AT THE FOREFRONT The DISC Sports & Spine Center holds surgeon and technology panel meetings to discuss new devices and hardware as they arrive on the scene.

After 7,000 orthopedic, spine and pain cases in 7 years, we've never had an MRSA infection, blood clot, pulmonary embolism or hospital transfer for a surgical complication. And we're not doing your run-of-the-mill outpatient spine procedures. Rather, we're handling abdominal-approach lumbar fusions, extreme lateral interbody fusions, pedicle screws, intradural tumors and more. And you can, too, if the proper attention is paid.

Make no mistake, though: It's been a progression over many years to develop a practice that focuses on higher-acuity cases in an outpatient setting. We've deliberately set out to lead the way by doing bigger and bigger cases with increasingly safe outcomes. With that in mind, here's an inside look at how one of the nation's busiest dedicated spine centers is pushing the outpatient envelope.

1 Surgeon selection
Good surgeon selection means the following to me: They're well-trained, they truly understand the goals of minimally invasive surgery, they're abreast of new technology and they're driven to meet the highest standards in all surgical protocols. These surgeons will seek out patients who will benefit most from less-traumatic procedures — from having less hardware implanted and fewer levels of the spine operated on. The result will be surgeons who don't resist change and who do the best by their patients. Our surgeons track what they're doing and follow up with analysis. For example, one of our surgeons has begun doing lateral spine cases through the abdomen, and has published the first 70 cases. He's putting in less hardware, doing less invasive surgery and reaping good patient outcomes.

2 Nurse selection and training
In addition to caregivers, we want our nurses to be teachers, students and motivators. Like our surgeons, we expect them to come with a philosophy of holistic care. Our patients aren't handed off from one person to the next (more on that later); instead, our nurses provide personal attention from admission to recovery, including patient education and encouragement. They have to interface with pain management and understand the clinical post-op progress desired for each procedure.

To that end, our administrator (who is a nurse), runs lots of ongoing development for the nurses: day-to-day education, re-education and competencies on washing hands, moving patients and the like. No concept is too basic or too advanced. We recently bought new EKG machines and I guarantee that, if I walked into the OR right now, anyone assigned to the room would know how it works and be able to run it.

I'll give you a good example of how crucial this is to practice: We recently trialed a new mobility headrest table attachment for patient positioning. It was meant to provide anesthesia a better view and be less intrusive for the surgeon. Before the first case with the headrest in use, the administrator had already run 4 in-services with the vendor and our techs and nurses. All this effort, on something we weren't even sure we were going to buy! But you know what? That level of knowledge translated to authentic practice. When the headrest slowed setup and teardown, and wasn't to the surgeons' liking, we knew it wasn't just growing pains — the headrest just wasn't right for us.

That's tens of thousands of dollars saved across all ORs, just because we took the time to educate up front. With weekly in-services, staff and per-diems can review new technology and refresh on old concepts. Remember: You can't just dust off your protocols a couple times a year and train everyone in one day. It's a continual process and a lot of effort but, without it, you won't be able to take on the higher-acuity, higher-risk cases that innovate.

SOLID FOUNDATION
5 Keys to a Successful Spine Program

AN ADMINiSTRATOR'S VIEW Karen Reiter, RN, CNOR, RNFA, of the DISC Sports & Spine Center.

Thinking about adding spinal capabilities to your facility? Here are 5 areas to consider:

1. Teamwork. You need a management philosophy that puts time and energy into staff. You need a financial team that can work with schedulers. And you need a champion who knows about the biologics, the equipment and implants. The tools are expensive, but you don't need everything all at once. The key is to roll out what you want to do in an organized and strategic manner. You can't just show up one day and start doing it.
2. Surgeons. You need proficient and realistic surgeons who understand how important it is to do the right surgery on the right patient for the right reason. You also want to make sure your facility is very attractive to them, so your staff needs to be well-educated. Surgeons love being able to walk in and start cases on time. It helps to have the same team every time. Greet and treat each surgeon as if he's at the top of the food chain: "Hello Dr. Blank. Thank you for bringing this case to us today."
3. Costs. Educate staff and surgeons on the cost of equipment, supplies and implants. Surgeons should make their own decisions, but you can influence them by telling them what's cost-effective. You can also use them to negotiate. If suppliers say, "You've done only 4 of those surgeries in the last year," I say, "Yes, but my surgeon did 50 at the local hospital. What should I tell them about how much you're willing to negotiate?" It works. With implants, I pre-negotiate everything. Often we can get no-charge trials.
4. Billing. Your coders must be very familiar with spine surgery so they don't leave anything on the table, either with out-of-network or in-network cases. That's the biggest challenge we've had. Cases have become more complex and insurers haven't always done their due diligence, so it's often challenging to get cases authorized, especially out-of-network. You need to prove your quality and success rate. And don't sign a low-rate contract.
5. Patients. You need to educate both them and their families, so when they're discharged, they know how to care for themselves. To gain their trust, you also need to be organized and efficient — patients and their families need to understand what makes your facility special. If your patient satisfaction scores are exceptional, make people aware of that important selling point.

— Karen Reiter, RN, CNOR, RNFA

Ms. Reiter ([email protected]) is the chief operating officer of the Diagnostic and Interventional Surgical Center in Marina del Rey, Calif.

3 Technological investigation and innovation
We hold surgeon and technology panel meetings to discuss new devices and hardware as they arrive on the scene, or as they're presented to us by companies. One device we're interested in right now is an implant that promises motion preservation without fusion. Before we decided to try it out, key surgeons on the panel thoroughly examined all the data and developed criteria for patient selection.

We start as we always do: with limited application, developed from the manufacturer's protocols, so we can closely monitor outcomes. The first set of patients will be those with degenerative joints but limited instability that might be made worse by decompression alone; those who need wide decompression for stenosis along with added stability; and those who are in early-phase (grade 1 or less) degeneration who want to take preventive measures.

Just a few key surgeons will be the ones to pioneer the technology for our center. After 10 or so procedures, we'll judge the progress in our patients and decide whether to modify the patient population, or continue on and pursue the study with an eye toward publication.

It's a proactive approach, but that doesn't mean we let just anyone through the door. There has to be a compelling clinical reason — that we see strong potential for reducing complications or achieving better outcomes — and the price can't be too exorbitant for us to extend the technology to patients. Lots of companies are scrambling to develop devices that preserve the spine segment and are durable, and we've turned down those we feel just aren't there yet, those in which the complication rates are too high in clinical studies or those the company wants us to use in an off-label manner.

4 Patient attention
Focused patient care is probably the biggest key to our success: We never have more than 1.5 patients per nurse, throughout the entirety of each patient's stay. The same nurse is with the patient in pre- and post-op. Patients like waking up to someone they already know.

When we perform those aforementioned fusions via the abdominal approach, we have patients walking in the hallway 2 hours later. We aren't trying to be a general surgery center; rather, we're trying to keep our volume in line with our nursing ratio. Bigger cases require more nursing contact, and we don't want to lose the ability to handle innovative procedures. The business model works because in doing these bigger, higher-acuity cases, we reap a higher margin of profit.

5 Pain management
The other factor that lets us have patients mobile so quickly is our approach to pain management. Each of our anesthesia providers is board-certified in pain management, and the protocols they've created are targeted toward not letting patients get into pain.

Intra- and post-operatively, we use nerve blocks where appropriate. Even then, we numb the skin so blocks generate as little pain as possible. Post-op, our approach consists of microdosing, or administering smaller doses more often. For example, the nurses won't give 2 to 3mg of Dilaudid; instead, they'll administer 25mcq?? of fentanyl or a similarly tiny bit of IV Valium, and then reassess 15 to 20 minutes later, administering again as necessary. Microdosing gets patients sitting up, doing deep-breathing exercises, and eating crackers and soup in no time, which lets us move to larger PO doses. We also get a muscle relaxant in early, so patients don't freeze up.

