Vertical IntegrationVertical IntegrationMoving Inpatient Total Moving Inpatient Total Joint Replacement to Joint Replacement to

OutpatientOutpatientin the Ambulatory Surgery in the Ambulatory Surgery

Center SettingCenter SettingCynthia Armistead, AdministratorCynthia Armistead, Administrator

Campbell Clinic Surgery Centers, L.L.C.Campbell Clinic Surgery Centers, L.L.C.

Learning ObjectivesLearning Objectives

Review the statistics relevant to the prevelance Review the statistics relevant to the prevelance of osteoarthritis in the national populationof osteoarthritis in the national population

Identify the steps necessary for developing a Identify the steps necessary for developing a total joint arthroplasty program in the ASC total joint arthroplasty program in the ASC settingsetting

Describe the clinical preopeartive and Describe the clinical preopeartive and postoperative protocols for total joint arthroplasty postoperative protocols for total joint arthroplasty patient managmentpatient managment

Background StatisticsBackground Statistics Arthritis is the most common cause of disability in Arthritis is the most common cause of disability in

adults.adults. Physician diagnosed arthritis and corresponding Physician diagnosed arthritis and corresponding

activity limitations are projected to increase over activity limitations are projected to increase over 40%, 40%, or to nearly or to nearly 67 million67 million in the next 25 years in the next 25 years in the United States.in the United States.

Nearly two thirds of adults reporting doctor Nearly two thirds of adults reporting doctor diagnosed arthritis are younger than 65 years.diagnosed arthritis are younger than 65 years.

Osteoarthritis is the most common type of Osteoarthritis is the most common type of arthritis and comprised 70% , or 1.2 million of the arthritis and comprised 70% , or 1.2 million of the 1.7 million 1.7 million nonfederal nonfederal short stay hospitalizations short stay hospitalizations in 2007.in 2007.

Background StatisticsBackground Statistics Total joint arthroplasty remains the treatment of Total joint arthroplasty remains the treatment of

choice for advanced, symptomatic joint pain.choice for advanced, symptomatic joint pain.

In 2006, hip and knee replacements accounted for In 2006, hip and knee replacements accounted for 96% of the 1 million arthroplasty procedures 96% of the 1 million arthroplasty procedures completed. Total shoulder replacement accounted completed. Total shoulder replacement accounted for 3% of this total.for 3% of this total.

Kurtz, et. al., estimate over 570,000 primary total hip Kurtz, et. al., estimate over 570,000 primary total hip replacements and 3.5 million primary total knee replacements and 3.5 million primary total knee replacements will be performed annually in the replacements will be performed annually in the United States by 2030.United States by 2030.

Total hospitalization cost of hip and knee joint Total hospitalization cost of hip and knee joint replacement has increased in the last decade by more replacement has increased in the last decade by more than 137% and is now estimated at approximately than 137% and is now estimated at approximately $60 billion annually$60 billion annually. .

Current TrendsCurrent Trends The Affordable Healthcare Act is driving practices to The Affordable Healthcare Act is driving practices to

provide medical care / procedures at a lower cost while provide medical care / procedures at a lower cost while demanding higher quality outcomes.demanding higher quality outcomes.

CMS -1589-P has proposed a new rule for 2013 eliminating CMS -1589-P has proposed a new rule for 2013 eliminating the mandate that total knee replacement be performed in the mandate that total knee replacement be performed in the hospital setting.the hospital setting.

Muscle sparing, smaller incision surgical techniques Muscle sparing, smaller incision surgical techniques contribute to less soft tissue disruption and faster contribute to less soft tissue disruption and faster recovery/rehabilitation time for total arthroplasty patients.recovery/rehabilitation time for total arthroplasty patients.

Advanced anesthesia techniques, i.e.., peripheral nerve Advanced anesthesia techniques, i.e.., peripheral nerve blocks, and the use of bupivacaine liposome injectable blocks, and the use of bupivacaine liposome injectable suspension ( Exparel ) allows patients to be pain free for up suspension ( Exparel ) allows patients to be pain free for up to 72 hours.to 72 hours.

BenefitsBenefits Reduced risk of nosocomial infectionReduced risk of nosocomial infection Reduced risk of iatrogenic illnessReduced risk of iatrogenic illness Reduced risk of complications from general Reduced risk of complications from general

anesthesia such as decreased respiration and hypoxia anesthesia such as decreased respiration and hypoxia from the administration of I.V. narcoticsfrom the administration of I.V. narcotics

Reduced risk of P.O.N.V.Reduced risk of P.O.N.V. Faster initiation of ambulation, R.O.M. and Faster initiation of ambulation, R.O.M. and

strengthening exercises from P.T , shortening strengthening exercises from P.T , shortening recovery times and resulting in faster return to work recovery times and resulting in faster return to work and activities of daily living.and activities of daily living.

