Outpatient total joint replacements are on the rise. Improvements in pain management are already driving a shift towards outpatient joint replacements; as surgical and anesthesia techniques become less invasive and more effective, we will see an exponential increase in total joint replacement (TJR) procedures being performed in hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASC).
We talked with Greg DeConciliis of Boston Out-Patient Surgical Suites to learn how he led the development of their program. If you’re ready to start moving into the future of total joint replacements, here are 14 questions Greg suggests you explore that will help you along the road to success:
1. Will our patients want this?
Understand your patient demographics to determine whether there will be interest and opportunity for outpatient procedures.
2. Are the physicians on board?
The best outpatient total joint replacement programs are physician-driven. Surgeons must be willing to participate in the process because they are critical to developing the clinical pathways, outlining protocols, proposing the procedure to patients, and providing support after surgery.
3. Are our facilities appropriate?
Evaluate the layout of your facility to determine whether your ORs and PACUs can accommodate same-day TJR patients. They should have sufficient space and amenities to make patients comfortable: consider the proximity of bathrooms, room to ambulate, and an area for family.
4. What limitations do we have in our staff?
Assess whether nurses, anesthesia, and PT have the knowledge and motivation to offer an outpatient TJR program. Determine whether you will need to extend hours—and consequently hire new staff—or incorporate training into your development plan.
5. What other logistical considerations need to be made?
HOPDs are perfectly placed for performing outpatient TJR procedures, but they may need to upgrade their supplies and equipment. Other facilities may want to consider arranging transfer and ambulance agreements, as well as privileges for surgeons in local hospitals.
6. How will we select patients?
Confer with surgeons and anesthesiologists to standardize patient screening. Being selective and conservative with the requirements will help improve patient outcomes and minimize the risk of the program getting shut down before it gets started.
7. How will we educate our patients?
Managing expectations is a critical component of the clinical pathway for outpatient joint procedures. Ensure that your education program provides knowledge and motivation for patients. They should have the opportunity to meet with anesthesia, PT, and nursing staff, to tour the facility, and to have their questions answered. Staff should be delivering a consistent message to the patient: namely, that they will be going home after surgery.
8. Should we perform home assessments?
An evaluation of the home—number of stairs, maneuverability, obstacles to ambulation, support networks—will help you determine whether patients are good candidates for the procedure and to minimize the risk of postoperative complications.
If a home assessment is not possible, then it’s even more important to provide helpful tips in the patient education guide to help them prepare the home before the procedure.
9. What will happen before, during, and after surgery?
There are three important considerations: 1) Preoperative and interoperative ‘cocktails’ and antibiotic regimen; 2) nerve block delivery strategy; 3) post-op pain management. The way these are managed depends on your facility, but be sure they are standardized.
Discharge criteria and methodology is also important—be sure that surgeons, PT, and nurses are on the same page about what expectations must be met for discharge.
10. How and at what points will we follow up with patients?
Record patient satisfaction and patient-reported outcomes (e.g. HOOS and KOOS). Consider developing your own survey that can be used to streamline and improve the clinical pathway.
11. Are we confident in our value proposition and minimum reimbursement rates?
Insurance negotiations are key to making outpatient TJRs a success at your facility. There are two things to remember during these discussions:
a) Outpatient TJRs are a win for insurers. It saves them money and improves patient outcomes, so bring the studies that demonstrate that the procedures are being done safely and successfully across the country.
b) Know your minimum reimbursement rates. Build your margins into your prices so you can cover costs—and be sure to include intangibles like marketing and increased OR time.
12. Do we have good relationships with vendors?
Vendors can be an excellent resource when it comes to getting started with outpatient joint procedures. If they’ve had experience providing instruments for previous clinics and hospitals, they may be able to offer consultations, education, and site visits to help you get your facility ready for outpatient TJRs.
13. How will we market our new service?
Your aim will eventually be to change ideas and expectations so patients come to your facility requesting outpatient joint procedures. Start by getting consent from your early patients to shoot photos and videos for marketing materials. If you’re the first in your area to offer outpatient TJRs, send out a press release and communicate with media outlets.
14. How will we evaluate our successes and failures?
Plan to hold a formal meeting after 10 or so procedures to learn what went well and what could go better so you can improve the process moving forward.