Here are seven secrets for success for spine surgeons performing cases in ambulatory surgery centers, according to Fred Naraghi, MD, director of the Comprehensive Spine Center in San Francisco.
1. Patient selection. Selecting the appropriate patient for spine surgery in the ASC is crucial for optimizing your success rate. Patients who have comorbidities, such as cardiac problems, shouldn't be brought to the ASC. Dr. Naraghi also steers patients with a body mass index of more than 30 or a significant dependence on pain medication (taking more than eight narcotics per day) to the hospital setting. These patients are at a higher risk for complications, so it's too risky to perform their surgeries in an ASC.
"For every case it is different, but as a rule I tend to have lower risk patients for outpatient spine surgeries," says Dr. Naraghi. "An important part of that is pain management for the patient. If the patient has a high pain management requirement, I would be very careful about doing those procedures as outpatient procedures because controlling the pain is going to be hard."
2. Procedure selection. Procedure selection is as important as patient selection for ensuring successful cases in the ASC. Dr. Naraghi never does revision surgeries or anterior lumbar disc replacements in the ASC because of the complexity of the procedures and the high risk of complications. He does perform single level anterior cervical discectomy and fusions, posterior lumbar fusion discectomy, single-level cervical disc replacement, cervical foraminotomy and lumbar microdiscectomy.
3. Pain management. It's important to have spine-appropriate pain management tools available to you in the ASC, which includes anesthesiologists who are experienced with spine cases. Dr. Naraghi typically has a facet block and a median branch block performed to the level of surgery and the level above the surgery. He also recommends being generous with the anesthetics so the patient will be able to tolerate the pain. "Using these techniques gives the surgeon good pain control so the patient is able to return home as quickly as possible," he says.
4. Perform new procedures at the hospital first. Many spine surgeons like to remain at the forefront of their field, which often means learning new techniques. Dr. Naraghi recommends surgeons who have learned a new procedure or technique perform it first in the hospital setting until they are comfortable with the surgery. "I try not to do new procedures in the surgery center because the learning curve increases the risk factors and potential for complications," he says. "I do a gradual transition — after I've done the procedure a few times and I'm comfortable with it, I'll take it to the ASC."
The transition from the hospital to an ASC can be difficult and surgeons should be more attentive than usual during the first couple of cases in the ASC. Communication with the staff members is key during the transition period. "Encourage the staff to communicate with you and ask questions all the time," says Dr. Naraghi. "Otherwise, something could go wrong."
5. Training ASC staff. Spine surgery is a different type of procedure than most procedures performed in the ASC, and surgeons must make sure the staff members are experienced and prepared to work with them. Even after you begin bringing spine cases to the ASC, you must train your staff on each new type of procedure before performing the case. Dr. Naraghi holds an in-service day at his ASC before bringing a new procedure to the facility so the staff will understand the different components of the surgery.
"It's common to have an in-service and ask the device company to bring in the equipment for the procedure so you can do a dry run and make sure everyone understands what will happen when the patient arrives," he says. "When a new procedure starts in the ASC, you might be missing something and that could mean the case might not go smoothly. Have a checklist for the procedure and make sure the components can adapt to the ASC. Once you start ahead of time, you can find the kinks and it isn't an issue; but if problems occur during the actual surgery, it could be a major complication."
For example, if a wrong-sized cannula is pulled for the case and the surgical team doesn't realize it until the surgery has begun, finding the appropriately sized cannula will take time and the patient will most likely need admittance to the hospital.
6. Consider 23-hour extended stays for high-risk procedures. For more complex procedures, such as the ACDFs and posterior lumbar fusions, have patients stay at the ASC overnight for 23 hours (if your ASC has been approved for it) and allow them to go home first thing in the morning. Additional measures might be needed, such as measuring neck circumference of the ACDF patients postoperatively, to make sure they aren't experiencing difficulties before discharge.
7. Infection control. Paying strict attention to infection control protocol for spine cases is another big factor in successful operations. Surgeons should make sure the antibiotic is given to the patient within one hour or 30 minutes before making the incision. Patients should also receive an antibiotic postoperatively. Processing the equipment through sterilization is also important, and can be different from the sterilization process for other procedures.
"Typically, in an ASC setting, we use endoscopic equipment, such as cannulas and tubes, and they need to be processed separately," says Dr. Naraghi. "They have separate brushes that need to be aggressively treated — otherwise the equipment could have some issues."
