The ability to perform total knee arthroplasty, or TKA, in the ASC
setting depends on state law — you must be allowed to keep patients up
to 23 hours, if necessary — but if your state permits overnight stays,
such a program can be a lucrative addition to your facility.
The ability to perform total knee arthroplasty, or TKA, in the ASC setting depends on state law — you must be allowed to keep patients up to 23 hours, if necessary — but if your state permits overnight stays, such a program can be a lucrative addition to your facility.
There are other options for surgery dealing with arthritis or injuries to the knee that are beginning to appear in ASCs. Such surgeries are unicompartment procedures, less-invasive resurfacing procedures and the use of homologous tissue implants. These procedures will all have their own issues, most importantly, paying for them. Russ Greene, RN, the administrator at Physicians’ Surgery Center in Fayetteville, Ark., offers these keys to successful outpatient TKA based on his 12 years’ experience with the procedure.
1. Patient selection
Patient selection is driven partly by payor limitations: Medicare won’t pay for outpatient TKA on its patients, though Medicare patients represent the majority of TKAs. The good news, says Mr. Greene, is that the number of older patients who are still working and have commercial insurance (or,
occasionally, the ability to pay cash) is growing; these are generally baby boomers who suffer from arthritis, or may have suffered a traumatic injury, and who may have had previous surgeries, but who want to remain active and are otherwise in
good health.
“People aren’t just retiring at 65 and taking
Medicare — they either can’t retire or don’t want to, and they feel fine,” says Mr. Greene. “Within this patient population, you still have to find those who are fairly healthy, without cardiac conditions or severe diabetes, and who aren’t going to need blood. While obesity may be a cause of osteoarthritis, those patients usually have underlying conditions that are contraindications for doing a procedure like this one outpatient.”
Another note: Only about 10 to 20 percent of orthopedic surgeons’ patients will be candidates for TKA, so it’s a good idea to analyze whether you have
sufficient volume to support an outpatient total knee program, says Mr. Greene.
“A couple per month is normal for us,” he says. “In a larger city, there may be 50 orthopods who can do 20 TKAs a month. That would be a
really robust program.”
2. Blood backup
One of the biggest intraoperative issues in TKA is the potential for serious blood loss; as a result, you will have to have a supply on hand for each procedure. One major obstacle here is that some states don’t allow ASCs to administer blood, says Mr. Greene.
“You can get around that by having patients donate their own blood in anticipation of possible transfusion,” he says. “TKAs are elective, so the patient can donate blood several weeks before the procedure to prep for this. You can either work out a deal with the hospital, or an independent blood bank or organization such as the American Red Cross, and bring the blood in on the day of the procedure.”
3. Regional anesthesia
There are different techniques available for anesthetizing patients and controlling their post-op pain, but the most effective have a regional component, so it’s important that your anesthesiologists be well-versed in these techniques.
“The best results are done with spinal anesthesia,” says Mr. Greene. “There are a lot of papers out there that recommend a spinal block and Duramorph, which is slowly absorbed, along with general anesthesia. That’s the technique we use, and patients don’t have much pain for 24 hours.”
Other options include spinal block paired with propofol, or other block techniques, such as continuous infusion (similar to epidural), which uses a different compartment of the spine. Anesthesia and the surgeon should work together to determine the most efficacious method for the center.
“Whatever the technique, anesthesia is very important to the ability to do these types of procedures in an outpatient surgery center,” says Mr. Greene. “The key is to keep the patients comfortable for the first 24 hours post-op; put them in continuous passive motion (CPM) to move the knee, keep adhesions down and help control some of the bleeding. Then they can be discharged and sent to a rehab facility to begin recovery.”
4. Overnight staffing
Staffing the 60- to 90-minute TKA surgeries has no requirements outside other orthopedic procedures being done in your facility. However, since patients will remain overnight, there must be at least an RN on staff overnight. Depending on your state’s rules, you may need to have two RNs or an additional nurses aide, notes Mr. Greene.
