Dr. Glenn Snyders.For ambulatory surgery center (ASC) operators, everything comes down to making sure patients get the right care in the right place.
As more complex procedures are moving into the outpatient setting, it is important to understand the factors that may make a patient a good fit for outpatient surgery.
Ambulatory Surgery Center News connected with Dr. Glenn Snyders, medical director and head of anesthesiology at DISC Surgery Center in Carlsbad, to go over some of the best patient selection processes, and what his goals are for his new center focused on spine, orthopedic and pain management procedures in San Diego.
DISC Surgery Centers operates several ambulatory surgery centers across California.
This interview has been edited for length and clarity.
ASC News: How do you see your role as it relates to patient selection?
Snyders: Patient selection is pretty critical. In the hospital, we have access to a lot more resources, like a cath lab and an ICU, and at the ASC we don’t. So that changes the equation. It means patient selection becomes one of the most important parts of creating a safe and effective surgical experience. That’s where my role really comes in.
I hear operators talk a lot about the importance of patient selection, making sure someone is really the right fit for outpatient surgery. Is that something you ever coordinate with the hospital on? And how do you actually determine who’s a good candidate?
Yeah, that’s a great question. So there are a lot of factors that go into it. We don’t really have a regular back-and-forth with the hospital on patient selection, although we’ve built a relationship with Tri-City Medical Center that could evolve into more of that collaboration. Generally speaking, though, we follow a number of established guidelines that help us determine whether a patient is appropriate for the ASC. That usually means they’re an ASA 1 or 2, so someone with well-controlled high blood pressure, or well-controlled diabetes.
Where it gets more complicated is when patients are kind of on the borderline. Maybe they have severe sleep apnea, or uncontrolled blood pressure that doesn’t respond well to medications, or their diabetes is just not under control. That’s when it really becomes a team discussion – between the surgeon, the anesthesiologist and our nursing staff. It’s very much a shared decision-making process, and sometimes it also involves a good amount of patient counseling too.
There are guidelines out there to help us navigate some of this. For example, SAMBA, which is the Society for Ambulatory Anesthesia, has guidance on managing patients with sleep apnea. But at the end of the day, there aren’t a lot of hard and fast rules. It really comes down to clinical judgment, experience and a lot of communication – emails, phone calls, discussions. Fortunately, we’ve got a really professional, highly experienced team at DISC. We’re constantly learning from each other and sharing those experiences.
From your perspective, what are some of your goals, whether that’s volume, types of cases or outcomes?
Yeah, that’s a big question, and there’s a lot to it. From an operational standpoint, we have three ORs, and we’d like to see all of those rooms being utilized consistently. We want to grow our volume to the point where we’re running at full capacity, with all three ORs going at once.
One of the limiting factors, though, is the perioperative phase. We can’t do three surgeries at once if the recovery area is already full. But we actually designed DISC with that in mind. We’ve got space for 10 patients in the pre-op and recovery areas, which helps us manage that volume while still keeping safety front and center.
Now, from a clinical standpoint, one of the things that really sets DISC apart is our ability to safely do complex spine surgeries in an outpatient setting. Dr. Robert Bray has really led the way on that. We’ve proven we can do these cases with minimal blood loss and incredibly low infection rates – zero for spine, actually. So we’re very focused on maintaining that high standard while expanding our capabilities.
That said, we’re not looking to push the envelope too far. We want to be able to handle more types of procedures – but only when we’re confident we can do them safely in an outpatient environment. So, as new data and guidelines come out, we may gradually widen our patient selection criteria.
We also have analytics helping us make those decisions. We use HST for medical records and another system, Ospitek, that tracks every patient’s status automatically. So we know exactly when a patient goes into the OR, when they start mobilizing, how long recovery takes. That kind of data is huge. It helps us fine-tune our approach and make sure we’re delivering the best outcomes across different patient groups.
With all of that in mind, do you ever run into patients who push to have surgery done at the ASC – even if you don’t think it’s the best fit?
Yes, absolutely. That does happen. And I get it. Outpatient surgery is often cheaper, more convenient, and statistically, it comes with fewer complications in many cases. So when patients want that experience, I totally understand.
But I always tell them, we have to look at the whole picture. If you’ve got comorbidities that significantly increase your risk – say you’re at higher risk for a cardiac or respiratory event – that changes the conversation. We go through a full risk-benefit discussion. I’ll say, “Look, I know you want to do it here, but let’s walk through what happens if something goes wrong. Would you rather pay more and be safer, or save some money and increase your risk of complications?”