Learn more about Dr. Fred Naraghi.
Related Articles on Spine Surgery:
Spine Surgery in 2011 and Beyond: 7 Points About the Future of Spine Surgery
6 Reimbursement and Business Concepts for Spine in ASCs
8 Design Specifics for Development of Spine Surgery Centers
"For every case it is different, but as a rule I tend to have lower risk patients for outpatient spine surgeries," says Dr. Naraghi. "An important part of that is pain management for the patient. If the patient has a high pain management requirement, I would be very careful about doing those procedures as outpatient procedures because controlling the pain is going to be hard."
2. Procedure selection. Procedure selection is as important as patient selection for ensuring successful cases in the ASC. Dr. Naraghi never does revision surgeries or anterior lumbar disc replacements in the ASC because of the complexity of the procedures and the high risk of complications. He does perform single level anterior cervical discectomy and fusions, posterior lumbar fusion discectomy, single-level cervical disc replacement, cervical foraminotomy and lumbar microdiscectomy.
3. Pain management. It's important to have spine-appropriate pain management tools available to you in the ASC, which includes anesthesiologists who are experienced with spine cases. Dr. Naraghi typically has a facet block and a median branch block performed to the level of surgery and the level above the surgery. He also recommends being generous with the anesthetics so the patient will be able to tolerate the pain. "Using these techniques gives the surgeon good pain control so the patient is able to return home as quickly as possible," he says.
4. Perform new procedures at the hospital first. Many spine surgeons like to remain at the forefront of their field, which often means learning new techniques. Dr. Naraghi recommends surgeons who have learned a new procedure or technique perform it first in the hospital setting until they are comfortable with the surgery. "I try not to do new procedures in the surgery center because the learning curve increases the risk factors and potential for complications," he says. "I do a gradual transition — after I've done the procedure a few times and I'm comfortable with it, I'll take it to the ASC."
The transition from the hospital to an ASC can be difficult and surgeons should be more attentive than usual during the first couple of cases in the ASC. Communication with the staff members is key during the transition period. "Encourage the staff to communicate with you and ask questions all the time," says Dr. Naraghi. "Otherwise, something could go wrong."
5. Training ASC staff. Spine surgery is a different type of procedure than most procedures performed in the ASC, and surgeons must make sure the staff members are experienced and prepared to work with them. Even after you begin bringing spine cases to the ASC, you must train your staff on each new type of procedure before performing the case. Dr. Naraghi holds an in-service day at his ASC before bringing a new procedure to the facility so the staff will understand the different components of the surgery.
"It's common to have an in-service and ask the device company to bring in the equipment for the procedure so you can do a dry run and make sure everyone understands what will happen when the patient arrives," he says. "When a new procedure starts in the ASC, you might be missing something and that could mean the case might not go smoothly. Have a checklist for the procedure and make sure the components can adapt to the ASC. Once you start ahead of time, you can find the kinks and it isn't an issue; but if problems occur during the actual surgery, it could be a major complication."
For example, if a wrong-sized cannula is pulled for the case and the surgical team doesn't realize it until the surgery has begun, finding the appropriately sized cannula will take time and the patient will most likely need admittance to the hospital.
6. Consider 23-hour extended stays for high-risk procedures. For more complex procedures, such as the ACDFs and posterior lumbar fusions, have patients stay at the ASC overnight for 23 hours (if your ASC has been approved for it) and allow them to go home first thing in the morning. Additional measures might be needed, such as measuring neck circumference of the ACDF patients postoperatively, to make sure they aren't experiencing difficulties before discharge.
7. Infection control. Paying strict attention to infection control protocol for spine cases is another big factor in successful operations. Surgeons should make sure the antibiotic is given to the patient within one hour or 30 minutes before making the incision. Patients should also receive an antibiotic postoperatively. Processing the equipment through sterilization is also important, and can be different from the sterilization process for other procedures.
"Typically, in an ASC setting, we use endoscopic equipment, such as cannulas and tubes, and they need to be processed separately," says Dr. Naraghi. "They have separate brushes that need to be aggressively treated — otherwise the equipment could have some issues."
Learn more about Dr. Fred Naraghi.
Related Articles on Spine Surgery:
Spine Surgery in 2011 and Beyond: 7 Points About the Future of Spine Surgery
6 Reimbursement and Business Concepts for Spine in ASCs
8 Design Specifics for Development of Spine Surgery Centers