Becker's ASC Review

25 ASC Management Bonaventure Ngu, MD, Premier Spine Institute, The Woodlands, Texas: It's important to make sure the patients' pain is controlled. We're making the switch from using IVs to oral narcotics. Now with the less invasive procedures, the patients require less narcotics than they did before. They're also in pain for fewer days. Q: What do spine surgeons need to know about transitioning cases from inpatient to outpatient? SH: Start taking the healthy patients to the outpatient surgery center and then take older patients there as you feel more comfortable, if they're a good fit for outpatient surgery. Begin with injections. Then expand to laminecto- mies and discectomies. Whether they are percutaneous or open, that's a fail- safe procedure. Then go to fusions but make sure you have a good vascular surgeon with you if they are anterior fusions. BN: The most important aspect to emphasize is medical preparation. Pa- tients think they are coming in for surgery and then they'll stay at the hospital for two or three days before going home. But if the patient's surgery is in the ASC, they have to leave earlier and you want to make sure they're ready for that. Make sure they're ready to experience some pain after they go home. SS: Book patients conservatively for the outpatient ASC when first transi- tioning cases. There is a learning curve to get everyone transitioned, but it's certainly feasible for discectomies, decompressions performed with implants, and anterior cervical spine surgeries. Percutaneous fusions can be challeng- ing to perform in an ambulatory setting but with the right patient and the right team can be performed. TA: Plan for problems that may occur. Collect emergency contact numbers for patients and plans for transfer to the in-hospital setting if necessary. Sometimes the outpatient plan does not work. You need a plan in place to deal with that upfront so that "bounce backs" don't happen. Q: Where do you see the biggest opportunities in outpatient spine in the future? SS: With the reimbursement declining and expectations that surgery should cost less, there is more pressure on healthcare providers and facilities to get patients home sooner. I think the push from the financial standpoint will drive innovation and change. People are critically looking at whether a per- son needs a certain procedure like spinal fusion because there are alternatives. Costs and finances matter in the transition to outpatient procedures. In this economy, a lot of spinal care is being driven toward ASCs because their core function is getting patients home sooner. But one caveat is this trend shouldn't compromise patient safety. Just because you can save on costs for outpatient procedures doesn't mean every case should go there. Make sure you're treating the patient appropriately for their condition. SH: ASCs are one of the few opportunities surgeons still have to invest, and when surgeons own part of the facility they demand it run better. At our spe- cialty hospital, which we still have ownership in, we run outcomes tests and ask how patients felt about their stay. The ownership also gives physicians an ancillary source of income. GT: New technologies that could impact outpatient spine surgery in the fu- ture include the development of cost effective implants that can be used in the ASC and surgical technology that allows traditionally inpatient proce- dures to be done in an outpatient setting. Two main factors in technology development that facilitate this are less invasive procedures and shorter sur- gical time. One example is interspinous spacer or clamp as an alternative to pedicle screw fusion. Q: Will more spine surgeons be performing cases in outpatient ambulatory surgery centers? NB: Absolutely the trend toward outpatient spine surgery and minimally in- vasive spine surgery will continue to grow. More surgeons are continuing to adopt and expand these techniques. There is a great benefit to our patients because of less pain, less blood loss and faster recovery. Also, with the con- tinued emphasis on controlling healthcare expenditures, it is important to transition procedures to the outpatient setting. GT: There's definitely a shift towards outpatient spine procedures already occurring. As the costs of implants continue to decline and as the technol- ogy for truly minimally invasive spine surgery improves, I believe more spine surgeons will be performing cases in an ASC environment. Additionally, as the emphasis from patients and insurers grows to perform procedures in an ASC, more spine surgeons will probably begin a paradigm shift of perform- ing cases on an outpatient setting. n

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