Malignant Hyperthermia What are the First Signs? ASF SOURCE - SUMMER 2008

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Malignant Hyperthermia
What are the First Signs?
Richard J. Greco, MD
A recent death by a teenager in an
accredited facility undergoing corrective breast surgery has brought the
condition of Malignant Hyperthermia
(MH) to the front of the public's
awareness. Malignant Hyperthermia
is a rare, but potentially lethal, acute
hypermetabolic syndrome. The use of
general anesthesia can trigger these
events in susceptible individuals. We
originally wrote about MH in the summer newsletter in 2004. In order to reeducate and make our facilities aware
of the treatment for MH we decided to
update you on the topic.
The first step in the treatment of this
disease is to understand it and its
genetic transmission. MH, occurs
when a susceptible patient is exposed
to a "triggering" agent. The main, well
documented triggering agents are the
halothane, enflurane, isoflurane,
sevoflurane, desflurane and the depolarizing
Succinylcholine. It is important to elicit a personal or family history of difficulties with general anesthesia.
All patients with a positive family history should be managed as susceptible
to MH. Elective ambulatory surgery is
not contraindicated, but the patient
should be managed with regional
anesthesia or general anesthesia using
non-triggering anesthetic agents.
After an uneventful anesthetic,
patients should be observed for 3-5
hours and, upon discharge, provided
with an emergency telephone number
to contact if problems arise. There
have been discussions regarding the
use of prophylactic pre-treatment with
oral or IV Dantrolene, however, the
current recommendation from the
Malignant Hyperthermia Association
of the United States (MHAUS) is that
prophylactic treatment is not necessary with non-triggering agents,
appropriate monitoring, and an adequate supply of Dantrolene.
The key is to avoid the use of triggering agents. Anesthetic techniques that
are considered safe include: local or
regional anesthesia and monitored
anesthesia care, nitrous oxide, and
deeper anesthesia using intravenous
Continued on page 10
New Study from AAAASF Data
Also In This Issue...
Malignant Hyperthermia..................
Board of Directors..............................
Big Apple M.D. Blues.........................
Legislative Update..............................
AAAASF President’s Message.........
Emergency Therapy For MH.........
Safe Surgeries/New Study................
Education Update...............................
AAAASF Committees........................ 11
Newly Accredited Facilities.............. 13
SFR Global Accreditation.................. 14
ASF Deadlines and Feedback........... 15
News You Can Use, Fee Schedule... 16
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American Association for Accreditation of Ambulatory
Surgery Facilities, Inc.
2008-2009 Board of Directors
Alan H. Gold, M.D., President
Lawrence S. Reed, M.D., Vice President
Harlan Pollock, M.D., Secretary/Treasurer
James A. Yates, M.D., Past President
Richard D’Amico, M.D.
Richard J. Greco, M.D.
Phil C. Haeck, M.D.
Ronald E. Iverson, M.D.
Geoffrey R. Keyes, M.D.
Michael F. McGuire, M.D.
Dennis P. Thompson, M.D.
Edward S. Truppman, M.D.
Gustavo A. Colon, M.D.
Daniel C. Morello, M.D.
Robert Singer, M.D.
Jeff Pearcy, MPA, CAE, Executive Director
ASF Editor
Richard J. Greco, M.D. Publications Committee Chairman
ASF Design/Production Director
Jaime Trevino - Communications Director
The ASF Source is published on a tri-annual basis.
Contributions to the ASF Source are welcome, but
may be edited for clarity and placement purposes.
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, electrostatic,
magnetic tape, photocopying, recording, or otherwise,
without the full written permission from the publisher.
The opinions expressed within are those of the contributors to the ASF Source and do not necessarily reflect the
opinions or views of the AAAASF.
AAAASF Mission Statement: It is the mission of
the Association to develop and implement standards
of excellence for quality patient care through an accreditation system for ambulatory surgery facilities and to
serve the public interest by providing accurate and timely information regarding surgery in ambulatory surgery
facilities and ASCs.
Patient Safety
Order Form
$35 (Pkg. of 25)
$100 (Pkg. of 100)
Quantity _______
The American Association for Accreditation of
Ambulatory Surgery Facilities, Inc.
