Operating a successful outpatient total joint replacement program

The Total Joint Center of St. Louis, an affiliate of United Surgical Partners International, opened in 2014, with the first case performed in October of that same year. Since then, surgeons have performed more than 300 outpatient total joint replacements in the center.

The 19,000 square-foot surgery center includes seven large operating rooms and nine private overnight rooms.

"It's really taken off and been a fun project. There is a lot of physician involvement," says Doug Lashley, regional vice president for United Surgical Partners International. The physician owners developed the total joint replacement center along with Marshall | Steele™, who developed program protocols and patient education materials. "One of the things we learned is we need to educate the patients about leaving the surgery center the same day. We've explained the benefits of the outpatient setting to our patients and have been thrilled with the outcome."

Robert Sciortino, MD is one example. He began taking his patients to the ASC after initial hesitation and found all his patients loved the experience. The staff was helpful and friendly, and patients now want to return home as quickly as possible. "I tell patients this is something they 'get' to do because they're healthy enough. It's not an experiment; they are in good shape and fortunate enough to have the ASC experience," says Dr. Sciortino. The patients love it, so it's easy for me to do cases there."

The staff members typically begin the process by taking extensive patient histories three to four weeks before surgery, and patients attend a total joint class to learn expectations about surgery, recovery and the postoperative period. There is a facility tour included in the class.

Finally, a total joint coordinator works with the patient to coordinate the preoperative classes and schedule all appointments. This person is on the front lines of communication with the patient from the selection process through surgery. The coordinator also works with anesthesiologists to make sure the patients are good candidates for an outpatient procedure, and coordinates the postoperative therapy and home health.

"The surgeon begins the process by telling patients at their office that they are candidates for surgery at a special facility where otherwise healthy patients can have surgery," says Tanya Hague, RN, MSN, MHA, administrator of St. Louis Surgical Center and the Total Joint Center of St. Louis. "We reiterate in our preoperative classes the expectations that they'll get up within a few hours after surgery and undergo assessment. We encourage them to go home the same day — the sooner the better — and give them that message as often as possible. The preoperative nurses and overnight stay nurses are educated on messages for the patients who are on the edge of staying the night for convenience factors instead of clinical issues."

"A lot of the reason[s] patients end up staying at the hospital is because they have the hospital mindset," says Dr. Sciortino. "The patients expect to be at the hospital, and the hospital expects to watch them there, so they aren't anxious to get patients up right away and begin to ambulate. But the patients have better outcomes if they are up faster and not waiting a few days before moving." If our patients do spend the night, it’s usually because they have their surgeries later in the day and don't have time to fully recover before discharge.

As of April 2016, the surgery center has not reported any serious complications or infections, yet another indication that the outpatient setting might be preferable to the hospital setting where sicker patient populations could lead to increased risk of infection. The patients also undergo a multimodal pain management approach that includes intraoperative pain management and pain medication for returning home. Patients also experience reduced pain because they ambulate after surgery sooner and begin physical therapy within hours of surgery.

The Total Joint Center of St. Louis has received few complaints about poor pain control during patient follow-up [interviews] and has noticed that patients are able to return to their full range of motion quickly. Patients still experience some pain postoperatively, but are able to manage at home without seeking additional help.

The physician satisfaction with the surgery center experience is also strong, which makes a huge difference for facility use.

"The feedback we've received from physicians is positive," says Mr. Lashley. "The fact that we can do these procedures in the outpatient setting is a benefit for the patients and it reduces costs to the payer and the healthcare system in general."

St. Louis Surgical Center's Total Joint Center was the first USPI center solely dedicated to total joint replacements. The center's staff underwent significant pre-education before opening, including implant familiarity and participation in mock procedures. Since the staff was already familiar with the outpatient mentality, training them to prepare patients for same-day discharge wasn't a huge learning curve.

The next big issue to tackle was patient selection — "That was one of the first hurdles the physicians had to get over; how to select the patient from the insurance perspective, but also identify the otherwise healthy patients who were young and active," says Mr. Lashley. "There was a lot of debate around the pain protocols and patient selection, but the steering committee worked with us to make sure the physicians were comfortable with the final decision."

The protocols have changed slightly since the center opened. For example, the center's physicians worked with anesthesia to prevent nausea/vomiting. The clinicians developed a new pre- and postoperative medication regimen to reduce the nausea/vomiting.

The ASC didn't need any structural changes — it was already built for orthopedic cases — but the sterilization process was ramped-up to accommodate total joints.

The biggest challenge was convincing payers to negotiate contracts with the center. The ASC currently is contracted with a few payers in the market, but Mr. Lashley and his team keep in constant conversation with them all. "Our strategy was to give the payers proof total joints could be done effectively for their patient population in the outpatient center and we are getting closer to wrapping up new payer contracts," he says.

The total joint replacement center has been a tool for recruiting new physicians in the market and developing a relationship with independent providers who otherwise wouldn't be able to perform cases at the ASC.

"I wasn't one of the first people who signed up for outpatient surgery; it was an interesting concept and I heard people talking about it, but when you are used to bringing patients to the hospital, it's difficult to see how an ASC will work," says Dr. Sciortino. "But the same could be said about regular outpatient surgeries 10 years ago. I saw the efficiency at the outpatient center was appealing compared to the hospital. The ASC's efficiency could translate to practice efficiency."

Dr. Sciortino was initially nervous about bringing his patients to the outpatient setting but with new minimally invasive procedures, patients experience less pain and have a faster recovery. There are fewer postoperative issues and they don't need a long length of stay.

In early April, The Total Joint Center of St. Louis' Matt Bradley, MD, became the first surgeon in St. Louis to perform a customized knee replacement. The technology uses a three-dimensional CT scan to develop custom-fit implants that align with the patient's unique anatomy. The technology also limits the number of implants and instruments per case, which makes the knee replacement more efficient.

"We are very optimistic about the future of this center," says Mr. Lashley. "We have a number of early adopter physicians who are more progressive in their thinking and now young physicians are coming out of training wanting to perform outpatient total joints. Physicians who are more conservative are now comfortable performing outpatient cases in a proven center and they can see our positive results. Surgeons are starting to reach out to us because they want their patients at our center."

The ASC's strategy has been so effective that USPI is working with other orthopedic groups to develop similar total joint programs. The first of these initiatives is expected to launch in early 2017.

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