5 Steps to a More Prosperous ASC June 12, Greg Poulter, MD, Vail Summit Orthopaedics

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1 Greg Poulter, MD, Vail Summit Orthopaedics 1

2 Complex Spine Surgery Complex Spine Surgery Capital intensive Challenging setup Technically difficult Minimally invasive Little pain May be outpatient 2

3 Concerns Safety Unexpected admissions Pain control Complexity of cases Length of cases Factors to consider Implant costs Medicare definitions of outpatient surgery Length of procedures Few spine surgeries Staff familiarity with spine procedures Capability of staff and anesthesia support Conflicts of interest Initial capital costs Factors to consider Patient factors Age / Comorbidities Payer Patient Preference 3

4 Which Procedures? Cervical Foraminotomies Endoscopic Disc replacement Anterior cervical discectomy and fusion Which Procedures? Thoracic Kyphoplasty / Vertebroplasty Biopsy Lumbar Discectomy Decompressions Interspinous process spacers / X-Stop Kyphoplasty QuickTime and a YUV420 codec decompressor are needed to see this picture. 4

5 Discectomy Minimally Invasive Lumbar Decompression 5

6 Minimally Invasive Lumbar Decompression Minimally Invasive Lumbar Decompression Lumbar Decompression 6

7 Literature Support for Outpatient Microdiscectomy Griffith, Br J Neurosurg 1987 A selected series of 14 patients with lumbar disc prolapse causing sciatica have been operated successfully with outpatient (daycase) surgery. Postoperative pain has been much less than expected. This form of surgery has proved very acceptable to patients and to their family doctors. Literature Support for Outpatient Microdiscectomy Zahrawi, Spine patient with HNP 34.6 month follow-up 96% would have surgery in ASC 3 stayed overnight nausea, urinary retention 1 superficial infection 1 re-herniation No: dural tears, phlebitis, PE, neurologic deficit Outpatient Lumbar Decompression Best, J Spinal Disorders and Tech patients with HNP or stenosis 21 7

8 Age >65 Best, Spine of these on patients 65 years of age or older 4.1% were converted to inpatient status pain, sedation, or urinary retention 3.4% total complication rate infection most common Outpatient Cervical Decompression Tomaras J Neurosurg patients No unexpected admissions 3 complained of symptoms of nausea after discharge Outpatient Cervical Fusion Fountas, Spine % Mortality 19.3% Morbidity 9.5% dysphagia 5.6% Hematoma 2.4 % surgical intervention 3.1% Recurrent laryngeal nerve palsy 0.5% Dural tear 0.3% Esophageal perforation 0.02% Neural injury 8

9 Outpatient Cervical Fusion Stieber, Spine J consecutive patients 1-2 level cervical fusion 10% minor complications Outpatient Cervical Fusion Erickson, Am J Orthop patients 1-3 level cervical fusions No admissions 1 infection Outpatient Cervical Fusion Liu, BMC Inpatients 4 Complications 45 Outpatient No Complications No admissions 9

10 Outpatient Cervical Fusion Fountas, Spine % Mortality 19.3% Morbidity 9.5% dysphagia 5.6% Hematoma 2.4 % surgical intervention 3.1% Recurrent laryngeal nerve palsy 0.5% Dural tear 0.3% Esophageal perforation 0.02% Neural injury Once decision has been made Discuss all of the previous concerns with the ASC Physicians, Nurses, Administrators Determine level of support Decide which cases Realistically assess your cases before moving to an ASC Length, post procedure pain, likely hood of admission Make detailed lists of equipment and preference sheets Verify that all is in place before the first case Inservice / dry run Start small (single level, straight forward, quick, healthy) 10

11 Techniques to Minimize Pain Pre-incision local anesthetic 10cc 0.25% marcaine Minimize use of bovie Medial branch block Muscle splitting techniques Local anesthetic at the end 10cc 0.25% marcaine with 100 mcg fentanyl Do not place foley or remove promptly Techniques to Minimize Pain Takano, Can J Anaesth 2003 Group 1 - no additional Group 2 - fentanyl Group 3 - lidocaine 30 Patients - Spine Surgery Moving Forward Reassess Grow indications in time Motivation should be quality care Always think safety In spine surgery you are remembered not for your successes as much as for your failures 11

