Outpatient Total Joints - coa.org · Outpatient Total Joints The ASC is not your Hospital OR....

Outpatient Total Joints

The ASC is not your Hospital OR

OutpatientHospital

OutpatientASC

<24 HrsHospital

ReduceLOS

OutpatientHospital

OutpatientASC

<24 HrsHospital

ReduceLOS

2012

2013

2018

Tipping Point

TOTAL

JOINTS

INPATIENT

TIPPING POINT

CHEAPERBETTERPATIENTS WANTSURGEONS WANT

TIPPING POINT

OUTPATIENT

Patient Selection

Stick to Protocols

Start in Hospital

TIPPING POINT

SAFE TRANSITION

ASC

2016: Hospital

94% Home Same Day

70% Home <6 Hrs

2% Stayed unexpectedly

If you are healthy enough for a total joint…Our Philosophy:

You are healthy enough to go home the same day.Our Philosophy:

Medicare CMS Data

Jan 3, 2018Lowest LOS in

US

0.65 Days

Work on Protocolsin Hospital

Collect Data

Scrutinize Results

Institute A Change

Collect Data

Scrutinize Results

Institute A Change

Reclaim Control

2018

Hospitals High CostsInefficiencyAdministrator

Control

Low Satisfaction

Scores

Surgery Centers Low CostsEfficientSurgeon

Control

High

Satisfaction

Scores

COST SAVINGS

MORE

EFFECTIVE

LESS COST

No Differences

Readmissions

Re-operations

ER Visits

Phone Calls

112

2685

FAILURESSUCCESS

Dizziness/Hypotension

Pain

Patient Preference

Ambulatory Issues

Urinary Retention

9

6

5

2

1

24 %

Failure

Failure is Not Possible in ASC

FAILURE (is a GIFT)

+Analysis

=

Improve

Pain

Volume

Nausea

Blood Loss

80% of worlds narcotics

prescribed in US

“JCAHO’s enforcement of its

Pain Management Standards and its

widespread misinformation campaign

about the safety of opioids has also

led to an over-prescribing of opioids”

West Virginia cities filed suit in

US District Court - November 2017

By Eric Eyre Staff Writer Nov 2, 2017

Qualify for surgery: 7/10 Intensity

What is acceptable pain in the PACU ?

When patients arecomfortable enough

to go home…

PAIN

7/10

PAIN

3/10

PAIN

EXPECTATIONS

ACCEPTABLE UNACCEPTABLE

PAIN EXPECTATIONS

PAIN

PYRAMID

REASONABLE

TOLERABLE

TERRIBLE

EDUCATION

NON-NARCOTIC

RESCUE

PATIENT

EXPECTATIONS

Our

Multi-modal

Protocol

P

A

I

N

Acetaminophen

NSAIDs

Pregabalin

Ketamine

Dexamethasone

ACB- block*

Infiltration x 3

7 layers

MMAPMulti – Modal Analgesia Protocol

Multiple

Unique abilities

Complementary

Synergistic

A Team of Super-Heroes

Narcotic Side Effects

• Nausea/ Vomiting

• Dizzy/Weak

• Respiratory Depression

• Sedation

• Urinary Retention

• Addiction

Inadequate Pain ReliefCurr Opin Anesthesiol 2017, 30:458–465 Opioid-induced hyperalgesia in clinical anesthesia practice:

Actually

Makes

Pain Worse !!

Opiate

Induced

Hyperalgesia

Pre-Op

Cocktails

In Surgery

PACU

Floor

Tylenol/Motrin

No Morphine

Ketamine

Therapy

Protocols

Multi-Modal

VOLUME

Preoperative Drinking:

• – Phillips S1, Hutchinson S, Davidson T.

• Br J Anaesth. 1993 Jan;70(1):6-9.

Gastric Contents

Preoperative Drinking:

• – Phillips S1, Hutchinson S, Davidson T.

• Br J Anaesth. 1993 Jan;70(1):6-9.

pH Fluids

Preoperative Drinking:

• – Phillips S1, Hutchinson S, Davidson T.

• Br J Anaesth. 1993 Jan;70(1):6-9.

Aspiration

Preoperative Drinking:

• – Phillips S1, Hutchinson S, Davidson T.

• Br J Anaesth. 1993 Jan;70(1):6-9.

Regurgitation

Dehydration enhances pain-evoked activation in the human brain compared

with rehydration.

• –Anesth Analg. 2014 Jun;118(6):1317-25.

Ogino Y1, Kakeda T, Nakamura K, Saito S.

DEHYDRATED PATIENTSHURT MORE…

PAIN

NPO Status

No solids after midnight

Clear liquids/Gatorade

Encouraged till

arrival to ASC

Timer Starts:PACU

< 4Hours Deal with:Family Expectations

Hypotension

4 HoursHypotension

Nausea

Pain

Ambulation

Families

Traditionally Adversarial Roles

Surgeons Anesthesiologists

Anesthesiology

Same Teams

Same Protocols

Demand in ASC

Spinal Doses

Fluid Mgmt

Nausea Mgmt

Narcotic Use

Hypotension

PRE-OP OPTIMIZATION

+

=HYPOTENSIVE

ANESTHESIA

+TRANEXAMIC

ACID

Must know

Hb Prior

One Month

Assume 3 g/dl

Drop in Hb

No More Post-op Blood Checks

Hospital to ASC

Same Surgeons

Same Anesthesia

Same OR Staff

Same Equipment

Same Implants

Avoid

Change

QUALITYSUPERIOR OUTCOMES

FEWER COMPLICATIONS

HIGH PATIENT SATISFIACTION

VALUE

COST

Financial Pressure

Recruit New Surgeons

Cheaper Anesthesia

Less OR Staff

Cheaper Equipment

Cheaper Implants

Quality

Is King

ASC Capability

SPD

OR Space

Implant Stock

Instrument turnover

Number of Cases

Less Capacity

Smaller

Less Options

Reduced

Reduced

PACU

How many rooms?

Where patients walk ?

How much narcotic ?

How long can they stay ?

Overnight capability ?

KEY TO SUCCESS

Thank You