ists in Little Rock, Arkansas, says it is not necessarily the age but the medical condition of a patient and the complex- ity of the surgery that determine if the patient is a good candidate for the ASC setting. “If a patient has sleep apnea or a high BMI, they might not be a good candidate for the ASC,” he says. “Or if the surgery is multi-level and there are chances of too much pain, an ASC stay might be prohibitive for pain manage- ment. I would do 1- and 2-level surger- ies at an ASC and 3 or more levels at the hospital for both cervical and lum- bar. If somebody has the need for a cer- vical or lumbar fusion that involves a high level of complexity from the tech- nology point of the surgery, I might do them in the hospital as well because there might be postoperative issues.” ASCs do not have the capability to
keep a patient for more than 23 hours, so “they have to make sure that their patients do not have concurrent med- ical problems that would unaccept- ably increase the risk of complication or make it unlikely that existing anes- thetic techniques would allow for rea- sonable control of pain, preventing timely discharge,” Asher says. “It is a matter of balance. If it is a smaller procedure and a patient is otherwise a good candidate for outpatient surgery, we might consider doing the procedure in an ASC even if they have more than one medical problem—but we cer- tainly err on the side of conservatism.” Major issues aside from age and medical problems to consider when selecting patients for the ASC setting are
pain management and ambula-
tion, Asher says. “We are doing pro- cedures that were inconceivable in the outpatient settings even five to six years ago,” he says. “We are perform- ing more advanced operations because minimally invasive surgical techniques have been optimized, and we have bet- ter pain control agents. Comprehen- sive pain control strategies, which now include long-acting intra-mus-
Patient Education For an outpatient ACDF surgery to be successful, patients must be educated on pre- and postop care, surgeons agree. “At Laser Spine Institute, our
patients have a dedicated spine care consultant who guides them through the entire process, handling all matters from insurance to scheduling,” Perry says. “Patients are able to ask ques-
cular anesthetics, have dramatically improved postop pain control. As a consequence, patients have been able to ambulate much quicker.” In addition, as mentioned previ-
ously, with prospective data collection, surgeons now have been able to define the windows in which patients are most likely to develop serious postop com- plications. “We found that the most serious postop complications, such as bleeding, occur in a definable win- dow of four hours for patients under- going ACDF,” Asher says. “We are in the midst of defining comparable high- risk intervals for other procedures and patient populations. That data will help us dramatically reduce or eliminate the risk of transfer to an inpatient setting for much larger patient cohorts.”
tions throughout that period, and they can also ask questions to the medical staff that they meet with when they arrive for their pre-operative appoint- ments.” The staff also sends descrip- tive language and collateral on Laser Spine Institute and its processes to the patients’ home prior to their pro- cedure. Following surgery, patients are given verbal and written instruction to aid them in their recovery, including a list of what to do and what not to do, as well as exercises to help build neck or back strength and stability, he says. Schlesinger’s ASC does the usual pre- and postop education for all its patients, he says. “They get the standard doctor and nursing educa- tion no matter whether they are out- patient or inpatient. We send them links to our web site too, so they are prepared when they come for their procedure.” The difference for out- patient is the drain and patient care instructions, he says. “Those are the unique instructions for outpatient surgery because they have to control and manage their pain level and their drain instead of the nurses.”
Quality Metrics to Track To show that spine procedures can be done safely in the ASC setting, certain metrics must be tracked. “Patient safety should be based on clinical outcomes, patient satisfaction and the likelihood of adverse events,” Perry says. “All of those parameters should be taken into account when evaluating if a specific surgical pro- cedure is appropriate for an ASC set- ting. At all of our ASCs, we stress the importance of patient safety and feel the data on our outcomes reflects that. Our infection rate is 0.13 per- cent, which is considerably less than the national hospital rate of up to 4.7 percent. And our complication rate is only 4 percent, compared to the 4 to 16 percent hospital complication
ASC FOCUS NOVEMBER/DECEMBER 2016 9
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