November 2, 2022

A focused, careful and targeted approach should be in place before you activate a spine service line.

Thanks to advances in minimally invasive techniques, cost reductions and the reality that it's what patients and commercial insurance companies want, spine procedures are migrating to outpatient settings. Here are five suggestions on how to successfully start an outpatient spine line from those who've done it.

Get expert advice. Before the leadership at Steamboat Orthopaedic and Spine Institute opened Steamboat Surgery Center in Steamboat Springs, Colo., in 2019, they considered new construction, but after consulting with an architect opted to retrofit an existing building instead. The consultant also facilitated a compromise among surgeon-owners to build two larger operating rooms instead of three smaller ones, a decision that co-founders Andreas Sauerbrey, MD, says helped with patient flow and in turn became a crucial element of the facility's daily success.

Negotiate with payers. As more data and positive outcomes roll in from ASCs and HOPDs, insurance companies increasingly prefer that many spine procedures be performed on a same-day basis. "The fee structures associated with outpatient spine surgery are often much lower, so payers have an interest because it saves them a lot of money," says Steamboat orthopedic surgeon J. Alex Sielatycki, MD. Dr. Sauerbrey suggests getting payer contracts in place in advance, and advises that leaders understand before launching a spine line how long it will take to secure reimbursements.

Work with the best. The surgeons you recruit should be experienced in achieving good results with same-day spine, and should be comfortable or open to using a variety of surgical techniques and implants.

Perform non-instrumented cases. At the surgery center, Dr. Sielatycki performs many less-invasive procedures that relieve pressure caused by one or more compressed nerve roots on the spinal column, and which don't require implants. "If a patient has a one- or two-level nerve root irritation, I can make a small incision and take the pressure off those nerves," he says.

Spend money to make money. Complex fusion means buying expensive technology and equipment, including fluoroscopy, navigational systems, robotics platforms and surgical microscopes. However, the investment allows the center's surgeons to perform more involved surgeries. "With some of the newer techniques, particularly pain control methods, I can safely perform spinal fusions and disc replacements in an outpatient setting for more patients," says Dr. Sielatycki.

Keeping these factors in mind will enable a center to safely and profitably perform spinal procedures at facilities that patients and payers prefer over hospitals.

The journey to developing and opening this new ASC took many decisions, customized options and collaborative teamwork with an experienced solutions provider like Stryker to become a reality.

The "one-size-does-not-fit-all" theory is certainly true in the ambulatory surgery world. Each facility has its own personality and footprint in its community. In a physician-owned facility, the stakes are high to ensure a successful launch and ongoing operations. That's why ASC owners and administrators look to others for advice and seek partnerships, from companies like Stryker, that are tailored to their specific needs.

A great example of a successful partnership is Riverfront Surgery Center in Chattanooga, Tenn. Their journey can shed some light into the process and challenges of opening a new ambulatory center and the future planning critical to its success. In January 2022, Riverfront Surgery Center opened its doors and began surgeries.

With a focus primarily on spine, total joints, sports medicine, pain management, podiatry and orthopedic procedures, this physician-owned facility delivers options to its community for customized patient care. Dawn McElhone, RN, administrator, who was involved in the planning and construction process of the ASC, currently oversees daily operations and completed every step required to get to grand opening. Outpatient Surgery Magazine spoke with Dawn about the path to opening the ASC and Riverfront's partnership with Stryker.

Thank you! Riverfront Surgery Center will provide, not only for our local, but for neighboring communities, an alternate choice for their surgical needs. ASCs have been shown to provide more cost-effective and personalized care to their patients with lower risk of infection.

Q: What and who drove the decision to build this new ambulatory center?

Some of the physician owners discussed how Chattanooga had very few surgery centers compared to other major cities in Tennessee. Those physicians approached other independent physicians about joining an ASC and received a positive response. Most of these doctors had never worked at a surgery center before, and they liked the idea of investing in a patient-centered approach to surgery that would benefit the community. Today, we have 17 physicians on medical staff at Riverfront Surgery Center.

Q: How important was it to choose Stryker as your partner? What did you learn in the process?

It was the service that sold me on Stryker. Stryker did not try to sell us on products we did not need. They were very receptive to my questions and concerns and were very transparent. Partnering with Stryker allowed us to obtain the majority of our capital with low-cost, high-quality equipment.

Through this process I have learned so much it is difficult to express. I knew very little of what the process of opening a surgery center would entail. In working with Stryker, I was able to find guidance, teamwork and support.

Q: What types of surgery did your center decide to focus on initially and why?

