A hepatitis outbreak traced to ambulatory surgical center practices in the state of Nevada has led Missouri and other states to tighten inspections of their own outpatient surgical facilities.

Each year, Missouri normally reviews the practices of between 3 percent and 5 percent of its 118 outpatient surgical centers. Two of them are in St. Louis, 40 in St. Louis County, five in St. Charles County, and one in Jefferson County.

Nevada traced its hepatitis outbreak to an endoscopy center, where nine people were sickened. They believe the outbreak occurred because workers were reusing syringes that contaminated medication being administered to patients. Because the disease can be fatal, the outbreak created anxiety for about 50,000 people who had been treated at the clinic in 2007 and 2008.

This incident explains why Missouri now hopes to begin inspecting up to 33 percent of its centers annually, meaning all would be inspected at least once every three years, says Eddie Hedrick (right), emerging infections coordinator for the Missouri Department of Health. That change wouldn't occur in a state with serious budget problems were it not for the Centers for Disease Control and Prevention.

The federal agency has expressed alarm over the Nevada outbreak and offered $9 million nationally for increased inspections. Missouri will get about $167,000 of the funds. It remains unclear how the cash-poor state expects to finance more frequent inspections in future years.

low risk for infections

Hedrick, who previously spent 35 years working in infection control at hospitals, says that federal and state health officials were surprised by the developments in Nevada because they had assumed that ambulatory surgical centers were relatively low-risk sites for infections.

"In the past, these centers have taken care of very healthy people," he says. "With managed care, everybody is moving to that outpatient environment. Now you're dealing with (all kinds of patients) -- people who are immune-suppressed, have underlying chronic conditions. Although they (federal officials) thought the oversight was enough, it wasn't. What brought it to light was the big outbreak we saw in Nevada."

He adds that while facilities in Missouri always have been monitored, "this probably wasn't done to the degree that we did to hospitals because the problem wasn't thought to be as bad."

Actually, state reports show that infection rates at outpatient surgical centers in Missouri have been below the national average. But the numbers might change once inspectors -- who are usually nurses who are trained to know what to look for -- begin taking more frequent and intense looks at surgical centers in Missouri. The incidents in Nevada were not isolated. Outbreaks also have occurred in California, Florida, Maryland, Nebraska, New York, North Carolina and Oklahoma, Hedrick says.

Still, industry groups argue that Missouri and the feds are fixing an inspection model that isn't broken.

"It's always good to make sure health care is safe and efficient, but there's a happy medium," says John Blanck (right), regional vice president of Novamed, an ambulatory surgical center in Kansas City, and an officer in the Missouri Ambulatory Surgery Center Association, based in Kansas City.

"What happened at Las Vegas clearly was a case of individuals not following proper protocol in medications," he says. "It's something that I'm not sure someone would have caught" as part of the inspections Missouri intends to do.

Patient safety organizations

A second industry concern involves a new state rule requiring ambulatory clinics to enter into contracts with patient safety organizations as a condition for being eligible to treat Medicaid patients. State officials say patient safety organizations can help health facilities avoid medical mistakes and improve patient safety.

But Blanck says many centers already receive accreditation from the Association of Ambulatory Health Care as part of a voluntary accreditation process, every one to three years. He says the contract requirement imposes another burden on ambulatory centers.

"From my perspective, it's unnecessary legislation and redundant to what we already do. We have safety measures in place, have infectious control training, and we track and monitor (the) very, very few complications" that occur.

The association's executive director, Jill Watson, accuses Missouri of being arbitrary and unreasonable. She says the association is "very supportive of patient safety" but doesn't feel the rule about working with a patient safety organization is useful. She says it should be limited to hospitals because the patient safety organization focuses on issues that don't necessarily happen in surgery centers.

"We don't do heart surgery, for example, so patients (at outpatient centers) wouldn't have those kinds of complications," she says.

The state rule will be costly, she added. The association says its ambulatory center members are being offered flat-fee contracts with patient safety organizations costing $2,500. For now, the association is advising members to either comply with the state rule by signing a contract or stop accepting Medicaid patients.

But it says it might continue fighting the rule by appealing to state lawmakers to exempt outpatient surgical centers from having to sign patient safety contracts as a condition for being allowed to treat Medicaid patients.

It's still unclear how much safety the feds and states will buy for $9 million in extra inspections, especially in light of the decision by Nevada to get tough. It has decided to subject ambulatory surgical clinics to annual, unannounced inspections.

This comes as Missouri and many other states, meanwhile, are moving to inspecting facilities every three years. Nevada had a similar policy before the hepatitis outbreak jolted it into raising the bar.