Total Cost $_______
To view the brochure,
visit our web site:
Patient Safety
Facility Name ____________________________________________________
Address _________________________________________________________
P.O. Box 9500
5101 Washington Street, Suite 2F
Gurnee, IL 60031
1-888-545-5222 (toll free)
847-775-1970 • Fax: 847-775-1985
Web Site:
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Faxes must include a credit card number (Visa, Mastercard, or American
Express) the card’s expiration date, and written authorization to charge the
amount shown or mail to:
AAAASF - P.O. BOX 9500-Gurnee, IL 60031 Or fax to: 847-775-1985
9:31 AM
Page 3
Big Apple M.D. Blues
Lawrence Reed, M.D. - New York, NY
Understandably, when word of the state mandated accreditation of all medical facilities which
utilize more than mild sedation for their procedures began its unwelcome dissemination, there
was confusion, anger, disbelief, denial, resentment, posturing, protestation and a prevailing
atmosphere of malaise and procrastination. This was from the doctors. Others, however, with
prescience and perspicacity found within this morass a verdant field that needed some fertilization and nurturing, a little watering and some not so gentle stoking of the growing flames of
Enter the lawyers, consultants, money lenders and office management groups... "If you don't
get accredited by July 14th of 2009 you will be out of practice as you know it, or subject to
severe penalties and fines," the doctors were told. "But don't worry because we can take care of
the whole thing for you." The faces of the doctors that attended the many meetings in New York City set up by the
lawyers, consultants, banks and others revealed a sense of anguish and despair that is normally, sacredly, reserved
for the end of the baseball season when the Yankees once again go off to "Mudville" after a promising start.
AAAASF was also present and unlike our competitors, we brought to the table almost 26 years of experience as a
doctor run, not for profit, accrediting agency that specialized in office based surgical facilities. We had in our group
over five times the number of accredited OBS facilities as our competitors combined. We also had a knowledgeable
and supportive executive staff which was readily available to help the doctors through the process. If you wanted to
hire consultants and lawyers and financial planners and medical mangers, by all means, go to it. If you wanted a
simple and much less costly approach well then, AAAASF was ready to serve.
AAAASF created a Procedural Standards Manual tailored just for the needs of the non-surgeons.
Gastroenterologists and nurses with experience in the non-surgical specialties provided great assistance. Help also
came from other sources so that we could fully understand the needs of the different specialties. We also listened
carefully to the concerns of our potential applicants and worked to resolve these problems. The New York State
Department of Health has wisely made it known that they are not pleased by, nor will they permit overt solicitation
by any of the groups that have tried to capitalize on mandatory accreditation. The doctors already have enough to
contend with and do not need the additional trauma of solicitation.
So where are we now? The Procedural Standards Manual is a success and I see amongst my colleagues in New
York a greater understanding of the value of accreditation and recognition of the expertise that AAAASF brings to
the table. A lot of people worked really hard to achieve this level of appreciation and clearly there is much more to
do. But, of course, that is what AAAASF does, and has done since l982. That is our only business.
Big Apple M.D. Blues? Fuhgetaboutit!
Dr. Alan Gold – New President of ASAPS
Dr. Alan H. Gold is the new president of the American Society for Aesthetic Plastic Surgery
(ASAPS). The Society is the leading national organization of board-certified plastic surgeons
specializing in cosmetic surgery of the face and body. ASAPS elected its new set of officers
on May 4, 2008 during the ASAPS 2008 Annual Meeting in San Diego, CA.
Dr. Gold has been a member of the ASAPS since 1985. He is currently in private practice,
holding an academic appointment as Clinical Associate Professor of Surgery at the Weill
Cornell Medical College. Prior to his new responsibility as President of the Society, Gold has
served as the Society’s Historian, Secretary, Treasurer, and Vice-President. He is also currently serving as the Society’s representative to the American Society of Plastic Surgeons Board
of Directors.
Other credentials of Dr. Gold include holding responsibilities as the immediate past-president of both the Aesthetic Surgery Education and Research Foundation (ASERF) and current president for the
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Gold was also the Co-Chair of
the Joint Silicone Implant Task Force. He is a Clinical Editor of the Aesthetic Surgery Journal and serves on the Journal's
task force.
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Legislative Committee Update
Theresa J. Griffin-Rossi, CAE - Director of Legislative Affairs and Education
AAAASF continues to work diligently with State legislators and regulators throughout the
country on issues that impact patient safety and the ambulatory care environment.
On April 21, 2008, Jeff Pearcy, MPA, CAE, AAAASF Executive Director and Theresa GriffinRossi, CAE, AAAASF Director of Legislative Affairs attended and gave testimony before the
Nevada Legislative Committee on Health Care at the committee's request. The full day meeting addressed the patient safety issues surrounding patient exposure to Hepatitis C in Nevada.
AAAASF also participated on a conference call with the Nevada Department of Health prior to
the hearing to discuss the patient safety concerns in Nevada and the infection control standards
currently enforced by the national accrediting agencies.
