Total joint replacements in ASCs during the pandemic: Key technology and concepts for success

During the coronavirus pandemic, many orthopedic practices and ASCs temporarily halted elective procedures and transitioned to telemedicine for weeks, or months, until it was safe to resume procedures.

The American Alliance of Orthopaedic Executives reported that orthopedic practices on average dropped from 700 elective procedures per month to 273, a 61 percent decrease. Elective surgeries typically comprise around 73 percent of orthopedic practice volume and represent around $332,197 in monthly revenue; postponing those procedures has put significant financial strain on organizations across the nation.

However, many states are moving past the estimated peak of the COVID-19 pandemic and beginning to lift bans on elective procedures. Orthopedic surgeons are adapting to address their backlog of cases by utilizing ASCs and specialty hospitals as safe and efficient sites of service for patients who are good candidates for outpatient procedures. Most ASCs did not care for COVID-19 patients, which makes them easier to reopen for non-coronavirus care.

"The general hospitals are still so burdened by COVID-19 and patient stigma about not knowing whether they want to have their procedures in the hospital," said Dr. Sridhar Durbhakula, MD, an orthopedic surgeon at OrthoBethesda in Bethesda, Md. "ASCs will play an important role in resuming elective surgery because they can be up and running sooner than hospitals. The patient comfort and nimbleness of ASCs also make them ideal for total joint arthroplasties."

Patients have also become more skeptical of hospitals and weary of long stays due to the risk of exposure to infectious diseases; often they’d rather have surgery at a surgical center and then recover at home if possible. With that in mind, ASCs and specialty hospitals are instituting extended hours and adding weekend OR time to care for as many patients as possible in the coming months.

"The pandemic will potentially accelerate the pace of technology adoption in joint arthroplasty because there will be a focus on efficiency and supply chain, and enabling technology has the potential to benefit both areas," said Michael Ast, MD, an orthopedic surgeon at Hospital for Special Surgery (HSS) in New York City. "You can also achieve more predictability with these types of technology, including OrthAlign, and they have downstream supply chain benefits, such as decreasing the number of trays needed for each case, as well."

OrthAlign offers single-use, disposable hand-held surgical navigation for knee and hip replacement surgeries that can help surgeons achieve more precise, accurate and predictable results. The KneeAlign device can be used with any knee implant system and provides data to ensure surgeons accurately cut the distal femur and proximal tibia as well as gap balancing data to guide intra-operative decision making for knee stability. Surgeons can also use the HipAlign system to with any hip implant or surgical approach for intraoperative acetabular component placement and leg length verification; it also tracks pelvic motion during surgery and displays pelvic tilt information.

During this time, it is more important than ever for surgery centers to operate at top efficiency and provide high-quality care as the nation eases into the "new normal."

Tech to support total joints in ASCs

Technology will play a big role in the elective surgery ramp-up, both in clinical care as well as operationally.

Surgery centers need technology that will fit seamlessly into their workflows to address inefficiencies in the supply chain, sterilization and patient discharge. Some ASCs may not have been originally built for total joints, which take up more space than other lower acuity procedures, and even centers built with those cases in mind will face new space constraints as providers stock up on PPE and other necessary equipment.

"ASCs don’t typically have the capacity to deal with nine trays and complicated room turnover. They benefit from technology that integrates easily and will be able to adopt to their individual center’s capacity," said Dr. Ast. "Surgery centers will also have financial considerations when purchasing new equipment. Some will not be able to afford a huge capital outlay for technology like robots, and instead will opt for single-use, patient matched technology or handheld navigation systems that make sense on a cost-per-case basis."

The most valuable technology will have both clinical and operational benefits, contributing to positive patient outcomes and lowering overall costs. Dr. Ast said that at his previous surgery center the surgeons collectively decided on the technology that would be most useful for workflow optimization in a limited space and utilized that technology to better streamline their cases.

"Using standardized technology for knee replacements allowed us to get our vendors down to three trays total," he said. "That enabled more simplified processes and sterilization for outpatient cases. Everyone saw the real value and operational efficiency of the technology we selected."

