February 8, 2023

Orthopedics

By: Outpatient Surgery Editors

Published: 2/7/2023

Share:

THIS WEEK'S ARTICLES

Building Blocks of Successful ASC Total Joints Programs

ASC’s Redesigned ORs Embrace Multimedia Possibilities

Orthopedic ASCs Continue Growth in New Year - Sponsored Content

What It Takes for Advanced AAAHC Total Joints Certification

An Ortho ASC Built to Please Patients, Providers and Investors

 

Building Blocks of Successful ASC Total Joints Programs

Before launch, consider these crucial aspects for success.

Total Joints
LEG WORK Numerous factors must be addressed before the first patient arrives to ensure financial success and superior outcomes. | Ohio State News

As freestanding surgery centers welcome an ever-growing number of hopeful total joints patients, core components of successful programs have enabled various surgery centers to capitalize on the surge. Here’s a short list of evidence-based, experience-supported areas which two experts suggest interested ASCs focus on before launching total joints lines.

Patient selection. Anthony Mascioli, MD, an orthopedic surgeon at the Campbell Clinic in Memphis, Tenn., says strict adherence to a patient selection algorithm is key for establishing a program. His published algorithm outlines appropriate patients based on numerous factors, including meeting American Society of Anesthesiologists (ASA) guidelines for surgical patients, with ASA IV excluded; a full medical history and preoperative testing for electrocardiography; normal, healthy ranges for comprehensive metabolic panels and complete blood counts; and exclusion of patients with comorbidities such as obstructive sleep apnea, BMI greater than 35 kg/m2 and hypertension.

Standardized clinical pathways. Dr. Mascioli recommends multimodal anesthesia strategies, including preoperative peripheral blocks, intraoperative spinal blocks, perioperative intravenous antibiotics, and preoperative and intraoperative applications of chlorhexidine. Blood management should be addressed through intraoperative intravenous tranexamic acid unless contraindicated, followed by topical tranexamic acid. Pain management may also include pericapsular injection of liposomal bupivacaine, nonsteroidal anti-inflammatory drugs, gabapentin, tramadol, acetaminophen and, as needed, oxycodone.

Michael Ast, MD, orthopedic surgeon and chief medical innovation officer at the Hospital for Special Surgery in New York City, urges centers to focus on three things: blood management by including tranexamic acid and excluding patients with anemia; fluid management during regional anesthesia, with the patient hydrated two hours prior to and during surgery and rehydration after postoperatively to avoid dizziness and facilitate ambulation; and opioid-sparing multimodal pain management.

Adequate staffing. Both surgeons believe staffing shortages are likely the greatest challenge surgery centers face in launching total joints programs. "It would not be prudent to start total joint surgeries with limited staff," says Dr. Ast, who suggests flexible staffing models as a possible solution. For example, centers that are part of large ASC groups can share staff among their facilities, while smaller centers can bring in per diem staff from local hospitals. "With any staffing approach, training is key to get staff up to speed quickly," adds Dr. Ast.

Patient preparation.Dr. Mascioli’s approved patients complete a preoperative total joint class with physical therapy to understand their own roles in recovery. "Identifying those patients on the front end that can do it, telling them what will transpire, and helping them understand we are all on the same team sets an expectation with the patient up front," Dr. Mascioli notes. "From there it is up to me and my team to deliver that expectation through our predetermined approach and watch it bear fruit."

Capital purchases. Leaders at new or retrofitted centers must be agile by considering various creative avenues to meet their capital equipment needs for total joints, says Dr. Ast. Options include partnering with a surgery center management company or other source of outside capital. Dr. Ast suggests investing in a larger sterilizer along with a patient engagement platform that can deliver a personalized level of care throughout the patient journey. "You have to understand the logistics of purchasing and managing instruments such as mallets and drills, as well as handling implants, because these things aren’t normally kept on-site at an ASC," adds Dr. Ast.

 

ASC’s Redesigned ORs Embrace Multimedia Possibilities

At Eisenhower Desert Orthopedic Center, surgeons not only view images and video more comfortably in the OR but contextualize and share them with patients postoperatively.

VideoHEADS UP With monitors strategically placed around the OR, surgeons and their teams can see more information, data and images, and do so in an ergonomically friendly way.

ASC renovations should go far beyond simply creating extra space for providers and their patients. Many facilities also leverage these occasions to upgrade their technological capabilities to enhance clinical practices and outcomes.

Take, for example, the recently renovated Eisenhower Desert Orthopedic Center (EDOC) in Rancho Mirage, Calif. It now boasts eight 595-square-foot ORs filled with robotic platforms, two 80-inch wall-mounted ultra-high-def video (UHD) monitors and three 36-inch UHD monitors positioned on booms around the surgical table.

"We’re monitor-heavy," explains Stephen J. O’Connell, MD, a fellowship-trained and board-certified orthopedic surgeon at EDOC who specializes in surgery of the hand, wrist and shoulder. Thanks to numerous screens positioned strategically around the room, Dr. O’Connell and his colleagues now can refer whenever they would like to preoperative and intraoperative images in much more ergonomically sound and efficient ways than they could before. "No matter where I’m working on the patient, I can look up directly at a screen," says Dr. O’Connell.