In December 2007, AAAASF staff attended a two day CASCA meeting in Colorado that laid the
ground work with the Department of Health and State legislators for CO-HB1234, enacted on May 27, 2008, that recognizes AAAASF as a deeming authority. AAAASF continues to monitor over 50 bills introduced in 2008 related to
ambulatory surgery.
We Need Your Eyes and Ears
Many of our facilities are the first to hear about legislative changes that may affect all of our facilities, please call
Theresa Griffin-Rossi, CAE, Director of Legislative Affairs & Education (888-545-5222) or email her at:
[email protected]
In addition, you may hear about significant adverse events that have occurred in other facilities in your area.
Please call Pamela Baker, Director of Accreditation (888-545-5222) or email her at: [email protected] so that we
can evaluate and help resolve these problems for the best interest of the patients and our facilities.
We heard you.
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AAAASF President’s Message
required peer review submission as a stanAs my final year as Board President of
dard. Dr. Geoffrey Keyes, who has promulAAAASF comes to an end, I have the opporgated this effort over the many years, was
tunity to reflect on the challenges and opporonce again lead author of an article that was
tunities presented to our association in
published in the July issue of Plastic and
recent years. The job of the President is to
Reconstructive Surgery®. "Mortality in
provide consistent and knowledgeable overOutpatient Surgery" was derived from a
sight and strategic guidance and decision
study of over one million cases during a five
making regarding those challenges and
and one-half year period that demonstrates
opportunities on a weekly, if not daily, basis.
the importance of accreditation in the
I have tried to fulfill that role to the best of
ambulatory surgery environment. In this
my ability. Working with our tireless Board
review of data collected, using the IBQAP
and staff, we developed numerous new inifrom January of 2001 through June of 2006,
tiatives in my two years and made solid conthere were 23 deaths in 1,141,418 outpatient
tributions to lingering issues, such as the
ever-growing complexities of CMS compliembolism caused 13 of the 23 deaths. Only
ance and the Medicare accreditation proone death occurred as the result of an intragram administration.
operative adverse event during that period.
I believe that one of the most important
One death, of course, is one too many, and
and complex projects I initiated was the
we hope that this study and article usher in
restructuring of the Board of Directors. I
a new perspective on quality improvement
am certain that the recently adopted
in surgical practice in the ambulatory surrestructuring will help future presidents
gery environment.
and Executive Committee members expeThe fact that AAAASF has been collecting this data since
dite decision making and facilitate progress. A reconstituted
2001 is testimony to our foresight in this area. Unfortunately,
and expanded Advisory Board will draw on the talents of
even today, many medical societies, healthcare associations,
physicians from a variety of disciplines, representatives of
legislators, insurance companies and healthcare media struggle
other allied medical organizations, and even non-medical repto collect data, and fail to present facts to substantiate the effecresentatives to offer their expertise on important standards and
tiveness of medical programs or of existing or proposed legislasafety issues concerning our diverse group of facilities, and
tion. With the inclusion of more diverse ambulatory facilities
help provide an expanded knowledge base to render recominto our expanding accreditation fold, I see continued growth
mendations to the Board.
and success in this revolutionary AAAASF program. I comAn additional critical initiative, the creation of new
mend Dr. Keyes for his years of dedication to this program and
Procedural Standards to accommodate non-surgical facilities,
his diligence and detail-mindedness in accomplishing this
such as gastroenterology, pain management, and fertility clintremendous task. We hope it opens some eyes and encourages
ics, has proven to be a valuable and well-received addition to
some new thinking in how to effectively monitor and improve
our product line.
ambulatory surgery safety and outcomes though a program of
Yet another highly visible initiative was the revision and
inspection and accreditation. This effort exemplifies the unique
expansion of our educational programs. The number of accredcontributions provided by volunteer physicians working
ited facilities and trained inspectors has expanded steadily over
together to improve the quality of patient care. As a peer to peer
the last two years. There are a growing number of talented and
association, we have stayed true to our mission and trust that
committed physicians who now actively participate in committhe next generation of volunteer physicians will continue this
tee activities, ensuring our stability and future progress.
high level of commitment and service.
Through their dedication and vision, we have totally recreated
It has truly been both an honor and a privilege to have
our inspector training programs, have produced instructional
served as AAAASF President for the past two years. In the fall,
DVDs, including one on insurance reimbursement, and have
I will leave my post as President of the Board of AAAASF and
made available new Policy and Procedure templates, also in
dedicate myself to the Presidency of the American Society for
DVD format.
