geffen School of Medicine. He is also the chief of plastic surgery at Harbor-UCLA Medical Center and chair of the UCLA Plastic Surgery Residency Education Committee. He received his undergraduate degree in chemistry at Southern College (Chatta­nooga, Tenn) and his medical degree at Loma Linda University School of Medicine (Loma Linda, Calif). He can be reached at (310) 206-7520.

Brian P. Dickinson, MD, received his undergraduate degree in neuroscience at Brown University (Providence, RI) and completed medical school at the Mount Sinai School of Medicine (New York City). He is currently a resident surgeon in the Division of Plastic and Reconstructive Surgery of the University of California—Los Angeles David Geffen School of Medicine. He can be reached at [email protected].

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