By the Numbers: Total Joints Metrics to Measure Success

From average case time to readmission rates, savvy surgery centers rely heavily on data to improve.

When Korie Enscoe, MSN, RN, became a nurse 20 years ago, patients who had total joint replacements would spend a week in the hospital followed by a few days in a rehabilitation facility. Today, advancements in technology and other innovations in total joint replacements, which in many surgery centers can have patients home within hours from admission to discharge, have greatly improved patient satisfaction scores.

“We had one patient who was fist-bumping everybody and then threw her hands in the air,” says Ms. Enscoe, director of quality for the ambulatory surgery division of Allegheny Health Network in Western Pennsylvania. “She was so happy that she was being wheeled out of the surgery center six hours later and on the way home.”

Benchmarks for success

Maybe all patients aren’t whooping it up in that manner on the way out the door after a total joint procedure, but patient satisfaction scores are one of the metrics that surgical facilities track. Others include cost reimbursement, average case time, education compliance rates, patient selection, infection rates and readmission rates. Savvy surgery centers and hospitals use these metrics as guides to continually improve in those areas.

• Patient selection. In the outpatient setting, it all starts with selecting the right patients for total joints procedures, says Jesse Hixson, MSN, RN, CNOR, administrator of Allegheny’s Monroeville (Pa.) Ambulatory Surgery Center. His facility employs what it calls the Diamond Care Program, in which a nurse sees the patient all the way through their entire surgical process.

“That nurse ramps that patient up for surgery, making sure they have all the testing they need, whether they’re the right fit and if they have the right attitude to be done in an outpatient surgery environment,” says Mr. Hixson. “Not every patient is a candidate to come to the surgery center health-wise or attitude-wise. Some people like the extra ease and comfort of staying in a hospital, while a lot of patients are motivated and want to be home.”

“We collaborate with anesthesia pretty closely,” adds Jennifer Hartz, MSN, RN, administrator of Bethel Park (Pa.) Surgery Center. “They like to review every patient to avoid any same-day cancelations. We’ve had success with shoulders. I believe patient selection is key to that, and the collaboration with anesthesia to find the right fit.”

How are patients selected? Ms. Hartz says there is a thorough review of the patient’s medical history to identify any underlying comorbidities. The patient’s ASA (American Society of Anesthesiologists) Physical Status Classification score is used to assess the patient’s overall health. Perfectly healthy patients with no comorbidities receive an ASA 1 score. As the ASA score rises, so does the patient’s risk from receiving anesthesia.

“With the improved physician satisfaction, nurse satisfaction and patient satisfaction, we can actually do more cases now.”
Jesse Hixson, MSN, RN, CNOR

• Patient education. This process starts in the office and continues through the patient’s visit to the surgery center, says Mr. Hixson. At Monroeville, physical therapists see patients pre-op and post-op, and provide a lot of education prior to the patient’s discharge. “Between nursing and PT, safety is always first, and if we cannot feel that the patient is going to be safe, then they are admitted to the local hospital,” says Mr. Hixson. “That is a metric that we track on the back end — how many people are getting admitted to the hospital.”

• Patient readmission rates. One of the best ways to track this rate is with a post-op phone call to patients the day following surgery, says Katelyn Poston, quality coordinator for Allegheny’s ambulatory surgery division.

“We check in with the patient and see if anything happened with them post-discharge when they got home,” she says. “We can see if they went to the emergency department. Fortunately, we haven’t had a ton of those patients where they have been admitted to the hospital for days upon days.”

Ms. Enscoe adds that the health network’s readmission rate is virtually non-existent.

“We have reporting through our electronic medical records that we’re able to see the histories of all our patients — if they’ve had lab work, if they have had readmission. If any of those things have happened, it triggers us and lets us know what patients went back in and for what reason,” says Ms. Enscoe. “We monitor that on a weekly basis.”

• Case times. Mr. Hixson believes that case durations, turnover times and set-up times are areas where improvements can be made. “When we first started our total joints program, we noticed our turnover time was a little bit longer than we wanted,” he says. “And we weren’t very happy with our set-up originally. We noticed we were opening way too many instruments.”

The solution was to partner with the health network’s vendors to reduce the number of instruments on the tray, using more size-specific technology and utilizing X-rays to get a better idea of the correct size of implants to use. That, in turn, helped the sterile processing department by reducing the workload there.

“We have only two or three trays for one joint now versus the seven or eight we were doing before. That’s allowed us to keep reprocessing our trays in-house,” says Mr. Hixson. “And with the improved physician satisfaction, nurse satisfaction and patient satisfaction, we can actually do more cases now.”

• Infection rates. These are tracked on all patients, but it’s particularly important to do so with total joints cases, says Mr. Hixson. His center has had only one infection after a total joint case.

“It’s something we track a lot and take ownership of. The surgeons are very passionate about that and it’s something we like to brag about to the patients if they are a little bit uneasy,” he says. “When we’re doing patient selection, we’ve had patients reach out to us and that’s one of the things we can talk about, that we have a lower infection rate than even the hospitals in our health system.”

• Enhanced Recovery After Surgery (ERAS). ERAS is a patient-centered, multidisciplinary approach to perioperative care that aims to improve recovery, facilitate earlier discharge and potentially reduce healthcare costs without increasing complications or readmissions by optimizing care before, during and after surgery. St. Cloud (Minn.) Surgical Center developed its own perioperative protocols starting with prehab exercise, which is an important precursor to the post-op rehab, says Joseph Nessler, MD, former chief of staff at the surgery center. “Anesthesiologists do a combination of general anesthetics and regional anesthetics, but then they also do specific regional blocks, especially for knees in terms of preoperative adductor canal blocks,” he says.

Dr. Nessler adds that the preoperative intravenous steroid dexamethasone is a big part of ERAS pathways. “Patients still use some opioids, but the amounts have been decreased from historical levels significantly because of the other modalities we’re using,” he says.

What about robotics?

GOOD FIT In addition to making sure patients have all the testing that they need, staff must ensure they’re the right fit and have the right attitude to undergo total joints procedures in an outpatient surgery environment.

St. Cloud was an early adopter of robotics for total joint procedures in the ASC setting. Although there was a time when using robotics in surgery was controversial and costly, Dr. Nessler says it has helped the center increase efficiencies, decrease turnaround times and reduce the amount of instrumentation needed for procedures. That, in turn, decreased the amount of instruments the center needed.

“We’ve been able to pare down pans and trays and customize instruments to that patient for that case. We have 3D imaging and we’re using technology-assisted surgery with the robotics, so that helps with some of that in-OR time and it really decreases the variability of outcomes,” he says. “The reproducibility of it from surgeon to surgeon and patient to patient is a big thing. It stands out in my mind as to what really helped establish the practice.”

Analyzing and utilizing metrics and data

Dr. Nessler looks for trends at his facility, then compares his data to how other ASCs in his health network and others around the country are performing. With patient outcomes, for example, you want to be below certain thresholds and monitor for any increases of adverse events to determine if they’re just blips or an actual trend, he says.

“We’re now down into the six- to eight-hour range for a total length of stay for the patient, so we don’t vary from that,” says Dr. Nessler. “If some new practices or technologies are introduced in surgery, we want to continue to monitor them to see if they have a negative or positive influence on any of the metrics or outcomes.” OSM