Already have a successful spine program and want to add more advanced procedures, such as multi-level cervical discectomies and fusions, to your case mix? Start by answering these 4 questions to see if your facility's ready to make the leap.

Why expand? Any ambulatory surgical facility that has found success doing basic spine procedures at some point will want to take stock and analyze how it can expand and improve its services. You don't want to force patients to go elsewhere for treatment they could have received from physicians they know and trust in an efficient, welcoming atmosphere. Nor do you want to turn away cases at a time when all healthcare facilities are competing for market share.

Thanks to technological and surgical advancements, advanced spine procedures like trans lumbar interbody fusions and multi-level discectomies no longer need to be performed in hospitals alone, letting physicians expand their services with fewer overhead costs. In many outpatient settings, rooms are set up quicker and surgeons can better navigate their schedules, booking their surgeries with less downtime between cases. This higher level of convenience and efficiency will entice physicians to perform any spine procedure that can be done outpatient, whether basic or advanced, at your facility. Patients, too, will appreciate the opportunity to go home within 24 hours of their procedure rather than having to stay in a hospital bed overnight.

What new procedures will you add? Collaborate with your physicians to determine the entire list of both basic and advanced procedures that you will be able to safely offer patients in your facility. You'll need to take into account Centers for Medicare and Medicaid Services' regulations regarding which types of surgeries can be done on an outpatient basis, and assess the complexity and potential adverse outcomes of each procedure to determine whether your facility can safely host it. Once you've agreed upon the list of procedures that will comprise your advanced spine program, expect the transition to take 6 to 12 weeks.

How much additional equipment will you need? Advanced spine procedures are on the same continuum as your basic discectomies, microlaminectomies, laminectomies and foraminotomies. When assessing your equipment needs, start by examining the basic procedures you already do and then ask, if you wanted to add something more advanced, like multi-level cervical discectomy and fusions or multi-level lumbar decompressions, what more would you need? Surprisingly, the instruments and equipment, such as the surgical microscope and routine fluoroscopy, aren't that different from what's required for simple spine procedures. The 2 big additional purchases you may need are:

• Jackson table or Allen frame. For positioning patients during complex fusion cases, compare a specialty OSI Jackson table for roughly $135,000 to an Allen frame to adapt a standard OR table at a fraction of the cost ($35,000).
• Specialty surgical instrument trays, such as those required for anterior approaches. These trays are usually a one-time purchase, with instrumentation varying in cost from $10,000 to $30,000. Be sure to factor in the cost of upkeep, as you'll need to do maintenance on a monthly basis to ensure, for example, that the curettes stay sharp. We're fortunate in my practice that many of the instruments we use are brought in by vendors on a case-by-case basis, which helps minimize cost and allows us to work with cutting-edge tools.

How will staffing needs change? Aside from equipment, staffing is another major consideration to plan for when moving from basic spine to advanced cases. For starters, your anesthesia providers may make some changes to their approach, such as using a different type of anesthesia to accommodate spinal cord monitoring in patients. But other than slight changes in the way anesthesia is administered in certain cases, the role of the anesthesia provider should not change dramatically for the most part when you move from basic to complex spine.

A greater consideration is the possibility that you'll have to offer 23-hour care for some patients, usually for pain control purposes. Labor is the biggest cost associated with 23-hour care, as you'll need 2 RNs to stay and care for the patient after hours. Whether patients are being kept overnight or not, any staff involved in the advanced spine program will require proper training for pre- and post-operative care for every patient. Most perioperative nurses who are trained on basic spine procedures can be cross-trained to handle the care necessary for advanced procedures.

Depending on the complexity of individual cases and the range of services you aim to provide your patients, you'll want to develop relationships with other types of specialists to assist with special circumstances or patients. For example, in some procedures you might need to have a vascular surgeon available, or a urologist for that small percentage of difficult cases where catheterization is required. Dieticians, physical therapists and other specialty staff members might be required on site to administer in-care during the patient's stay at your facility. And in some instances, physicians may perform advanced spine in the outpatient setting but have relationships established with other entities so they can send patients to selected rehabilitation facilities to perform scheduled rehab as needed. You'll need to develop protocols for establishing and facilitating these relationships before you begin hosting more advanced spine procedures.

Planning makes perfect
Transitioning from basic to advanced spine is not that complicated as long as you carefully plan for the more technologically advanced cases. The building blocks should already be in place thanks to the success of your basic spine program. From there, you just need to work with your surgeons, anesthesia providers and nurses to address the core questions we've outlined. If done right, taking your outpatient spine program to the next level should be a win-win situation: You and your physicians can boast the expansion of available services, while patients will receive higher quality care in a convenient setting that allows for more personalized attention and, ideally, a smoother recovery.