TEAM EFFORT To succeed with outpatient total joints, numerous people have to know exactly what their jobs are, and they have to do those jobs consistently and well.

We've developed a comprehensive approach to outpatient hip and knee replacements, so we know a thing or two about what it takes to launch a successful program. We also know that by upgrading your ortho offerings now, you'll be ideally positioned to meet a growing patient demand and out in front of the cutting edge of care, waiting for other facilities to catch up. If your orthopedic center is already performing major joint repairs, adding outpatient total joints is well within your reach. Here's what you need to know to make it happen.

Planning and prepping
To ultimately succeed at outpatient total joints, you need surgeons who are committed to the idea — who are willing to start the program, who are going to build and improve on it, and who are ultimately going to champion it. Once you have that, it becomes possible to line up the buy-in and commitment you need from the rest of the team.

With the right care plan in place, most patients can ambulate within a few hours of surgery, and most want to get home as soon as possible. My patient selection criteria for inpatient and outpatient are very similar. Truly sick patients — those with major cardiac issues or seizure disorders, for example — aren't good outpatient candidates. One thing that will disqualify patients, at least temporarily, is obesity. We're not afraid to say: You're going to be a great candidate for outpatient surgery, but first, we'd like you to get your BMI down below 40. Most people will do that, given a rationale. They want the surgery to be easier and they want to decrease the chance of infection.

Although outpatient total joints aren't for every patient, there's a large segment of the population for whom it's the perfect choice. In fact, I recently did an outpatient total joint on an octogenarian. We tend to underestimate patients, even those in their 80s. And this new approach aligns perfectly with where health care — with its increasing emphasis on costs — is heading. Most total-joint patients don't need overnight stays. In fact, of the dozen or so patients I've talked to who've had one joint done in a hospital and another done in an ASC, without exception, they've preferred the ASC experience.

Marriott Rivercenter
San Antonio, Texas
Oct. 13-16
orexcellence.com

Register Now for 3-Hour Total Joints Pre-Conference Workshop at ORX
Nothing is hotter than outpatient total joint replacement surgery. If you'd like to explore adding total joints to your facility, this session is for you. Orthopedic surgeon Mark Gittins, DO, and Diane Doucette, MBA, RN, president of the Mount Carmel New Albany (Ohio) Surgical Hospital, will explain the clinical and operational keys to replacing knees and hips, and then getting patients ambulatory a few hours after closing — everything from patient selection and pain management to reimbursement and at-home nursing care. Register now at orexcellence.com to see Dr. Gittins and Ms. Doucette in San Antonio.
Space is limited.

The patient and the patient's family need to be part of the team. Well before the day of surgery, we provide a detailed booklet and DVD that explain the entire process. Our nursing staff continually educates patients and families, making sure expectations are clear and ensuring the support structure will be in place once the patient gets home.

Complications are rare, but naturally you have to be on call and prepared if they occur. All contingencies need to be established well before the surgery, including where to send patients if they require stays longer than allowable by your local laws. That's happened fewer than 5 times in 3 years at our facility.

EASY CHOICE Almost all patients are outpatient candidates, and those who've had one joint done in a hospital and another done in an ASC overwhelmingly prefer the ASC experience.

On the day of surgery
The first patient arrives at 5:30 a.m. and is escorted to pre-op at 6 a.m. The first cut happens at 7 a.m. You can't be in a rush, but you can be efficient, and you have to have the expectation that you're going to get everything done in a timely fashion. The typical case lasts about an hour, and I've been able to do as many as 8 procedures in a single day. We try to have all joints done by 2 p.m. and want all patients discharged to home by 7 p.m. at the latest.

To reduce the risk of infection, we give patients antibiotic soap to shower with for 2 days before the day of surgery. We also give them IV antibiotics an hour before surgery and use chlorhexidine wipes in pre-op. Later, we put a gram of vancomycin powder in the wound as we close.

