Planning for Success in Total Shoulders

Demand for outpatient shoulder replacements is increasing as we continue to see improvements in surgical techniques and multimodal pain management strategies that shorten the length of stay for patients. With the right patient selection and perioperative protocols in place, these procedures can be performed safely and predictably in ambulatory surgery centers.

• Evolving approaches. Shoulder replacements are more minimally invasive thanks to newer stemless or short-stem implant designs, which require minimal prep of the humerus bone and less metal implanted into the body — resulting in less pain for patients and faster post-op recoveries. Individual surgeons, especially those performing high volumes of total shoulder procedures, have proven their ability to handle soft tissue in ways that minimize bleeding or damage, which further limits intraoperative blood loss and post-op pain — critical parts of a surgical technique that lead to the most successful outcomes. Surgeons are further aided by medications such as tranexamic acid (TXA) that are helpful in the perioperative period to decrease blood loss.

• Extended analgesia. The reduction of pain for patients undergoing shoulder replacements is critical to being able to perform these procedures on an outpatient basis, and for this we need to give credit to advances in anesthesia care. An anesthesia provider’s ability to place interscalene regional blocks under ultrasound guidance around the brachial plexus is extremely helpful for both intraoperative and postoperative pain control. Patients leave the facility with their arm in a sling, so having a numb limb is a negligible issue.

Placing a block means they can go home the day of surgery and recover with essentially no pain during the first postoperative day. Providers can extend the analgesic effects of the block by placing an interscalene catheter attached to a pain pump that delivers steady doses of local anesthetics. Surgeons can also inject long-acting liposomal bupivacaine at the surgical site during surgery to provide patients with additional pain relief.

Taken together, these improvements and innovations result in surgeries that minimize blood loss, risk of infection and offer better pain management — and improved results.

• Patient selection. This is one of the most important aspects of optimizing outpatient outcomes. I participated in a lot of research on this topic when I worked at Duke University Medical Center and collaborated with my colleagues there to develop some excellent risk calculators that help identify suitable candidates for outpatient shoulder replacement. The calculators essentially allow surgeons to plug in variables related to a given patient that can predict their ability to go home the day of surgery. These peer-reviewed calculators have been published and are widely available at no cost.

The calculators take into account a variety of conditions that impact patient recovery, including mobility issues, severe medical comorbidities and even the home “safety net” — the availability of caregivers and other resources to support at-home convalescence. These factors are critical in an outpatient scenario for obvious reasons: You want your patients to be able to go home the day of surgery and recover safely. If the calculator deems this scenario too risky for a patient, they shouldn’t undergo the procedure in your facility.

• Insurance reimbursement. CMS currently reimburses for total shoulders performed in HOPDs, but not in the ambulatory surgery center setting. This payment policy has changed a few times within the past 12 months, and many experts believe it will change again. There are a lot of discussions among various stakeholders to add total shoulders to the ASC-approved list. I think that will eventually happen, but it’s a process that needs to play out.

Most of our practice’s non-Medicare shoulder replacements are done at an ambulatory surgery center. The complication rate for outpatient shoulder arthroplasty is lower than the rate for inpatient shoulder arthroplasty and the procedure is cost effective.

• Total team effort. To effectively offer outpatient shoulder replacements, facilities need to take a few steps internally. One of the most important is establishing a team of dedicated professionals — from the front desk worker who checks in patients to the discharge planner.

This team-based approach can also include sending a physical therapist to the patient’s home soon after they’re discharged to teach them early postoperative exercises and how to don and doff the sling. This isn’t mandatory, but it’s a nice value-added service to offer patients. The initial physical therapy can also occur in post-op before patients are discharged.

Everybody who touches the patient must be on board with preparing them for same-day discharge. Outpatient total shoulders is a newer concept and patients might have some doubts or concerns when it’s first broached. That’s why every member of the care team must be on the same page and buy into making the procedures work. Having everyone involved in communicating and educating patients with a unified voice results in optimal outcomes.

In terms of staffing, there are a few key providers to have in place: Anesthesia professionals who are skilled with regional blocks and surgeons who can execute surgeries with minimal blood loss and few complications. Surgeons should have a proven track record of success in replacing shoulders with patients requiring only an overnight hospital stay for observation before attempting to transition cases to the outpatient setting.

For members of the surgical team, the details of performing outpatient procedures are similar to what’s done in inpatient facilities. It requires the same preparation, planning and thinking about how to best complete each step of the care plan from the moment the patient enters the facility to when they leave at discharge. 

It’s important to consider every clinical scenario. For example, if the patient’s bone quality is poor, do you have bone cement on hand to help hold the implant in place? Surgical teams that discuss every possibility early enough to put plans in place to address them provide a higher level of care.

If you’re already performing outpatient hip and knee replacements, adding total shoulders will be an incremental change. For outpatient centers with an orthopedic service line in place, this will generally be a straightforward service line to move into.

The numbers of outpatient shoulder arthroplasties are increasing at an exponential rate, something that started before the pandemic and has only accelerated by the increased interest in moving elective procedures to the same-day setting. Surgical centers would be well served to investigate adding this service line to capitalize on expanding case volumes. OSM