Aesthetic Plastic Surgery (ASAPS). I will, however, still remain
I am confident and pleased to report that there is expandengaged in AAAASF activities while still serving on the Board
ed recognition of AAAASF as an accrediting agency by my
and the Board of SFR. I feel confident in the direction in which
home state of New York, as well as increased solicitation by
the Association is headed, and in the abilities of the incoming
various states for AAAASF to comment on, or assistance in,
President, Dr. Lawrence Reed. Dr. Reed, through his many
drafting accreditation legislation. We have also witnessed
years of work with AAAASF, has an excellent understanding of
increased recognition of Surgical Facilities Resources (SFR),
all aspects of ambulatory surgery and the needs of both the
and our important relationship with the International Society
physician and the patient. I am certain that with his clarity of
for Aesthetic Plastic Surgery (ISAPS) in establishing internavision, superb administrative skills, attention to detail, and
tional patient safety standards in ambulatory surgery facilities.
absolute commitment, he will provide the guidance to our
Expanded media recognition has been evidenced by multiple
extremely talented and tireless staff that will ensure continued
requests for board member interviews and story contributions.
success for AAAASF.
Our Internet-Based Quality Assurance and Peer Review
(IBQAP) reporting system has shown once again the value of
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Page 7
Awareness, Preparation and Training Essential to Prevent a Tragic Outcome
For more information or a MH Protocol Poster PDF visit
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Safe Surgeries Performed in Accredited Facilities
The American Association for Accreditation of Ambulatory
Surgery Facilities (AAAASF) has developed a new study which
analyzes data submitted by accredited ambulatory surgery facilities from January 2001 through June 2006. An article, “Mortality
in Outpatient Surgery,” derived from the study was published
in the July issue of Plastic and Reconstructive Surgery® and
demonstrates that surgery in accredited ambulatory facilities can
be as safe as inpatient surgery. The key fact extrapolated is that
only one death occurred, out of 1,141,418 outpatient procedures
performed, as a result of an intraoperative adverse event.
AAAASF has reported statistics on morbidity and mortality for
facilities that it accredits based on an analysis of unanticipated
sequelae and surgical mortality. Data acquired through the first
ever Internet Based Quality Assurance and Peer Review reporting system (IBQAP) were first reviewed and published in 2004. "The Internet has provided us with a wonderful tool to improve patient safety and document surgical
practice," says Geoffrey R. Keyes, M.D., Quality Improvement/Peer Review Committee Chair and AAAASF board
member. He has been integral in the establishment of the IBQAP system and the new study.
This article based on the study reports the accumulated data in the IBQAP through June of 2006, analyzing death
associated with procedures performed in facilities accredited by the AAAASF. With the exception of some statistics
on the Medicare aged population, there are few data reported in the literature related to deaths in outpatient surgery.
The study also shows that 13 of the deaths that occurred (there were 23 deaths in 1,141,418 outpatient procedures
performed during the five and one-half years of the study) were due to pulmonary embolism. "Any death is one too
many, but until we elucidate the etiology of pulmonary embolism, we are faced with this grave potential sequelae of
surgery regardless of whether the procedure is performed in a hospital or an outpatient surgery facility," says Dr.
The Cases:
Postoperative Medication Abuse
Three patients died as a result of abuse of postoperative pain medications. The first patient was a 53-year-old hispanic woman who underwent a mastopexy and removal of breast implants under intravenous sedation. She was seen on
the first and fourth postoperative days. There was no indication of postoperative sequelae during those visits. On the
fifth postoperative day, she was found dead in her bedroom. There was a history of drug abuse. The suspected cause
of death was a pain medication overdose.
The second patient was a 57-year-old Caucasian woman, who also had a history of drug abuse. She was found dead
on the second postoperative day. She had been wearing a fentanyl patch and postoperatively took an unknown
quantity of Vicodin orally. The third patient was a 62-year-old Caucasian woman who died on the second postoperative day after having a face lift with multiple associated procedures. The nurse responsible for her care noted the
patient to be somnolent on the evening of her operation. The patient’s pain management consisted of the administration of Vicodin and a fentanyl patch. She stopped breathing on the morning of the second postoperative day. She
was admitted to the intensive care unit at a nearby hospital, but died as a result of respiratory failure. The suspected
cause of her death was a drug overdose leading to respiratory failure.
Myocardial Infarction
A 54-year-old Caucasian woman died days after having an abdominoplasty and liposuction of the back. An autopsy
revealed a myocardial infarction. A second patient, a 45-year-old Caucasian woman, died three weeks after
abdominoplasty and breast augmentation from ischemic heart disease. There was no known history of cardiac
disease before surgery.
