Top-Notch Total Joints

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Finely tuned clinical protocols and patient-centered care are the keys to taking your program to the next level.


If you're running a successful outpatient total joint program and want to increase case volumes, the future is bright. Last year, CMS began paying for total knees performed in ASCs and this year gave surgery centers the green light to take on total hips. In addition to an influx of Medicare cases, increasing numbers of patients with private insurance are buying into the benefits of having their joints replaced at freestanding facilities.

In the coming years, I believe the only joint replacements done on an inpatient basis will be complex revisions, repairs of periprosthetic fractures and procedures performed on patients without at-home support who require hospitalization and a stay at a rehab facility after surgery.

There's no need to wait for these factors to positively impact your facility, however. By focusing on preoperative medical optimization of patients, constantly fine-tuning your clinical protocols and remaining focused on the best practices of same-day surgery, you can take your total joints program to the next level right now.

The surgery center my partners and I founded in 2013 is about to surpass 12,000 joint replacements performed. Our team does about six cases each day — nearly an even split between partial knees, total knees and total hips — in each of the center's two operating rooms. We've been able to approach that major milestone by constantly focusing on these pillars of proven success.

  • Patient selection. With Medicare now paying for hip and knee replacements performed in surgery centers, consider expanding the pool of potential surgical candidates to include older and heavier patients. I don't have any cutoffs when it comes to age or BMI, but all of my patients must be medically optimized before their procedures. We make sure elevated hemoglobin A1C is corrected and any hint of a cardiac issue is assessed and addressed. The medications patients are on are evaluated. A family practitioner or internist must confirm a patient's heart and lungs can handle the stress of surgery. The physicians we work with specialize in preoperative assessments and know they have full authority to tell me whether a patient should have their procedure done in our surgery center or a full-service hospital.

ON THE MARK Dr. Lombardi signs the surgical site before a knee replacement, one of 10 to 12 that take place in his two-OR surgery center each day.

The bottom line: Cases should be delayed for any patient who is not medically optimized until they can be safely cared for in an outpatient setting. Patient safety should always be the top priority.

We created a star system to identify patients who have the insurance to pay for procedures and the support from friends or family needed for at-home recoveries: green stars mean patients have the appropriate insurance coverage and the necessary support system; blue stars identify Medicare patients; and red stars identify patients who don't have the necessary insurance coverage or support structure to undergo surgery in our facility.

  • Pre-op expectations. Comprehensive pre-op education should serve to answer most questions patients have about their procedures and help prepare their mindset for same-day discharge. Our patients are outfitted with walkers, canes and compression boots the day their surgeries are scheduled. About a week before their procedures, they meet with a physical therapist to review rehab exercises and discuss the best ways to prepare their living spaces for at-home recovery. (Physical therapists also visit patients in recovery on the day of surgery to review their rehab program, and discuss how to negotiate stairs and ambulate first with a walker, then a cane.) Pre-op admission testing performed by a family practitioner or internist is also completed a week before surgery.

Each patient receives our Rapid Road to Recovery book, which contains basic explanations of hip and knee replacements, notes about what to expect during the first two weeks of recovery, answers to frequently asked questions and a list of complications that necessitate an immediate call to a member of our team to determine if follow-up care is needed. We used to require patients to attend group educational sessions, but found patients prefer meeting individually with a physical therapist, receiving written instructions and learning about the procedure directly from multiple members of their care team.

My patients want to go home after surgery.

Many surgeons from around the country tell me their joint replacement patients want to stay in the hospital for a day or two. I've never encountered that issue — my patients want to go home after surgery. I think that attitude is set by how our team communicates with them throughout their care journey. We're sure they understand that ambulating as soon as possible in recovery increases circulation, which prevents blood clots, pulmonary embolisms and pneumonia. Most patients light up when we tell them they're going to be walking two hours after their procedure, and that they're going to be heading home about two hours after that. We talk about the excitement of getting them back to living full lives again.

One of the keys to the continued development of an outpatient total joints program is that every member of your staff — from the receptionist who greets patients when they arrive to the nurse who helps them to their vehicle as they leave — communicates a clear and consistent message leading up to surgery. Share some version of this positive reinforcement with patients: "You have a sore joint, and we'll fix that. We're going to treat you like the healthy patient you are, and our entire focus will be on getting you up and moving in post-op so you'll be ready to go home on the day of surgery." Establishing that expectation during the initial stages of care ensures patients' goals are aligned with those of your team.

COMFORT MEASURES Preventing PONV and controlling pain are two key factors that facilitate timely discharges, so Dr. Lombardi and his colleagues document the specifics of their PONV and multimodal analgesia combinations.

