February 10, 2021

Baptist Health's enormous campus is a one-stop shop for essential services.

Health systems are moving in the direction of bringing traditional hospital services, including surgery, closer to where their patients live. In the process, they're creating large outpatient health centers that do many of the things hospitals have done for years, but without the ER and inpatient critical care components — and reflecting the times in which we live, without acute COVID-19 patients being treated on site.

This kind of next-generation facility opened its doors to patients in late November. Baptist Health's new 112,000-square-foot wellness and medical complex in Plantation, Fla., is providing residents of Broward County with orthopedics, cardiology, spine, cancer and endocrinology services and surgeries, urgent and primary care, diagnostic imaging, physical therapy and a pharmacy — all in one outpatient campus.

The arrangement allows providers in the facility's urgent care clinic, diagnostic imaging center and ASC to work together closely. Thanks to them all being on the same site, Baptist says it can expedite treatment for injured and sick patients who walk into urgent care to produce better, quicker outcomes.

The full-service diagnostic imaging center is equipped with CT, MRI, ultrasound and PET-CT capabilities, as well as breast imaging and interventional procedures to serve numerous specialties. "From the patient's perspective, it's a real convenience to have imaging performed on the same day and in the same place as your doctor appointments," says Lawrence Elgarresta, MD, medical director of imaging at the facility. "From a doctor's perspective, they're able to consult with other specialists in the same facility, allowing them to provide even better care to their patients."

The site's ASC features eight large ORs equipped with the latest technology, including robotic assistance. "Whatever type of surgery patients require — robotic, orthopedic, urologic, cancer, gynecologic, breast, ENT, plastic — can be done here," says John P. Diaz, MD, the center's medical director. The ASC is designed for same-day surgeries and less-than-23-hour stays, but can accommodate overnight stays if necessary.

Describing the center as a "health hub" that provides a more convenient, seamless patient experience, Baptist points to the facility's patient-centric design, which focuses on wellness as an integral part of health care. "We'll always be here for you when you're sick or injured," says Baptist Health COO and Executive Vice President Bo Boulenger, "but we also want to be a trusted resource for those who want to incorporate physical and emotional wellness into their daily lives."

Efficient departments maximize every square foot of space.

Mount Sinai West in New York City recently completed a $24 million expansion of its sterile processing department (SPD) that transformed it from a nondescript 2,000-square-foot work area to a 7,000-square-foot high-tech hub. William DeLuca, CRCST, CHL, CIS, associate director of the SPD, provides these tips if your company is building or redesigning an SPD.

• Let workflow guide design. Fully understand how your SPD techs actually work, and integrate that into the department's design to make them less stressed and more productive. For example, how easily can staff access and operate critical equipment like sterilizers, autoclaves and decontamination workstations? How far do they need to walk while moving instrument trays from a decontamination sink to the instrument washer? They shouldn't have to cover a long distance to do so, says Mr. DeLuca, not only because it takes extra seconds, but because wet trays could drip, creating a slipping hazard.
• Futureproof the space. A new SPD might seem perfectly designed on day one, but circumstances change, especially if you plan to grow case volume over the years. Mr. DeLuca built with the future in mind by including three extra unused decontamination workstations that are ready to go. The last thing you want to realize down the road is that you've run out of usable space, he says, and you'll likely need to store more supplies and equipment in your SPD as case volumes grow. Mr. DeLuca got creative with space-saving elements such as installing a double-sided sterilizer next to a storage area. The sterilizer is loaded on one end and, when the cycle completes, its other end is opened in the storage area for cool down.
• Address ergonomics, safety and efficiency. Sterile processing is hard work, so think of how you can alleviate your techs' physical stress. For example, Mount Sinai's new SPD boasts adjustable-height decontamination workstations. "At a minimum, you need workstations that can move up and down to accommodate the various heights of your staff," says Mr. DeLuca. "Tall members of your team who have to hunch over low sinks will wind up with repetitive strain injuries." To boost efficiency, the SPD's ultrasonic washers remove blood and bioburden from complex, hinged instruments and lumened devices that are difficult to manually clean.
• Involve SPD staff. "When you add their suggestions, they own the changes," says Mr. DeLuca. "They're invested in making the suggestions work and they take better overall care of their SPD." Investing in the tools they need to improve their performance will pay you back in the form of a more engaged staff, he says.

"An efficient SPD essentially comes down to two things: process flow and ease of use," says Mr. DeLuca.

Expanding and updating ASCs is key to meeting the growing demand, especially in orthopedics.