And to be honest, those conversations are what we do every day as physicians. Besides doing procedures, we spend a lot of time educating patients. At DISC, that’s something we really focus on. We talk to patients about their expectations, about mobilization, about after-care, about what kind of support they’ll need. And part of that education is talking through the risks and making sure everyone is on the same page. In the end, we usually come to an agreement. It’s very rare that we have to flat out say no.
How are you approaching staffing in light of the anesthesia shortage?
It’s definitely a challenge, but ambulatory anesthesia is a unique environment, and it actually attracts a certain kind of provider. It’s fast-paced, and the procedures and hours are more predictable than in the hospital. Some people love that and really thrive in it.
That said, in the early days of an ASC, when you’re still ramping up and getting surgeons and patients on board, the ORs aren’t always full. And that variability makes it hard to find anesthesiologists who want to commit. They’re often looking for consistency and predictability.
But DISC has a strong reputation, and that’s helped us attract great people. Our model appeals to a lot of anesthesiologists who might not be interested in working at a hospital or even at other ASCs. It’s definitely not a universal solution, but for us, it’s worked.
As for other providers, yes, we’re watching what’s happening with CRNAs and AAs. I’m from Virginia, and they just passed a law allowing anesthesiologist assistants to practice. In California, the laws are more restrictive, but I think long-term, we’ll see more of those providers playing a role.
What are your thoughts on using CRNAs or AAs more broadly?
Speaking for myself, I spent 12 years in the military, and we extensively used CRNAs. Some of my best friends are CRNAs. They’re incredibly skilled and have a lot of utility, especially in a team-based model.
That said, there is a difference in training. And because ASCs lack some of the hospital’s emergency resources, I do think it’s critical to have anesthesiologists involved, particularly in leadership roles. I believe the future will involve more CRNAs and AAs, and that’s a good thing in terms of access and coverage. But leadership from anesthesiologists is still really important, and I think DISC has done a great job making that part of the model.
I’ve been reporting on robotic technologies being used in outpatient surgery. Are there any systems or tools you’re especially excited about?
Yeah, we have surgeons using both the Mako from Stryker and Rosa from Zimmer. These systems are helping make procedures more precise, which ultimately leads to better outcomes and faster recovery.
We also have a surgeon who’s going to start using a system called Pixee, which is an augmented reality navigation tool. I think that’s really exciting. A lot of these technologies reduce the need for X-rays, which saves time and decreases radiation exposure, for both patients and staff. I think that’s where things are heading. These tools will let us do procedures that used to require large incisions in a much less invasive way.
What are you most excited about for the coming year?
I think what’s really exciting is this move toward specialization. DISC isn’t trying to be everything to everyone. We’re focused on orthopedic and complex spine surgeries, and that allows us to build a team – surgeons, nurses, anesthesiologists – who all have deep experience in those areas.
It’s something I remember reading about in The Innovator’s Prescription, which is a great book by one of the authors of The Innovator’s Dilemma. He talks about creating specialized subunits in health care and separating them from the general hospital environment. I read that almost 20 years ago when I was working for Epic, and it’s incredible to see that vision playing out now in real life.
I’ll definitely check that out. Is there anything else you’re thinking about?
Actually, there’s one more thing I meant to mention. One of the things we’re doing at DISC that’s pretty unique is telemetry monitoring. That’s typically something you only see in hospitals.
Because we sometimes keep patients overnight, especially after more complex spine surgeries, we wanted a way to monitor them safely without constantly waking them up to take vitals. With telemetry, we can track heart rate, blood pressure and EKG remotely from a central monitor. It allows our nurses to keep an eye on multiple patients while still giving those patients a restful recovery. It’s one of the ways we’re trying to build a high-acuity, patient-focused model that still.
So, telemetry is remote vital monitoring.
Exactly. “Tele” means far, “metry” means to measure. It allows us to continuously monitor heart rate, blood pressure and EKG from outside the room. It’s less disruptive and safer. Especially for abdominal spine surgeries, it’s invaluable.
What’s the longest you would monitor a patient after a procedure?
We’re allowed up to 23 hours for observation. Rarely do we go that long, but that’s the limit. Most patients are discharged within two to four hours, even after spine surgery.
That’s wild.
It is, right? But it’s a proven model. Dr. Robert Bray pioneered it. Patients have a fantastic experience and better outcomes. They’re not at risk for hospital-acquired infections or disorientation from being in an unfamiliar environment. Personally, I’d much rather recover at home than in the hospital.
