THIS WEEK'S ARTICLES
Making the Case for Same-Day Total Hips
Tremendous strides have been made in the quality and efficiency of this life-altering procedure.
Steven Dellose, MD, is an orthopedic surgeon at Delaware Orthopedic Specialists in Wilmington who performs 800 to 1,000 hip and knee replacements and revisions each year. What's his secret? "One major reason we're able to perform such a high volume of cases is specialization," he says. "I don't perform upper-extremity procedures and our joint replacement team is made up of sub-specialized, fellowship-trained surgeons."
Dr. Dellose says one secret to his facility's high volume is the approach he uses for hip replacements. Instead of the widely discussed direct anterior or posterior approaches, he prefers to employ the anterolateral approach. "It lets me operate through a single small incision and work between muscle groups, which minimizes trauma to soft tissue in the joint," he says. Ultimately, says Dr. Dellose, surgeons should use the approach with which they are most comfortable.
Another key for Dr. Dellose is the use of multimodal techniques for postoperative pain management, which allows his facility to complete four cases a day, with patients ready to go home within four hours of their surgeries. "We give patients different medicines that treat their pain in different manners to decrease the amount of opioids used postoperatively," he says.
Dr. Dellose says total hip replacements can be a profitable endeavor for surgical facilities who manage patients effectively. "It's really a feel-good type of medicine, and it's great to give quality of life back to patients," he says.
Instrument Tracking Builds Communication and Efficiency
Here's how one busy sterile processing department stays on top of its workload.
Bill DeLuca, CRCST, CHL, CIS, the associate director of the sterile processing department at Mount Sinai West in New York City, is laser-focused on running an efficient department. Instrument tracking software is helping him and his staff achieve their goals.
"We manage 2,000 instrument sets and 47 techs work around the clock to reprocess more than 300 trays each day, from basic laparoscopy equipment to complex orthopedic instrumentation," says Mr. DeLuca. He says the use of tracking software has been a lifesaver, especially when a surgeon calls looking for a specific instrument.
"We once received a call from an OR where the surgeon was about to perform a total knee replacement and needed a Hohmann retractor, which was missing from the instrument tray," he recalls. "It was the only retractor we had in stock, or so I thought."
Mr. DeLuca punched the tool's serial number into the hospital's instrument tracking system and discovered they had another retractor in a tray that'd been sitting in storage for months. One of the reprocessing techs ran it up to the OR so the case could start on time. "Without the benefit of tracking software," says Mr. DeLuca, "it would have been like finding a suture needle in a haystack."
The software has other practical benefits as well, including the ability to record how long it takes to clean, sterilize and reassemble instrument sets. "It provides the information you need to increase efficiencies in sterile processing and improve collaboration between reprocessing techs and members of your surgical team," says Mr. DeLuca. "Instrument tracking provides the insights leaders from both departments use to improve the flow of instruments through the reprocessing circuit."
All told, tracking software has greatly improved communication between the sterile processing team and surgical leaders, says Mr. DeLuca.
Five Tips to Maximize Efficiency in Your Orthopedic Facility
It's crucial to run your growing orthopedic program as efficiently as possible to avoid delays, minimize costs and achieve patient satisfaction.
Given the high-stakes nature of orthopedic procedures, it's crucial to run your orthopedic program as efficiently as possible to avoid delays and cancellations. Any improvements that can be instituted in the ASC offer the opportunity to stay competitive while growing business.
The average time and cost spent on a surgery amounts to more than four hours of administrative time and up to 11 hours of staff time overall, which accounts for more than almost 40 percent of operating expenses.1 As increasing pressures to recruit and retain staff continue to challenge ASCs, it's important to look at what can be done to maximize efficiency for orthopedic procedures.
Here are five tips that can help reduce the administrative burden and streamline workflow.
Reduce manual, redundant and paper-based tasks. Tried-and-true solutions to reducing tasks can help staff do more important things. When ordering narcotics using the DEA's paper 222 form, for example, you may want to consider a front-end user interface that automates the task and eliminates the need for paper. Automation systems may be available from your distributor for a nominal fee or no fee at all, and they can be accessed from the same system you use to place orders. Some online ordering systems also allow you to accept and approve invoices online and that helps to avoid the manual process of matching invoices, purchase orders and packing slips. Automating a three-way match with packing slips, purchase orders and invoices electronically eliminates the need to mail, fax and scan hard invoice copies.
Harness the power of kits and trays. Optimizing procedure trays is a great way to manage costs and efficiencies especially if you're doing bundles. You're probably using custom procedure trays (CPT), for your most common cases, but are you taking full advantage of the added efficiency kits and trays can bring? It may be worthwhile to do time studies on some of your less common ortho procedures to assess whether you can save time by pre-kitting them, too. Using room turnover kits can help drive consistent and efficient turnover times. By kitting standard items such as sheets and headrest covers with kick buckets and even mops, for example, the staff doesn't need to track down several items after every case.
Use data and analytics. It's difficult to improve efficiency if you're not measuring key data that have the biggest impact on the bottom line. Investing in data and analytics to improve efficiencies can help grow your margins, but accessing key data doesn't have to cost a lot. In fact, some important metrics such as performance dashboards, for example, can provide visibility into possible redundancy and waste and may be offered at no charge as part of a system.
