Becker's ASC Review

27 Executive Briefing Sponsored by: T here are more than 250 ambulatory surgery centers (ASCs) across the U.S. where surgeons perform total joint replacements, and that number is expected to grow due to regulator updates and a focus on value-based care. In 2020, CMS will pay for total knee replacements in ASCs for the first time, opening up the possibility for an entirely new patient population to undergo surgery at an ASC. The agency has also removed total hip replacement from the inpatient-only list, allowing surgeons to perform them in hospital outpatient departments. Total joint replacement patients who are good candidates for the outpatient setting are now able to seek care in ASCs, which provide a high-quality, low-cost option for orthopedic care. Additionally, as the healthcare system moves toward value-based care, the volume of outpatient total joints is expected to skyrocket, driving even more total joint traffic into the ASC. According to Sg2, 15 percent of total joint replacements were performed outpatient in 2017, and that number is expected to reach 32 percent next year. By 2026, 51 percent of total joint replacements could be outpatient procedures, which is a huge opportunity for ASCs. Surgeons across the country, including Alexander Sah, MD, of Sah Orthopaedic Associates in Fremont, California, and Donald Knapke, MD, of Michigan Orthopaedic Surgeons in Troy, have gotten a head start on outpatient joint replacement in ASCs and have perfected a method for performing these high-value procedures at their centers. The actual surgery is the same procedure surgeons perform in the inpatient setting, but they must be performed more efficiently and with enhanced comprehensive protocols, and ASC staff must give the patient the right tools for a successful recovery at home. "Outpatient total joints is really building upon a successful inpatient program and doing those procedures in the hospital first, and then moving them to the surgery center," Dr. Sah said. "Surgeons need the right foundation for protocols in place for proper patient selection, education, anesthesia techniques, and discharge within 24 hours before moving cases into the ASC. Then, the real challenge is there is much less time that you have the patient in the facility to treat and educate them before discharge. You have to make sure everything is done right the first time and the patient has a consistent message about what to expect so they can recover well at home." This article outlines how Drs. Sah and Knapke transitioned total knee replacements to the ASC and refined their techniques to achieve better patient outcomes, lower narcotic use among patients, and success with bundled payments. Consistent messaging and protocols From the day patients decide to undergo an outpatient total knee replacement through scheduling the procedure, Dr. Knapke makes sure his colleagues and staff deliver a consistent message about outpatient expectations to the patient. During the month between scheduling surgery and the actual procedure, patients attend a class or meeting at the surgical center, which also allows them to become familiar with the facility before surgery. The presurgical protocol also includes: • Pain management and medications • Meeting physical therapists and nurses that will care for them during the postoperative period • Beginning an exercise protocol When Dr. Sah first proposed performing outpatient total joint replacements at his facility, his staff was skeptical. The nurses and therapists he worked with didn't want to move forward with early ambulation because they were concerned about pain and swelling levels. So, Dr. Sah personally returned to the hospital in the evenings to ambulate the patients himself. "When they saw that I was willing to do this myself and I was a believer in it, the nurses took notice. They also saw how well the patients did when we ambulated them immediately and then could discharge patients within 24 hours, and then they were willing to make the switch," Dr. Sah said. Over time, he was able to collect data on more than 100 consecutive knee replacement patients who underwent the outpatient protocol and was able to discharge 74 percent of them within 24 hours. This data set included all patients, not just those screened and selected for an outpatient procedure. "The data showed me I had the right tools and program in place to transition knee replacements to the ASC successfully," Dr. Sah said. To ensure the program remains successful, Dr. Sah tracks readmissions and complications among patients at the ASC, as well as pain scores. An elevated pain score is a common reason for delayed discharge and early readmissions. Both Dr. Knapke and Dr. Sah employ multimodal pain management strategies to ensure patients are as comfortable as possible after surgery and minimize postoperative narcotic use. "Narcotic use has gone down significantly within the last five to 10 years and that has been a good thing," Dr. Knapke said. "The major reason why is we are much more able to control postsurgical pain because of the improvements in peripheral nerve blocks. The quality of peripheral nerve blocks and pain How ASCs can solve the value equation with total knee replacements

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