Four surgeons speak about trends in total joint replacement in the ASC setting.
Q: To successfully bring total joints to an outpatient setting, what procedures and protocols must be in place?
Chad Burgoyne, MD, The Spine & Orthopedic Surgery Center (Santa Barbara, Calif.): The most important factors in performing a joint replacement as an outpatient procedure are the coordination and protocols that allow the surgical team to provide streamlined service.
The surgical team needs to be consistent and well trained in joint replacements; the shorter the surgical time, the less pain and subsequent anesthesia is required, and the more the patient is able to participate immediately in therapy comfortably. Second is the anesthesia team. With a combination of spinal, regional and local anesthesia, we are now able to have postoperative patients that need little to no pain medication in the first days after surgery.
The nursing staff must also shift their focus to enable the efficient discharge of patients. Their role is as much coach as caregiver. They must care for, educate, facilitate and encourage all in one breath. All the resources and steps must be in place so they can focus on the task at hand. Finally, there is the therapy team. The therapists must organize their days around the operating room schedule to minimize down time. A patient cannot be allowed to sit in bed and simply "recover." The therapists must be available to start ambulation within the first hour after surgery is complete.
Charles A. Hope II, MD, Optim Orthopedics (Savannah, Ga.): An experienced and cohesive surgical team is required for an efficient TJA practice, whether the operation is inpatient or outpatient. Also, a consistent message must be delivered at all points along the way to mold appropriate patient expectations. The flow from entry to exit must be smooth, predictable and expeditious, and experienced team members must be available to provide routine postoperative monitoring and to troubleshoot any issues that arise.
Matt Riordan, MD, Ambulatory Surgery Center of Stevens Point (Wis.): In terms of the facility, you must have appropriate OR size, (INR checks, SCDs), the capacity for expanded equipment, sterilization equipment, a hospital bed, a reclining chair, medications for pain and an injectable block mix, a sterile set-up space, the Institute of Healthcare Improvement's standard preparation, antibacterial irrigation, space suits and an effective infection prevention program.
In terms of the payer, the ASC must demonstrate safety, competency, lower costs, market demand, the non-experimental nature of the care, the organization of process and preapproval.
Mark Scioli, MD, NorthStar Surgical Center (Lubbock, Texas): To successfully bring total joints to an outpatient setting, one must be sure the patients are properly selected, home care and assistance and therapy are arranged and pain management as well as deep vein thrombosis prophylaxis is coordinated. In addition, there must be clear lines of communication open to the facility, the surgeon and his or her staff during the patient's stay as well as after discharge.
Home care should be arranged with protocols well understood by the nursing agency. Durable medical equipment should be pre-arranged and in place. Staffing for total joint cases should be part of each facility's effort to deliver the highest level of care.
Q: How can surgeons set themselves up for success for total joints in the outpatient setting?
Dr. Hope: The journey to outpatient TJA begins with developing an efficient, high-volume arthroplasty practice. Once inpatient stays are reduced one or two nights, then the concept of a 23-hour program is a small step, rather than a giant leap. True outpatient procedures without an overnight stay are possible but are probably better limited to those completed prior to noon.
While the surgeon, anesthesia, support staff and facility are all important, patient selection is crucial. The ideal patient is younger, healthier (medically and mentally), probably more educated and must have a reliable home support network. Patients with major medical issues, chronic narcotic use or those with inadequate help at home should be excluded.
Dr. Burgoyne: The team-oriented protocol is the key to success in outpatient joint replacement. On the day of surgery, a surgeon can only be responsible for what happens in the operating room. The rest of the process needs to run on "autopilot." In fact, a process such as this should actually be driven by the facility, not the surgeon. Protocols must be in place well before the time of the procedure. At the end of the day success depends on the process not the individual.
Whenever possible we try to get preapproval from all insurance carriers prior to the patient having surgery. We have a good success rate with getting these surgeries approved.
Q: What do you do to prevent complications?
Dr. Hope: In order to successfully perform total joint arthroplasty as an outpatient procedure, one must address and prevent the complications that have made it historically an inpatient procedure. These include bleeding, venous thromboembolism, uncontrolled pain, nausea and urinary retention.
A comprehensive preoperative optimization program can boost hemoglobin to the desired range, which when combined with an aggressive perioperative blood management protocols makes the need for blood transfusions rare. Routine use of antifibrinolytics, advanced cautery devices and tourniquet-less techniques minimize perioperative blood loss.
Avoiding over-aggressive chemoprophylaxis for VTE decreases postoperative bleeding. A multimodal pain management protocol emphasizing non-steroidal anti-inflammatory drugs, periarticular injections and regional anesthetic techniques can minimize pain during the first 72 hours, and avoiding parenteral narcotics results in less sedation, nausea and constipation.
