THIS WEEK'S ARTICLES
Five Tips to Maximize Efficiency in Your Orthopedic Facility - Sponsored Content
The Two Pillars of Outpatient Joint Replacement Safety
Patient selection and post-op care are the keys to same-day success.
A study of nearly two million joint arthroscopies performed over eight years found no significant difference in overall complication rates among inpatient and outpatient procedures. Patients who had their knees replaced in outpatient facilities, however, experienced slightly higher incidences of complications.
The study of 1.8 million patients treated between 2010 and 2017 by surgeons at the Hospital for Special Surgery (HSS) appeared in the November 2021 edition of The Journal of Arthroplasty. The authors sought to compare complication rates between patients who went home hours after their procedures versus those who spent a night or two in the hospital.
The patients were divided into groups based on which surgery they had and whether it was performed on an inpatient or outpatient basis. For each group, researchers collected data on patient demographics, comorbidities and complications within 90 days of surgery that required readmission to the hospital.
The researchers found that outpatient knee procedures increased by almost 16%, while outpatient total hips increased by 11%. The same-day patients were younger and healthier overall, with fewer medical conditions such as diabetes and chronic pulmonary disease. No significant difference in complications requiring readmission to the hospital within 90 days was found between inpatient and outpatient procedures. Overall, the complication rate for total knee procedures was less than 1%, and that group contained slightly more outpatient than inpatient procedures.
Geoffrey Westrich, MD, one of the study's authors, says same-day discharge following joint replacement is safe with appropriate patient selection and additional early post-op monitoring. He says patients with heart or lung disease, diabetes or sleep apnea are not good outpatient candidates, nor are smokers or people in their mid-70s or older.
"Individuals considering same-day discharge should feel comfortable forgoing a night in the hospital where they would receive nursing care," says Dr. Westrich, research director emeritus in the adult reconstruction and joint replacement service at HSS. "A patient who is very anxious about surgery or experiences a great deal of stress about recovery may not be a good candidate."
Dr. Westrich notes the migration of total joint arthroscopies from inpatient to outpatient settings will continue to accelerate because payment bundles from the Centers for Medicare & Medicaid Services (CMS) now incentivize the reduction of nonessential hospital-associated costs and lengths of stays.
"Our study aimed to augment the literature on outpatient joint replacement surgery to help orthopedic surgeons and their patients make an informed decision," says Dr. Westrich. "Although we found it can be performed safety and efficiently, it's an option, not a requirement. Every patient is different, and individuals and their doctors should make an informed decision based on what makes patients feel most comfortable."
Opioids Are Not the Only Option After ACL Surgery
Non-addictive drugs could offer the same degree of pain control.
Anterior cruciate ligament (ACL) knee reconstruction surgery leads to painful recoveries, but a recent study has shown that addictive opioid painkillers are not the only option for patients seeking relief.
A team led by Kelechi Okoroha, MD, an orthopedic surgeon and sports injury specialist at the Mayo Clinic in Minneapolis, evaluated a pain management protocol with 34 patients who underwent ACL surgery between February 2019 and January 2020. The patients were offered opioid-free pain medicines post-op, including nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen and muscle relaxers. Pain levels 10 days after pain treatment began were then compared with those of 28 other patients who were treated with an opioid.
The results, published online in The American Journal of Sports Medicine, showed that pain relief was the same across both groups. "With appropriate multimodal management, we can make this pain tolerable, while eliminating opioid use," says Dr. Okoroha.
The study suggests NSAIDs, acetaminophen and muscle relaxers offer an equivalent degree of pain control as prescription opioids such as morphine, hydrocodone or oxycodone, although Dr. Okoroha says opioids still can be helpful in managing high levels of pain when appropriately prescribed.
With almost 28% of U.S. opioid prescriptions written for patients with orthopedic and spine conditions, effective multimodal pain management continues to emerge as an effective alternative to addictive narcotics, enhancing the safety of not just individual patients but entire communities.
Five Tips to Maximize Efficiency in Your Orthopedic Facility
It's crucial to run your growing orthopedic program as efficiently as possible to avoid delays, minimize costs and achieve patient satisfaction.
Given the high-stakes nature of orthopedic procedures, it's crucial to run your orthopedic program as efficiently as possible to avoid delays and cancellations. Any improvements that can be instituted in the ASC offer the opportunity to stay competitive while growing business.