It's no secret that the ongoing coronavirus pandemic has challenged American health systems in ways that they are not used to being challenged. Many have had to adjust rapidly to best meet the needs of their patient population, while doing what they can to stay afloat financially. Among the most attractive solutions to this problem is the migration of procedures to ambulatory surgical centers (ASCs).

This also makes sense from a patient perspective. Free-standing ASCs provide the ability for patients to access surgical services while avoiding potential exposure to hospitalized COVID-19 patients. But how can surgeons benefit from this solution, and what do they need to know if they are considering it? The challenges of expanding or renovating this type of facility – or, in fact, building a new facility from the ground up – and then managing either can be daunting.

According to Joseph P. Nessler, MD, there are a number of important considerations to keep in mind as the migration to ASCs gains prevalence. Dr. Nessler is a partner at Saint Cloud Orthopedics, Sartell, Minn., owner/partner in the Saint Cloud Surgical Center, Saint Cloud, Minn. and an adult hip and knee reconstruction surgeon with an emphasis on outpatient and robotic joint replacement and revision arthroplasty. He points out these considerations, including the viewpoint that the ASC setting can make the surgeon's life easier.

"ASCs can provide profound quality-of-life benefits for surgeons, especially those who have only ever worked within the restrictions of a larger hospital setting," says Dr. Nessler. So what are these benefits?

"One such benefit is increased responsiveness. Larger hospitals have to meet a variety of different needs for a variety of different employees and stakeholders, but because ASCs have a much smaller footprint, they can be laser-focused on making sure that surgeons are able to do their work efficiently," says Dr. Nessler. "ASCs can be quick to change workflows and patient pathways to make outpatient surgery more efficient."

Moreover, ASCs can respond quickly to changing surgical demand as was the case during the early days of the pandemic last year.

According to Dr. Nessler, "Case in point, our local physician-owned ASC responded quickly with expanded operating hours including early morning, evening and even weekend hours as needed to address the backlog of elective surgical caseloads once our state restrictions on elective surgery were lifted."

ASCs also can be conducive to more intimate patient-doctor interactions. Particularly in larger hospitals, it can be difficult to balance the constant demands of moving between operating rooms and often distantly placed family waiting and consultation areas. By virtue of being a much smaller, more focused environment, ASCs make it significantly easier to spend more time with patients and their families both pre- and postoperatively, vastly improving the patient and physician experience.

Expanding with a partner

ASCs can also offer advanced technology. According to Dr. Nessler, "Given the focused and responsive nature of ASCs, many of them are equipped with advanced technology that's as good as hospitals. For example, we currently are partnering with Stryker's ASC business to help expand and update our ASC to meet the growing orthopedic case volume. After meeting with them to communicate our needs, they developed plans to assure everything was covered, from totally outfitted operating rooms, including Mako SmartRobotics^™, to central sterile processing. No details were left uncovered. They proved to be a great partner providing one-stop service."

Of course, there are challenges with migrating new and more complex surgical procedures to an ASC and Dr. Nessler advises, "You'll have to make a long checklist of things that need to be done – including making sure you have adequate in-servicing both internally and with vendors, making sure your staff is able to adjust to new workflows and determining the best way to communicate the benefits of ASCs to patients."

Furthermore, in tackling the other hurdles associated with migrating procedures, Dr. Nessler says, "It can be helpful to use a third party that's familiar with the business model, such as Stryker's ASC business. As we migrated more complex cases, Stryker played a huge role in every step of the process. Stryker's familiarity with our surgeons' workflows helped the ASC surgical team learn our surgeons' preferences, so that each doctor had personalized equipment according to their wants and needs for each kind of procedure. Overall, they made what can be a very complicated process extremely simple, allowing myself and the surgeons on my team to focus on patient care."

Stryker is committed to providing the latest operating room equipment and accessories with flexible options for technology refresh to keep that equipment state of the art for years to come.

The migration to ASCs is not going away any time soon, even after the pandemic is in the rearview. Just recently, the CMS proposed a 2.6% boost to ASC payment rates for the 2021 coverage year, and recommended inclusion of THA on the ASC-approved list of procedures which will speed the migration of spine and joint procedures out of the hospital setting.

"The potential benefits of ASCs are clear, and though migration provides certain challenges, there are options available to make the process much simpler. Vendors such as Stryker can help ensure that whenever the time is right to begin moving procedures to the ASC, it can happen as seamlessly as possible," says Dr. Nessler.

Surgery centers are beginning to pop up in former retail stores.

