Vertical Integration
Moving Inpatient Total
Joint Replacement to
Outpatient
in the Ambulatory Surgery
Center Setting
Cynthia Armistead, Administrator
Campbell Clinic Surgery Centers, L.L.C.
Learning Objectives

Review the statistics relevant to the prevelance
of osteoarthritis in the national population
 Identify the steps necessary for developing a
total joint arthroplasty program in the ASC
setting
 Describe the clinical preopeartive and
postoperative protocols for total joint arthroplasty
patient managment
Background Statistics




Arthritis is the most common cause of disability in
adults.
Physician diagnosed arthritis and corresponding
activity limitations are projected to increase over 40%,
or to nearly 67 million in the next 25 years in the
United States.
Nearly two thirds of adults reporting doctor diagnosed
arthritis are younger than 65 years.
Osteoarthritis is the most common type of arthritis and
comprised 70% , or 1.2 million of the 1.7 million
nonfederal short stay hospitalizations in 2007.
Background Statistics

Total joint arthroplasty remains the treatment of choice
for advanced, symptomatic joint pain.

In 2006, hip and knee replacements accounted for 96% of
the 1 million arthroplasty procedures completed. Total
shoulder replacement accounted for 3% of this total.

Kurtz, et. al., estimate over 570,000 primary total hip
replacements and 3.5 million primary total knee
replacements will be performed annually in the United
States by 2030.

Total hospitalization cost of hip and knee joint
replacement has increased in the last decade by more
than 137% and is now estimated at approximately $60
billion annually.
Current Trends

The Affordable Healthcare Act is driving practices to provide
medical care / procedures at a lower cost while demanding
higher quality outcomes.

CMS -1589-P has proposed a new rule for 2013 eliminating the
mandate that total knee replacement be performed in the
hospital setting.

Muscle sparing, smaller incision surgical techniques contribute
to less soft tissue disruption and faster recovery/rehabilitation
time for total arthroplasty patients.

Advanced anesthesia techniques, i.e.., peripheral nerve blocks,
and the use of bupivacaine liposome injectable suspension (
Exparel ) allows patients to be pain free for up to 72 hours.
Benefits







Reduced risk of nosocomial infection
Reduced risk of iatrogenic illness
Reduced risk of complications from general anesthesia
such as decreased respiration and hypoxia from the
administration of I.V. narcotics
Reduced risk of P.O.N.V.
Faster initiation of ambulation, R.O.M. and
strengthening exercises from P.T , shortening recovery
times and resulting in faster return to work and activities
of daily living.
Greater surgeon control of management of the
postoperative patient
Patient satisfaction rates of 99% or higher - Excellent
Benefits
COST
The cost of total joint replacement surgery in the ASC
setting is approximately 1/3 to over ½ times lower than
the same procedure performed in the inpatient setting.
Campbell Clinic Experience

230 Total Joint Procedures

74 Total Hip

79 Partial Knee

38 Total Shoulder

31 Total Knee

5 Total Ankle

3 Total Shoulder Revision




Avg. age 58
Avg LOS - < 7 hours, 85% discharged DOS
0% Infection
0% DVT Incidence
Keys to Success

Patient Identification

ASA I or II

BMI < 35

Negative sleep apnea history

No impediments to mobility other that joint pathology

Ability and motivation to be discharged same day or
within 23 hours with strong, appropriate home care
support network
Keys to Success

PATIENT EDUCATION
Patient must have a detailed explanation and understanding of the
surgeon’s expectations.
Preoperative P.T. consult to review ROM, strengthening, weight bearing and
gait training with crutches, walker, etc.
Preoperative assessment by surgery center preoperative admission nurses
to review medical history, tour facility, and give preoperative instructions.
Preoperative assessment by anesthesia and explanation of spinal, block, etc.
procedures and expectations.
Prescribe COX – 2 preoperative loading dose ( 400mg ) and instruct patient
to take 48 and 24 hours preoperatively. Prescribe anticoagulants and instruct in
postoperative use.
Distribute D.M.E in the office setting preoperatively.
Keys to Success

STAFF EDUCATION




Plan for the procedure by discussing with all
involved staff members their responsibilities
in the care of the patient.
Establish standing orders/protocols for each
total joint procedure and patient. In service
all staff.
Perform “dry runs” of the procedure before
the day of surgery, specifically in the O.R.
Mandatory assessment of each total joint
replacement surgery for care given, and
quality assessment/improvement data.
What About Blood??

OPTIONS




Autologous blood can
be transfused in the
ASC without major
logistical obstacles.
Prescribe iron
preoperatively.
Develop relationship
with local blood bank
for potential
transfusion.
OR…,
Tranexcemic Acid



Tansexamic acid is an
inhibitor of plasminogen
activation.
CCSC protocol is to give
1 GM IV on arrival to O.R.
and 1 GM at end of case.
Total Hip Replacement
patients have averaged
300 – 700ccs blood loss
per case.
Preoperative Standing Orders

Preadmission:

Type & Screen





CSC, Basic Metabolic Profile, PT,
PTT, UA with micro
EKG
Must come to CCSC for
anesthesia clearance
If diabetic, instruct patient to
bring home meds & contact
medical M.D. for clearance
Instruct patient on N.P.O. after
midnight
Standing Orders





Obtain Consent
Ensure surgeon has
written” correct” on
operative side
No shave or prep in
preop holding
Remove nail polish
from operative
extremity
Vancomycin 1 GM
IVPB and 1 Gm Ancef
IVP
Standing Orders




Prep area with
betadine/chlorahexidine
1 GM Transexamic Acid
IVPB on arrival to OR
1Gm Tylenol IV
Repeat 1 GM
Tranexamic Acid at
completion of case in
the O.R.
Standing Orders






Ice to operative site
IV lactated ringers
TKO
Advance diet as
tolerated
Routine vitals
Record all I & O
If drain, empty q
8hrs and record.
Pull before D/C
Standing Orders



Oxycontin 10mg po q
12 hours for pain
1 GM Vancomycin
IVPB q 12 hours
( total of 2 doses )
1 GM Ancef q 8 hours
x 2 doses ( total of 3
doses ) Omit if PCN
allergy
Standing Orders

Ambulate with PT
before D/C. Call PT
on arrival to PACU
to ambulate when
ready.
 Compression boots
bilateral until
discharge
 HCT at 5:30a.m.
prior to discharge
Standing Orders



Dressing may be
removed in three
days
Administer 1st dose of
Lovenox SQ ( from
patient’s home meds )
in a.m. before d/C
Teach pt/caregiver
how to administer at
home
Postoperative Care
Daily phone call
for five days to
screen for anemia,
mobility, pain
control, incision
care, etc.
 1st postoperative
visit at 7 – 14 days

Questions???
References



Kurtz SM,Ong KL,Schmier J,et al: Primary and revision
arthroplasty surgery caseloads in the United States from
1990 to 2004,J Arthroplasty, Feb;24(2):195-203,2009.
Kurtz SM,Ong KL, Lau E, et al: Projections of primary
and revision hip and knee artrhoplasty in the United
States from 2005 to 2030, J Bone Joint Surg AM,
April;89(4):780-5,2007
Ravi B,Croxford R, Reichmann WM, et al: The changing
demographics of total joint arthroplasty recipients in the
United States and Ontario from 2001 to 2007, Best Pract
Res Clin Rheumatol, Oct;26(5):637-47,2012.