All nerve blocks are done in pre-op (for knees, we use an adductor canal block). That's crucial. The OR is strictly for surgery. We make sure our anesthesia providers have their own space and don't feel pressured by surgeons. It's their turf and they have nurses dedicated to helping them draw medications and place blocks. A mastery of ultrasound is extremely important and our anesthesia providers are gifted when it comes to using it.

Once the regional blocks are placed, we whisk patients into the OR, where the surgeon, an anesthesia provider, a PA and an RN circulator await. Ideally, the surgeon is alternating between 2 ORs and can move between them as the PA closes and the staff turns over the room. That's our standard protocol, and it also requires a helper who goes between the 2 rooms, taking care of any odds and ends that may need attention.

Pain control is a huge part of the process. We want to make sure people don't experience pain prematurely and become overly anxious. To help control pain, we use COX-2 inhibitors before surgery and during the acute post-op period. That's one of the important little tricks. It short-circuits the acute inflammatory pain response. We also use the same multimodal approach for every patient, and the surgeon usually starts a pericapsular block, as well.

It's important to educate patients as to what they should expect in terms of pain. The blocks we use are very long acting, but we make it clear that they're going to wear off. Otherwise, patients might get a little anxious when the pain starts to occur. We also give them some pain medicine (Percocet or something similar) to take home for when the blocks wear off. We try to avoid giving them opioids before they go home, because we don't want to see issues with urinary retention, hypoxia, lethargy or PONV. Above all, patients need to be comfortable before they're discharged.

JOINT INITIATIVE
CMS to Test Bundled Payments for Total Knees and Hips

COST CUTTING CMS wants to reduce what it's paying for total joints. Sanctioning outpatient procedures could be a solution.

Saying it's overpaying for inpatient hip and knee replacements, CMS is proposing a 5-year bundled-payment initiative that would put the onus on hospitals in 75 geographic areas to contain costs for lower-extremity joint-replacement.

Medicare paid more than $7 billion for more than 400,000 hip and knee replacements in 2013, according to CMS (osmag.net/cK8pMY), with the average cost across geographic areas ranging from $16,500 to $33,000. In some areas, it says, complications such as infections and implant failures were more than 3 times as common.

Under the proposed plan, hospitals "would be held accountable for the quality and costs of care from the time of the surgery through 90 days after discharge," says CMS. This, it says, would provide "an incentive to work with physicians, home health agencies and nursing facilities to make sure beneficiaries get the coordinated care they need."

The plan would go into effect on January 1, 2016, and cover all hospitals in areas as geographically and demographically diverse as New York; Los Angeles; Lubbock, Texas; and Fort Collins, Colo. Hospitals in these locations may qualify for additional payments or be forced to reimburse Medicare for a portion of the costs, depending on the facility's quality and cost performance. Healthcare providers would continue to be reimbursed under the current Medicare model, according to CMS.

The full list of targeted areas appears on pages 58 and 59 of the proposed rule (osmag.net/DafH2X), which was published in the Federal Register on July 14. The comment period runs until Sept. 8.

— Jim Burger

Future possibilities
We've found that insurers pay less for total joints in the outpatient setting, even though we're doing the procedures more efficiently and economically. To make money on outpatient total joints, it's imperative to control your case costs, especially for implants. We save the healthcare system approximately $8,500 for each outpatient total joint we perform, and I think every insurer is going to eventually want those cost savings. We've been able to get reimbursed for certain cases that previously weren't payable in the outpatient setting because insurers have seen the quality of what we're doing. Some say, Really, you can do this? I meet with payor reps all the time to educate them about exactly what we're doing. That's been important to the success of our outpatient joint programs and will continue to be as more programs launch.

Unfortunately, CMS isn't on board with outpatient total joints yet, but I think they're looking really hard at the procedures and I suspect they'll come around. This is a much more economical alternative for the right candidates. Ever-evolving technology is going to play into it, too, as incisions get smaller and smaller, and as blocks become more and more universal. The future of outpatient total joints is already bright. What we used to do in 3 days, we can now do in 3 hours.