Three years ago, Michael Joyce, MD, noticed total joint replacement patients were mobilizing more quickly than in the past. Advanced surgical technology and new pain management techniques meant patients had shorter recovery times and hospital stays. They asked the question: What if these cases could go outpatient?
Dr. Joyce and his colleagues began to perform some of their total joints as outpatient procedures at the hospital to develop an efficient process for patient selection, surgical flow and postoperative discharge. They used a resiliency score for patients based on responses to six questions measuring whether they had the temperament for outpatient surgery.
“We started thinking about our patients not just in terms of their risks with diabetes or risk for infection, but instead thinking about whether our patients have a robust personality,” said Dr. Joyce. “You have to understand the patient’s mindset and how the evolution from the inpatient to the outpatient setting will be perceived differently.”
The surgeons also collaborated with anesthesiologists to use long-acting local anesthetics and limit narcotic use so patients would be discharged home in relative comfort. The last step was having patients undergo their initial physical therapy shortly after surgery.
The process worked, and after successfully performing outpatient total joints for several years at the hospital, the surgeons decided it was time to take their cases to an ASC. Dr. Joyce and his partners collaborated with St. Francis Hospital to develop Lighthouse Surgery Center in Hartford, with assistance from outside vendors, including Stryker. Dr. Joyce had used Stryker implants for more than 25 years , but as he worked to develop the ASC, Stryker was much more than a pure implant vendor; they became a true partner, providing guidance for inventory management and design advice based on best practices.
“I think of Stryker now as a company that provides both products and services to help make your ASC a reality,” said Dr. Joyce. “When we want to buy a knee replacement implant, we go to Stryker. But developing a surgery center requires a lot of expertise and it’s great to have those services as well. As a surgeon in the operating room, we aren’t always thinking about the surgical booms, lights and stretchers. Having Stryker come to the table with so many different ideas gave us a higher degree of expertise.”
Over the past three years, the surgeons saw the volume of outpatient cases grow from dozens to hundreds annually. Then, COVID-19 accelerated the migration of total joints to the ASC. “Patients didn’t want to be in the hospital,” said Dr. Joyce. “We were COVID-free and became a safe alternative.”
Once surgeons and patients became familiar with the ASC setting, there was no turning back. Dr. Joyce anticipates continued movement of total joints to Lighthouse Surgery Center and predicts similar ASCs will continue to emerge across the U.S.
Steps for success
To move a high volume of total joints from the inpatient hospital to outpatient ASC setting, organizations need strong leadership to build a collaborative culture, said Dr. Joyce. Surgeons must have the ability to discuss challenges with each other and the larger surgical team, especially if they are coming from separate independent clinical practices.
The surgeons also need an extreme focus on clinical data. “Beginning at CJRI at St. Francis Hospital, the team started sharing results of all surgeons together and then broke that down to show individual surgeons’ results and collaborated to improve those results individually and as a group,” said Dr. Joyce. “That process unfolded over several years and allowed us to become very comfortable with it. The standardization of best practices wasn’t a threat to anybody; instead, it was a way for everyone to deliver much better care.”
The surgical team also pays close attention to cost metrics to deliver the best care at a lowest cost. The team aims to invest in new technology to improve care and cut unnecessary spending when it doesn’t lead to the best outcome. It is also helpful for ASCs to replicate processes from the hospital so surgeons feel comfortable making the move. Anesthesiologists have to be on board with taking surgeries to the ASC and agree upon patient selection criteria. Dr. Joyce and his partners regularly communicate about patients with anesthesiologists before the day of surgery to make sure the case is in the right setting.
“You have to have a detailed understanding and method of administering anesthesia in a standardized way,” said Dr. Joyce. For outpatient surgery “patients have to participate in their care a few hours after surgery. That’s done through anesthesia and your anesthesia team has to be a collaborator.”
The preoperative work with patients is more significant for outpatient procedures. Prior to surgery, patients and family members discuss the plan for returning home and learn their postoperative physical therapy regimen. The physical therapists’ space attached to the ASC allows patients more convenient access to care. “They need to know how to take care of themselves at home. The therapists that we collaborate with really understand these patients in their home setting.”
The sterile processing department at the ASC also plays a critical role in the success of a total joint program. “Sterile processing has to be robust,” said Dr. Joyce, so CJI built a sterile processing department that was similar to the hospital’s department, with the same policies, procedures and standards of care. Among the first 300 TJA’s patients at the surgery center, there were no hospital admissions and the current infection rate is well below 1 percent.
The stellar outcomes and low infection rates at Lighthouse Surgery Center aren’t an accident; Dr. Joyce and his partners put in 18 months of planning and careful research to develop the surgery center. “This isn’t something you can do shooting from the hip,” he said. “You can’t avoid the long-term planning. We think outpatient total joints are an opportunity for better care and reduced healthcare costs, but we don’t want to ruin it by making a mistake.”
Dr. Joyce said Stryker was helpful in planning out the sterile processing workflow and inventory management system at the ASC. Inventory management is different at an ASC because centers can’t keep as many instrument trays on hand as hospitals do. “Stryker has a breadth of experience working with centers across the country, and as we started to face some of the development challenges of building an ASC, they were a point of contact for us to collaborate with other centers that faced similar issues,” said Dr. Joyce. “We created a culture of collaboration where they helped us meet some of our design, billing and operational challenges. Stryker was instrumental in all phases of developing the ASC.”
A promising future
When Dr. Joyce first began performing outpatient total joints, patients were skeptical. Now, patients are asking for surgery in the ASC. They are motivated to recover from surgery quickly and return to normal activity.
“You can’t deter a motivated patient,” he said. “In sports medicine, if you have a motivated patient who wants to play basketball after ACL surgery, they can do it. The same thing is true for total joint patients. People now come in and tell us they are exactly the right person for an outpatient total joint.”
The motivated patients bode well for continued ASC industry growth. Dr. Joyce and his partners see the value in performing more total joints in a physician-owned setting.
“Health organizations are getting very large,” he said. “I think surgeons, who are ultimately face-to-face with patients and care for the patients, feel that our ability to dictate important elements of their care is being diluted by larger bureaucracy of the big organizations. With our ASC, we have operational control.”
A small group of owners hold decision-making power at the ASC, which allows centers to quickly decide whether to implement new technology. Big corporations have national contracts that may not allow surgeons to bring in new technologies.
“There are a lot of avenues where innovation is found and brought to us, and we don’t have a barrier to entry,” said Dr. Joyce. “That’s something we all believe in strongly, and if the technology is reasonably priced, we work with surgeons to bring it to the center and evaluate it. Our goal is to make surgeons’ lives easier, and we can do that.”
Dr. Joyce is a paid consultant of Stryker’s ASC business. The opinions expressed by Dr. Joyce are those of Dr. Joyce and not necessarily those of Stryker. Individual experiences may vary.
This article was sponsored by Stryker.
