Overview »
Capital City Surgery Center (CCSC) is a multispecialty ambulatory surgery center (ASC) serving central North Carolina with seven operating rooms and four procedure rooms. The freestanding facility located on WakeMed Health & Hospitals’ Raleigh Campus is associated with the hospital and local physicians. NAPA’s anesthesia team, comprising a Chief, eight physician anesthesiologists, and 13 certified registered nurse anesthetists (CRNAs), is fully integrated into the Center’s highly collaborative culture. Their contributions to standardizing procedures have helped CCSC produce outstanding results and earn a prestigious dual AAAHC Center of Excellence certification, awarded for the highest level of healthcare.
This case study describes how NAPA’s anesthesia leadership worked with CCSC’s medical staff and administrators to transition total joint procedures safely and efficiently from the hospital to the ASC. By decreasing variability and applying best practice protocols from pre-admission testing through recovery, the team was able to define standardized patient pathways for orthopedic care. That enabled the surgery center to significantly increase volume and patient satisfaction while reducing costs and the use of opioids. Following evidence-based processes implemented over a six-year period, CCSC’s excellent clinical outcomes were recognized with Newsweek’s “Best ASC” for North Carolina in 2021, 2022, and 2023.
Situation »
Capital City Surgery Center opened in 2012, offering orthopedic, ENT, urology, ophthalmology, neurology, and general surgical procedures. Robert E. Seymour III, MD, a former president of the North Carolina Society of Anesthesiologists who had previously served for three decades at a Level I trauma center, soon joined the ASC. He continues to serve there as NAPA Chief of Anesthesia.
In 2016, CCSC sought to expand its orthopedic service line by moving total joint (TJ) procedures from WakeMed’s Raleigh hospital to the ASC setting. Gradually, a mix of WakeMed and community orthopedic surgeons began working with the Center’s administrators and anesthesia department to develop criteria for case appropriateness. But as each surgeon preferred different types of anesthesia, implants, and other clinical recommendations, their inconsistent needs made it difficult to follow the various surgeons’ protocols. The only commonality was that all TJ patients were admitted for 23 hours, requiring an anesthesiologist to spend the night in the facility to respond to patient needs and be available for unanticipated emergencies. As TJ case volume increased, it became clear that CCSC needed to develop a consistent best practice pathway for all TJ patients.
Solution »
CCSC and NAPA share a commitment to promoting a collaborative work environment in which everyone understands that each member of the administrative, medical, and anesthesia staff plays a critical role in the organization, and everyone feels valued for their individual contribution. Thus, when the need to standardize protocols became apparent, the ASC had a strong foundation for a transformative, group-driven initiative.
Since 2016, NAPA anesthesiologists and CRNAs, CCSC administrators, perioperative staff, surgeons, and an orthopedic nurse navigator have instituted robust Pre-Admission Testing (PAT) and Enhanced Recovery After Surgery (ERAS) programs that are integrated within the Center and utilized by all the TJ surgeons. Dr. Seymour and the anesthesia team have worked with all stakeholders—including patients—to develop and implement a consistent anesthetic plan that is safe, efficient, and reproducible. The team utilizes leading-edge tools of regional anesthesia and narcotic-sparing, multimodal medications for all TJ cases, as well as a standardized post-operative pain management care plan. Prescribing less or no opioids enables patients’ early ambulation and regained cognitive ability, allowing most patients to leave the facility within two to three hours after arriving in the PACU. With ongoing benchmarking and new initiatives, this uniform approach continues to evolve and improve.
Results »
Standardized TJ protocols have produced meaningful clinical and financial outcomes. In 2021, CCSC’s outstanding patient safety and quality metrics were awarded with a rare dual AAAHC Advanced Certification for Orthopaedics & Spine Surgery, and the distinction of Best ASC in North Carolina. The increased case volume facilitated by operational efficiencies has improved surgeon satisfaction, which is further enhanced by working with reliable anesthesia clinicians who provide efficient and consistent service.
At an estimated labor cost of $3,000 per patient night, reducing 23-hour TJ admissions from 87 ($261,000) in 2018 to 27 ($81,000) in 2021—and two ($6,000) in the first quarter of 2022—has had a positive impact on CCSC’s balance sheet, while decreasing costs for payors and patients. Enabling patients to go home the same day with little pain also drove patient satisfaction to 100% in 2020 and 2021, a particularly significant accomplishment during these Covid-19 years. And after having one successful hip or knee procedure at CCSC, many patients return for a second complex TJ surgery on another joint, further evidence that providing patients with excellent experiences helps drive brand loyalty.
NAPA adds value by being a true partner. As we put patients first, we recognize that contributing to a collaborative culture of safety also creates an environment that encourages clinician recruitment and retention, which helps ensure that CCSC and all our partners can continue to serve their communities with high quality care.
