Managing transition risk
Successfully making the transition to the outpatient environment involves the careful consideration of many questions. Here are seven key areas of focus that represent something of a checklist for surgeons to consider, especially in terms of risk management. It’s not a comprehensive list but it is helpful to frame the key issues and lay the foundation for a smooth transition. They apply both for surgeons seeking to establish new, spine-focused ASCs, and for surgeons planning to add spine to existing ASCs.
1. Patient selection. Not every case is ideal for ASCs. Therefore, risk management for outpatient environments starts with careful assessment and evaluation of the patient. Obviously, the younger and the healthier the patient, the more likely he or she will be a good candidate for outpatient surgery. Probably the biggest concern is with complex treatments like anterior neck or spine procedures, which have a higher risk of hematoma. Obese patients and those with a history of respiratory problems often don’t make sense for outpatient spine surgeries.
2. Managing patient perceptions. A good way to build patient comfort and confidence in outpatient spine surgeries is to handle epidural steroid injections (ESI) at an ASC. The treatment usually takes no more than 20 minutes and patients don’t have to change out of their street clothes. They can relax for an hour or two afterwards and go home. If they must come back to the ASC later for a surgical procedure, patients and their families will have a better feel for the staff, routine and tempo of treatment at an ASC.
3. Building surgeon confidence. Patient perceptions are largely determined by medical personnel. If you, as a surgeon, are confident handling spine surgeries on an outpatient basis, your patients will also be confident. Referring physicians and support staff should also make it clear that ASCs are perfectly suitable for these procedures, and indeed preferable to hospitals. To build their own comfort level with outpatient spine surgeries, some of our colleagues start handling surgeries on an outpatient basis at hospitals. That’s especially true for surgeons who are waiting for new ASCs to be built.
4. Postoperative care. Outpatient environments can give surgeons more control over postoperative care. Specifically, they, or their staff, can provide better and more personalized oversight and care instructions at the time of discharge. They can share detailed instructions about when and how to take medicines, how to deal with pain and what to do if anything goes wrong. Again, the reduced trauma of minimally invasive techniques and better drugs give surgeons a lot to work with. Compare that to typical hospital environments, where surgeons have little or no influence over the discharge process.
5. Responding to complications. Surgeons who remain skeptical about outpatient spine surgery seem most worried about managing the complications, which can sometime arise. As for hematomas, the incidence is low, and all of us had to deal with them. In outpatient cases, you must be certain you can get to the ER in time to re-explore, if necessary. In some ways, preparing for complications in outpatient environments is the same as in traditional inpatient settings; that is, it’s primarily a matter of planning and foresight.
6. Staffing. Physicians control the staff at ASCs — that’s a big advantage of operating at an ASC. Surgeons love working with staff they trust and feel comfortable with, which is also a big plus for ensuring quality outcomes. It’s easier to hire who you want, and train a small, focused staff in an ASC, than trying to manage large hospital staffs. With outpatient surgeries, you’ll want staff — including OR nurses and anesthesiologists — who are skilled and experienced with specific treatments. You have more say in evaluating the performance of everyone in the OR and you can more directly interact with your anesthesiologist to plan ahead and solve problems. There are more anesthesiologists who have grown comfortable working in outpatient environments. That’s good news.
7. Technology. With so much new technology (and more being released all the time), it’s easy to overestimate the importance of tools and instruments. In many ways, technology is a red herring when it comes to transitioning spine treatments from inpatient to outpatient. I know surgeons who prefer to use older (but still highly useful) tools in their outpatient ORs.
The point is, you don’t need the latest, most expensive instruments to succeed with outpatient spine surgery. In my experience, it’s the more humane parts of medicine — patient assessment, building the right OR team, and self-confidence — that enable smooth transitions to outpatient environments.
Dr. Roski serves as chief medical officer at Blue Chip Surgical Center Partners. Contact him at rroskimd@bluechipsurgical.com.
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