It's a smooth transition from there to mobilization. In addition, getting the patient comfortable early increases trust and decreases the psychological stress that can delay patient recovery. Remem-ber, the goal isn't just to knock the patient out, then wake him up — the goal is to move the patient toward wellness.

6 Infection prevention
We started thinking about infection control before we'd even built the facility, spending nearly $1 million extra during construction to install a 100% HEPA-filtered, UV-treating, high-flow HVAC system throughout. And our protocols are equally proactive. Some examples:

• Scrubs aren't to be worn outside — they're strictly for in-facility use, and laundered by a third-party service.
• Cell phones don't go in the OR unless they've been cleaned with alcohol.
• Cardboard from boxes brought by vendors visiting the facility isn't allowed in sterile areas.
• Patients undergo a triple-prep: shower at home, wipe down in pre-op, then prepped in surgery.
• Patients are subject to nasal swabs and cleaning to keep MRSA contained.

Enacting rules that might seem overly stringent to some and empowering all staff to speak up for their enforcement are just par for the course now. The surgical industry isn't going to win against infections with antibiotics, but rather with protocol management, isolation and proper treatment.

Bigger and better
Ambulatory surgery is moving toward bigger cases, performed in better-managed environments, with better outcomes. Pursuing new ideas and staying ahead of the curve are our goals for the future. Our administrator (see "5 Keys to a Successful Spine Program" on page 52) is a champion of education — she goes to the national and state meetings, as do our surgeons and I. Whether it's looking at changes in infection control, new techniques or the latest implants, the key is to be able to accept that surgery is constantly evolving. With a core group of management, docs who are interested and nurses who have input, quality improvement is an ongoing process. This is the real business model, one that will make a facility profitable at the end of the day.

NO-STITCH SPINE SURGERY
A Primer on Minimally Invasive Lumbar Decompression

MILD Minimally invasive lumbar decompression (MILD) is a keyhole procedure for lumbar spinal stenosis.

One of the most common degenerative diseases of aging patients is lumbar spinal stenosis (LSS). It can cause debilitating pain and decreased function. But now a safe, effective, cost-efficient and minimally invasive outpatient procedure for LSS has been approved for ambulatory surgery centers by CMS — minimally invasive lumbar decompression, also known as MILD.

More than 1.2 million patients in the United States have been treated for LSS, and that number is bound to rise as the population ages. There was a time when all I could offer them was short-term palliative medical management. But if symptoms persisted or worsened, I referred them out for invasive inpatient decompression procedures. Not anymore.

The MILD procedure involves using fluoroscopic imaging to guide resection of the thickened ligamentum flavum through a 5.1mm treatment portal. There's minimal tissue disruption and structural stability is maintained. No general anesthesia or implants are required. To achieve decompression of the spinal nerves, the surgeon removes small amounts of bone and hypertrophic ligamentum flavum under local anesthesia and light sedation. The epidurogram is the most invasive part, because fluoroscopic visualization is used throughout, and all devices stay posterior to the dura.

The contrast flow improvement in the epidurogram shows when sufficient decompression of the space is achieved. Then the devices are removed, and the incision is closed with a Steri-Strip. You don't even need stitches.

Treatment can be performed at single or multiple levels, unilaterally or bilaterally. Each procedure takes about 30 to 60 minutes, and patients remain in recovery for 1 to 2 hours. No special follow-up care is needed. They typically walk out and resume light activities within a few days. More than 81% report statistically significant improvements in mobility and decreased pain.

More than 16 peer-reviewed clinical journal articles on MILD have been published and no major complications have been reported. Its safety and efficacy have also been validated in 11 clinical studies of 542 patients conducted at leading interventional pain institutions. In one study from the Cleveland Clinic, functional outcomes included an increase in standing time from 8 to 56 minutes, and increased walking distance by more than two-thirds of a mile at 1 year, from 246 feet to 3,956 feet.

— Yogesh V. Patel, MD

Dr. Patel ([email protected]) is board certified in pain management and is based at Coastal Pain Spinal Diagnostics in Carlsbad, Calif.