Continued on page 12.
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Education Committee Update
Theresa J. Griffin-Rossi, CAE - Director of Legislative Affairs and Education
The inspector training course held at the ASAPS meeting on May 2, 2008 in San Diego was well
attended. AAAASF certified 48 physician inspectors and 20 nurse inspectors and 29 Medicare
inspectors. The next inspector training course will be held at the ASPS meeting this Fall in
Chicago on October 31, 2008. Registration forms will be mailed out to all AAAASF Facility
Directors approximately two months prior to the meeting.
AAAASF inspectors must be re-certified every three years. If you are an inspector and have not
attended a training course recently, please check the date on your inspector certificate or call the
AAAASF office at 1-888-545-5222 to ensure that your certification does not lapse.
Education Committee Co-chair David Watts, M.D. and Committee
Staff Liaison Theresa Griffin-Rossi, CAE have completed a second DVD project titled,
“Preparing for Accreditation.” The DVD is designed to assist new facilities in preparation
for the accreditation process. A companion CD is being developed that will include sample policy and procedure documents in Microsoft Word format that can be customized by
facility staff to streamline the process and make the AAAASF accreditation program even
more user friendly. Packaged along with the first DVD titled, "Inspector Training
Overview", the two DVD and CD set will be available later this summer.
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Malignant Hyperthermia
drugs include propofol, ketamine, barbiturates, benzodiazepines, narcotics, etomidate, non-depolarizing neuromuscular blockers, anticholinesterases, anticholinergics, and non-steroidal anti-inflammatory drugs. The potent inhalational
agents and Succinylcholine are unsafe. The FDA currently recommends that Succinylcholine should not be used routinely. It is important to note, that by our AAAASF standards, the facility must have Dantrolene present even if the
only triggering agent in the facility is Succinylcholine.
Some patients do not have a family history of MH and one should be
aware of the first signs of difficulties. Typically, MH will manifest
itself during the first 2 hours of anesthesia. However, cases of MH
have been reported during prolonged anesthesia and even during
recovery; therefore, the 12 hours immediately after surgery are considered a critical time for MH-susceptible patients. Masseter spasm is
often the first sign of an impending MH crisis. Masseter spasm is "jaw
muscle rigidity in association with limb muscle flaccidity after
administration of succinylcholine." It is not simply inadequate relaxation or "stiffness." Any patient who has masseter spasm upon induction of anesthesia should be observed overnight for a possible MH
episode. Even patients who experience mild increases in jaw tension
should be observed for signs of MH for at least 12 hours.
Other early symptoms of an impending MH crisis during anesthesia
are sinus tachycardia, hypertension and tachypnea. Because these
signs are often misinterpreted as signals of inadequate anesthetic
depth, they are treated by increasing concentrations of inhaled anesthetic agents. Increased temperature is usually a
late sign. The skin becomes mottled with cyanotic areas and patches of bright red flushing. Generalized skeletal muscle rigidity is observed in approximately 70% of patients. Central thermoregulation remains intact during a MH crisis;
temperature increases only after continuous muscle contraction generates more heat than the body can dissipate.
Temperature can rise at a rate greater than 1.5 C in less than 5 minutes and can go as high as 110 F or 46 C. Ventricular
tachycardia and fibrillation may become evident.
Early management includes cessation of all inhalation agents and triggering agents, finishing the surgery as quickly as
possible, hyperventilating with 100% Oxygen, initiating Dantolene 2.5 mg/kg IV and using cooling blankets and ice
packs as necessary. Immediate transfer to a hospital facility should be considered. Cold intravenous fluids, lidocaine
for arrhythmias, and sodium bicarbonate for metabolic acidosis would be used as necessary.
All of our facilities that utilize general anesthetics that can trigger MH must be equipped with a kit or cart to manage
MH. It should include dantrolene, sterile water sufficient to dilute dantrolene, D50, antiarrhythmics, mannitol, calcium chloride, sodium bicarbonate, insulin, and furosemide. This is true even if the only triggering agent preset is
SuMH. Drills may be useful for your facility and it is recommended that you consider practicing the dilution of
Dantrolene with your outdated vials because some find the drug difficult to dilute.