Riverfront Surgery Center offers a variety of orthopaedic, spine and pain management procedures. This includes podiatry, hand surgery, sports medicine, total joint replacements, minimally invasive back and neck surgery, spinal fusions, total disc replacement, steroid injections, spinal cord stimulators, along with other interventional pain management options.

Q: What three tips would you give anyone contemplated a project of this size?

1. Perform due diligence, read the fine print and question everything.
2. Don't be afraid to ask for help. Find people who have been in your situation and learn from their experiences
3. Build a strong team from the inside! I have been blessed with the best staff Chattanooga has to offer. They have worked harder than ever before with getting Riverfront's doors opened and passing our inspections and surveys and doing so with a genuine smile on their faces and joy in their hearts. They are just as dedicated to Riverfront as I and the physicians are.

Note: Whether you're building a new ASC or adding a spine sub-specialty to your ASC, Stryker's ASC business can help you build and grow strategically. By giving you access to our world-class portfolio of wall-to-wall capital, head-to-toe implants, and ASC specialists who understand your unique challenges and ongoing support, we deliver everything your ASC needs to win today – and tomorrow. To learn more about Stryker's ASC business, visit https://www.stryker.com/us/en/care-settings/asc.html

A live surgery showing the procedure in action was streamed at a recent conference.

At The 2022 Orthopaedic Summit in Boston in September, a groundbreaking total shoulder arthroplasty procedure pioneered by Anthony Miniaci, MD, deputy chief medical executive with Baptist Health Orthopedic Care, was livestreamed. The 40-minute surgery was performed by John Zvijac, MD, at Baptist Health's Surgery Center in Coral Gables, Fla., while Dr. Miniaci moderated the case from Boston.

Described as "total shoulder arthroplasty with a nonspherical humeral head implant with an inlay glenoid," the two-part technique is designed to more accurately mimic the anatomy of a patient's shoulder while employing a minimally-invasive inlay technology on the glenoid that salvages more of the patient's bone than traditional techniques do.

Dr. Miniaci first proposed the technique after observing unmet needs in his patients, predominantly athletes. A specialist in sports medicine and shoulder and knee surgery, he joined Baptist Health in August after two decades with Cleveland Clinic Foundation's Center for Sports Health in Cleveland and Sports Medicine Clinic in Toronto, where he treated numerous Olympic, MLB, NFL and NHL athletes and served as the head team physician for the Cleveland Browns.

Several Baptist Health surgeons now perform a high volume of procedures using Dr. Miniaci's method. "This technique gives our doctors the ability to preserve as much of the bone as possible and to replicate a patient's own anatomy," said Dr. Zvijac.

"It's rewarding to know this concept we formulated nearly 30 years ago is now being used as a standard approach and shifting the way in how we perform this type of shoulder surgery," says Dr. Miniaci.

Four zero-footprint, digitally connected, 600-square-foot ORs fit into a long-term goal of performing joint replacements at the facility.

Some facilities are built to provide total joints surgeries on day one. In the case of facilities like Essentia Health's recently opened Miller Hill Surgery Center in Duluth, Minn., they're built to accommodate them in the future.

Currently the new multispecialty center is equipped to perform orthopedic, ophthalmic, ENT, urologic, gynecologic and pediatric surgeries, with a stated long-term goal of adding joint replacements. The groundwork for a smooth launch of a total joints line, however, has been well-laid for whenever that time comes.

The center's four 600-square-foot ORs are equipped with state-of-the-art technology, including an integration system that is easily accessible via touch panel controls. The 55-inch monitors in the ORs display crystal-clear images and x-rays of the patient for the entire surgical team to view. Those images can be easily uploaded into the electronic health record, which providers can access during future consults with the patient and their family.

A surgeon's preference card can also be pulled into the integration platform and displayed on the monitors, ensuring surgical techs know exactly how the room should be set up and how back table instruments should be laid out for a particular case.

The ORs' zero-footprint design means that all surgical equipment used is located outside the actual room. This provides a safer, cooler, more sterile operative environment, according to Jefferson Davis, DO, an orthopedic surgeon at Essentia Health. "The integration clears up a lot of the cords and monitors and everything else that tends to clutter up the OR, making it much easier to navigate around without worrying about slips and trips and bumping into things that aren't sterile," he says.

Stacy Lund, operations director for acute surgery, says the ultimate purpose off all the technology is to maintain patient safety. "This is an ambulatory surgery center that is not connected to our main campus, so one of the things we really wanted to be able to provide for our physicians and patients in this space is the ability to contact others if needed," she says. "It was really important for us to have the ability to do that immediately during a procedure, so the technology and the integration platform allows us to video conference and engage in peer-to-peer consults in real time."