Total joint replacements & spine in ASCs: Meeting the Triple Aim with new pain management protocols


The outpatient ambulatory surgery center is the next frontier for orthopedic surgery. Knee arthroscopies and ACL repairs have been done in the outpatient setting for years, and now technology is moving total joint replacements and spine surgeries into ASCs.

"The outpatient surgery centers are focused on orthopedics and spine procedures," says Paul Jeffords, MD, a spine surgeon at Resurgens Orthopaedics in Atlanta. "There is a definite patient benefit because everyone on the team is focused on one thing as opposed to at the hospital where all types of procedures are going on. The ASC is more efficient and we're doing fewer cases, so we can really give patients more attention."


The higher patient satisfaction is an important aspect of delivering high quality care, and will be crucial as providers are graded on their outcomes and patient experience.


"I think as time goes on, you'll see more of these cases going into the outpatient center," says Dr. Jeffords. "Technology is driving that change, and surgeons are becoming more familiar with minimally invasive techniques and managing postoperative pain. Patient demand is also driving change; as more surgeons are doing outpatient cases, other surgeons will feel the need to learn these techniques and keep up. Thirdly, payers will eventually demand that procedures are done in the most cost-effective setting — the outpatient center."


Meeting the Triple Aim
Healthcare providers across the board are focused on providing quality care at a lower cost to meet the Triple Aim. ASCs cater to otherwise healthy patients undergoing elective procedures and thus patient selection is important. The sterile environment in the ASC reduces infection and complication risks. ASCs are also reimbursed at a lower overall rate than hospitals.


"With the healthcare system going in the direction it's going in, there is a push towards taking patients out of the hospital and into the outpatient centers where the cost is reduced," says Dr. Jeffords. "There is a lower overall cost for surgeries done in the outpatient centers, and physician owners see the financial advantage of ownership stake."


ASC and hospital physicians are concerned with achieving high patient satisfaction and a quality healthcare experience. They can implement a favorable nurse-to-patient ratio, manage patient expectations and use a strong pain management regimen to improve the surgical experience. In centers where the operating rooms and staff are dedicated to joint replacement surgery, everyone is able to focus on improving patient care.


Anthony J. Berni, MD, an orthopedic surgeon with St. Charles Orthopaedic Surgery Associates in Missouri hasn't experienced readmissions for any of his joint replacement cases performed at the surgery center; nor have patients needed admission to skilled nursing facilities. Readmissions add significant cost to orthopedic cases and lower patient satisfaction. Pain is the second leading cause for readmission in spine surgery, right behind wound complications. Tanya M. Hague, RN, administrator of the St. Louis Surgical Center/Total Joint Center of St. Louis, opened a total joint-focused center in partnership with United Surgical Partners International last fall and experienced success with the program.


"We hired a total joint coordinator who has been an essential asset to the program," says Ms. Hague. "She is the point person for the patient before surgery and follows-up with them postoperatively."


Transitioning to outpatient
Surgeons making the transition often begin performing outpatient cases in the hospital. When surgeons are comfortable achieving good outcomes there, they begin taking cases to an ASC.


"The surgeon has to be comfortable with his ability to perform minimally invasive techniques and comfortable with his patients going home the same day," says Dr. Jeffords. "I performed 40 to 50 outpatient spinal fusions in the hospital to assess how comfortable I was that I could achieve reproducible results sending patients home the same day."


The surgeon is also responsible for anticipating issues and setting patient expectations, as well as making arrangements ahead of time. For example, if the patient experiences postoperative nausea at the hospital, a nurse can take an order the medication; if they're at home, the patient needs the prescription for that medication in advance.


"Anticipate any complications to try to avoid having issues," says Dr. Jeffords. "Make sure you've walked through every step of the process so you can prepare the patient and staff."


Performing outpatient joint replacements and spine procedures require a philosophy change, especially for nurses and surgical teams familiar with three- to four-day hospital stays.


"Joint replacement surgeons aren't of the mindset of outpatient procedures," says Dr. Berni. "Many of them have PAs and other midlevel providers that do hospital rounding and dressing changes. Those people have their mindset that the patient needs to be in the hospital for a certain length of time."


The patients may also need education about outpatient procedures if they are good candidates for the outpatient setting. Reducing readmissions and doing what is best for the patient comes down to patient selection criteria and setting the right expectations.


"There are patients who have friends that stayed in the hospital for several days after joint replacement surgery, and that's their mindset as well," says Dr. Berni. "For procedures that are traditionally viewed as inpatient procedures by the public, it's a big challenge to dispel the myth that every case requires a long hospital stay. Once you get over that hurdle, patients really have a positive experience."


The surgeon can set expectations about going home within 24 hours of surgery from the very beginning using educational material. Their nurses reinforce the outpatient education in subsequent interactions gathering patient information and preparing patients for surgery. There are some programs that require patients to undergo "pre-habilitation" before surgery, learning the physical therapy they'll do after surgery.


"We worked about three months on protocols, patient selection criteria and pain management to make sure patients could be brought safely into the ASC environment and then transitioned safely home with the resources they needed to go forward," says Ms. Hague.


Patients need to return to a safe and accessible home after joint replacement and spine surgery, and have family members who can support them. The center can also partner with outside nursing and physical therapy services to visit the patient and make sure they're following the postoperative plan.