Greater surgeon control of management of the Greater surgeon control of management of the postoperative patientpostoperative patient

Patient satisfaction rates of 99% or higher - ExcellentPatient satisfaction rates of 99% or higher - Excellent

BenefitsBenefits

COSTCOSTThe cost of total joint replacement surgery in the ASC The cost of total joint replacement surgery in the ASC

setting is approximately 1/3 to over ½ times lower setting is approximately 1/3 to over ½ times lower than the same procedure performed in the inpatient than the same procedure performed in the inpatient

setting.setting.

Campbell Clinic ExperienceCampbell Clinic Experience 230 Total Joint Procedures 230 Total Joint Procedures

74 Total Hip 74 Total Hip 79 Partial Knee 79 Partial Knee 38 Total Shoulder 38 Total Shoulder 31 Total Knee31 Total Knee 5 Total Ankle5 Total Ankle 3 Total Shoulder Revision3 Total Shoulder Revision

Avg. age 58Avg. age 58 Avg LOS - < 7 hours, 85% discharged DOSAvg LOS - < 7 hours, 85% discharged DOS 0% Infection0% Infection 0% DVT Incidence0% DVT Incidence

Keys to SuccessKeys to Success

Patient IdentificationPatient Identification ASA I or IIASA I or II

BMI < 35BMI < 35

Negative sleep apnea historyNegative sleep apnea history

No impediments to mobility other that joint No impediments to mobility other that joint pathologypathology

Ability and motivation to be discharged same day or Ability and motivation to be discharged same day or within 23 hours with strong, appropriate home care within 23 hours with strong, appropriate home care support networksupport network

Keys to SuccessKeys to Success PATIENT EDUCATIONPATIENT EDUCATION

Patient must have a detailed explanation and understanding of the Patient must have a detailed explanation and understanding of the surgeon’s expectations.surgeon’s expectations.

Preoperative P.T. consult to review ROM, strengthening, weight Preoperative P.T. consult to review ROM, strengthening, weight bearing and gait training with crutches, walker, etc.bearing and gait training with crutches, walker, etc.

Preoperative assessment by surgery center preoperative admission Preoperative assessment by surgery center preoperative admission nurses to review medical history, tour facility, and give preoperative nurses to review medical history, tour facility, and give preoperative instructions.instructions.

Preoperative assessment by anesthesia and explanation of spinal, Preoperative assessment by anesthesia and explanation of spinal, block, etc. procedures and expectations.block, etc. procedures and expectations.

Prescribe COX – 2 preoperative loading dose ( 400mg ) and instruct Prescribe COX – 2 preoperative loading dose ( 400mg ) and instruct patient to take 48 and 24 hours preoperatively. Prescribe anticoagulants patient to take 48 and 24 hours preoperatively. Prescribe anticoagulants and instruct in postoperative use.and instruct in postoperative use.

Distribute D.M.E in the office setting preoperatively.Distribute D.M.E in the office setting preoperatively.

Keys to SuccessKeys to Success

STAFF EDUCATIONSTAFF EDUCATION Plan for the procedure by discussing with Plan for the procedure by discussing with

all involved staff members their all involved staff members their responsibilities in the care of the patient.responsibilities in the care of the patient.

Establish standing orders/protocols for Establish standing orders/protocols for each total joint procedure and patient. In each total joint procedure and patient. In service all staff.service all staff.

Perform “dry runs” of the procedure before Perform “dry runs” of the procedure before the day of surgery, specifically in the O.R.the day of surgery, specifically in the O.R.

Mandatory assessment of each total joint Mandatory assessment of each total joint replacement surgery for care given, and replacement surgery for care given, and quality assessment/improvement data.quality assessment/improvement data.

What About Blood??What About Blood??

OPTIONSOPTIONS Autologous blood can Autologous blood can

be transfused in the be transfused in the ASC without major ASC without major logistical obstacles.logistical obstacles.

Prescribe iron Prescribe iron preoperatively.preoperatively.

Develop relationship Develop relationship with local blood bank with local blood bank for potential for potential transfusion.transfusion.

OR…, OR…,

Tranexcemic AcidTranexcemic Acid

Tansexamic acid is an Tansexamic acid is an inhibitor of plasminogen inhibitor of plasminogen activation. activation.

CCSC protocol is to give CCSC protocol is to give 1 GM IV on arrival to O.R. 1 GM IV on arrival to O.R. and 1 GM at end of case. and 1 GM at end of case.

Total Hip Replacement Total Hip Replacement patients have averaged patients have averaged 300 – 700ccs blood loss 300 – 700ccs blood loss per case. per case.

