OUTPATIENT GROWTH Have you considered adding an outpatient total joint program?

Thinking of adding a total joint replacement program? You're not alone. These programs are becoming increasingly common as advanced anesthesia techniques and muscle-sparing procedures have become the norm.

"It's taken more than a decade to get people interested," says Richard Berger, MD, a hip and knee reconstruction and replacement orthopedic surgeon at Midwest Orthopaedics at Rush in Chicago, Ill., who was one of the first to perform a same-day joint replacement, about 14 years ago. "But over the past 2 to 3 years, the idea of outpatient total joints has really started to take off."

The benefits of outpatient total joints are easy to see. "People would rather be at home," says Robert Kohen, MD, an orthopedic surgeon performing total joints at UnaSource Surgery Center in Troy, Mich. He says patients requiring these procedures are also becoming ideal for outpatient surgery. "There are more young people needing the surgery," says Dr. Kohen, who has performed outpatient total joints for about a year. "Most of these people are healthier than the traditional population."

Additionally, ambulatory surgery centers can offer freedom and accommodations surgeons can't always get at a hospital, driving demand for these programs, says Dr. Berger. "On the inpatient side, it's becoming more and more cumbersome, and more and more restrictive on what you can and cannot do," he says. "This is a way to get control back into the surgeon's hands."

While Medicare hasn't yet authorized payments for total joint replacements performed in an ASC, that doesn't mean private insurers aren't taking note of same-day joints' big financial benefit. With costs about one-third of hospital inpatient care, more insurers are working with centers to offer the procedure to their members. Dr. Kohen notes that while his center can currently only offer total knees, due to insurance constraints, he sees the tide turning. "I think it will change over time," says Dr. Kohen. "We do it at such a lower cost than inpatient procedures at a hospital."

As these factors continue to work together, total joint replacements will increasingly favor an outpatient environment, experts say. "It's going to skyrocket," says Dr. Berger. "It's on the brink of exploding."

Staffing and equipment needs
Adding total joints is easier for ortho-heavy centers, says Dr. Berger, especially because you will need equipment on hand like "space suits" and specialty tables designed for total hip replacements. Dr. Kohen says his center's heavy orthopedic caseload made its total joint program transition smoother and more cost-effective since the needed equipment was already on hand. "We were already performing big procedures there, so things like helmets and orthopedic power tools were already available," he says.

You may also want to hand-pick surgical staff who have a background with these procedures. Dr. Kohen says his center turned to nurses who worked on total joint cases at a local hospital, something he suggests for facilities just beginning their programs. Otherwise, the complex procedure can be a sharp learning curve for some. "It's a big step for someone who's only done an arthroscopy to go to a total joint," he says.

Dr. Berger notes that surgeons also may want a surgical assistant available for these cases, something many smaller centers might not offer. You can contract these services or bring someone on payroll, although in some cases, a surgeon may hire his own. "For total joints, where you need someone to hold the patient's leg or retractors, it's important to have that staff available," says Dr. Berger.

OR EXCELLENCE
Same-Day Joint Workshop Coming to ORX

SAME DAY JOINTS Learn more about how to start a total joints program at our OR Excellence Conference.

Do you want to know more about how to start a total joint program at your facility? Check out our pre-conference workshop at this year's OR Excellence. Dave Berkheimer, BSN, CRNA, and surgeon Christopher McClellan, DO, of Same Day Joints will help you establish a successful program from the ground up.

Same Day Joints is an outpatient total joint replacement program with more than 3 years of experience and hundreds of cases under its belt. Mr. Berkheimer and Dr. McClellan will go over the establishment, pitfalls and success stories to help you set up your own same-day joints program. The workshop will run from 8:30 a.m. to 11:30 a.m. on Wednesday, Oct. 14 at OR Excellence, held this year at the San Antonio Rivercenter in San Antonio, Texas. For more information, go to orexcellence.com.

— Kendal Gapinski

Changes in technique
You'll also need the right docs on board to make your total joint program a success, including surgeons with experience performing minimally invasive joint replacements and anesthesia providers proficient in the latest techniques, says Dr. Berger.

