Running, jumping, climbing, playing. Those are the things that healthy active kids (and adults) do. Unfortunately, the sounds of laughter and joy that accompany healthy activities are also occasionally accompanied by the snap, crackle and pop of bones and tendons. Rather than head to the hospital emergency room or urgent care center in the strip mall, a growing number of patients are seeking out care — and next-day appointments with orthopods — at outpatient surgical facilities. We talked to several facilties who are triaging and treating sidelined warriors about the keys to success.

'It's all about access'

A few years ago, as urgent care centers were popping up around her, Monica Eckhardt RN, MSN, wondered why her facility couldn't go one step further. "Often, they'd give patients the names of orthopods to follow up with, but they still couldn't be seen quick enough," says Ms. Eckhardt, service line administrator for neurosciences and orthopedics at St. Mary Medical Center in Langhorne, Pa. "I said, 'How can we make this work?'"

The key was to convince her 45 orthopedic surgeons to hold open certain times for patients with fractures and other manageable traumas that could be seen and treated either at the hospital's surgery center or at another nearby ASC. Besides that commitment, all that's needed is a dedicated phone line.

"When patients call, they get a nurse who does a very brief intake to find out what the chief complaint is," says Ms. Eckhardt. "Typically, we see strains and sprains, although there could be minor fractures. It's typically injuries from daily living — trips and falls, sports, things of that nature."

"Patients can be seen and treated promptly," she says, "and that's the name of the game. It's all about access. We really just wanted to make sure patients had that access."

"Doods" come through

Sandy Singleton, MBA, was certain her hospital was losing trauma patients who had to wait up to 5 days to see an orthopod.

"If you have a child with a broken arm, you don't want to wait 5 days," she says. "And we had competition that could see them right away."

That changed 7 years ago when Cincinnati Children's Hospital, which operates a Fracture and Sports Trauma (FAST) Clinic on the hospital's main campus, and several satellite clinics, came up with the idea of having dedicated orthopedic on-call doctors, or "doods" for short. Nine orthopods agreed to dood duty on a rotating basis. They're scheduled 6 months in advance and evenly distributed. The key was incentivizing docs to miss a day in the OR.

"The buy-in from the surgeons came when we started to pay on-call pay," says Ms. Singleton, orthopedic business director at Cincinnati Children's. "Because when they're doods, they have to cancel their other consultations. Our physicians are paid based on productivity, so if they're having to cancel elective surgeries to be in the clinic, it means they're not necessarily earning anything."

This way, when dood time comes around, at least they're guaranteed something, she says.

The arrangement lets patients who come in with a fracture or other injury see a physician right away. Severe cases can be admitted on the spot. With less severe cases requiring surgery, the procedure is scheduled for the next morning and the patient is temporarily discharged.

"When we can, we let them go home," says Carie Norris, RN, MSN, clinical manager for ambulatory orthopedics and sports medicine at Cincinnati Children's. "That way we save the time, we save the charge and we save the anxiety of a hospital stay for the family."

Flexible flow

At the highly specialized Orthopedic Surgery Center of San Antonio, it's not uncommon for trauma patients to be treated almost immediately.

"Are we able to get patients into the clinic and bring them into the OR the same day? The answer is yes," says Ron Bullock, director of clinical and ambulatory services for the San Antonio Orthopedic Group and the surgery center.

A recent example? "One of our hand doctors got a call from a referring provider about a patient who'd come in with a cut on his thumb," says Mr. Bullock. "They said we think it's a tendon, not just a normal cut. He sends him over, the hand doctor looks at it and says, absolutely, we need to go in and fix it. And he adds it on at 4 that afternoon. So all within one day, the guy saw his primary care, got referred to the ortho doc, got surgery and was back home."

Although the vast majority of Mr. Bullock's nearly 9,000 outpatient cases per year are elective orthopedic procedures, a typical week is likely to include at least a couple of patients who've fallen off ladders, fractured an arm playing basketball or slipped on some ice, and who need attention immediately, he says.

To make it work, "you've got to be flexible in terms of staffing," says Mr. Bullock. "Most ASCs don't have on-call or late teams. You have to have staff that are willing to flex. Adding a case at the end of the day might turn an 8-hour day into a 10-hour day, and we accommodate for that. We have 10-hour shifts."

That goes for vendors, too. "You never know what type of implant you're going to need," says Mr. Bullock. "If a fracture comes in and needs a plate, you've either got to have it on-site or have a vendor that can get it to you quickly. We try to have a primary vendor, but that doesn't cover everything. Supplies aren't always available on a moment's notice, so we work with many vendors."

Extensive pre-planning also lets the San Antonio surgery center take on a lot of cases that most ASCs won't touch. "We've carved out a lot of procedures that maybe aren't approved on an outpatient basis but that our surgeons and the medical director of that payer think it's safe to do," says Mr. Bullock. "For example, a distal radius fracture broken in 3 or more places is not on the ASC-approved Medicare list, but we've carved that out with payers, because from an orthopedic standpoint, it doesn't matter if it's fractured in 2 places or 3."

Negotiate as many carveouts with insurers for as many procedures as you think you can safely perform, says Mr. Bullock. "Obviously, you can't do it when the patient is there waiting," he says. "You have to have some forward thinking. Get a list of procedures you can comfortably do and have them all ironed out ahead of time." OSM