That’s a huge improvement from before when he needed to crane his neck to see arthroscopy video on a monitor that was less-than-ideally positioned around the sterile field, or decipher anatomical images on a small screen attached to a C-arm while trying to drill a pin. Now all of those images are seamlessly routed to the large monitors in the room.

Even more impressively, the imaging system connects to EDOC’s EMR and fluoroscopy systems. Any video or image captured during a patient’s episode of care — not just in the ORs but also at EDOC’s on-site clinic, radiology suites and physical therapy office — is automatically loaded into the facility’s PACS system or patients’ medical records. Everything that is stored can be easily accessed by its surgeons.

How easily accessed? After each of his procedures, Dr. O’Connell steps into a private room adjacent to the ORs and uses an iPad to immediately access the case’s information including captured videos and images. He can edit and annotate the videos and images, and then record a short video message that he emails to the patient that not only discusses post-op instructions and a follow-up appointment reminder, but also reviews the steps he took during surgery with supporting images. When patients are recovering at home, they can review Dr. O’Connell’s multimedia message, respond to him and ask questions through the EMR’s portal.

Dr. O’Connell and his partners believe EDOC’s new "wired" ORs are now built to better keep pace over time with continuing improvements in same-day surgical care.

 

Orthopedic ASCs Continue Growth in New Year

Sponsored Content

Learn from leaders who have been there how to face the challenges in planning for a new facility or a renovation.

Dr Snibbe
Dr. Jason Snibbe | Credit: Snibbe Orthopedics

Ambulatory surgery facilities are busier than ever in 2023, and leaders anticipate increased case volumes this year. Orthopedic practices are growing around the country as new centers are opening and existing facilities are renovated to accommodate more patients. Opening new or upgraded ASCs takes partnerships and careful planning. Dr. Jason Snibbe, a board certified orthopedic surgeon practicing in Beverly Hills, opened a new orthopedic facility and offers some valuable insights into the process.

Q: What is the biggest challenge when launching a new ASC or even when undertaking a renovation?
The biggest challenge opening an ASC is the upfront cost of all the capital equipment and disposable equipment. It takes a large investment to get the ASC ready for surgery and procedures. It is important to unify the physicians so there is limited duplication of equipment and implant companies… to drive down costs and create efficiencies. This also makes the staff less confused when common cases are scheduled with different surgeons. For example, using Stryker for all joint replacement surgeries creates a streamlined efficiency for the staff and surgeons.

Q: What do you think surgeons should look for in a partner when opening a new ASC, renovation or equipment upgrades?
When an ASC is selecting a capital/equipment provider, the essential part is a global contract. An ASC should select a company that has quality products that can be used for a variety of procedures, for example, arthroscopy towers, power equipment, surgical robots, sports medicine and arthroplasty implants and sports medicine tools. A global company that can provide all of these products can be very creative with financing and rebate programs. As the ASC grows, rebate programs can be expanded to other products or locations. This can be a very powerful tool to fuel growth.

Q: What are the top three things to keep in mind as the project progresses?
First are the surgeons. The culture of the ASC is critical to its survival. Surgeons are the engine that drives business in the center. All of the surgeons should meet regularly and keep a transparent view of the workings of the ASC. The second thing to keep in mind is that this is a business. The surgeons should all be educated in the structure of how an ASC makes money, the overhead structure and understanding the billing process. This also stimulates a structure where surgeons want to help drive down the overhead and increase profits. The third is have a one-year plan for the first year. Avoid the temptation to buy too much equipment that is not needed. Create goals for the first year as well as the next several years. As the volume grows, the ASC can buy more equipment and expand the surgical cases.

Q: What factored into your decisions about equipment for your ASC?
My decision for equipment centered around robotic total joint surgery and quality equipment from a global company. Instead of using multiple companies with different contracts and sourcing, I used one company that had the majority of the equipment I needed and had the premier implants as well. I also wanted to use the best robot in the market that would provide excellence in outcomes and patient safety. In my opinion, the only company that can fulfill these goals is Stryker. They are truly a leader in so many facets of the business and can provide excellent product, capital equipment and service.

Q: What advice would you give to someone before they decide to build, renovate or expand an existing facility?
The best advice is to create a strong core of surgeons that have a common goal. The key to success is surgical volume and surgeons that drive business to the ASC. Before someone builds or renovates a new facility there should be an understanding of the need for an ASC. Are there enough surgeons to support the facility? Are the contracts with insurance companies in the community adequate to support a successful ASC? The best way to understand this is to seek out the most successful ASC in the area and have a deep discussion with the management and top surgeons. Learning from leaders in your community is very helpful and can provide critical insight into the business.

Q: Is there anything you'd like to highlight about the process of finding the right equipment and partner for your ASC?
I feel very fortunate and blessed to have Stryker as a strategic partner with my ASC. They have integrity and honesty with everything they do. They have continued to help us grow our business by helping with marketing of the ASC and our robotic program. They have held various community outreach programs to increase the exposure of the ASC to patients, physical therapist, chiropractors and primary physicians. The global rebate program helps drive down cost, which increases our bottom line. I cannot express enough how having a partner like Stryker has changed our business for the better and continues to make us treat patients better.