One fallout of an increasingly digital economy, further accelerated by the pandemic, is the acres of office and retail space sitting idle. Nowhere is that more apparent than the uniquely American phenomenon of "dying malls," whose diminished and sometimes abandoned spaces have been the settings of endless news reports, blogs and exploratory video shoots. Fortunately, and strategically, healthcare providers are moving to adapt these former social and commercial centers of their communities into easily accessible, neighborhood-oriented providers of convenient patient care, including surgical services.

In December 2019, Medical University of South Carolina's (MUSC) new West Ashley Medical Pavilion opened in a 126,000-square-foot former JC Penney store that had served as an anchor of the Citadel Mall in North Charleston, five miles from MUSC's downtown Charleston campus. The facility features a large diagnostic imaging center, multidisciplinary physician clinics, a muscular skeletal institute and a surgery center with two ORs and two procedure rooms.

With ample free parking and a convenient location, the facility brings MUSC's services closer to many patients. When asked why MUSC made the move, its interim COO Tom Crawford stated, "We needed to do a better job of integrating health care into the communities we serve."

This model is being replicated across the country. For example, news of a project by Essentia Health for a mall-based outpatient surgery center surfaced early this month, with construction slated for this spring and an opening planned for spring 2022. Referred to by one company official as a "day surgery center" that will also include a laboratory and pharmacy, its planned location is a 32,000-square-foot-space consisting of 40% of a former Sears store at Duluth's Miller Hill Mall, which already houses numerous of the health system's other services.

"The new day surgery center will serve the growing demand by patients who want to use outpatient services and recover at home," Essentia Director of Facilities Dan Cebelinski told Duluth's planning commission in a letter described in the StarTribune. "The new facility also reflects the growing number of surgeries and other procedures that can be done safely without hospitalization." The city's planning commission was slated to consider the proposal on February 9.

The StarTribune reports that Essentia Health, which not only owns the Sears store, but other space in the mall — including a clinic, fitness center, physical therapy office and rehab facility — now holds the largest share of square footage in the 1970s-vintage shopping center. It also operates an orthopedic urgent care clinic close by.

Potential hazards could result from poor layout and workflow.

Spilled fluids, stray cords and misplaced equipment are some of the slipping and tripping risks you'll find in many ORs. When you have a chance to build a new room, keep these dangerous factors in mind during the design phase.

Anjali Joseph, PhD, EDAC, director of the Center for Health Facilities Design and Training at Clemson (S.C.) University, reimagines current OR designs with the goal of creating safer spaces. She spends a lot of time watching surgical teams in action and provides these observations on how to keep OR staff upright and safe.

• Consolidated equipment. Outpatient ORs increasingly are packed with new devices and equipment that enable more complex procedures, but also can clutter walking lanes and limit maneuverability around the operating table. Consolidating equipment is the simplest way to keep floors clear of tripping hazards. "OR clutter is a big concern based on our observations and conversations," says Dr. Joseph, who suggests space-saving solutions like floor- or ceiling-mounted booms that not only limit the number of towers and carts needed around the table, but enable you to safely add more equipment over time.
• Assigned zones. Dr. Joseph suggests organizing ORs into four work areas — anesthesia at the head of the table, sterile zones on both sides of the table and a circulation zone outside the sterile field. These dedicated areas keep appropriate staff "in their own lanes," minimizing steps and limiting movement during cases. Another idea: Moving the surgical table closer to a side wall and angling it toward one corner to free up space around its surface, giving staff more room to move and maneuver equipment during cases. The anesthesia workstation should be located in the corner closest to the head of the table, which is often dead space in conventional ORs. Dr. Joseph says this keeps tubes and cords away from moving equipment and staff members while ensuring that vital connections between the patient and anesthesia machine aren't accidentally dislodged.
• Built-in storage. Storage that's built into the walls of the OR is the new order of the day. Dr. Joseph says designing integrated storage locations in the anesthesia work area and where the circulating nurse patrols are particularly efficient because they limit the amount of distance these providers must travel during surgeries.
• Wireless imaging. Leveraging wireless technology wherever you can in your design removes numerous pesky cords and cables from the OR. Images can now be transmitted wirelessly from video towers to large flat-screen monitors positioned around the room.
• Freedom of movement. Mobile workstations allow circulating nurses to position themselves near the surgical table for a better view of surgery while limiting the amount of walking they must do around the sterile field. They also allow the nurses to safely move aside if something or someone needs to be repositioned.

Remember, it only takes a split second for a team member to lose their balance and suffer an injury. Examine your ORs closely to see how you can better prevent these accidents by eliminating clutter and floor hazards.