COVER STORY The Role of the 23-Hour-59-Minute Rule in Higher Acuity Cases

ASCs are allowed to keep patients up to 24 hours after admis- sion unless state law provides a more restrictive time limit.

“The whole issue of 23 hours, 59 minutes is remarkably ar- bitrary and completely artificial, and it needs to be re-ex- amined,” says Anthony L. Asher, MD, ASCA Board member, director of the Neuroscience Institute at Carolinas Health- Care System and senior partner at Carolina Neurosurgery and Spine Associates in Charlotte, North Carolina. “Why

can’t that period be re-defined as 36 hours, for instance? If we had an intelligent way of expanding the approved observation interval, we would unquestionably be able to expand patient access to ASCs, particularly for those individuals with moderately increased surgical acuity and surgical risk factors.”

One way to help promote case expansion and patient access to ASCs would be to provide payers such as the Centers for Medicare & Medicaid Services (CMS) with substantial data that objectively demonstrates the value of cases performed in ASCs versus hospital settings, he says.

“We cannot perpetually remain in a reactive mode,” Asher says. “We have to proactively determine which procedures we believe are appropriate for treat- ment in ASCs, then use a variety of quality tools at our disposal, such as clinical registries and payment databases, to compare the safety and value of perform- ing surgeries in different settings.”

Moreover, ASCs should use such data to engage and, hopefully, partner with other stakeholders such as payers. “As we share a mutual interest in improving patient outcomes while allowing for the creation of more sustainable delivery systems, it is my belief that payer groups, faced with reliable data that surgical care could be provided with greater cost efficiency and at least equivalent out- comes in an ASC versus hospitals, should be more willing to consider intelligent modification of existing standards, such as expanding approved stays in an ASC beyond the present 24-hour limit,” he says. “Simply put, if we took patient safety off the table—meaning, show conclusively that patient safety would not be com- promised—and demonstrated at least equivalent outcomes to inpatient settings along with enhanced cost effectiveness, then why wouldn’t we expand the use of ASCs? Failing to do so under those circumstances would defy logic.”

ASCs could easily expand their quality data acquisition to include higher acu- ity procedures and the impact of allowing expanded stays, Asher says. “Such care paradigms can and should be modeled with specific payers to look at the value of doing larger procedures and extending stay—perhaps initially by 6–12 hours—in the ASC. This would allow our outcomes to be transparent and would also create trust through enhanced partnership between relevant health care stakeholders. The stakeholder group could be expanded to include representa- tives from patient groups, ASCs, the physicians they represent, payers, and even those hospital systems that have already determined the future of surgical care must include ASCs are part of the comprehensive solution.”

We have just begun to realize the potential of ASCs to save the health care sys- tem tens of millions of dollars, Asher says. “This potential would unquestionably be enhanced without the existing time constraints. Advanced spine surgeries and orthopedic cases, such as total joint, are complex cases that would benefit from expanding existing uses of ASCs,” he says. “The writing is on the wall for increased utilization of ASCs, but we need to lead the way to that future with data that unequivocally supports such expanded use.”


risk of readmission or uncontrolled pain,” he says. “We are not looking for unicorns such as 55-year-old marathon run- ners, but we cannot accept patients who are extremely sick, like an ASA 4, or have multiple medical comor- bidities, a history of chronic pain or heavy reliance on opioid pain medi- cation, or rely on anti-coagulants,” he says. “Individual comorbidities could be managed in an ASC but maybe not a combination of comorbidities.” Kim Jablonski, RN, total joint pro- gram director of Ortho and Sports Institute in Appleton, Wisconsin, says her ASC can perform high-acuity pro- cedures on higher-risk patients because it sends those patients to an adjacent skilled nursing facility (SNF) to stay overnight. “We do BMI patients over 40, type 1 diabetics and patients that are anti-coagulated,” she says. “They have surgery and are discharged from our center in four to six hours and admitted to the SNF for two to three nights.” The SNF has a medical direc- tor and is attached to the ASC. Patients are directly admitted and transported down the hall to the SNF. “It is a cheaper model for the insurance com- panies,” she adds. “Our model allows for a one- to three-night stay for total joints, providing the necessary IV anti- biotics, pain medications and acceler- ated therapies. It also allows for higher acuity spine cases that stay overnight for pain control.”

Postop Asher says his ASC is presently con- sidering extended stay in conjunction with other surgical facilities. “Conva- lescent centers (CC) represent one of the options, also an apartment setting monitored by individuals with medical backgrounds,” he says. “A vast major- ity of our patients, however, can safely leave within the window as appropri- ate for ASCs.”

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