8 key thoughts on best practices for outpatient cervical spine surgery


A panel of spine surgeons and clinicians published an article in Spine titled "Best Practices for Outpatient Anterior Cervical Surgery" to outline the best practices for selecting patients and performing cervical total disc replacement and fusion procedures in the ASC.

The study authors include Anita Mohandas, Chris Summa, MD, W. Bradley Worthington, MD, Jason Lerner, PT, Kevin T. Foley, MD, Robert J. Bohinski, MD, PhD, Gregory B. Lanford, MD, Carol Holden, RN, and Richard N.W. Wohns, MD, JD, MBA. The study authors conducted a three-round modified Delphi method to generate the best practice statements and set the predetermined consensus for each statement at 70 percent.


The panel evaluating the statements included five neurosurgeons, three anesthesiologists, one orthopedic spine surgeon and a registered nurse. The panel defined outpatient spine surgery as safe discharge for patients four to eight hours after arrival at the clinic. All panelists had participated in at least 100 outpatient spinal fusions or disc replacements over a two-year period prior to participating in the panel.


In the first round, the panelists generated statements about outpatient cervical spine surgery and 61 statements immediately achieved consensus; nine additional statements achieved borderline consensus and eventually achieved consensus after being updated; and 13 of 14 new statements generated in the round achieved consensus.


In the second round, panelists rated their level of agreement and provided comments and edits for statements, as well as additional statements in the predetermined categories. The researchers then moved along statements that achieved consensus based on frequency statistics and revised statements that were borderline.


In the third round, panelists rated the updated and new statements from the second round and provided information on their ratings, as well as provided an additional rating for the updated statements. In total, the panel developed 83 consensus statements.


General best practices in the consensus statements include:


1. The patient's age, BMI greater than 35 kg/m2 and previous anterior surgery alone shouldn't preclude outpatient surgery. Patients undergoing two-level procedures and those with myelopathy that impairs their gait shouldn't be excluded from outpatient surgery.


2. Patients with severe cardiopulmonary comorbidities are poor outpatient surgery candidates.


3. A majority of the panelists recommended short-acting anesthetic agents for outpatient spine surgery patients and avoiding opioids.


4. The panelists all agreed that preoperative analgesia plans were necessary and the statement on using mild analgesics for initial pain control before turning to opioids for persisting pain achieved consensus. All panelists agreed decisions about the type of nonopioid analgesic should be based on the surgeon's preference and surgery type, according to the report.


5. A majority of the panelists agreed on patient and caregiver education about:


• Aim of surgery
• Procedural details
• Anesthesia-related issues


The panelists also "emphasized the need to establish patient and caregiver expectations with respect to postoperative care, including smoking cessation, medication use, warning signs, access to emergency care, wound care and other aspects of the care pathway." Postoperative pain management and hematoma/edema awareness education were a particular focus of the panelists.


6. Most panelists backed discharge checklist use from first- to second-stage recovery and 80 percent recommended observing patients for at least three hours after surgery. All panelists backed postoperative nurse follow-up the morning after surgery.


7. The best practice statements for surgery centers on proactive negotiation for private payer contracts were endorsed by the panel and the panelists agreed on establishing procedure-specific reimbursement rates for each facility. The panelists also recommended ASC staff confirming patient coverage in the ASC setting and notifying patients about their cost obligation.


8. Best practices for ASC operations endorsed by the panel include:


• Creating self-pay policies for patients
• Accessing cost-accounting data
• Standardizing implants


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