There is also a learning curve to implementing most new technology that surgeons and their teams must overcome.

Using an entirely new type of system for orthopedic surgeries, like robotic technology, takes time to train and then integrate into the normal workflows. In the beginning, using this type of technology could add time to the procedure and might not have a significantly better outcome.

"Surgeons want to avoid disruptive technologies that will add time in the OR and change their normal processes," said Dr. Durbhakula. "They want to offer technology for their patients that improve outcomes but doesn’t disrupt the flow of cases or require a huge cash outlay. They need to be able to pay for the technology on a case-by-case basis."

Long-term changes

The pandemic had a swift and immediate impact on orthopedic practices, and it will continue to frame how the field evolves for years to come. Dr. Ast said the entire preoperative workflow has changed in his practice; now all patients undergo antibody and viral testing, including a test within one week of surgery as well as a nasal swab upon entering the ASC or hospital. Patients also undergo a temperature check and are sent home if they exhibit any concerning symptoms.

"In the first week of implementation, we had four asymptomatic patients test positive for COVID-19 on the morning of surgery, and their procedures were canceled," said Dr. Ast. "Now we are trying to figure out what the next step will be. That is changing our workflows and preoperative screening methods."
Hospital for Special Surgery surgeons also anticipate making telehealth a permanent part of their practice and conducting virtual physical therapy and rehabilitation sessions with some patients postoperatively. The pandemic has also highlighted the clear advantages of specialty hospitals and ASCs to delivering surgical care.

"Long term, the pandemic will reinforce some of the negative views of general hospitals, and I think in the future it will drive patients to seek care at surgery centers and specialty hospitals," he said. "Patients view HSS as a potentially safer place to be than others because we focus on orthopedics."

Dr. Durbhakula also predicts that the fears about hospitals could bleed into any healthcare setting. Some patients may decide to delay medical treatment in any setting due to fears and prefer telehealth as a convenient way to receive care. Patients will also turn more to online education about their conditions and treatments.

"They may decide to do online consults and research on their own about joint replacements before seeing the doctor," said Dr. Durbhakula. "This will make medicine more technologically advanced and we will be able to use more resources for patient education."

ASCs in the next five years

While total joint replacements were already trending to the outpatient setting, the pandemic has sped up the transition.

Dr. Ast and his team at Hospital for Special Surgery have spent the past five years adopting the protocol and patient selection policies for joint replacement in the outpatient setting and are now prepared to take on additional patients during the pandemic.

"We are prepared for the sudden onset of more joint replacements in the outpatient setting from a capacity and safety standpoint," he said. "That’s why the ramp up will be so dramatic. CMS and private payers have been predicting the shift of outpatient total joints and I think there will be a big opportunity in the next five years for that trend to accelerate."

In the near term, budget restrictions will slow the purchase and implementation of expensive technology, especially without a clear path for improved patient care. "With leaner budgets and not as much reimbursement as the hospital, technology has to be cost-effective," said Dr. Durbhakula. "There are also many ASCs with multiple owners who will not use the technology, some of which aren’t even orthopedic surgeons. Not everyone wants full robotic technology, and the technology they do implement has to be mobile so rooms can be transitioned for other procedures quickly."

Dr. Durbhakula sees computer-assisted surgeries and navigation technology as becoming a large part of orthopedic practices moving forward, especially as the percentage of total joints performed in the outpatient setting grows. He projects that up to 40 to 50 percent of total joint arthroplasties could be outpatient in the next five years. He also sees insurance companies incentivizing members to have cases done in the less costly ASCs when it’s safe.

In conclusion

ASCs have a long road ahead to recover from the COVID-19 pandemic, but there is clear opportunity in adopting efficient and effective total joint arthroplasty procedures. The high-acuity cases can be performed safely in the ASC for the appropriate patients, and technology can help ease the operational and clinical transition.

This article is sponsored by OrthAlign.


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