SPINAL FUSION Outpatient surgery for anterior cervical discectomy and fusion is a safe and favorable option for suitable patients.

Nowadays, you measure the length of stay for spinal fusion surgery in hours, not days: 3 to 31???2 hours from entrance to discharge for a lumbar laminectomy and 6 hours for an anterior cervical discectomy. How do you get patients street-ready so quickly? You closely screen and stratify suitable candidates, and you manage their pain.

Same-day ambulatory spinal fusion is becoming a preferred option for both patients and providers, spurred by minimally invasive surgical techniques that let surgeons perform spine fusions with less tissue trauma and multimodal pain management protocols, as well as favorable economics. Patient selection and managing post-operative incisional pain are the keys to safely performing outpatient spinal fusion. Here are some tips you can follow.

Get their whole health history. It's critical to stratify patients pre-operatively so you have a really good picture of their health profile before they even come to the facility. Call the patient's cardiologist, pulmonologist and nephrologist, and ask for notes. You don't want patients showing up day of surgery only to cancel them. That's a huge expense and inconvenience. Refer patients with significant comorbidities to relevant specialists before Get their whole health history. It's critical to stratify patients pre-operatively so you have a really good picture of their health profile before they even come to the facility. Call the patient's cardiologist, pulmonologist and nephrologist, and ask for notes. You don't want patients showing up day of surgery only to cancel them. That's a huge expense and inconvenience. Refer patients with significant comorbidities to relevant specialists before scheduling for surgery.

Patient selection. What's the telltale sign that a patient is ready to go home after ambulatory surgery? If he can ambulate. If he can walk the hall an hour after he's been extubated. First, don't schedule patients who can't ambulate to begin with. You want to mitigate risk. Determine their comorbidities. Patients with severe cardiopulmonary comorbidities or those on dialysis are not the kinds of patients you want to send home after spinal fusion.

Can patients who are morbidly obese (BMI>35 kg/m2) undergo spinal fusion in an outpatient setting? Yes, provided their comorbidities are controlled and the OR table is capable of safely holding the patient's weight. On the other hand, patients with cervical myelopathy whose functional debility is likely to necessitate inpatient rehabilitation after surgery should be excluded from outpatient surgery.

More than 2 levels? Cervical surgeries for more than 2 levels can be performed in an outpatient setting, but surgeons planning to transition patients to freestanding outpatient settings should first gain proficiency in lower-complexity populations within the hospital environment. You don't start off doing 2 and 3 levels. If you can't control and manage the process in the hospital. what makes you think you can in an outpatient facility?

One nurse, one patient. Assign a nurse to be solely responsible for a patient's care from beginning to end. One nurse takes total control of each patient: phoning the patient in the days before surgery, admitting him to the facility, circulating the case, recovering the patient (I suggest a single-phase recovery process) and discharging him, and then following up with the patient at home. This way, nurses see the whole process unfold in front of them (watch their job satisfaction shoot up!). Plus, you eliminate dangerous handoffs. Accountability is a strong motivation.

Pain management. You can't discharge a patient whose pain is not controlled. Patient-specific, multimodal pain management protocols comprising a combination of non-opioid, short-acting analgesics, muscle relaxants and opioids (when pain persists) for rescue are the key to same-day discharge. Remember, post-op pain control starts before surgical trauma. Stress to your patients that they may have pain, but it will be well managed. While you want to minimize the use of intraoperative opioids, chances are that most spinal fusion patients will be on prescription pain medication pre-operatively. So you must be mindful of and ready to manage opioid-related adverse drug effects in a patient with a ruptured lumbar disc who's been taking oxycodone for days, weeks or months. These include nausea, vomiting, respiratory depression and constipation, all of which can delay discharge. Multiple drugs that have different analgesic mechanisms of action and multiple metabolic pathways are key.

Economics. Same-day surgical centers should negotiate contracts before scheduling a procedure with private insurers and establish procedure-specific facility reimbursement rates. Researchers recently compared inpatient and outpatient billed charges for single-level ACDF/CTDR using payers' explanation of benefit (EOB) documentation. Average outpatient charges ($11,144) were 83% lower than inpatient charges ($68,000) for cervical total disc replacement and 52% lower for anterior cervical discectomy and fusion (outpatient: $29,313, inpatient: $61,095).

Post-op complications. Educate patients and caregivers about the signs and symptoms of respiratory compromise due to post-discharge hematoma, a rare but potentially devastating complication. Know the common and rare complications and develop processes, protocols, and action plans before you perform the first case. If a complication can happen plan that it will and be vigilant. OSM