Dr. Berger suggests appealing to local surgeons who are already performing muscle- and tendon-sparing procedures, using a 3- to 4-inch incision on an inpatient basis. "If they're already doing that at an inpatient facility, moving to an outpatient center is an easy transition," he says. "But for a surgeon used to making a 12-inch incision that results in a lot of lost blood, he needs to learn how to do it differently." There are also training programs designed to help surgeons learn new techniques — some hosted by manufacturers who produce orthopedic equipment — but he says having "first-hand knowledge and a history of practicing this type of procedure usually works best."

Surgical technique is only 1 part of the equation for a same-day joints program. "Just because you can do the surgery well doesn't mean it stops there," says Dr. Berger. Experts say that ensuring anesthetists are knowledgeable on the latest regional blocks and multimodal pain management is one of the biggest keys to a successful total joint program. "The technique is largely the same, so long as a surgeon performs minimally invasive joint replacement," says Dr. Kohen. "The anesthesia though, is much different. They have the blocks, the pre-op cocktail, the pain pump, and the post-op narcotics."

RIGHT TECHNIQUE Having the right tools and techniques makes it possible for patients to go home just a few hours after their joint replacement procedure.

Almost all experts tout multimodal anesthesia for these procedures. Dr. Kohen says that his patients are given a pre-op pain cocktail that typically includes Celebrex or IV acetaminophen to "take the edge off." Then anesthesia providers deliver multiple blocks, typically a sciatic and a femoral block for knee replacements. Dr. Berger notes that while inpatient procedures rely on general anesthesia to paralyze a patient, the use of blocks means surgeons will need to adapt. "The muscles are no longer loose and have more tension, and it becomes harder to position the extremity the way you want to," Dr. Berger says. "It becomes more complicated."

After surgery, patients typically receive a mix of narcotics and anti-inflammatories, the doctors say. "There are a couple of different ways of doing things, and every physician has their preference and drug cocktail," says Dr. Berger. Dr. Kohen's patients receive an NSAID like Motrin or Celebrex along with oxycodone or Vicodin to help control pain in the days after surgery. Patients also receive an elastomeric pain pump that lasts up to 5 days and is "very effective" at limiting post-op pain, he says.

Dr. Berger's patients receive a similar post-op drug cocktail, but instead of a pain pump, patients receive a shot of bupivacaine liposome, which, he says, keeps pain away for several days and is more convenient. "Thanks to the style of surgery and sparing the muscles, they have less pain," says Dr. Berger. "But you still need to make sure they're comfortable."

Your patients are usually in and out, but that won't be the case with total joints. Since patients linger in recovery for several hours, Dr. Kohen notes that these procedures should be scheduled at the start of the day. "For total joints, we have patients get here early in the day, so if there are any complications or pain problems we can get that under control," he says.

TOTAL JOINTS Knees and hips are the most popular outpatient total joints being performed, although some centers are doing elbows and shoulders, too.

You may need to contract with or hire a physical therapist who can work with patients in a "step-down area" in recovery, says Dr. Berger. At his facility, total joint patients stay for several hours in this step-down area and work with a physical therapist until they can walk, take steps and use the bathroom. "You want to make sure the patient is able to come home," says Dr. Berger.

When patients do arrive home, their care continues. Most facilities performing same-day joints partner with physical therapy and home nursing programs to keep patients safe and enhance recovery at home, or have patients transferred to a rehab facility to stay for several days after surgery.

If you're not a part of a hospital-based system, your best bet is to partner with a local physical therapy group that is comfortable with working with patients directly after surgery, since most therapists tend to work with patients who've spent time recovering in a hospital, Dr. Berger says. His center works with a physical therapist that visits patients several times at home for the first week, until they can drive. After that, patients visit outpatient physical therapy for another 3 to 4 weeks. "There needs to be a lot of follow-up with these patients, since they aren't laying in a bed with a floor nurse checking on them several times a day," says Dr. Berger.

In addition to physical therapy, Dr. Kohen says his center also works with a home nursing program to ensure someone is there to help patients first move around their home, monitor their vitals and administer any medications after leaving the center.

The experts also suggest you clearly indicate in your post-discharge instructions whom patients should call if there are any problems — although they say complications are rare. "All physicians and anesthesia providers are also on 24-hour call, so patients can call me or anesthesia if there is a problem like excessive pain," says Dr. Kohen. "So far, though, that hasn't happened."