Patients should be monitored for EKG, blood pressure, temperature, pulse oximeter, and capnograph. An ice machine
and a refrigerator should be nearby. Advice regarding acute emergencies can be obtained through the MHAUS hotline
1-800-MH-HYPER. Susceptible patients and their families should be given the contact information so that they can
learn more about the risks of MH. The phone number for the MHAUS office is 1-800-98MHAUS; the e-mail address is
[email protected]
9:32 AM
Page 11
Get Involved In One Of Our Committees
Many of the important projects and initiatives are introduced by way of
committee recommendations. We have seen dramatic changes and development in our inspector training via the Education Committee, a major
Standards revision developed by the Standards Committee, and the
development of a third party reimbursement guide by the Reimbursement
Committee. You can make a difference by contributing to one of the
AAAASF committees, so please get involved.
If you are interested in a committee...
Complete the form below and fax or mail it to the AAAASF
Office, call 888-545-5222 or send an email to [email protected]
Interested in Serving on an AAAASF Committee?
We are also interested in getting more nurses and younger surgeons from our accredited facilities involved in all our committees in order
to broaden our perspectives, get new ideas, and develop future leaders of the Association. If you are interested in participating on a committee, please complete this form and mail/fax to:
P.O. BOX 9500 • 5101 Washington Street, Suite 2F • Gurnee, IL 60031
Fax: 847-775-1985
Name and Title: ________________________________________________________________________________________________________
Years in Practice: ________________________________________________________________________________________________________
AAAASF Facility Name or #: ____________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________
City: ________________________________________________________State: __________________________________Zip: ______________
Telephone:__________________________________Fax: ______________________________E-mail:__________________________________
Check the box next to the Committee that you are interested in:
If selected, you will be contacted by AAAASF staff. Thank you for your interest in serving as an AAAASF Committee member!
QA/Peer Review
Another Way You Can Help:
If you are a trained inspector please reassess your commitment to patient safety and say "yes" next time you are
contacted to perform an inspection.
If you have refused several inspections, you may not be on our active list. Please call or email the AAAASF Office
to let us know you are available.
If you would like to be an inspector, the next training will be held in Chicago at the ASPS Annual Meeting.
Visit our web site or call the AAAASF Office for the registration form.
If you are called and cannot perform an inspection, please let our staff know why you are unavailable and how we
can help you with future inspection requests.
The next time you are inspected, please be sure to thank your inspectors for their dedication to patient safety.
Visit Our Web Site and Click Contact Us!
9:32 AM
Page 12
Mortality In Outpatient Surgery
Continued from page 8.
A 65-year-old Caucasian woman developed an arrhythmia 24 hours after surgery. An autopsy revealed no evidence
of myocardial infarction, pulmonary embolism, or medication overdose. There was no history of cardiac arrhythmia
before surgery.
Intraoperative Anesthetic Adverse Event
A 67-year-old Caucasian woman underwent a face-lift procedure under intravenous sedation. The operating surgeon, without the assistance of a certified registered nurse anesthetist or anesthesiologist, administered propofol,
fentanyl, and midazolam. During the procedure, the patient developed hypotension and bradycardia. She underwent resuscitation and was transferred to a hospital, dying 15 days after admission.
On April 14, 2004, the American Association of Nurse Anesthetists and
the American Society of Anesthesiologists made the following statement
“Whenever Propofol is used for sedation/ anesthesia, it should be
administered only by persons trained in the administration of general
anesthesia, who are not simultaneously involved in these surgical or
diagnostic procedures.
This restriction is concordant with specific language in the Propofol
package insert, and failure to follow these recommendations could put
patients at increased risk of significant injury or death.”
AAAASF standards now require that the use of propofol be limited to
class C facilities accredited for the administration of general anesthesia,
or those accredited for the provision of the use of Propofol under the
direct supervision of an anesthesiologist or certified registered nurse
On the evening of her surgery, a 32-year-old Caucasian woman died
after a breast augmentation. She had a history of asthma. While sitting at
the dinner table, she became dyspneic with wheezing. She was taken to
the emergency room, where she died after unsuccessful resuscitative efforts. An autopsy was not performed.
Sleep Apnea Respiratory Arrest
A 67-year-old Caucasian woman underwent a face-lift procedure. She was reported to have been stable, alert, and
oriented in the recovery room 1.5 hours after surgery. She was discharged to her home with a pulse oximeter, which
apparently was never placed on the patient. She was found dead the next morning. This case is currently under
Respiratory Failure Unrelated to Surgery
A 32-year-old Caucasian woman had a nasal fracture reduced under general anesthesia. Two weeks postoperatively,
she developed respiratory distress, presumably caused by chronic obstructive lung disease. She died after having
thoracic surgery. The cause of death was lung cancer. The AAAASF standards require all deaths that occur within a
30-day period after surgery to be reported to the central office. This case is included in the study because of that
For a PDF version of the complete article, contact Jaime Trevino, [email protected]
9:32 AM
Page 13
Newly Accredited Facilities
Class Code Examples:
M7C = Medicare, 7 Physicians, Class C
R2B = Regular, 2 Physicians, Class B
R1C-M = Regular, 1 Physician, Class C-Modified
Facility Director
Evan Cohn M.D.