I have found that an adductor canal block gives similar pain relief to the standard femoral nerve block with dramatically less quadriceps weakness. Most patients with an adductor canal block can ambulate more than 100 feet on the night of surgery without a knee immobilizer, which helps avoid falls.
Pre-emptive antiemetics along with minimizing narcotics greatly reduce postoperative nausea and vomiting. Careful fluid management, avoiding long-acting spinal anesthetics and minimizing narcotics decrease the problem of urinary retention. Most patients who qualify for outpatient TJA would also tend to have not yet developed bladder outlet obstruction.
Q: Can total joints be done efficiently in an outpatient setting? Why or why not?
Dr. Riordan: Yes. Advances in medical management and preoperative risk assessment, surgery, pain management, nursing, home therapies, education, medications and equipment combine to yield a safe path for these outpatient procedures.
Dr. Hope: Efficient outpatient arthroplasty requires an adequate facility, an experienced surgical and anesthetic team and ample equipment. The surgery center must have enough room to prepare the patients, at least two large ORs, and a recovery area large enough to accommodate the patients for several hours while they are mobilized and monitored. The surgeon and team must be expeditious and predictable.
Minimizing variance in set up, surgical and clean up times will facilitate the optimal use of two surgical rooms. Ideally, the surgical time should be slightly less than the set up and clean up so the surgeon can move from room to room with minimal down time. Another issue is the complexity of the surgical trays. Clearly they must provide the needed tools, but multiple pans take time to open and also burden the sterilization process.
For a total knee arthroplasty, I routinely open four pans for a case: one pan with all the blocks and trials, a power pan, an instrument/retractor pan and my navigation tray. Total hip arthroplasty requires two trays for trials and reamers, a power pan and the instrument/retractor pan.
Dr. Scioli: Total joints can be performed efficiently in an outpatient setting when a systematic approach is taken and when each person involved knows what her or her role is. Logistically, the surgicenter affords the greatest amount of flexibility and adaptation, which should translate into a streamlined experience. Nothing should be left to chance.
Q: What data do ASCs need to show to prove total joints can be performed safely in an outpatient setting?
Dr. Riordan: First, ASCs must realize that surgeons, nurses, administrators, patients and their families, regulators, legislators, insurers and even hospitals are each groups to which we must be able to demonstrate our competency. Knowing this, we are then able to build the processes that meet each of their needs or concerns.
ASCs must then demonstrate, in measurable fashion, safety and efficiency combined with high patient satisfaction. Unaffiliated hospitals naturally may find this as a competitive activity. They are in the unenviable position of needing to justify why patients need to be exposed to the less satisfying, higher cost and particular risks of hospital versus ASC care. ASCs, most critically, need to prove that they deserve the opportunity to expand service lines. Important data is that which allows comparison to other care delivery models: complications and pain control included.
Dr. Scioli: ASCs need to pool data to prove that when joint replacements are performed as outpatient procedures they are more effective and less costly than when performed as inpatient procedures. The complication rates should be equal to, or better than, the same procedure when performed as an inpatient.
Q: Are total joints trending outpatient or inpatient, and why?
Dr. Burgoyne: Joint replacements are most definitely trending towards an outpatient model. At the most basic level, long inpatient stays are simply not necessary. Often my patients are bored, requesting discharge by the second day after surgery. The reality is that there is not much we do for patients during their two- to three-day hospital stay. If their pain is well controlled with the regional anesthesia, they are usually sitting around waiting for the one to two hours of therapy they receive. Why not sit at home and come in for outpatient therapy daily instead?
Dr. Riordan: Clearly outpatient joint replacements are trending upward. Our experience, as well as that of other facilities in our region, is that an exciting increase in patient and surgeon demand for this service is occurring. ASCs are ideally positioned to lead this movement that lowers costs, controls complication rates, improves satisfaction and is preferred by patients.
Q: Are insurance companies coming onboard with outpatient joint replacements?
Dr. Scioli: The insurance companies will be more inclined to endorse these procedures being performed as an outpatient once adequate data exists to support the practice as being safe and effective. Medicare and Medicaid should allow for certain criteria to exist such that special cases could be done as an outpatient. In time, outpatient joint replacement will gain the traction it needs to become routine.
Dr. Riordan: Insurers were initially cautiously supportive or sitting on the sidelines as interested observers. Lately, insurers have contacted us regarding our outpatient joint program, requesting data, asking to gain an understanding and even promoting our model in their other markets.
Dr. Burgoyne: Medicare has acknowledged this trend and is revisiting their policies in regards to payment for outpatient joint replacements. Once they allow for outpatient arthroplasties, it is likely other insurance companies will follow suit. With rising costs and the large volume of procedures to be performed in the coming years, I think this shift to outpatient care is crucial to maintaining access to these vital procedures.
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