on the safety and success of the patient. The patient’s needs always come first.”

Laying the Foundation

Some of the most important work that goes into providing patients with optimal TJR outcomes happens well before patients undergo surgery, says orthopedic surgeon Andrew Wickline, MD, who performs total hip and knee replacement at Apex Surgical Center in Westmoreland, New York. “It comes down to patient engage-

Improve Outcomes in TJRs

Patient engagement and education are critical BY ROBERT KURTZ


otal joint replacement in an ASC was once a far-fetched idea, but

now surgeons are performing these pro- cedures safely in surgery centers every day. With

private payers coming on board and Medicare weighing whether to provide coverage, surgery centers have an opportunity to become the pre- ferred site for an increasing number of total joint replacements (TJR). To achieve that standing will require ASCs to determine how to deliver pos- itive, predictable and reproduceable results, says orthopedic surgeon Louis Levitt, MD, owner and former chair- man of the Massachusetts Avenue Sur- gery Center in Bethesda, Maryland. “When we started performing total joints on an outpatient basis in 2015, we looked closely at what parameters for our program would be necessary for us to produce the best outcomes possible,” Levitt says. “We continue to explore

16 ASC FOCUS MAY 2019 |

ways to make changes to our program that will further improve our outcomes.” That same mentality has helped

drive the growth of the TJR program for Bedford Ambulatory Surgical Center in Bedford, New Hampshire, says Cathy Foti, RN, the ASC’s quality director and infection prevention nurse. The surgery center launched its program in 2014 with four surgeons performing total hips. Two years later, the ASC added total knees. Now the center has seven surgeons performing about 100 total joint surgeries, including total shoul- ders, annually and is hoping to increase that number by 50 percent in 2019. “We have a great core group of phy- sicians willing to put the time and effort into making our program as successful as possible,” Foti says. “They are sup- ported by our well-prepared, commit- ted nurses and anesthesia team. It is a full-team effort with everyone focused

ment,” Wickline says. “You need a platform that educates patients and encourages them to buy into what they must do so their surgery and recovery will be a success.” Foti provides one-on-one educa- tion to all of her ASC’s TJR patients. She also uses this time to look for red flags. “When you explain what the surgery entails, discuss what patients must do before and after the procedure and answer their questions, their body language will tell you a lot,” she says. “You need to look for indications that a patient is not prepared to do what is necessary on their end for a successful outpatient surgery. When I see these signs, I tell our physicians. If we are not confident that the patient is 100 percent on board, we will not proceed with surgery in the ASC.” Most patients, Wickline says, need

about six weeks to complete all the necessary preparation and preadmis- sion testing—e.g., blood work, uri- nalysis testing, coagulation testing— to safely prepare for surgery. As he sees it, those six weeks can make or break a surgery. “I use that time to optimize the patient for their procedure,” Wickline says. “If a patient is anemic, there is an increased risk factor for infection, so we work to optimize the hemoglobin. If vitamin D is low, that will increase infection risk, so we work to elevate it.” The blood sugar level is also very important. A blood sugar of 110 is the high limit of normal. A blood sugar

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