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22 Executive Briefing: Executive Briefing: Outpatient Total Knee Replacement to less blood loss and swelling which in turn can help with pain and recovery time for patients. Acute inpatient rehabilitation can be very costly — as high as $16,464 on top of other hospitalization costs. 6 A recent study found that for patients receiving iTotal, only 4.8 percent were dis- charged to a rehabilitation or other acute care facility compared with 15.7 percent of patients receiving a traditional implant. 7 Peter Gleiberman, MD, an orthopedic surgeon in Torrance, Calif., had a similar experience. Once he realized the procedure could be done in an outpatient setting, he partnered with an ASC to cre- ate the ideal environment for total knee replacements. "I took my preference card from the hospital to the ASC and said I wanted to start doing the total knee replacements," he says. "If they purchased the equipment and educated their staff, I would bring my cases there. The ASC was able to do that and now they want me to expand the program. They've been very supportive. You need a good organization behind you." The major clinical advantages of performing total knee replace- ment procedures in the outpatient setting are: • Surgeons have more control over the set up and operation, says Dr. Gleiberman. • The ASC may be able to accommodate for new drugs or technology better than the hospital, says Dr. Buch. • The surgery center — and typically patient homes — are more sterile than the hospital, says Dr. Buch. • Patients are able to sleep in their own beds instead of being disrupted at the hospital throughout the night, says Dr. Buch. • There is a better nurse-to-patient ratio, often one nurse for one to two patients spending the night, says Dr. Gleiberman. Customized knee implants also offer unique advantages: • Customized knee implants fit better, potentially reducing a source of residual pain. 8 • All cut bone surfaces are covered, resulting in a four times lower risk of needing a blood transfusion. Less postoperative swelling has been demonstrated. 9 • Less bone resection by 27 percent on average due to a cus- tomized implant design. 10 • Fewer ligament releases are required, enabling a straightfor- ward procedure. 11 • Surgeons use less postoperative pain medication, says Dr. Gleiberman. • Patients can control their own pain medicine delivery at home, says Dr. Buch. Operational differences While the procedure is relatively simple, there are additional oper- ational changes with the ConforMIS system and in the outpatient setting. Here are five key differences to note: 1. The ConforMIS system includes the customized implant along with a full set of patient-specific instrumentation for that case. The instrumentation is in sterile packaging, with only one tray of reus- able instruments, so staff only need to open the box before be- ginning a case. Then instruments are disposed of post-surgery, reducing the amount of sterilization or reprocessing. This system streamlines supply chain management by not needing inventory to be stored in the hospital and requiring only one tray of reusable in- struments compared with six or more for a standard knee implant. 12 "With the custom implants, I have everything I need with the cutting blocks and implant trays in a small box," says Dr. Berghoff. "You can't imagine the look on the staff's face when they come in and see what little set up we have. They really appreciate that, and the fact that they don't have to sterilize afterward. Plus, the patient has a custom, state-of-the-art knee that is made just for them." 2. Patient expectations should be set slightly differently; patients should expect to get up and move around shortly after the surgery and be prepared to return home within 24 hours. If they have that expectation, they are more likely to comply with early mobilization, which speeds along recovery. Additionally, this also extends to the exercises they do at home postoperatively. "The patient should feel like they are happy and given all the at- tention they need," says Dr. Gleiberman. "Everyone I have treated has really enjoyed the experience in the ASC. I think it's a good reflection on the surgeon when the patients are happy." 3. Make sure everyone on the team — from nurses to physical therapists — know the patient's recovery plan and understand how outpatient procedures work. If your colleagues aren't moti- vated and onboard with the recovery process, the patient may not be ready to leave after 24 hours. "Sometimes nurses and therapists don't understand the process," says Dr. Buch. "We've been teaching things one way for 30 years and they don't want to change. But you have to find and retain people who understand these shifts and know what they are do- ing. The hardest thing has been to train the nurse and therapist to change the paradigm in their heads." 4. Patients need the right support when they return home. At the hospital, there is a whole team built around making sure the patient has what they need for a successful recovery at home; that isn't the case at most ASCs. It falls upon the physician to make sure the patient's family can accommodate living needs and help them recover. "They need someone I can trust who will take care of them," says Dr. Berghoff. "Over time, we've built up secondary safety nets so that our center's nurse will answer their phone calls to help them with the patient's recovery. We have a number they can call and "Patients are demanding we move procedures into the outpatient setting and we are able to deliver those services because of technology development." — Dr. Richard G. Buch of The Dallas Limb Restoration Center