5. Realistic cost assessment
Total knees are costly to perform, no doubt; you must be practical about assessing the costs as well as the patient volumes to determine if the latter will support the former.
There are other options for surgery dealing with arthritis or injuries to the knee that are beginning to appear in ASCs. Such surgeries are unicompartment procedures, less-invasive resurfacing procedures and the use of homologous tissue implants. These procedures will all have their own issues, most importantly, paying for them. Russ Greene, RN, the administrator at Physicians’ Surgery Center in Fayetteville, Ark., offers these keys to successful outpatient TKA based on his 12 years’ experience with the procedure.
1. Patient selection
Patient selection is driven partly by payor limitations: Medicare won’t pay for outpatient TKA on its patients, though Medicare patients represent the majority of TKAs. The good news, says Mr. Greene, is that the number of older patients who are still working and have commercial insurance (or,
occasionally, the ability to pay cash) is growing; these are generally baby boomers who suffer from arthritis, or may have suffered a traumatic injury, and who may have had previous surgeries, but who want to remain active and are otherwise in
good health.
“People aren’t just retiring at 65 and taking
Medicare — they either can’t retire or don’t want to, and they feel fine,” says Mr. Greene. “Within this patient population, you still have to find those who are fairly healthy, without cardiac conditions or severe diabetes, and who aren’t going to need blood. While obesity may be a cause of osteoarthritis, those patients usually have underlying conditions that are contraindications for doing a procedure like this one outpatient.”
Another note: Only about 10 to 20 percent of orthopedic surgeons’ patients will be candidates for TKA, so it’s a good idea to analyze whether you have
sufficient volume to support an outpatient total knee program, says Mr. Greene.
“A couple per month is normal for us,” he says. “In a larger city, there may be 50 orthopods who can do 20 TKAs a month. That would be a
really robust program.”
2. Blood backup
One of the biggest intraoperative issues in TKA is the potential for serious blood loss; as a result, you will have to have a supply on hand for each procedure. One major obstacle here is that some states don’t allow ASCs to administer blood, says Mr. Greene.
“You can get around that by having patients donate their own blood in anticipation of possible transfusion,” he says. “TKAs are elective, so the patient can donate blood several weeks before the procedure to prep for this. You can either work out a deal with the hospital, or an independent blood bank or organization such as the American Red Cross, and bring the blood in on the day of the procedure.”
3. Regional anesthesia
There are different techniques available for anesthetizing patients and controlling their post-op pain, but the most effective have a regional component, so it’s important that your anesthesiologists be well-versed in these techniques.
“The best results are done with spinal anesthesia,” says Mr. Greene. “There are a lot of papers out there that recommend a spinal block and Duramorph, which is slowly absorbed, along with general anesthesia. That’s the technique we use, and patients don’t have much pain for 24 hours.”
Other options include spinal block paired with propofol, or other block techniques, such as continuous infusion (similar to epidural), which uses a different compartment of the spine. Anesthesia and the surgeon should work together to determine the most efficacious method for the center.
“Whatever the technique, anesthesia is very important to the ability to do these types of procedures in an outpatient surgery center,” says Mr. Greene. “The key is to keep the patients comfortable for the first 24 hours post-op; put them in continuous passive motion (CPM) to move the knee, keep adhesions down and help control some of the bleeding. Then they can be discharged and sent to a rehab facility to begin recovery.”
4. Overnight staffing
Staffing the 60- to 90-minute TKA surgeries has no requirements outside other orthopedic procedures being done in your facility. However, since patients will remain overnight, there must be at least an RN on staff overnight. Depending on your state’s rules, you may need to have two RNs or an additional nurses aide, notes Mr. Greene.
5. Realistic cost assessment
Total knees are costly to perform, no doubt; you must be practical about assessing the costs as well as the patient volumes to determine if the latter will support the former.