Preoperative Standing OrdersPreoperative Standing Orders Preadmission:Preadmission:

Type & ScreenType & Screen

CSC, Basic Metabolic Profile, CSC, Basic Metabolic Profile, PT, PTT, UA with microPT, PTT, UA with micro

EKGEKG

Must come to CCSC for Must come to CCSC for anesthesia clearance anesthesia clearance

If diabetic, instruct patient to If diabetic, instruct patient to bring home meds & contact bring home meds & contact medical M.D. for clearancemedical M.D. for clearance

Instruct patient on N.P.O. Instruct patient on N.P.O. after midnightafter midnight

Standing OrdersStanding Orders Obtain ConsentObtain Consent Ensure surgeon has Ensure surgeon has

written” correct” on written” correct” on operative sideoperative side

No shave or prep in No shave or prep in preop holdingpreop holding

Remove nail polish Remove nail polish from operative from operative extremityextremity

Vancomycin 1 GM Vancomycin 1 GM IVPB and 1 Gm IVPB and 1 Gm Ancef IVPAncef IVP

Standing OrdersStanding Orders

Prep area with Prep area with betadine/chlorahexidinebetadine/chlorahexidine

1 GM Transexamic Acid 1 GM Transexamic Acid IVPB on arrival to ORIVPB on arrival to OR

1Gm Tylenol IV1Gm Tylenol IV Repeat 1 GM Repeat 1 GM

Tranexamic Acid at Tranexamic Acid at completion of case in completion of case in the O.R.the O.R.

Standing OrdersStanding Orders

Ice to operative siteIce to operative site IV lactated ringers IV lactated ringers

TKOTKO Advance diet as Advance diet as

toleratedtolerated Routine vitalsRoutine vitals Record all I & ORecord all I & O If drain, empty q If drain, empty q

8hrs and record. 8hrs and record. Pull before D/CPull before D/C

Standing OrdersStanding Orders

Oxycontin 10mg po Oxycontin 10mg po q 12 hours for painq 12 hours for pain

1 GM Vancomycin 1 GM Vancomycin IVPB q 12 hours IVPB q 12 hours

( total of 2 doses )( total of 2 doses ) 1 GM Ancef q 8 1 GM Ancef q 8

hours x 2 doses hours x 2 doses ( total of 3 doses ) ( total of 3 doses ) Omit if PCN allergyOmit if PCN allergy

Standing OrdersStanding Orders

Ambulate with PT Ambulate with PT before D/C. Call PT before D/C. Call PT on arrival to PACU on arrival to PACU to ambulate when to ambulate when ready.ready.

Compression boots Compression boots bilateral until bilateral until dischargedischarge

HCT at 5:30a.m. HCT at 5:30a.m. prior to dischargeprior to discharge

Standing OrdersStanding Orders

Dressing may be Dressing may be removed in three removed in three daysdays

Administer 1Administer 1stst dose dose of Lovenox SQ of Lovenox SQ ( from patient’s ( from patient’s home meds ) in a.m. home meds ) in a.m. before d/Cbefore d/C

Teach pt/caregiver Teach pt/caregiver how to administer how to administer at homeat home

Postoperative CarePostoperative Care

Daily phone call Daily phone call for five days to for five days to screen for screen for anemia, mobility, anemia, mobility, pain control, pain control, incision care, incision care, etc.etc.

11stst postoperative postoperative visit at 7 – 14 visit at 7 – 14 daysdays

Questions???Questions???

ReferencesReferences

Kurtz SM,Ong KL,Schmier J,et al: Primary and revision Kurtz SM,Ong KL,Schmier J,et al: Primary and revision arthroplasty surgery caseloads in the United States from arthroplasty surgery caseloads in the United States from 1990 to 2004,1990 to 2004,J Arthroplasty, J Arthroplasty, Feb;24(2):195-203,2009.Feb;24(2):195-203,2009.

Kurtz SM,Ong KL, Lau E, et al: Projections of primary Kurtz SM,Ong KL, Lau E, et al: Projections of primary and revision hip and knee artrhoplasty in the United and revision hip and knee artrhoplasty in the United States from 2005 to 2030, States from 2005 to 2030, J Bone Joint Surg AM,J Bone Joint Surg AM, April;89(4):780-5,2007April;89(4):780-5,2007

Ravi B,Croxford R, Reichmann WM, et al: The changing Ravi B,Croxford R, Reichmann WM, et al: The changing demographics of total joint arthroplasty recipients in the demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007, United States and Ontario from 2001 to 2007, Best Pract Best Pract Res Clin Rheumatol, Res Clin Rheumatol, Oct;26(5):637-47,2012.Oct;26(5):637-47,2012.