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Outpatient TKR: Critical factors enabling successful TKR procedures in ASCs

Traditionally, total knee replacement has been a procedure that required patients to spend three to five days,  or more, at the hospital after surgery, and then often additional time in recovery facilities before heading home, still not completely steady on their new joints.

Now, more and more surgeons are considering performing these total knee procedures in an outpatient setting. A recent survey at a major medical conference indicated that 69 percent of orthopedic surgeons intend to start performing outpatient total knee replacement surgery.

One key reason for this change is advances in technology, one of which is Tthe ConforMIS iTotal knee replacement. iTotal is a customized implant produced to fit individual patient anatomy based on a CT scan of each patient's knee. Surgeons send their patients' images to the company and receive customized implants within a few weeks. The customization fits patients better so there is a reduced risk for residual pain from wrong-sized implants and by matching the patient's unique J-curves, the implant offers the potential to result in a "forgotten" and more stable knee.,

"Patients are demanding we move procedures into the outpatient setting and we are able to deliver those services because of technology development," says Richard G. Buch, MD, of The Dallas Limb Restoration Center. "In the past 10 years, there weren't any major leaps and bounds with joint replacement, but now with the ConforMIS technology, we are taking great strides forward."

"Two years ago, I started doing the outpatient procedures in the hospital, earmarking patients who I thought I could treat with just an overnight stay at the hospital. If they needed to stay an extra day they could, it wasn't a big deal," says William Berghoff, MD, of ONE Ortho Northeast in Fort Wayne, Ind. "Now we can almost predict those who are good candidates for the outpatient setting and those who aren't."

Moving patients to the ASC
There are three qualities Dr. Berghoff always looks for in patient selection for the outpatient setting, beyond the usual perimeters:

  • Motivation — Do they want a rapid recovery?
  • Anesthesia — Can this person safely undergo regional blocks? Can the anesthesiologists at the ASC perform them?
  • Technique — Will less invasive techniques help the patient? Is the physician confident in performing these techniques?

Before the ConforMIS technology, Dr. Buch and his team experimented with outpatient total knee replacements with mixed results. Most of the patients had to stay in the hospital more than 24 hours for rehabilitation.

"With the old knee replacements, people spent three to four days in the hospital, and around 20 percent of them also then had to go to a recovery home," he says. "Then I happened on the ConforMIS technology and began using it with my patients. Now patients go home 70 percent of the time on the first or second day after surgery, and none of them go to the recovery center. That's a major change."

Dr. Buch also speculates that the decreased amount of bone-cutting and the specific fit of the ConforMIS implant leads to less blood loss and swelling which in turn can help with pain and recovery time for patients.

Acute inpatient rehabilitation can be very costly — as high as $16,464 on top of other hospitalization costs. A recent study found that for patients receiving iTotal, only 4.8 percent were discharged to a rehabilitation or other acute care facility compared with 15.7 percent of patients receiving a traditional implant.

Peter Gleiberman, MD, an orthopedic surgeon in Torrance, Calif., had a similar experience. Once he realized the procedure could be done in an outpatient setting, he partnered with an ASC to create the ideal environment for total knee replacements.

"I took my preference card from the hospital to the ASC and said I wanted to start doing the total knee replacements," he says. "If they purchased the equipment and educated their staff, I would bring my cases there. The ASC was able to do that and now they want me to expand the program. They've been very supportive. You need a good organization behind you."

The major clinical advantages of performing total knee replacement procedures in the outpatient setting are:

  • Surgeons have more control over the set up and operation, says Dr. Gleiberman.
  • The ASC may be able to accommodate for new drugs or technology better than the hospital, says Dr. Buch.
  • The surgery center — and typically patient homes — are more sterile than the hospital, says Dr. Buch.
  • Patients are able to sleep in their own beds instead of being disrupted at the hospital throughout the night, says Dr. Buch.
  • There is a better nurse-to-patient ratio, often one nurse for one to two patients spending the night, says Dr. Gleiberman.

Customized knee implants also offer unique advantages:

  • Customized knee implants fit better, potentially reducing a source of residual pain.
  • All cut bone surfaces are covered, resulting in a four times lower risk of needing a blood transfusion. Less postoperative swelling has been demonstrated.
  • Less bone resection by 27 percent on average due to a customized implant design.
  • Fewer ligament releases are required, enabling a straightforward procedure.