Victoria Vitale-Lewis M.D.
Gregory Michael Bazell M.D.
Central Ohio Urology Surgery Center
Columbus OH
Cosmetic Plastic Surgery Center
Melbourne FL
The Aesthetic Plastic Surgery Center of Barrington, LLC
South Barrington IL
Hilton Becker, M.D.
Boca Raton FL
Kent V. Hasen, M.D., PA - Aesthetic Plastic Surgery of Naples
Naples FL
Central Coast Institute for Plastic Surgery
San Luis Obispo CA
Advance Gastroenterology
Forest Hills NY
Waccamaw Endoscopy Center, LLC
Georgetown SC
Women's Wellness Institute of Dallas
Dallas TX
South Miami Surgery Center, LLC
South Miami FL
Napa Valley Plastic Surgery, Inc.
Napa CA
Advanced Aesthetics
Fayetteville GA
Cobble Hill Ambulatory Facility
Brooklyn NY
The Boyd Gillard Institute of Aesthetic & Dermatologic Surgery
Ypsilanti MI
Walnut Creek Medical Center
Pembroke Pines FL
Ralph R. Garramone, M.D., P.A.
Fort Myers FL
The Plastic Surgery Group, PC
Rockville Centre NY
Southlake Center for Cosmetic Surgery
Southlake TX
VIP Plastic Surgery
Los Angeles CA
Gold Coast Surgery Center, LLC d/b/a Gulf Comprehensive Surgery Center
Englewood FL
McKenna Cosmetic Surgery Center
Cincinatti OH
Center for Breast and Body Contouring
Grand Rapids MI
Buckingham Plastic Surgery
Doylestown PA
Naples Surgical Center
Naples FL
South Shore Plastic Surgery, Inc./ DBA Boston Plastic Surgery
Quincy MA
Jefferson Obstetrics & Gynecology, LTD
Charlottesville VA
Digestive Wellness Center, LLC
Norton OH
Renvance Cosmetic Surgery Center
Murrieta CA
South Bay Surgical and Spine Institute
Long Beach CA
Aestique Ambulatory Surgical Center
Greensburg PA
Gastroenterology Group of Rochester, LLP
Rochester NY
Humboldt Bay Surgery Co-Op
Eureka CA
Premiere Center for Cosmetic Surgery
Coconut Grove FL
Premiere Center for Cosmetic Surgery
Tampa FL
Women Medical Wellness of Westchester
Mount Vernon NY
Specialty Surgical Center of Thousand Oaks
Westlake Village CA
Westchester Putnam Gastroenterology
Carmel NY
Ocean Park Surgical Center, Inc.
Venice CA
Southeastern Fertility Center
Mount Pleasant SC
Monterey Park Surgical Suite
West Covina CA
Hilton Becker M.D.
Kent V. Hasen M.D.
Gary R. Donath M.D.
Azeem Khan M.D.
Laurence Ballou M.D.
Wesley Anne Brady M.D.
Eduardo Barroso M.D.
WilliamJ. McClure M.D.
Paul D. Feldman M.D.
Pedro Canals-Ferrat M.D.
Charles Boyd M.D.
Jeffrey A. Steiner M.D.
Ralph R. Garramone M.D.
Antonio L. Uria M.D.
Michael Bogdan M.D.
Andrew K. Choi M.D.
Anthony DiTomaso M.D.
Peter J. McKenna M.D.
Dennis Hammond M.D.
MichaelA. Giuffrida M.D.
Stanley P. Gulin M.D.
Fouad Samaha M.D.
Michael Arnold M.D.
Ghulam Mir M.D.
Brian J. Eichenberg M.D.
Munir Uwaydah M.D.
Theodore A. Lazzaro M.D.
Howard Merzel M.D.
Robert M. Green M.D.
Howard Robinson M.D .
Herbert Stern M.D.
Guirlaine Agnant M.D.
Glenn Cohen M.D.
Michael Kushner M.D.
Anoush Ehya M.D.
John Schnorr M.D.
Alejandro M. Sanchez M.D.