Note: For more information visit Ambulatory Surgery Center (ASC) | Stryker

Dr. Jason Snibbe is a consultant of Stryker. The opinions expressed by Dr. Snibbe are those of Dr. Snibbe and not necessarily those of Stryker. Dr. Snibbe has been a team physician for the University of Southern California since 2003. He is also an orthopedic consultant for the Los Angeles Lakers, Sparks and Kings and trains the fellows from Kerlan-Jobe Orthopedic Clinic in advanced hip arthroscopy and other sports related surgeries.

 

What It Takes for Advanced AAAHC Total Joints Certification

Year-long process dives deep behind the scenes at The Surgery Center - Shrewsbury.

Late last year, The Surgery Center at Shrewsbury, a collaboration among Shields Health, Reliant Medical Group and UMass Memorial Health, became the first ASC in Massachusetts to achieve Advanced Certification in Orthopedics for Total Joints from the Accreditation Association for Ambulatory Health Care (AAAHC).

The nine-OR ASC, which opened in May 2018, performed total knee, hip and shoulder replacements during a year-long evaluation period. The certification combined a self-assessment with a rigorous onsite survey led by the AAAHC.

The AAAHC analyzed the center’s full continuum of care for its total joints program during this period, from pre-assessment to intraoperative and discharge, to ensure its practices met AAAHC standards throughout the patient journey. It assessed the ASC’s use of evidence-based clinical practice guidelines, evaluated its ongoing performance improvement strategies, and considered whether its organizational infrastructure promoted high-quality, safe and efficient care.

Prashanth Bala, Shields Health’s chief of ambulatory surgical services, says his surgeons’ collaborative approach to care and close monitoring of best practices enables the ASC to provide exceptional patient care in an outpatient environment, and ultimately to achieve AAAHC’s certification. "This accreditation is a testament to the expert care our surgeons and clinicians provide and signifies The Surgery Center as a champion in expert, cost-effective orthopedic care for patients across the Commonwealth," he says.

The Surgery Center at Shrewsbury, which also focuses on hand surgery and sports medicine, has made a significant impact during its five years of operation, notably in a hospital-rich state not considered to be particularly hospitable to ASCs. Mr. Bala published an article in Outpatient Surgery Magazine about the launch of the center’s same-day spine program.

 

An Ortho ASC Built to Please Patients, Providers and Investors

A look behind the scenes at an example of thoughtful design for high-volume total joints.

The $19.1 million Center for Advanced Ambulatory Surgery in Malta, N.Y., opened in September 2021. A joint venture of The Bone & Joint Center, Albany Med Health Center and Saratoga Hospital, the 28,500-square-foot facility features eight pre-op bays, six surgical suites, eight PACU bays and six discharge rooms. Everything in the center was designed and built with intended purpose, with a particular focus on making patients feel safe and welcome as soon as they arrive.

Several aspects of the facility could inspire those who are considering renovations, or who are in the process of imagining a new facility:

Lobby. The arriving patient’s first impressions are of wood floors and ceiling lights that evoke a high-end hotel rather than a medical facility. Such hospitality-based reception areas are becoming the norm in ASC design. "These designs reduce the anxieties and fears in patients, and that warmth gives them confidence in what’s about to happen during their surgical procedure," says Suraj S. Soudagar, MS, MBA, LEED AP, principal and project executive at IMEG, a healthcare engineering firm in Naperville, Ill., that was not involved with the project. "A cozy and homey first impression in the lobby stays with patients as they transfer to the clinical areas of the facility."

The front third of the center also includes its pre-op and PACU bays, as well as its discharge rooms, each of which feature sliding glass walls for privacy, a stretcher, a lounge chair for a visitor and a TV.

OR suites. The middle of the facility houses the sterile corridor, which includes a row of six spacious 24-by-24-foot ORs, each of which cost more than $1 million to outfit. Included are a robotic-assisted knee surgery system, large wall-mounted monitors, tables for hip replacements that allow for hyperextension and external rotation to facilitate faster discharges, and advanced tools and devices for spine surgery. The ORs’ front doors open to the sterile corridor, while the back doors lead to sterile processing and storage areas. "The patient goes in and out at the front of the room, and the instruments always go through the back," says David Quinn, MD, an upper extremity surgeon at The Bone & Joint Center.

Storage area. Significant space in the rear of the facility is dedicated to storage, eliminating the temptation to stash equipment in the corners of ORs, where they can become tripping hazards. Across the corridor from the back doors of the ORs, a large alcove runs almost the entire length of the building, housing all of the facility’s tools, implants, fluid management devices and other gear.

Sterile processing area. Total joints cases involve a lot of equipment. For example, at this facility, case carts the size of dishwashers are rolled into cleaner-sterilizers the size of refrigerators. As such, the center prioritized extra space for reprocessing.

Dr. Quinn says that although the design was difficult, shareholders feel they hit the sweet spot with a properly-sized center that is both welcoming and safe for patients and laid out to run at full capacity in its market for the next quarter-century.

Related Articles