What makes or breaks outpatient orthopedics?


It's not uncommon for some orthopedic surgeries to be done in the outpatient setting, but many factors go into creating a successful program.

Ask Orthopedic Surgeons is a weekly series of questions posed to surgeons around the country about clinical, business and policy issues affecting orthopedic care. We invite all orthopedic surgeon and specialist responses.

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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Wednesday, Sept. 14.

Editor's note: Responses were lightly edited for clarity and length.

Question: What factors make or break an outpatient orthopedic surgery program?

Philip Louie, MD. Virginia Mason Franciscan Health (Tacoma, Wash.): There are several factors that are critical for the success of outpatient orthopedic programs. Here are four important ones that I consider.

1. Medical comorbidity evaluation from a dedicated anesthesia team. Not all patients are candidates for outpatient procedures based on medical comorbidities. It may seem tempting to perform all "outpatient" surgeries at outpatient/ambulatory surgery centers — but patient selection is critical. Patient care must remain the cornerstone, and this all begins with ensuring that patients are properly indicated and reviewed by a dedicated anesthesia team that needs to manage the preoperative care day in and day out.

2. Effective Multimodal Analgesia (MMA) protocol with local injections (especially for fusions). I trained under Kern Singh, MD, several years ago and observed how he and his colleagues were meticulous in developing MMA protocols with multidisciplinary input. We have applied many of these same principles to our perioperative protocols — and this constantly is evolving with new literature. Local injections (erector spinae, rectus sheath and transverse abdominis plane) have allowed us to further improve our preoperative spine care to spine procedures traditionally performed in an inpatient setting.

3. Mapped out value stream pathways for ongoing evaluation of processes (pre-op, intra-op and post-op). "Without standards, there is no improvement." An initial mapping of all the processes and activities for each type of procedure with regular ongoing review of these processes ensures that there is ongoing focus on improving patient care and financial responsibility.

4. Multidisciplinary leadership with at least partial physician ownership. There are multiple roles that impact patient care in various ways. Surgery center leadership should be represented by multiple disciplines, and physicians must play a role in the ultimate decision making.

James Abbott, MD. Best Surgery & Therapies (Cincinnati): My three items where I place focus:

1. Patient education and support pre- and post-op are critical to providing patients the necessary level of medical support and information to be successful, especially with more complex outpatient surgeries like joint replacement and spinal fusion.

2. Contracts with vendors and payers to ensure you are not overpaying for devices or being underpaid by insurers for performing complex surgery in a lower cost environment.

3. It really all comes down to the staff delivering the care. Well-trained and happy staff makes the environment better and safer for patients. When the staff buys into the advantage of ASC care for the patient, everybody wins. A great patient experience yields more referrals.

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