City & State
9:33 AM
Page 14
New SFR Global Accreditation Certification Program
As an added benefit to those AAAASF Facility Directors who are members of ISAPS, SFR would like to extend to
you an offer to certify your facility as a globally accredited facility. This added certification will enhance your status
in the global marketplace. As you may know, SFR (Surgery Facilities Resources, a wholly
owned subsidiary of AAAASF) and ISAPS have partnered to offer a global program of
inspection and accreditation available to ISAPS members and we want to include your
facility in an expeditious manner.
For a nominal application fee of $250, AAAASF will automatically extend this global
accreditation certification to your AAAASF accredited facility. No additional inspection
is required as long as your facility is in good standing with AAAASF. This can be an
excellent way to promote your facility and attract new business from outside the United
States as the patient safety awareness level and the importance of inspection and accreditation increases around the world.
If you are an ISAPS member and an AAAASF Facility Director and wish
to join this list of Globally Accredited Facilities, please contact the AAAASF Office.
Facility Name
Gold Ambulatory Surgery Center
Lenox Hill Ambulatory Surgery, PC
Atlantic Plastic Surgery Center
Dana Care Surgery Center
Ambulatory Surgery Center - Bethesda
Plastic Surgery Institute of South California
The Plastic & Reconstructive Surgery Center
Pacific Clinic
Alan Gold, M.D.
Darrick E. Antell, M.D.
Lawrence Gray, M.D.
Henry M. Spinelli, M.D., F.A.C.S.
Bahman Teimourian, M.D.
Edward Terino, M.D.
Ronald E. Iverson, M.D.
Brunno Ristow, M.D.
City, State
Great Neck, NY
New York, NY
Portsmouth, NH
New York, NY
Bethesda, MD
Thousand Oaks, CA
Pleasanton, CA
San Francisco, CA
Prevent Medical Errors,
Monitor and Document Safe
Surgical Practices,
Ensure Ongoing Regulatory
And Reduce Costs!
9:33 AM
Page 15
ASF Source Newsletter Submission Deadlines
For Articles, Advertising and Photos
Fall/Winter 2008 Issue Deadline - September 5th, 2008
Articles on patient safety issues and quality care practices within the outpatient surgery environment are accepted
any time throughout the year. Please email your articles or ideas for articles to Jaime Trevino, Communications
Director at [email protected] and you will be notified if the Publications Committee decides to use your article.
ASF Source Newsletter Advertising 2007 Rates
Full page
1/2 page
1/4 page
1/8 page
Full page
1/2 page
1/4 page
1/8 page
7.5” X 10”
7.5”X 5”
3.75”X 5”
3.75”X 2.5
8.75”X 11.25”
8.75”X 5.5”
Reimbursement Guide Available to Accredited Facilities
John Pitman III, M.D., Reimbursement Committee Chair
Dr. Pitman has produced the “Guide For Third Party Reimbursement Of Facility Fees” to help
assist physicians through the quagmire that is today’s reimbursement landscape. This information
will evolve as the environment changes, so Dr. Pitman welcomes all comments and advice to make
this booklet the best it can be. As you know, the culture that envelopes this area of practice is continually changing, making it extremely difficult to anticipate every aspect. We hope that you gain
some insight from this guide, and we want to thank Dr. Pitman for all the time and energy spent
on this project.The Reimbursement Guide is currently only available in PDF format, and is free to
accredited facilities.
To order, visit
Products and Services Desired By Surgery Facilities
If you have a valuable product or service to sell (such as custom packs of surgical tools) or know of
a great company that does, email [email protected]
Request for a Newsletter
If you wish to be included on our mailing list or you know of a medical specialist
that has requested to be included, please complete this form and fax or mail to the
AAAASF Office.
Title or Specialty
Facility Name
Facility Address
Web Site
Fax to: 847-775-1985 or email all required information to: [email protected]
9:33 AM
Page 16
ASF Source News You Can Use
Standards Reminder - Version 11 is the current Standards edition. You will receive your copy of these Standards
upon receipt of renewal fees or with the purchase of a General Information Packet ($250).
B, C, C-M
1 - 2 specialties
1 - 2 specialties
3 or more specialties
1 - 2 specialties
3 or more specialties
1 - 2 specialties
3 or more specialties
B, C
1 - 2 specialties
1 - 2 specialties
3 or more specialties
1 - 2 specialties
3 or more specialties
1 - 2 specialties
3 or more specialties
Inspection Fees: $500 for provisional, $950 for regular, and $1400 for Medicare inspections in
addition to the annual fees shown above.
P.O. BOX 9500
Gurnee, IL 60031
1-888-545-5222 (toll free)
Fax: 847-775-1985