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“Some prosthetic cases have to be done in a certain type of room with a specific kind of air exchange, and some centers might not have that kind of environ- mental control.” For those patients who pick the ASC setting, the surgeon also reviews discharge instructions during the time when he or she counsels them on the surgery. “We verbally go through the instructions,” Lerner says. “In addition, in the preop area, the nurse reviews the instructions again with the patient and their caregiver. If something was not addressed before, it is taken care of at that point.” The staff goes over signs and symptoms that the patients need to be aware of postoperatively. “They dis- cuss fever, chills, difficulty urinating, nausea/vomiting, redness/swelling of incision, etc., that are also on their discharge sheet,” he says. “We have a call center set up for this purpose with an 877 number that is available 24/7. Patients have the option to go to their nearest emergency room or come to us if desired.” Patients also get pain management


instructions before they even go into surgery. “We have a discussion on the requirements of postop pain control in the office and prescribe the meds before the surgery,” Lerner says. “Typically, we electronically prescribe the meds, so the patients already have them at home after the surgery. We also use a lot of local anesthetics as well as IV Tylenol in certain cases for postop pain.”


Orthopedics


At Campbell Surgery Center in Ger- mantown, Tennessee, patient prep- aration starts with the physician, says Cynthia Armistead, administra- tor. “For total joint arthroplasty pro- cedures, the surgeon has to look at the physical condition of the patient, whether there are co-morbidities or other complexities, and talk to the patient/payer about their experience


If you can safely perform a procedure on an outpatient basis at a hospital, it can be done at an ASC.”


— Brad Lerner, MD, CASC Chesapeake Urology Associates and Summit Ambulatory Surgical Center


and expectations for the procedure and recovery period,” she says. “The surgeon then decides if that patient can be managed successfully in the ASC setting. Our surgeons even give patients their cell numbers. They start the patient education process at that point and want to let the patients know that they are available for ques- tions 24/7.” Patients with multiple, unstable co- morbidities and/or a less supportive family support group are not total joint candidates for the ASC setting, she says. “Due to Medicare’s restriction on performing total joint replacement in the ASC setting, our center’s patients are below the age of 65. If they have any medical complexities, we do con- sults and tests to make sure that they are medically stable.”


During preop consultation, the phy- sicians write prescriptions for oral postop pain management and Deep Vein Thrombosis prophylaxis medica- tions, Armistead says. “The patients are sent to the pre-admission test- ing office, located in the surgery cen- ter, and instructed on all postoperative medication administration and postop- erative activity. They bring the meds with them when they come for their surgery.” However, with the pain man- agement medicines that they receive during surgery few patients take pain medicine after they go home, she says. The center was keeping patients 23 hours for observation but now sends


them home the day of the surgery. “We have our own in-house physical ther- apy and our therapist comes over and does physical therapy with the patient as soon as their spinal anesthetic wears off,” she says. “They are given their walker/crutches preoperatively and the therapist gives them their instructions even before their surgery.” For postop care, “we have a dis-


charge sheet where we write down everything for the patient,” Armistead says. “We tell them what they need to do and how they need to proceed. If emergency symptoms arise, we ask them to call 911, go to their near- est ER, and then call their surgeon. We give them those same instructions before the surgery and postop. Our staff calls them the following day to check on them and goes over the dis- charge procedures again.” For total hip, the center does the anterior approach, not the posterior approach. “With the anterior approach, you don’t have the worry of disloca- tion,” she says. “So the patient doesn’t have to move as cautiously during the immediate postoperative period.”


Gynecology Pearl SurgiCenter in Portland, Oregon, specializes in laparoscopic gynecology. “We are doing groundbreaking work here,


transitioning hysterectomy—


which was recently done 100 percent in the hospital—to the ASC setting,” says Richard Rosenfield, MD, execu-


ASC FOCUS JANUARY 2015 15


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