I've striven to perfect rapid recovery protocols for total joints. In 2010 and 2011, most of my inpatient patients were discharged in less than two days. I've enhanced my perioperative protocols over the years since then to gradually reduce post-op stays to just a few hours.

  • PONV and pain control. Preventing post-op nausea and reducing pain are two of the most important factors in making sure patients can be safely discharged soon after surgery.

To prevent nausea, it helps to have them arrive for surgery hydrated. We suggest patients with diabetes imbibe a sugar-free, low-carbohydrate sports drink up to two hours before their scheduled procedures. Patients who don't have diabetes are encouraged to purchase a specially formulated pre-surgical carbohydrate drink, which reduces the body's surgical stress response, promotes wound healing, and decreases PONV and anxiety. We place IVs as soon as possible in pre-op, so patients receive at least three to four liters of fluid before discharge. We also administer IV dexamethasone and an ondansetron injection.

To help control post-op pain, anesthesia providers administer celecoxib and acetaminophen preoperatively. They also place an adductor canal block and an iPACK block in knee patients, and administer spinal anesthesia in hip replacement patients. Every patient receives an intraoperative local injection of 60 mLs of 0.5% ropivacaine and .5 mLs of epinephrine, the latter of which helps with post-op hemostasis and prolongs the effects of the ropivacaine. During surgery, we work as expeditiously as possible to keep tourniquet times low, a factor that can reduce post-op discomfort around the incision site.

Patients appreciate consistency of care, and it's comforting for them to see familiar faces in recovery.
  • Precise workflow. You need to develop versatility throughout your clinical team in order to keep cases moving during the busiest days. It's important for us to be able to shift staff members among different roles when our first case begins at 7 a.m. and we perform up to 12 replacements by 4 p.m. For example, our circulating nurses are cross-trained to scrub cases and scrub techs can help reprocess instruments in central sterile.

To maximize patient flow and staffing efficiencies, don't view pre-op and the PACU as separate areas. The beds that serve as pre-op bays in the morning can become post-op bays in the afternoon. With this set-up, nurses who prep patients for surgery help recover them afterward. This means patients interact with the same nurses before and after their procedures. They appreciate that consistency of care, and it's comforting for them to see familiar faces in recovery.

  • Instrument management. Look for ways to limit the number of instrument trays you open in order to make case setups more efficient, and shorten room turnover times between procedures.
SIZING IT UP Precise joint measurements allow surgeons to open only the instrument trays they'll need, which minimizes clutter in the sterile field and reduces the number of tools that need to be reprocessed.

We could open up to five trays during a total joint replacement. That makes for a cluttered sterile field and increases the amount of instruments that need reprocessing. Instead of opening the number of trays we might need, we open only the ones we know we'll need to successfully complete the case.

During knee replacements, we open the general instrument tray, which contains retractors, forceps and knife handles. We cut the end of the femur and upper part of the tibia, and use a sizing guide to determine which cutting block and implant trial we'll need from the femoral, tibial and patellar trays. Sterile processing techs wrap the contents of those trays individually during reprocessing, allowing us to open only the cutting block and implant trial needed for individual patients. This practice allows us to open specific tools that will be used instead of an entire tray of items that might not be needed, but will still need to be reprocessed.

Attitude matters

ALL FOR ONE Every member of the care team must be willing to pitch in and help, including Dr. Lombardi, shown here mopping an OR floor between cases.

The way you interact with your staff is another key component to your program's ultimate success. I'm fortunate to have hired great people, from the office workers to the anesthesia team. Surgeons need to be skilled providers, but also emotionally intelligent. The way they interact with staff determines the working climate of the OR and how efficiently it will run each day.

Never lose sight of the fact that your team works extremely hard for your patients. Stop for a minute throughout your day to check in, thank them for their efforts and ask how they're doing. The personal interactions team members have with individual patients is incredibly important, and they appreciate the same kind of attention.

Joint replacement programs are fueled by dedicated professionals who love what they do. I look forward to the daily challenges and getting to meet new patients each day.

High-volume joint replacement programs are fueled by the passion of dedicated surgical professionals. I look forward to the daily challenges, working with a large team and meeting new patients each day. The most gratifying cases involve my heavier patients, some of whom have gone on to lose weight and change their lives after many surgeons before me refused to operate on them.

Those types of results are the reward for all of the hard work required to run a successful joint replacement program. By having an entire perioperative plan in place and clearly communicating it to your team, you'll give patients in constant pain a new lease on life. OSM

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