"Education was a huge factor for us bringing in our patients," says Ms. Hague. "We also have collaborations with multidisciplinary resources we need. We start touching the patient almost three to four weeks head of the procedure for total joint replacements to make sure they fall into patient selection guidelines. They come in for a preop education class a week or two before surgery and they also get to tour the center and learn about our infection control precautions."


Key issues to address with the staff include:


• Expectations for the patient
• How long the patient will stay at the ASC
• What medications should go home with the patient
• Dressing change instructions
• Treatment and discharge protocols


"Make sure the team members have the right information," says Dr. Jeffords. "If the patient asks the same question to three different people on your team, they should get the same answer."


Not every patient is a candidate for the outpatient setting; patients with many comorbidities, sleep apnea or older patients may need access to care beyond the ASC's capabilities.


"You want a patient who is motivated to recover, not someone who is de-conditioned," says Dr. Berni. "The ideal patient has upper body strength and core strength. You have to weed out people with increased risks of medical complications, but some would argue patients who aren't fit for the ASC setting might not be a good candidate for joint replacement in general."


Developing pain management and care pathway protocols
Developing the right protocols for patient selection and treatment are imperative. Ms. Hague partnered with an outside vendor with inpatient total joint replacement protocol tweaked for the outpatient setting. The protocols include the pain management regimen as well as early ambulation.


"The anesthesia team was very involved in the process," says Ms. Hague. "They laid the foundation. There is a multi-modal pain protocol that is helping us do these procedures for patients without major pain. Any physician at our center has to use that protocol."
The presurgical protocol at Dr. Jeffords' center includes medication before the anesthesia is induced. The patient takes an oral pre-gabalin to reduce postoperative neuropathic pain. In some cases, depending on the patient's prior narcotic use and the extent of the surgery, his team administers a long acting oral narcotic pre-operatively. During anesthesia, his team may use IV ketamine to help reduce postoperative pain. Intraoperatively, he uses a liposomal bupivacaine that is indicated for single-dose infiltration into the surgical site to produce postsurgical analgesia


Postoperatively, he writes a prescription for seven days of oral Celebrex, which studies show doesn't reduce fusion rates as other anti-inflammatories do. He also takes the time to call his patients the first night home from surgery. "I call them that evening and they have my cell phone if they get worried or have issues," says Dr. Jeffords. "They can call me directly and that is reassuring."


With the appropriate protocol, the patient emerges from the operating room without severe pain. Dr. Jeffords and his staff are at the forefront of exploring non-opioid options to include in their protocol. Administering too much opioid could make the patient too dizzy and sick for early ambulation and adds cost to the procedure. Patients may also become addicted to opioids, leading to additional health issues. This protocol eliminates heavy opioid use, which makes the patient feel sick after surgery. Then they're ready to ambulate.


"Our patients see a physical therapist four-to-six hours after surgery is complete and walk through our hallways," says Ms. Hague. "They are usually able to be discharged six to eight hours after surgery."


Protocol development is an ongoing process and as more information and there is always room for improvement. This requires developing specific goals and selecting relevant outcomes that are agreed upon by the team. In addition, a thoughtful implementation program is needed to ensure the program achieves the desired impact on postsurgical pain management outcomes. It is important to identify the right procedure and patients, identify clinical outcomes measures, data sources to collect the outcomes, educate the staff and then make adjustments to the protocols.


"You really need the support of strong surgeon leadership to make these programs successful," says Ms. Hague. "We are still tweaking the program as we go and trying to find ways we can enhance it. One thing we do is patient reunion lunches to bring patients back a few months after surgery and get their feedback on our processes. We take that information back to make the program better."


Reducing opioid use
Opioid addiction is a huge problem in many communities across the United States and many addicts start taking opioids prescribed for back pain. Long term opioid use can have severe health issues, and many providers exploring ways to curtail opioid use as part of a multimodal pain management approach.


"We try to minimize opioid use as much as possible," says Ms. Hague. "We really educate patients upfront to try to keep their pain under control, and do it smartly. We are also making sure they aren't taking their old pain medications."


An article published in the Journal of the American Academy of Orthopaedic Surgeons shows orthopedic surgeons are the third-highest prescribers of opioid prescriptions in the United States. According to the National Institute on Drug Abuse, There are around 26.4 million people who abuse opioids worldwide, with 2.1 million people in the United States.


In the past 20 years, deaths in the United States due to prescription opioid pain relievers have more than tripled. But with new pain management protocols, some providers are are able to significantly reduce the amount of opioid use to control pain.


Clinton Devin, MD, and Matthew McGirt, MD, determined that spine patients should be weaned off of opioids prior to surgery. Their study found that increased preoperative narcotic use was significantly associated with increased length of hospital stay, as was age, type of surgery, and depression.


"We are finding patients use opioids so little with our current pain management protocols that we could get away from it with time," says Dr. Berni. "We are using some scheduled long-acting non-opioids and combining them with anti-inflammtories and reduced opioids if necessary. It's an evolving process and we are following our patients closely to see whether they are actually using the opioids we prescribe. We're looking into refining our protocols and keeping a very open mind for what is the best thing for our patients."



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