Becker's ASC Review

19 Executive Briefing: Outpatient Total Joint Arthroplasty Sponsored by: Introduction: Same day surgery discharge (SDSD) S/P UKA,TKA, and THA allows for safe, cost effective care for the appropriately selected patient. Several studies have outlined techniques of se- lecting patients suitable for this type of postoperative pathway. This abbreviated review outlines methodology for patient selec- tion, insurance considerations, OR concerns, home assessment, data collection, preoperative and postoperative patient education, anesthetic approaches for pain control and postoperative reha- bilitation. Patient & ASC insurance contracting: It is critical to make cer- tain that the insurance pre-approval process identifies any facility fee reimbursement issues as well as noncovered patient costs. It is not uncommon for some insurers to consider a TJA (total joint arthroplasty) at an ASC an "out of network" procedure as opposed to the local hospital. Credentialing of the ASC (ambulatory surgery center) to perform OP (outpatient) TJA is mandatory to obtain in advance. It is important to do a thorough pro-forma based upon payer mix and meet with each payer, and if possible, negotiate a bundled payment rate for each TJA procedure. Preparing the ASC and staff: It is important for the staff to be well-trained in total joints to allow for efficiency in the operating room. With "error checking modules" and "staff training software" systems available, this allows for a simplistic method of educat- ing the staff on each surgeon's preferences when performing the procedure. Service line resources: The patient needs to understand that the success of the operation is dependent upon their personal hard work and cooperation with the postoperative rehabilitative team. The orthopedic group must be willing to have a home nurse visit the patient or the caregiver has to understand the requirements for postoperative care in the home which means an understand- ing of assisting the patient with activities of daily living throughout the day. If the home situation is not amenable to this type of home care, or a home healthcare nurse, or physical therapist cannot be employed in this setting, then SDSD should not be considered. Service coordinator: There should be one nurse manager who is assigned as the "total joint coordinator." This individual's job is to make certain that all the surgeon's and patient's needs are being met as well as being the individual to make certain that the staff and service line resources have been coordinated successfully. Furthermore, someone in the billing and collections department of the group should be responsible for pre-approval for this type of procedure once the payer contracts are agreed upon. Data collection: It is important to designate a lead physician and someone in the IT department to collect data on patients as part of this project. The vast majority of insurers define quality as outcomes/cost, thus data should be collected using postopera- tive subjective scoring systems such as WOMAC scores. There is considerable national data confirming that increased referrals from insurers to the orthopedic group may occur as a result of cost reduction and maintenance of quality when performing these procedures in the ASC. Patient home assessment: The patient's social situation and home environment needs to be reviewed in advance and felt to be safe with a home caregiver present versus whether a home care nurse is required. A home healthcare nurse visit may be neces- sary for a wound check in the first week postoperatively as well as drain removal in the first 48 hours postoperatively. Home PT on a regular basis may be required to rehabilitate the patient at home until the patient is independently mobile. Patient selection criteria: Specific criteria are considered man- datory for a patient to be a candidate for SDSD. Only ASA classes 1-3 should be considered. Some surgeons have an age cut off of 70 and BMI of 35. Others have expanded their indications to include older patients that are healthy and BMI's of less than 40. Only primary total joint procedures should be performed. A medi- cal clearance must be obtained preoperatively. Patient expecta- tions need to be thoroughly discussed with the patient and accept- able to that patient and their caregiver prior to considering SDSD. It is critical that the patient understands that this is going to be a difficult transition although with appropriate perioperative pain control, it is definitely doable and avoids the need for hospitaliza- tion. Ideally, either home PT or outpatient PT beginning one to two days postoperatively should be performed. If the surgeon and/or the patient feels that they have an inherently low pain tolerance, they should be excluded from SDSD. Anesthesia: Adductor canal blocks are the procedure of choice for patients undergoing either TKA or UKA. Some groups continue to use femoral nerve blocks with indwelling catheters and knee im- mobilizers but the tendency to use adductor blocks has become Outpatient Total Joint Arthroplasty: A Safe, Cost-Effective Perioperative Pathway By Jack M. Bert, MD, Minnesota Bone & Joint Specialists

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