1. 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.

2. 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

3. 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.

4. 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.

5. 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.

6. 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

7. 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.

8. Campbell Clinic Experience  230 Total Joint Procedures 74 Total Hip 74 Total Hip 79 Partial Knee 79 Partial Knee 38 Total Shoulder 38 Total Shoulder 31 Total Knee 31 Total Knee 5 Total Ankle 5 Total Ankle 3 Total Shoulder Revision 3 Total Shoulder Revision Avg. age 58 Avg. age 58 Avg LOS - < 7 hours, 85% discharged DOS Avg LOS - < 7 hours, 85% discharged DOS 0% Infection 0% Infection 0% DVT Incidence 0% DVT Incidence

9. Keys to Success  Patient Identification ASA I or II ASA I or II BMI < 35 BMI < 35 Negative sleep apnea history Negative sleep apnea history No impediments to mobility other that joint pathology 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 Ability and motivation to be discharged same day or within 23 hours with strong, appropriate home care support network

10. 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.

11. Keys to Success  STAFF EDUCATION Plan for the procedure by discussing with all involved staff members their responsibilities in the care of the patient. 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. 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. 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. Mandatory assessment of each total joint replacement surgery for care given, and quality assessment/improvement data.

12. What About Blood??  OPTIONS Autologous blood can be transfused in the ASC without major logistical obstacles. Autologous blood can be transfused in the ASC without major logistical obstacles. Prescribe iron preoperatively. Prescribe iron preoperatively. Develop relationship with local blood bank for potential transfusion. Develop relationship with local blood bank for potential transfusion. OR…, OR…,

13. 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.

14. Preoperative Standing Orders  Preadmission: Type & Screen Type & Screen CSC, Basic Metabolic Profile, PT, PTT, UA with micro CSC, Basic Metabolic Profile, PT, PTT, UA with micro EKG EKG Must come to CCSC for anesthesia clearance Must come to CCSC for anesthesia clearance If diabetic, instruct patient to bring home meds & contact medical M.D. for clearance If diabetic, instruct patient to bring home meds & contact medical M.D. for clearance Instruct patient on N.P.O. after midnight Instruct patient on N.P.O. after midnight

15. 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

16. 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.

17. 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

18. Standing Orders  Oxycontin 10mg po q 12 hours for pain  1 GM Vancomycin IVPB q 12 hours ( total of 2 doses ) ( total of 2 doses )  1 GM Ancef q 8 hours x 2 doses ( total of 3 doses ) Omit if PCN allergy

19. 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

20. Standing Orders  Dressing may be removed in three days  Administer 1 st dose of Lovenox SQ ( from patient’s home meds ) in a.m. before d/C  Teach pt/caregiver how to administer at home

21. Postoperative Care  Daily phone call for five days to screen for anemia, mobility, pain control, incision care, etc.  1 st postoperative visit at 7 – 14 days

22. Questions???

23. 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.