Too many physician surgery offices in Florida are “filthy” and have poorly trained staff, putting patients at risk, health inspectors say.
In some offices, floors are caked with dirt, surgical devices are not properly disinfected, no one knows how to run sterilizing machines and the doctors perform procedures after only minimal training, three inspectors told members of the Florida Board of Medicine at a recent meeting in Deerfield Beach.
“They’re doing [tummy tucks], and five- and six-hour procedures, and the place is filthy,” said inspector Deanna Pfoff, from Tampa.
Hearing that, the board’s surgical-care committee called for a series of workshops to review all state rules on the matter. Members said they were aware that several dozen Floridians have died from routine office procedures in the past decade, and that the rules have loopholes.
“This is a serious issue that needs to be addressed,” said board member Onelia Lage, a Miami physician. Added board member Nabil El Sanadi, a Fort Lauderdale doctor: “Citizens are walking into those surgery offices and assuming they are safe. Not all of them are. We need to tighten some of the rules.”
Getting tougher won’t be easy. When the medical board first wrote the rules in 2000 after a series of cosmetic surgery deaths, the result was a bruising, yearlong battle of lobbying and lawsuits pitting doctors, lawyers and consumer advocates.
Changing the rules will be more difficult than in 2000, said Ed Tellechea, general counsel of the medical board. The Legislature must now approve any new rule that has a significant financial impact on the state budget or private business.
About 500 physicians now operate state-registered surgical suites in their offices. Office surgery has proliferated for minor procedures, as a less costly setting than hospitals or outpatient surgery centers, both of which are subject to extensive inspections and regulations.
Florida’s rules for office surgery are considered among the toughest in the country and have reduced deaths and injuries, according to a study last year. Yet the rules are only five pages long and do not prevent every problem, state officials said.
For example, surgical offices must have an autoclave to steam-clean surgical equipment, but there’s no rule that anyone know how to use it, inspectors said. Also, doctors must put someone in charge of sterilization, but some give the job to receptionists and bookkeepers with no training.
“The rules are over a decade old and circumstances have changed, so we probably need to take a look at them,” Tellechea said.
The 2012 study found 26 deaths and 131 hospitalizations related to office surgery in Florida from 2000 through 2009. At least six other patients have died since then, including four South Florida mothers in their 30s who were having liposuction to shrink love handles and bra rolls.
Department of Health inspectors raised a series of complaints and concerns to Allison Dudley, the medical board executive director. Dudley briefed the surgical committee about loopholes in the rules:
Infection control: Some surgical offices have no staff properly trained in sterilization and cleaning practices to prevent infections, and don’t have to.
Physician training: Some doctors perform procedures that are beyond their normal specialty. Doctors must be certified in a procedure or show they have “comparable” experience, but some start operating after taking only a 40-hour course.
“The public is putting their trust in the doctor and the assumption is they know what they are doing,” said inspector Rachelle Springer, a nurse practitioner from Boca Raton.
Christopher Nuland, who represents associations of Florida plastic surgeons and other physician groups, said trying to change this rule could cause the biggest controversy.
“If you increase the training, some [doctors] won’t be able to perform procedures, and that will be a big deal to them that they will fight,” he said.
Liposuction: Some doctors perform extensive liposuction using only a local anesthetic, in order to avoid stricter rules that arise from using stronger sedatives. At least two women who died had liposuction in unregistered surgery offices.
Traveling anesthesiologists: Those doctors bring their own supplies when they assist in office surgeries, but they keep equipment and drugs in hot cars that can render them less effective.
Pre-operative exams: Doctors must clear every patient in advance as healthy enough for surgery, but some don’t even do basic heart and lungs tests. Some complications stemmed from patients having underlying conditions that were detectable, said one co-author of the 2012 study.
IVs by paramedics: Some doctors use paramedics instead of nurses to insert intravenous lines for surgery. El Sanadi, who is medical director for several fire-rescue departments, said paramedics are not properly trained to start surgical IVs.
Drugs on crash carts: Some surgery offices lack lifesaving drugs that must be on hand in case of emergencies, because of manufacturer shortages. Inspectors said the list should be expanded to make sure doctors get a substitute drug.