Plan and Build for Same-Day Spine

In October 2021, Arno Sungarian, MD, UMass Memorial Health neurologic surgeon and assistant professor at UMass Chan Medical School, successfully completed the first outpatient spine procedure at our surgery center, a discectomy at the L3-L4 region. We’ve performed about five spine surgeries per month since, and plan to slowly increase the number of cases and procedural mix over the coming months and years.

Building a spine service line requires specialty-specific equipment and specially trained surgeons and staff. Additionally, it demands careful and thoughtful planning, understanding local market conditions, and having substantive discussions with surgeons, anesthesia providers and staff that result in collective agreement on what procedures, equipment and protocols your center will offer, utilize and implement.

Here’s what you’ll need to create a spine surgery facility that is set up to grow steadily and successfully over time.

• Physical space. Your spine ORs should be roomy, but they don’t need to be enormous. At 520 square feet, each of our facility’s nine ORs were built to be specialty-agnostic. They are large enough to accommodate total joints procedures, which we added right before the pandemic hit and with which we’ve experienced great success. Currently, we’re performing 30 total joints cases per month. Plus, we’ve even started to perform some cardiology procedures in our ORs.

Adding spine, which to us represents the most exciting frontier for the musculoskeletal work we do, was always the logical next step after total joints. While an important consideration for a spine OR is to provide the surgeon with enough room for the numerous instrument trays they need for each case, adding this service line didn’t require specific modifications to our waiting rooms and pre-op or recovery spaces.

Because we knew from the beginning that we would eventually add spine, we proactively prepped for it by saving shelf space for everything we could possibly need when we did take that step. If you’re designing a new facility, look forward five, 10 or 15 years into the future. What procedures do you envision doing then? Always design for growth if you plan to expand upon your service lines, especially if, like spine, they will require significant space.

• Capital equipment. The key here is getting your spine surgeons on the same page and standardizing as much equipment as possible to avoid overinvestment based on any one surgeon’s preferences. We were able to control costs by focusing first on purchasing equipment and supplies for specific procedures all our surgeons would use, and then strategically adding to our fleet of attachments as needed. Start slow and grow from there once you have a foundational inventory.

Two years before we started our spine program, I met with a neurosurgeon who shared my interest in operating here, and we started the process of understanding what we wanted to do, when we wanted to do it, and what procedures we would start with from the outset. By the time we were ready, we knew we would start small, with just certain instruments and equipment. For example, our predominant focus right now is on discectomies and laminectomies. We’re not performing fusions just yet, but we’re close to doing anterior cervical disc fusions, and our equipment inventory will reflect and support that service when the time comes for us to offer it to our patients.

The two most important spine-specific types of equipment you’ll need are positioning frames for different procedures, and a microscope. Plan judiciously so you don’t overinvest in this equipment at the start.

Specialty patient positioning devices, which attach to the table to enable the surgeon to access the spine appropriately for a given procedure type, are expensive and take up valuable space. To save both money and square footage, only buy the frames you absolutely need. By not making unnecessarily large purchases, this enables you to deliver the best quality of care to patients while also keeping costs low.

We realized surgical microscopes, which we don’t use for our other musculoskeletal work, are important to some but not all spine surgeons. Some surgeons prefer to use them because they can stand up and see vascular conditions in and around the different components of the spine without needing to hover over the surgical field.

We started with a provider who didn’t need a microscope or any specialty patient positioning devices, so we didn’t invest in them at first. As other surgeons joined the practice, we acquired a microscope and appropriate positioning devices for specific procedures they would perform, along with the necessary instruments and equipment. 

• Implants and trays. You need enough space to handle the many trays and implants your spine surgeons need. Spine procedures typically involve five to seven trays in the room. A key for us was narrowing down exactly how much instrumentation our surgeons would need for a given case. We’ve engaged our vendors to focus our supply purchasing process and, as a result, we’ve reduced that typical average of five to seven trays down to three to five trays. We call them our “spine sets,” and all our surgeons have agreed on what they should include.

Reducing the number of trays will help your sterile processing staff on the back end, as well. As with our capital equipment investments, by acquiring collective agreement among our surgeons on what spine sets should include and not allowing for excessive individualization based on any single surgeon’s preferences, we’ve avoided overloading sterile processing while also saving storage space.

• Staff. You won’t necessarily need staff that is specialized in spine, but performing same-day spine surgeries requires careful attention to preoperative preparation and postoperative recovery. Remember, the surgery might be the same as what’s done in a hospital, but the recovery phase is different because patients aren’t wheeled to the floor postoperatively where someone can monitor them overnight. Instead, you need to prepare your patients to go home the day of surgery and recover appropriately. 

They need to understand preoperatively the nature of their at-home recoveries.

We were very thoughtful about staffing needs and responsibilities. A staff nurse designated as our full-time “complex care coordinator” works with our surgeons to ensure the expectation is set with patients who, even though they will go home with some pain the day of surgery, will be helped through it by us. We also offer an education class for our patients to understand what to expect before and on the day of surgery, as well as what they’re likely to experience during recovery.

Once each surgery is scheduled, our complex care coordinator secures the patient’s information from the surgeon’s office and consults with the surgeon on areas of concern about the patient’s condition, so we can ensure the patient a safe surgery. In addition, all our surgeons have established visiting nurse programs within their clinics to ensure a patient can be seen by a nurse if needed at any hour following the procedure.

• Payments. Commercial payers have demonstrated enthusiasm for the value of spine cases being performed in safe, proven outpatient environments. CMS did return 14 spine procedures to the inpatient-only list this year. This change reinforces the necessity of having a diversified procedural portfolio that doesn’t rely on just one service offering. We continue to work with our commercial payers to inform them of what else our surgeons can do successfully in outpatient spine, and how we can prove it to them.

On a national level, spine cases are migrating to ASCs more quickly than they are here in Massachusetts, perhaps because local patients and even providers have long been accustomed to having surgeries performed at the world-class hospitals and teaching institutions in and around Boston. Our center remains one of only a few ASCs performing spine procedures in the state, so we have a responsibility to ensure patients know that it is no longer required to get this type of care at a hospital, and that they’ll receive the highest quality of care at our outpatient facility.

That extends to our surgeons as well. They must have a proven track record of performing spine surgeries in hospitals before they bring cases to our outpatient facility. 

To attract top physicians, we have tailored an efficient, safe, standardized program that will make them feel comfortable and confident working here. From our perspective, a standardized program ensures every patient receives the same high quality of care.

Everything we’ve done with our spine line has been a “crawl before we walk, walk before we run” approach. We’re slowly ramping up in an appropriate fashion for our patients. Our growth in spine is designed to be thoughtful and purposeful, so that when we expand, we’re not just growing for the sake of growth. OSM