Outpatient joint surgery is here to stay. Improved anesthesia techniques and physician-owned ASCs, together with payor and patient demand, are all factors accelerating outpatient surgery. When done methodically, outpatient joint surgery is not only a safe option without any adverse risk to the patient, but it is also leading to increased patient satisfaction in many hospitals.
At the 2018 Musculoskeletal Leadership Summit, Stephanie Kelly, Executive Director, Connecticut Joint Replacement Institute and Spine Institute of Connecticut at Saint Francis Hospital and Medical Center, discussed the key elements of success the leaders of CJRI discovered when implementing an outpatient program in a hospital setting.
Transitioning to Outpatient Joint Surgery
The Connecticut Joint Replacement Institute was initially slow to embrace the transition to outpatient joint surgery. But the leaders of CJRI believe they grossly underestimated the percentage of patients who will have outpatient joints in the coming years (likely from 20% up to 70- 80% of patients).
The transition at CJRI began in January 2016. The goal of the first phase of this program was to create an experience that did not jeopardize patient quality, safety or experience. They aimed to understand what the outpatient experience was like while performing it under an inpatient admission. In other words, CJRI continued to pre-certify patients as an admission, while treating them like they were going home.
In phase two of CJRI’s transition to outpatient surgery, patients are now being discharged the day of surgery. The goal in this phase was to retain surgeon business while sustaining the high value and high satisfaction created for the inpatient program. This has had a huge financial impact on the hospital. CJRI averaged about a $5,000 loss per case, however, this was a better outcome than losing surgeons to an outpatient facility.
Key Elements of Outpatient Joint Surgery Success
Over the last three years, CJRI discovered the following elements were key to the success of the program:
- Managing the Cultural Shift
One of the greatest challenges CJRI faced in this transition was changing the culture of outpatient joint surgery. “It only takes one person – one nurse or therapist – to say, ‘Oh you can stay the night if you want to,’ and derail us,” Kelly said in her presentation. “It happens all the time.” CJRI has worked hard to ensure all staff understands the hospital’s vision for where joint replacement surgery is going.
- Recruiting the Outpatient Team
CJRI took their time to identify a focus workgroup of CJRI staff who would lead the development of the outpatient program. Patients coming through the hospital in an outpatient setting would then be cared for by this group. CJRI sent these leaders to ASCs to help them understand what that process would look like. They met with physicians and the leadership group to understand the scripting of what needed to happen for patients that wavered on the border of same-day discharge.
- Patient Screening
Patient screening was critical in phase two of the process. Those selected for outpatient surgery included healthy patients that were non-chronic-opioid users with a BMI of less than 40.
The anesthesiologists at CJRI are using regional blocks and general anesthesia on knees and a short-acting spinal and general anesthesia on hips. TXA was also a game-changer for CJRI. And PACU has become a very busy time for the patients. It’s no longer solely dedicated to monitoring nausea, vomiting and pain control but also making sure patients can eat, and that they can use their DME.
- Pre-Op Education
The timeline of patient education has changed at CJRI. The hospital has successfully managed patient expectations through education. Often patients arrived expecting to have a similar experience as a friend or family member who had joint replacement surgery and stayed at the hospital for two to three days before going to a rehab facility. CJRI had to educate these patients to prepare them for early mobilization and discharge on post-op day one. The surgeons have taken a leading role in evolving with this process and introducing all necessary education upfront.
- Rapid Mobilization
In order to ensure patients were going home on post-op day one, CJRI had to revamp their ambulation program at the hospital. While previously relying on physical therapy, they transitioned to nursing in order to get patients out of bed day of surgery.
- Post-Op Follow Up
All surgeons at CJRI performing outpatient surgery have committed to calling the patient the night after surgery. They also call all patients – whether inpatient or outpatient – the night before surgery.
- Measuring Patient Outcomes
CJRI has been tracking Patient Reported Outcomes for many years. One of their key priorities in transitioning to outpatient surgery was ensuring patients didn’t take a step backward. They wanted to make sure patients were still returning to work and getting back to a healthy lifestyle in the same amount of time. So far, CJRI is not seeing any change in outcomes related to outpatient joint surgery. In fact, their research has shown that if you are following the proper protocols in patient selection and education, there is no change in outcomes for this patient population.
Future Goals for Outpatient Joint Surgery
In phase three of the process, CJRI is working towards implementing a joint venture orthopedic ASC across the street from the hospital. The ASC is expected to open in 2020, with a total of six operating rooms including two joint rooms, two spine rooms, and two sports medicine rooms. The program here will complement the work CJRI is doing in the hospital.
As part of this transition, the CJRI team is working to fine-tune the patient screening process further; identifying which patient belongs in the ASC versus the hospital setting, and therefore determining what percentage of patient volume will shift to the ASC. The goal of the evolution of the CJRI program moving forward continues to focus on maintaining the same patient reported outcomes, while increasing patient satisfaction overall.