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20 13th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine – Call (800) 417-2035 usually on a one- or two-year rotation and everybody is hesitant to open that contract up when it comes due. Sometimes ASCs can even lose money on a TJR case. I was good to go with one payer starting off, developed a track record and then took that record to other payers. Some had concerns about safety and some were fine, but their contract had unfavorable terms for both me and the ASC. It took time, but now all the commercial payers are on board. As for patients, their pain control needs to be dialed in. I actually don't take patients if they are on more than two Percocet equivalents per day. If the patient is on chronic narcotics such as morphine or methadone, they will be much more difficult to manage post-op because their system has tolerance to pain medications. RH: It is incumbent upon the surgeon to spend time with both the patient and their spouse or significant other prior to surgery to help them under- stand the nature of outpatient surgery. Outpatient total joint replacement requires both the patient and their care giver understand how to deal with impaired mobility in the first several days following surgery. This impacts the ability to get to the bathroom, the ability to get dressed, the ability to leave the home, and in many cases the ability to get up and down one or two flights of stairs. MR: The advances in anesthesia, pain control, perioperative monitoring, pre- op screening along with abundant preparation via education of the patient and helping family and/or friends has allowed for accurate assessment of risk. We have less than 0.5 percent of patients requiring hospital admission in the 60 days post-procedure. Less than 25 percent of our patients require an inpa- tient rehabilitation facility after discharge. Q: How well do surgeons educate patients on what an outpatient total joint replacement consists of? RH: Prior to the surgery, each patient receives a call from the surgery cen- ter to review the use of preoperative medications for minimizing pain, the proposed anesthesia, the operative procedure, and the postoperative require- ments. When patients are discharged, they are discharged with teaching materials. All patients are seen by a physical therapist for instruction in gait training prior to leaving the institution. We are in the process of putting together a CD to provide patients upon dis- charge. Presently there are pre- and postoperative rehab protocol linked to my website for easy patient access. MR: I hope adequate time is allowed for education. My staff and I spend at least two to three hours reviewing all aspects of perioperative care for pa- tients undergoing ambulatory total joint arthroplasties. Some patients and family members require, or want four to five hours of education. Generally, the more rural the patients live, the more self-sufficient they are. If they cut, split and dry their own firewood for heat, we're fairly sure they will love their outpatient surgery experience. Q: What technologies are crucial in making these procedures successful? TE: In the past there's been confusion about whether minimally invasive surgery leads to more rapid outcomes which works well in the outpatient surgery environment. I'm actually doing standard approaches that are very reproducible. It's through better pain control methods, better psychological management and preoperative education that we are able to send patients home with a standard approach. RH: The technologies crucial to success of the surgery center are multidis- ciplinary. For example, our anesthesiologists have created a preoperative medication cocktail to help minimize pain and minimize the use of narcot- ics postoperatively. We try to do most of all of our total joint replacements under a light general anesthetic or spinal anesthetic. If a general anesthetic is used, all patients receive a peripheral nerve block. At the time of surgery, the posterior capsule of the knee and the peri-articular soft tissues of the hip are injected with a long-acting local anesthetic. Finally, from a more technical standpoint, minimally invasive techniques are used for both hip and knee replacements. The direct anterior approach has been more favorable for rapid patient mobilization and less postoperative pain. Most direct anterior approach total hip patients are capable of going home on the same day of surgery. MR: Actually very few "cutting edge" technologies are needed. Outpatient joints should be possible in the hospital setting before the surgeon and sup- port staff move these into an ASC. Basic and long proven medications, tech- niques and counseling for controlling pain, nausea, anxiety and bleeding are utilized. Patient selection, peri-articular blocks, preparation via education concerning home equipment, "prehab" for safe ambulation and transfers, adequate pain control measures (especially emphasizing the need for extremity elevation) and the availability of professional support by telephone or at-home check- ups are key aspects of our program. We've found that intravenous acetamin- ophen is quite helpful prior to discharge home or transfer to a rehabilitation facility. There has been much discussion regarding the use of femoral nerve blocks for controlling pain in knee arthroplasty. We have found blocking the saphe- nous nerve, a sensory nerve, is as effective for pain control while avoiding dis- abling the patient's quadricep muscle. n info@physiciancontrol.com or call 404.920.4950 www.physiciancontrol.com At IMS affiliated ASCs, physician owners are involved with decision making for the organization, a rare concept in today's ASC environment. IMS specializes in development and management solutions for all types of ASCs. Our emphasis on physician control and our no-nonsense ap approach set us apart from traditional ASC management companies. Our experience allows us to finalize transactions quickly, so you can focus on what matters: your patients. Let us show you how partnering with IMS can enhance your center's success through physician control. Interventional Management Services Less Red Tape. More Time For What Matters.