Total knee replacement surgery in an ambulatory surgical center? It's not as improbable as it might sound. The leaders of Mississippi Valley Surgery Center in Davenport, Iowa, share 5 keys that let patients walk out of their facility within 23 hours of getting their knee replaced.

1. Case scheduling. You'd think Mississippi Valley would schedule its total knees first thing in the morning so the complex cases are cleared before its bread-and-butter procedures hit the ORs. Not so, says Nancy Jipp, ARNP, CASC, Mississippi Valley's surgical services and quality manager, who says the facility's leadership recently decided to push total knee cases back to 10 a.m. so her staff had time to prepare patients and ORs for surgery under the lingering pressure of the 23-hour discharge deadline.

"Patients scheduled for 8 o'clock procedures would be on our doorstep at 6:30 in the morning," says Ms. Jipp. "That meant they'd have to be out by that time the following day."

Problem was, Mississippi's surgeons typically arrived at 7:30 a.m. Patients who showed up an hour earlier than that on the day of surgery forced surgeons to do the same the following morning for pre-discharge assessments. Early arrivals also came and went in darkness during Iowa's cold winter months, which didn't help the center's patient and physician satisfaction scores.

2. Surgeon selection. Total knees are "complex, challenging cases," says John Dooley, MD, Mississippi Valley's chief of anesthesia. "But they build on what (orthopedic centers) are doing now." Surgeons need to be expert in muscle-sparing techniques and able to operate in deeper surgical incisions, says Dr. Dooley. "They shouldn't learn in your facility," he adds.

3. Post-op complications. Plenty of intraoperative bleeding and the potential for post-op surgical and anesthetic complications are associated with total knee cases, warns Dr. Dooley. Your anesthesia providers must work with your staff, troubleshoot clinical problems, have a uniformity of practice and be available after hours. An anesthesia provider's ability to handle "those issues without bothering physicians is one more reason surgeons might choose to bring their cases to your facility," he says.

Patients receive spinal anesthesia (bupivacaine) combined with oral analgesics and morphine injections for pain control. Common post-op complications include nausea, vomiting and urinary retention, says Dr. Dooley. Spinal narcotics combined with pain medications tend to exacerbate the inability to urinate in older male patients, who often have enlarged prostates, says Ms. Jipp. To resolve that issue, she explains, all total knee patients are catheterized so their bladders remain empty until medications have worn off.

4. Equipment purchasing. You'll likely need to augment your orthopedic instruments with large power hand tools and quality surgical headlights. Dr. Dooley says his facility is outfitted with 6 trays of the complex instrumentation, which cost about $200,000. Table attachments (costing about $6,000) that hold patients' knees in place are a must, he says, as are hooded infection control "spacesuits" for each member of the surgical team (at a cost of about $1,500 each). Operating rooms should be at least 400 sq. ft. in order to accommodate the equipment and staffing requirements.

5. Overnight stays. Operating on carefully selected patients plays a key role in the success of outpatient total knee. Dr. Dooley says patients should be healthy and stable, and have family members or friends available to care for them during the first 24 hours they're home following surgery. They should be open to being discharged after an overnight stay at your facility and able to clear their homes of obstacles that could pose as tripping hazards during initial stages of ambulating.

Thanks to quad muscle-sparing surgical techniques, patients "are usually up and walking within 4 to 6 hours after surgery," says Ms. Jipp, which is key to getting them ready for same-day discharges. It's vitally important to set patients' recovery expectations before surgery. "They will experience pain, but shouldn't fear it," explains Ms. Jipp. "They're informed that physical therapists will be on hand to get them up and moving."

Patients recover overnight in one of Mississippi Valley's 5 private pre-op/PACU bays outfitted with soft lighting and televisions. The facility rents hospital beds (at about $40 per night) and orders whatever food patients want (within reason). Family members are encouraged to spend the night in a cot next to the hospital bed or in an adjacent bay if one's available.

Added comfort and more focused care are a few of the benefits patients enjoy while having their procedures performed in a surgery center. Ms. Jipp says her facility is equipped to keep up to 6 patients overnight and always have at least 2 staff members on duty. "That's a staffing ratio you won't get in a hospital," she says. "We've had patients who had a knee replaced at a hospital and one done here," says Ms. Jipp. "They told us they'd never go anywhere else."