In June 2017, the team at Boston Out-Patient Surgical Suites performed Massachusetts’ first total joint replacement surgery in a free-standing ambulatory surgery center. Physician Assistant Gregory DeConciliis was key to the development of their successful outpatient total joint replacement program, so we spoke with him to get his take on some of the questions people have when they are considering the development of a similar program.
Here is what he had to say:
How far in advance are patients being scheduled for outpatient total joint replacement surgery?
We have no specifics in terms of timing. I would say ensure there is enough time to complete all the preoperative measures that are part of your pathway, for example: pre-op lab work, pre-op consults for medical clearance, MRSA screening and results, pre-op tours, anesthesia center visit, PT, home assessment, and stopping herbal medications, blood thinners, smoking, and so on.
Do your patients receive assistance devices prior to surgery and how do you arrange it?
I am certain all facilities have different DME scenarios, whether they purchase wholesale from a distributor, or just stock and bill through a distributor.
We provide the patient with the walker or crutches on the day of surgery. It’s also an option to provide the assistance devices earlier when it’s easier to size them and t0 allow them time to practice. The only issue I can see is that if they forget it on the day of surgery – which would probably occur more than you think – then you will have to give them another set. I think either way can work, with that caveat.
What types of medication do you use for your blocks?
Our anesthesiologists are all ultrasound trained and provide the nerve blocks under ultrasound guidance. This is key. They are typically self-sufficient but we will have our pre-op nurses prep as much as they can, and the anesthesiologist will draw up the medications. They adjust the amount given based on the usual factors, including patient size and what the surgeon is going to give inter-operatively.
They typically utilize 0.5% plain Marcaine (bupivacaine) and draw up about 20cc. In most situations, they’ll only administer 15cc. Some of our doctors pre-inject with lidocaine, but most will go right in with the Marcaine.
Do patients often encounter post-op pain issues and does it interfere with their discharge?
We have not had pain as a post-op issue at all. The only issue we have had was nausea for one particular patient.
I would say pain should not be an issue when the patient is within your facility, but be sure to utilize a multimodal pain management approach to ensure it.
This could include:
1) a pre-op “cocktail” of your surgeon and anesthesiologist’s choice, for example, some combination of PO Celebrex or IV/PO Tylenol, Gabapentin, Lyrica;
2) a pre-operative nerve block; 3) an inter-operative injection by your surgeon – usually a combination of Marcaine or EXPAREL.
We thought for certain when the block wore off at home the patients would have issues, but they have not. It’s all about setting the expectation for the patient that the block will wear off and they will have pain. It’s normal – they had surgery after all!
The key is to stay ahead of the pain medication with the minimum PO narcotics they can tolerate and be diligent about ice. If your surgeons approve indwelling nerve catheters, that would be a home run – very long-lasting pain relief!
What are you using for post-op pain management? Do you send patients home with antibiotics?
We use PO Percocet or Vicodin only, unless a patient has an allergy and they would require another PO narcotic like Dilaudid. We have our surgeons give the prescriptions out in the office prior to the day of surgery so the patients can fill it. It just saves a step.
Most of our doctors give another dose of IV antibiotics in the PACU – no PO to go home with.
Do you use a knee immobilizer if the patient is still numb?
We do utilize a knee immobilizer for TKAs. We use a knee immobilizer or brace on all patients who receive a lower extremity nerve block. Of course, our doctors encourage the patients to come out of the immobilizer ASAP so they don’t get stiff, but until that block wears off, they remain in it. The home PT and outpatient PT encourage the progression of removing the immobilizer on follow up.
What are your thoughts on utilizing a home healthcare agency to meet the patient on the day of their outpatient total joint replacement surgery to help with the transition home?
My thoughts are, initially, excess will spell success! If this will bring the patient comfort and encourage insurers and other doctors to buy in to the program, then it doesn’t hurt. If you can invest the resources, then meeting the patient at their home and understanding their home environment may be money well-spent. Following this up with a visit on the day of surgery at the facility, again albeit excessive, will certainly give reassurance to the patient. This continuity of care – seeing the same healthcare providers before, during, and after the procedure – has worked well for us.
What were the insurers main concerns around the pathway?
Insurers’ main concerns were patient selection and what happens if something goes wrong. Once they saw that we had a strong clinical pathway and a plan for transfers, they were content.
When it came to price, they started with a low offer for covering patients. We knew that inpatient hospital fees cost a lot more than the pathway, so we stuck to our numbers and in the end the price wasn’t an issue.
The key was having the MDs talk to their MDs. The success of the program will depend 100% on bringing the MD surgeon, MD anesthesia, nursing, techs, clerical, and management together to lay out the pathway prior to beginning. Everyone should agree that it’s the right thing for the facility and the patient.
Have you created a bundle?
We have not finalized a bundle but the conversations are ongoing. We’re anticipating logistical difficulties, but would be willing to try it if the insurers really want it. With that said, the latest notification from CMS on what they propose paying HOPD’s and ASC’s for these outpatient total joint replacement procedures will not help our cause. Doing the procedures at that price just isn’t workable. Bundles are a major win-win for the insurer if they can enact a facility shift, so they should be willing to play ball!
Hear more about what Greg had to say in this free webinar.