Higher acuity procedures, once the sole domain of hospitals, are on the move to the outpatient environment and ambulatory surgery centers are poised to become the ideal setting.
During a Dec. 9 webinar hosted by Becker's ASC Review and Pacira, Patrick Toy, MD, an assistant professor at the University of Tennessee in Knoxville, and Benjamin Domb, MD, an assistant clinical professor with Loyola University in Chicago, laid out five imperative steps to take before introducing total hip and total knee replacement procedures in the ASC setting.
1. Organization. The introduction of a new ASC service line always requires structured organization. "Someone needs to be the quarterback of the whole process," said Dr. Toy. "Empower this person so you can rely on them to make sure everyone is on the same page." Major issues to consider and create a plan for include:
• Necessary equipment. Does the ASC have all of the supplies and technology needed to perform the procedures?
• Intraoperative control. Does the ASC team have an effective blood management plan in place?
• Postoperative patient function. Will patients be ready to go home the same day or will the ASC need 23-hour stay capabilities?
• Payer issues. Will commercials payers be receptive to the introduction of total joints? Will carve-out rates need to be negotiated?
• Materials management. Will the ASC have the proper supplies and in a cost-effective manner?
• Rehabilitation. Care following the procedure must be provided. Will the patient have access to home health services or will they travel to an outpatient physical therapy center?
2. Patient selection. "Patient selection is a critical step," says Dr. Domb. Once an ASC has put considered the preliminary organization, the next step is establishing patient selection criteria. A patient that is a viable candidate for any type of high acuity outpatient procedure will have few to no co-morbidities and adequate knowledge to take control of their postoperative care.
3. Motivation. Patients that are potential candidates for ASC total joint replacement must be active participants in their care. Surgeons are responsible for educating patients and giving them the tools to play a role in recovery. "Patients need to understand they will be mobile the day of surgery," said Dr. Toy. "These are things they need to hear. Patients need to be motivated to improve early on."
Communicate with patients regularly and offer educational resources to ensure they understand the process of outpatient surgery and their recovery trajectory. "Most of the success of outpatient total joint replacement lies in the preoperative patient preparation and conversation," says Dr. Domb.
4. Preparation. Every member of an operating room team should be well-versed in the process of total joint replacement before the first ASC case is ever performed. The team includes the surgeon, anesthesiologist, nurses, surgical staff and physical therapist. "Anyone who does total joints knows that the people around you make a difference," said Dr. Toy.
Rather than leap straight to performing cases in the ASC, practice the process. "Simulate a case first. Don't schedule a total hip and start tomorrow. Do it at a hospital first," said Dr. Toy. "You need to get to the point where a patient is ready to go home on day number one."
5. Execution. When the time comes to begin performing total joints in the ASC, one of the most critical elements of the process is pain management. The patients' preoperative regimen, intraoperative treatment and postoperative pain control strategy will play a large role in the procedure's success and the patient's experience. In addition to strategies such as opioids, nerve blocks and spinal anesthesia, Dr. Domb and Dr. Toy use bupivacaine liposome, a long-acting injectable. "Pain control with bupivacaine liposome can reduce opioid-related adverse events," said Dr Domb. Both surgeons have found the multimodal pain management approach to be effective.
In a study comparing liposomal bupivacaine with bupivacaine, Dr. Domb found patients who received liposomal bupivacaine had a median length of stay of 1.9 days following total hip arthroplasty, while the group receiving bupivacaine had a median length of stay of 2.5 days. The average morphine equivalent use during the 24 hours following the procedure was 24 mg in the study group and 53.4 mg in the control group. The study's researchers concluded that liposomal bupivacaine for total hip replacement decreases length of stay and the need for postoperative opioid use.
"Good experiences will generate more opportunities," said Dr. Domb. Effective pain management coupled with successful total joint protocols will demonstrate success to patients and payers alike.
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