Don't be caught off guard. Procedures such as large joint replacements use a considerable amount of instrumentation. You don't want to be caught off guard without enough instruments ready to use. It's not uncommon for an ASC to have a sterilizer that only fits two pans at one time, which can make it difficult to do larger volumes of joint replacements.
According to Delores O'Connell, senior clinical education specialist with STERIS, obtaining physician preference cards from other facilities is an excellent blueprint for assessing overall equipment and instrumentation needs for a new joint program in particular. She cautions that they may only include general procedural items such as basic orthopedic instrumentation, power equipment and retractors and in many instances they will not include vendor-specific trays for the joint implants themselves. Typically, loaned instrument systems arrive 24 to 48 hours ahead of the scheduled case. Instrument sets that are delayed at the previous facility where used could require overtime to process.
"These types of special circumstances may require a second vendor's implant system to be held on stand-by which, can be an additional seven to 15 sets," O'Connell says.
Additionally, if a capacity study of washers, sterilizers and ultrasonics hasn't been done, a facility could find they do not have the throughput to process this number of trays effectively and efficiently. If the capacity of the equipment isn't adequate, this could require hours between cases and may not be the most effective use of surgery suite scheduling or sterile processing operations.
Not all mechanical washers, sterilizers or ultrasonic units are the same. Equipment should be designed to reprocess surgical instrumentation. Careful planning and right-sizing the equipment to maximize patient care and safety can yield a strong ROI on reprocessing equipment.
If you're planning to add a large joint procedure and want to ensure you're prepared, your distributor – working closely with equipment manufacturers' planning experts – can help assess the amount of throughput you'll need based on the expected caseload.
Reduce readmissions. With the average rate of readmission 30 days after a hip or knee replacement at 4.2%, it's important to understand the leading causes of readmission after joint procedures.2 Surgical site infections and sepsis, deep vein thrombosis and falls all lead to a poor patient experience as well as a cost burden and inefficiency, but there are ways to reduce and even prevent readmissions. Check out this detailed guide for reducing readmissions after a joint replacement for more information.
Note: For more information, please go to mms.mckesson.com/orthopedics.
1. VMG Health Intellimarker Multi-Specialty ASC Study 2017
2. Hospital Compare. Data collected July 1, 2014 - June 30, 2017
The Allure of Wide-Awake Surgery
Eliminating the use of general anesthesia during upper extremity procedures can greatly enhance efficiency and outcomes.
Adoption of the anesthetic technique known as Wide-Awake Local Anesthesia with No Tourniquet (WALANT) is gaining significant momentum during hand and wrist surgeries due to its favorable outcomes and patient satisfaction, according to a recent study.
The WALANT technique, first identified over a decade ago as an effective treatment for certain outpatient hand trauma cases, involves analgesia delivered directly to the awake patient's operative site through a local injection containing lidocaine and epinephrine. According to the study published in Anesthesia & Analgesia, WALANT saves clinical time because it is no longer essential for anesthesia providers to obtain surgical clearance, administer sedation or monitor the patient.
"The ability to perform common hand procedures without the use of a tourniquet avoids pain and discomfort experienced by the awake patient while providing optimal pain control and hemostasis," notes author Steven M. Koehler, MD, of the Department of Orthopaedic Surgery and Rehabilitation Medicine at SUNY Downstate Medical Center in Brooklyn. "Moreover, OR ancillary staff and inpatient providers are no longer needed, which significantly saves healthcare resources and minimizes the financial strain placed on the health system."
Because utilizing this technique requires minimal sterile draping and a smaller sterile field, it's environmentally responsible, adds Dr. Koehler. In addition, he says, patients are able to actively participate intraoperatively, which has been associated with lower rerupture tendon rates and improved clinical outcomes. "Recovery time is optimized through the avoidance of common side effects accompanying general anesthesia and, as a result, postoperative anesthesia care unit monitoring is negated," he notes.
WALANT's combination of increased efficiency and patient safety with shorter recovery times could carry great appeal for outpatient surgery centers.
Regional Anesthesia Remains Underutilized
Same-day surgery stands to benefit from increased use of peripheral nerve blocks.
Regional anesthesia contributes to improved surgical outcomes, fewer post-op complications and faster times to discharge, but a recent study suggests nerve blocks could be placed more frequently in the outpatient setting.
Authors of the study, published in Anesthesia & Analgesia, accessed the National Anesthesia Clinical Outcomes Registry (NACOR) to review nearly 13 million outpatient surgeries performed between 2010 and 2015. Regional anesthesia could have been used in about a quarter of the cases, but was employed in only 3.3% of the procedures.
"Despite this low frequency of overall utilization, when looking specifically at certain orthopedic surgeries, we found a much higher prevalence of regional anesthesia use," note the authors. In fact, blocks were placed in 40% of some shoulder arthroscopies and 32% of ACL reconstructions. However, continuous nerve blocks were used in only about 10% of these cases.
The researchers did find a significant uptick in the overall use of local and continuous nerve blocks during the study period, perhaps because of emerging evidence demonstrating the benefits of regional anesthesia and ongoing training in ultrasound-guided placement techniques. However, they also say utilization of continuous nerve blocks remained stagnant, perhaps because of the resources needed to manage patients who receive them.
"Regional anesthesia offers significant positive impact for perioperative outcomes, and it remains unclear what factors limit wider use," write the researchers. "Future research and efforts may focus on identifying barriers to increasing utilization of continuous nerve blocks for certain outpatient orthopedic procedures."