The average time and cost spent on a surgery amounts to more than four hours of administrative time and up to 11 hours of staff time overall, which accounts for more than almost 40 percent of operating expenses.1 As increasing pressures to recruit and retain staff continue to challenge ASCs, it's important to look at what can be done to maximize efficiency for orthopedic procedures.
Here are five tips that can help reduce the administrative burden and streamline workflow.
Reduce manual, redundant and paper-based tasks. Tried-and-true solutions to reducing tasks can help staff do more important things. When ordering narcotics using the DEA's paper 222 form, for example, you may want to consider a front-end user interface that automates the task and eliminates the need for paper. Automation systems may be available from your distributor for a nominal fee or no fee at all, and they can be accessed from the same system you use to place orders. Some online ordering systems also allow you to accept and approve invoices online and that helps to avoid the manual process of matching invoices, purchase orders and packing slips. Automating a three-way match with packing slips, purchase orders and invoices electronically eliminates the need to mail, fax and scan hard invoice copies.
Harness the power of kits and trays. Optimizing procedure trays is a great way to manage costs and efficiencies especially if you're doing bundles. You're probably using custom procedure trays (CPT), for your most common cases, but are you taking full advantage of the added efficiency kits and trays can bring? It may be worthwhile to do time studies on some of your less common ortho procedures to assess whether you can save time by pre-kitting them, too. Using room turnover kits can help drive consistent and efficient turnover times. By kitting standard items such as sheets and headrest covers with kick buckets and even mops, for example, the staff doesn't need to track down several items after every case.
Use data and analytics. It's difficult to improve efficiency if you're not measuring key data that have the biggest impact on the bottom line. Investing in data and analytics to improve efficiencies can help grow your margins, but accessing key data doesn't have to cost a lot. In fact, some important metrics such as performance dashboards, for example, can provide visibility into possible redundancy and waste and may be offered at no charge as part of a system.
Don't be caught off guard. Procedures such as large joint replacements use a considerable amount of instrumentation. You don't want to be caught off guard without enough instruments ready to use. It's not uncommon for an ASC to have a sterilizer that only fits two pans at one time, which can make it difficult to do larger volumes of joint replacements.
According to Delores O'Connell, senior clinical education specialist with STERIS, obtaining physician preference cards from other facilities is an excellent blueprint for assessing overall equipment and instrumentation needs for a new joint program in particular. She cautions that they may only include general procedural items such as basic orthopedic instrumentation, power equipment and retractors and in many instances they will not include vendor-specific trays for the joint implants themselves. Typically, loaned instrument systems arrive 24 to 48 hours ahead of the scheduled case. Instrument sets that are delayed at the previous facility where used could require overtime to process.
"These types of special circumstances may require a second vendor's implant system to be held on stand-by which, can be an additional seven to 15 sets," O'Connell says.
Additionally, if a capacity study of washers, sterilizers and ultrasonics hasn't been done, a facility could find they do not have the throughput to process this number of trays effectively and efficiently. If the capacity of the equipment isn't adequate, this could require hours between cases and may not be the most effective use of surgery suite scheduling or sterile processing operations.
Not all mechanical washers, sterilizers or ultrasonic units are the same. Equipment should be designed to reprocess surgical instrumentation. Careful planning and right-sizing the equipment to maximize patient care and safety can yield a strong ROI on reprocessing equipment.
If you're planning to add a large joint procedure and want to ensure you're prepared, your distributor – working closely with equipment manufacturers' planning experts – can help assess the amount of throughput you'll need based on the expected caseload.
Reduce readmissions. With the average rate of readmission 30 days after a hip or knee replacement at 4.2%, it's important to understand the leading causes of readmission after joint procedures.2 Surgical site infections and sepsis, deep vein thrombosis and falls all lead to a poor patient experience as well as a cost burden and inefficiency, but there are ways to reduce and even prevent readmissions. Check out this detailed guide for reducing readmissions after a joint replacement for more information.
Note: For more information, please go to mms.mckesson.com/orthopedics.
1. VMG Health Intellimarker Multi-Specialty ASC Study 2017
2. Hospital Compare. Data collected July 1, 2014 - June 30, 2017
Cooled Radiofrequency Ablation Controls Total Knee Pain
Results of study also show significant improvements in quality of life and joint stiffness.