Operational differences
While the procedure is relatively simple, there are additional operational changes with the ConforMIS system and in the outpatient setting. Here are five key differences to note:

1. The ConforMIS system includes the customized implant along with a full set of patient-specific instrumentation for that case. The instrumentation is in sterile packaging, with only one tray of reusable instruments, so staff only need to open the box before beginning a case. Then instruments are disposed of post-surgery, reducing the amount of sterilization or reprocessing. This system streamlines supply chain management by not needing inventory to be stored in the hospital and requiring only one tray of reusable instruments compared with six or more for a standard knee implant.

"With the custom implants, I have everything I need with the cutting blocks and implant trays in a small box," says Dr. Berghoff. "You can't imagine the look on the staff's face when they come in and see what little set up we have. They really appreciate that, and the fact that they don't have to sterilize afterward. Plus, the patient has a custom, state-of-the-art knee that is made just for them."

2. Patient expectations should be set slightly differently; patients should expect to get up and move around shortly after the surgery and be prepared to return home within 24 hours. If they have that expectation, they are more likely to comply with early mobilization, which speeds along recovery. Additionally, this also extends to the exercises they do at home postoperatively.

"The patient should feel like they are happy and given all the attention they need," says Dr. Gleiberman. "Everyone I have treated has really enjoyed the experience in the ASC. I think it's a good reflection on the surgeon when the patients are happy."

3. Make sure everyone on the team — from nurses to physical therapists — know the patient's recovery plan and understand how outpatient procedures work. If your colleagues aren't motivated and onboard with the recovery process, the patient may not be ready to leave after 24 hours.

"Sometimes nurses and therapists don't understand the process," says Dr. Buch. "We've been teaching things one way for 30 years and they don't want to change. But you have to find and retain people who understand these shifts and know what they are doing. The hardest thing has been to train the nurse and therapist to change the paradigm in their heads."

4. Patients need the right support when they return home. At the hospital, there is a whole team built around making sure the patient has what they need for a successful recovery at home; that isn't the case at most ASCs. It falls upon the physician to make sure the patient's family can accommodate living needs and help them recover.

"They need someone I can trust who will take care of them," says Dr. Berghoff. "Over time, we've built up secondary safety nets so that our center's nurse will answer their phone calls to help them with the patient's recovery. We have a number they can call and someone will always answer right away."

5. Don't assume the ASC has everything needed for the procedure, or your preference items. Hospitals often have multiple surgeons using the same equipment, but the ASC might not. "At the hospital, you assume they have everything," says Dr. Gleiberman. "At the ASC, they might not have your saws. You have to make sure they have everything you need there before scheduling the case."

How to prepare the ASC
Everyone from the scheduler to the nurses, physical therapists and support team should give patients a consistent and positive message about their procedures. "When my patients select outpatient surgery, they head down a different path to only meet with people who are doing outpatient procedures," says Dr. Berghoff. "There are no mixed messages. The staff are highly motivated to support the patients."

It also falls upon the surgeon to coordinate postoperative treatment. "Most surgeons are used to having the hospital do everything, but when you are at the ASC you have to plan postoperative nursing and physical therapy and schedule that ahead of time," says Dr. Gleiberman. "That was more of the learning curve for me than the clinical technique."

When patients realize more benefits from outpatient procedures, they're more likely to drive additional patient volume. "In my practice, I've seen patients come back for additional procedures," says Dr. Berghoff. "I've done one of their knees, but now they want me to do their other knee or hip. They are happy with the procedures at the ASC."

What the future holds
There are a few roadblocks to bringing these patients into the outpatient setting — the biggest being payers. If a payer won't reimburse for procedures at ASCs, the patient will go to the hospital. But non-coverage could become a non-issue in the future.

The potential is there for this technology in an outpatient setting to address three of the primary goals of healthcare: delivering better outcomes, higher patient satisfaction and at a lower cost.

"I think total knee replacement in the ASC is going to become more and more common, and I think insurance companies are going to drive it to the point where they tell people if you want to have your surgery done at an ASC, they'll eliminate the copay or medication payment to incentivize the low-cost, high quality setting," says Dr. Berghoff.

As more surgeons endeavor to learn new technologies and perform total joint replacement in outpatient settings the best advice is consistent: seek out those who are already doing it, and learn from the best.

"Take time out of your practice to visit the surgeon already doing it and get an idea of how everything works," says Dr. Gleiberman. "There is no sense in beating your head against the wall with common issues if someone has already figured it out. That's better than starting on your own and running into headaches."

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