Planning to Perform Total Joints? Take These 9 Steps First

If your ASC is considering launching a total joint replacement program, you're in good company. Advancements in minimally invasive surgical techniques, devices, anesthesia, and pain management have spurred numerous surgery centers across the country to start performing total joint replacements.

While the prospect of completing that first total joint in your ASC may be a new challenge and could represent a significant development in the history of your facility, use caution. Adding a new procedure or program, particularly one that is of a higher complexity like total joints, should not be taken lightly, says Mary Jo Steiert, BSN, RN, director of nursing and clinical director for Lowry Surgery Center in Denver.

"You will want to take your time to ensure your ASC is adequately prepared on all fronts —financial, clinical and operational — to properly and safely perform that initial procedure," she says. "That is certainly better than having something come up and not knowing what to do, which can potentially lead to significant challenges."

Here are nine of the steps Steiert says Lowry Surgery Center took before performing its first total joint replacement in November 2018.

1. Complete credentialing and privileging. "Verify that the surgeons who intend to perform total joints at your ASC have been credentialed to do so and your delineation of privileges for these surgeons is up-to-date to include total joints," Steiert says.


2. Determine patient criteria. ASCs should carefully select patients who will be undergoing outpatient total joints. "You want to set up your center, physician, and patient for a successful outcome," Steiert says. "Develop specific admission criteria for your total joint patients and follow it without fail."
   

   She says the criteria for total joint patients at Lowry Surgery Center, which was reviewed and approved by the ASC's medical executive committee and governing board, addresses multiple patient qualities. These include a body mass index equal to or less than 35; hemoglobin A1c of less than 8 percent; hemoglobin count of greater than 12 grams per deciliter; 70 years of age or younger; ASA physical status classification of I or II; and no comorbidities.

   "We also strive to ensure these patients have proper postoperative support," Steiert adds. "You want to make sure they will be able to go home and receive the support they need during their recovery. You don't want to be performing surgery on a patient in an ASC who you will need to turn around and admit to an inpatient facility."



3. Secure coverage. The Centers for Medicare & Medicaid Services (CMS) removed total knee arthroplasties from the Medicare inpatient-only list of procedures in 2018, but this approved only Medicare reimbursement for these procedures in hospital outpatient settings. While ASCs cannot receive Medicare reimbursement for total joints, many private payers are willing to cover these procedures.

   "From a business perspective, you won't want to proceed with that first case until you have appropriate payer contracts in place," Steiert says. "Find out whether your payers will reimburse you for the types of total joint replacement procedures you plan to perform and then allocate time to negotiate fair contracts and reimbursement."



4. Update transfer agreement. Update the transfer agreement you have in place with your hospital, Steiert advises. "The hospital should be aware that you are starting a total joint program and be willing to support you in the event that there are complications during surgery that require a transfer."


5. Provide preoperative patient education. All patients who undergo total joint replacement at Lowry Surgery Center must first complete a preoperative education class. "During this class, patients learn about their procedure," Steiert says. "We review areas such as infection control, medications, physical therapy, home health needs, any required durable medical equipment, and other expectations. It's beneficial in preparing patients for their experience."


6. Provide staff training. Don't overlook the importance of preparing your staff. "You may have some team members who have been in inpatient facilities and worked with total joint patients, and you may have some staff members without any experience," Steiert says.

   Lowry Surgery Center sent its clinical staff to a hospital to observe one of the surgeons who would eventually perform total joints in its ASC. "Our staff had the opportunity to watch this surgeon perform the procedure and pick the physician's brain," Steiert says. "We also arranged for our nursing staff to review the other phases of the case. They observed admission and preop, including the education class, and postop."

   She continues, "They also spent some time learning about the physical therapy aspect of care. While we do not require our nurses to provide physical therapy teaching — that's completed by a professional therapist — we still felt it was important that the nurses gain an understanding of the physical therapy component so they could answer patient's and family members' questions."



7. Perform a mock case. To help ensure staff was comfortable with performing total joint replacements, Lowry Surgery Center completed a mock case before its first real case.
   

   "We arranged to have the surgeon here, the equipment vendor here and had all the instrumentation and positioning devices out and ready for use," Steiert says. "We created a mock chart, our administrator posed as the patient, and then we went through and practiced all the phases in the case. This helped ensure we had everything we needed and had not overlooked something. Doing a mock case definitely helped the staff feel more comfortable when the time came for the actual case."



8. Prepare for emergent blood use. In the event a patient requires a blood transfusion, the ASC is now better prepared. "This is not something surgery centers usually need to plan for, but we didn't want to be caught off-guard," Steiert says. "We went through several drills to address what steps we would take to obtain and provide blood if a total joint patient required it."


9. Implement ERAS protocol. If your ASC isn't already doing so, consider implementing the enhanced recovery after surgery (ERAS) protocol with your total joint program, Steiert says.

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