A study presented at the annual meeting of the Radiological Society of North America (RSNA) last fall produced intriguing results about a minimally invasive ablation procedure that offers long-term pain relief for patients with knee arthritis who experience chronic and debilitating pain after knee replacement surgery.
RSNA says more than 14 million Americans suffer from knee arthritis, with many developing a severe form of the disease that creates intense pain and lack of mobility. When these individuals opt for total knee arthroplasty to regain mobility and improve their quality of life, 15% to 30% continue to experience knee pain and stiffness, which sometimes leads to additional surgeries that aren't always successful.
Cooled radiofrequency ablation (C-RFA) is claimed to provide long-term relief for knee replacement patients. "A lot of these patients don't achieve resolution of pain," says study lead author Felix Gonzalez, MD, an assistant professor in the Division of Musculoskeletal Imaging of the Department of Radiology and Imaging Sciences at Emory University school of Medicine in Atlanta. "It's a big problem, and up till now, there weren't any other treatment options."
During C-FRA, an introducer needle is inserted around the knee under local anesthesia to target specific nerve locations, and then a probe is guided through the introducers. The probe's tip imparts a low voltage radiofrequency current to the deep sensory nerves around the knee. Water circulates through the system to allow for a greater dissipation of the heat generated by the probe's tip.
"With a larger propagating heat wave, you can account for the differences in nerve anatomy from patient to patient because of a larger treatment zone," says Dr. Gonzalez. "Treating a larger zone increases the effectiveness of the procedure." Dr. Gonzalez's research group had previously shown that C-RFA provides lasting pain relief for patients with knee, shoulder and hip arthritis.
The 21 patients in the study had no underlying hardware complications, and all failed conservative care. They filled out clinically validated questionnaires to assess pain severity, stiffness, functional activities of daily living and use of pain medication before and after the C-RFA procedure, and follow-up outcome scores were collected up to one year after the procedure.
On average, the patients experienced a statistically significant improvement in quality of life, and their pain and stiffness scores improved dramatically. No major complications were encountered, and no patients required repeat treatment, surgical revision or other intervention. Because of the long-term pain relief it provides, C-RFA is characterized as possessing a major advantage over cortisone injections, which usually offer only about three months of pain relief. It also could reduce or eliminate the use of opioids for these patients.
"It's very encouraging that up to a year out these patients have such significant pain relief and a better quality of life," says Dr. Gonzalez. "The hope is that in that period of time, patients can become more mobile and increase their activity. Even if pain comes back, we predict that it won't come back with the same intensity as before."
Promising New Research on Combatting Post-Op Pain
Care pathway can reduce the lingering discomfort knee replacement patients experience after their procedures.
A new study in the journal The Lancet Rheumatology described a promising approach to keeping the moderate to severe postoperative pain that one in five patients experience after knee replacement surgery at bay, adding to the growing body of evidence on the effectiveness of comprehensive care protocols such as Enhanced Recovery After Surgery (ERAS) pathways.
The study found that patients who went through what was called the STAR (Support and Treatment After Joint Replacement) care pathway experienced reduced severity of their post-op pain. The five-year STAR program, designed and tested a new treatment in a randomized controlled trial at eight United Kingdom hospitals to find ways to improve the care and support that patients with ongoing pain receive.
"People have a knee replacement to relieve their pain and it's immensely disappointing if they find that they have long-term pain afterward," says Rachael Gooberman-Hill, lead researcher for the STAR program and professor of health and anthropology and director of Bristol's Elizabeth Blackwell Institute. "Unfortunately, one in five people who have knee replacement have long-term pain afterward, [which is] around 20,000 people each year in the UK alone."
Patients who went through the STAR pathway attended an hour-long clinic three months after surgery led by specially trained healthcare professionals. They filled out detailed pain questionnaires and had X-rays and a blood test for infection taken; if needed, patients were referred for further ongoing treatment. The patients received up to six check-in phone calls over the next 12 months.
The study found that, compared with individuals who didn't go through the pathway, STAR patients experienced less pain severity and impact on daily life at both six and 12 months after treatment (nine and 15 months after surgery, respectively), had half the number of hospital readmissions and experienced reduced lengths of hospital stay for inpatient admissions three months after surgery.