12 Thank You Bibliography Anterior cervical decompression and fusion with plate fixation as an outpatient procedure Stieber, J.R., et al., Anterior cervical decompression and fusion with plate fixation as an outpatient procedure. Spine J, (5): p Improved detection of orthopaedic surgical site infections occurring in outpatients Michelson, J., Improved detection of orthopaedic surgical site infections occurring in outpatients. Clin Orthop Relat Res, 2005(433): p Lidocaine or fentanyl applied to the surgical wound during spinal surgery produces potent postoperative analgesic Takano, Y., et al., Lidocaine or fentanyl applied to the surgical wound during spinal surgery produces potent postoperative analgesia. Can J Anaesth, (7): p Local anesthetic infiltration of the wound for supplemental postoperative pain management in a pediatric liver transplant patient Kim, T.W. and C.C. Chan, Local anesthetic infiltration of the wound for supplemental postoperative pain management in a pediatric liver transplant patient. Paediatr Anaesth, (1): p Microlumbar discectomy. Is it safe as an outpatient procedure? Zahrawi, F., Microlumbar discectomy. Is it safe as an outpatient procedure? Spine, (9): p Outpatient anterior cervical discectomy and fusion Erickson, M., et al., Outpatient anterior cervical discectomy and fusion. Am J Orthop, (8): p Outpatient cervical spine surgery Lewis, P.J., et al., Outpatient cervical spine surgery. J Neurosurg, (2): p Outpatient conventional laminotomy and disc excision Newman, M.H., Outpatient conventional laminotomy and disc excision. Spine, (3): p Outpatient laminotomy and discectomy An, H.S., J.M. Simpson, and R. Stein, Outpatient laminotomy and discectomy. J Spinal Disord, (3): p Outpatient lumbar microdiscectomy: a prospective study in 122 patients Singhal, A. and M. Bernstein, Outpatient lumbar microdiscectomy: a prospective study in 122 patients. Can J Neurol Sci, (3): p Outpatient lumbar spine decompression in 233 patients 65 years of age or older Best, N.M. and R.C. Sasso, Outpatient lumbar spine decompression in 233 patients 65 years of age or older. Spine, (10): p ; discussion Outpatient surgery for prolapsed lumbar disc Griffith, H. and C. Marks, Outpatient surgery for prolapsed lumbar disc. Br J Neurosurg, (1): p Patient satisfaction with outpatient lumbar microsurgical discectomy: a qualitative study Hersht, M., E.M. Massicotte, and M. Bernstein, Patient satisfaction with outpatient lumbar microsurgical discectomy: a qualitative study. Can J Surg, (6): p Spine surgery migrates to outpatient setting 1Mathias, J.M., Spine surgery migrates to outpatient setting. OR Manager, (11): p Success and safety in outpatient microlumbar discectomy Best, N.M. and R.C. Sasso, Success and safety in outpatient microlumbar discectomy. J Spinal Disord Tech, (5): p Surgery for lumbar disc prolapse on an outpatient basis] Ahlburg, P., et al., [Surgery for lumbar disc prolapse on an outpatient basis]. Ugeskr Laeger, (17): p Performing Complex Spine Procedures in an ASC Lisa Austin, RN, CASC, Vice President of Operations 12

13 Advantages of an ASC Flexibility in scheduling May decompress a busy hospital Operating Room schedule High patient satisfaction Control over work environment Physician Selection Fellowship trained Commitment and motivation Credentialing Approved procedure list Owner/investor buy-in Existing owners Opportunities Marketing efforts Satisfaction Patient Selection Determine selection criteria. Acuity Geographic Assess expectations. Patient driven care Self-referrals Increased knowledge Internet Perception of procedural process Mobilization and recovery Success Complications Infections Satisfaction Back to work Back to life 13

14 Staff Selection Motivated to quality and innovation. Assess expectations. Provide education, in-servicing, and praise. Equipment & Instrumentation Assess current inventory. Consider overall needs and costs. Determine ROI. Purchase or lease? Establish and maintain vendor relationships. Reimbursement Review charge master. Review current contracts. Groupers Flat fees Implants Assess staff commitment. Coding and collecting = key elements for success 14

15 EVERYONE MUST BE COMMITTED TO ENSURING SAFE & SUCCESSFUL CARE TO ALL PATIENTS. Questions? Lisa Austin, RN, CASC, VP of Operations