No need to reinvent the wheel in outpatient orthopedics, Dr. Alexander Sah says

As orthopedics grew exponentially in ASCs in the last few years, some orthopedic surgeons still see challenges with the transition to outpatient cases, Alexander Sah, MD, said. However, keeping the process uncomplicated and following the examples of others can help.

Dr. Sah, an orthopedic surgeon in Fremont, Calif., spoke with Becker's about the evolution of outpatient orthopedics, his predictions for the future and how ASCs could alleviate an impending challenge in the specialty.

Note: This conversation was edited for length and clarity.

Question: What are three trends you're following when it comes to orthopedics and ASCs?:

Dr. Alexander Sah: Total joints have been migrating to ASCs prior to the pandemic. But then the pandemic accelerated everything, because we couldn't do these surgeries in the main hospital because of concerns of overcrowding of main hospitals or staffing shortages. So really, if people wanted a joint replacement done, they had to do it at an ASC or go home the same day from a main hospital. ASCs really accelerated in their adoption, which meant that the staffing there, the administration there, the support there had to grow very rapidly to handle this adoption. It was multifaceted. Patients who were hesitant prior who wanted their hips replaced, were very willing to have it done at an ASC, which they may have never considered before. It completely changes the patient's mindset. For surgeons who are unwilling or not ready to adopt to outpatient joint replacement, they are forced by necessity to perform these procedures to become comfortable doing [them in] an ASC. From all sides, the pandemic really accelerated the transition to ASCs unlike anything we've ever seen before.

Q: What's the biggest mistake that you see people fall into when trying to adopt outpatient orthopedics?

AS: The biggest challenge for surgeons is because it's the same surgical procedure, they assume that it's going to be the same as what they're doing in their main hospital. Even though you've probably done hundreds or thousands of these procedures, just because you do it under a different roof doesn't mean it's going to go the same way.

I think we often underestimate the importance of having the staff that we're used to, working with the nurses and the scrub techs, having all the equipment and all the implants and everything that we're used to. We're used to having things just as simple as the drapes we're used to or the tools and instruments that we're used to. I think surgeons tend to overlook that and then things get lost in the details.

You need a lot of work on that behind the scenes to have that staff. Do they have the right implants? Do they have the right backup instruments? Have they thought about how to make the case go smoothly? Because in the hospital, we're used to doing total joint cases in an hour or less; in a surgery center, if you haven't done it before, it could take two hours or longer simply because you're getting slowed down by all these details.

Q: How can ASC administrators and surgeons get ahead of these challenges?

AS: It's all preparation. While this is new to that individual ASC, this is not new to many of the ASCs already out there. The main pitfall for surgeons and groups is that they try to reinvent the wheel themselves. And there's no reason to do that, because there's already been a number of surgeons and groups who've already gone through all the pitfalls and trials and tribulations of doing this. Learn from them and use your resources. For example, MicroPort Orthopedics has a Pathways program that is essentially a guidebook on how providers can be successful in ASCs.

Q: How do you picture the ASC landscape and orthopedics in five to 10 years?

AS: It's going to really continue to grow. At least with joint replacement, we still see patients who come in and say, "I know you're doing your surgery this way, but how come I don't have the CPM that my mother had?" which is a knee-moving device that is really archaic. Or, "How come I'm not staying in the hospital for four days after my surgery?" So the patients are so used to knowing about a surgery based on what their parents' or grandparents' experiences were. Patients are very slow to adapt to what is new until you educate them. So that's why the pandemic was unique in that it accelerated patients' adoption of having a same-day discharge after total joint replacement. But there's still a lot of room for that to grow.

Q: To what extent do you see ASCs helping to curtail the projected shortages in orthopedic surgeons?

AS: So the nice thing about when orthopedic surgeons work closely with ASCs to provide this specialty care is that you can provide much better and efficient orthopedic care, because you're not distracted by the other challenges of the main hospital. So in the main hospital, you're going to have other surgeries, you're going to have emergencies, you're going to have shortages of staff, people are going to get pulled in different directions.

But the movement of orthopedics to ASCs is almost creating a specialty-like hospital so that you could really fine tune the care to that specific procedure so that you can do more cases more efficiently, more safely for the patients and have better overall outcomes. So that's where that partnership between surgeons and ASCs have an opportunity to continue to grow.


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