same day surgery live webcast - amazon web services€¦ · · 2014-12-11–convincing hospitals...

Same Day Surgery Live Webcast

Overview

WWW.SAMEDAYJOINTS.COM

©2013 Same Day Joints, All rights reserved.

History of Advanced Center for Surgery in Altoona, PA

Establishing a Same Day Joint protocol− Getting Started

− Aligning Goals across care teams

− Preparing and Implementing protocols

Care Pathway Assessments− Anesthesiologist

− Home Health Services

Surgery featuring VISIONAIRE and JOURNEY II BCS− Patient arrival

− Intraoperative care

− Patient discharge

Patient Testimonial

Panel of experts− Anesthesiologist: Dave Berkheimer

− Home Health Care Services: Amy Hancock and Sheena Henry

− Reimbursement expert, CEO UOC and Director of the ACS: Dave Davies

Advanced Center for Surgery



First TKA performed December 2012− 126 TJA performed with measured outcomes

− 55 THA and 71 TKA

FREESTANDING SURGICAL CENTER− 0.125 Stay – NOT 23hr program

− Home in 3-4 hours from surgery

− Highly advanced protocols

Patient Demographics− Age 22-72

− BMI less than 50

− 68 Female and 58 Male

− ASA Classification 1 and 2 only

− 1st Revision

Discharge− No OTHER option, all d/c straight home

− Requires excellent communication between all providers

− Care Pathway management

This is “accountable care” at its highest level

Understand your Practice and Patient Demographics– Referral Base

Assess team’s clinical capabilities – Surgical

– Anesthesia

– PT

Evaluate service line resources – PT

– Home Nursing

– Home Pharmacy

Negotiate payer contracts in advance

Understand costs and necessary resources – Facilities

– Instruments

– Staffing

Implement a Joint Coordinator

Identify Team Leaders

Where to start?



Communication begins with the first office visit– Patient Education

Cloud Based Care Pathway – Multi-disciplinary contact

– Direct and Rapid Electronic Communication

Open communication amongst all providers – Vital to ensure safe and successful joint program

Care is protocol driven – Changes in patient status, care or condition is communicated to all

providers

– Protocol changes are implemented at Joint Team Board level and

communicated

Communication



Educate referral base of new improved patient options

Educate office staff and care teams– Care Pathway and Implementation

– Home Nursing

– Physical Therapy

– Home Pharmacy

Educate surgical team– Anesthesia Protocol

– Procedure

– Care Pathway Implementation

Train, Practice, Discuss!– Surgical Run Through

– Equipment/Supplies

– Pharmaceuticals

Data collection – PI with Care Pathway Process in place

Preparation



Office Visit– Patient Complaint- Pain/Arthritis/Avascular Necrosis

– Alternatives to Total Joint Replacement have not aided patient complaints

– Severity of Disease-Requires Surgical Intervention

Patient– Surgical Candidate

– Motivated

– Wants to avoid inpatient stay

Same Day Joint Replacement Candidate– Meets selection Criteria

Patient Education – Identify and understand Home Care Needs

– Patient Responsibilities

Initiate Care Pathway through Joint Coordinator

Implementation



• Execute Care Pathway Process

• Referral received 3-4 weeks in advance

– Insurance verified

– Potential out-of-pocket expenses identified

• PT schedules Home Assessment 1-2 weeks in advance

– Home Assessment checklist completed

– Patient home assessed for safety and areas of concern

– Post op teaching tools provided

– Baseline vitals obtained

– S.A.F.E- Risk stratification tool will be completed

• Review of medications

• Pre-operative functional ability

• Home environment and support system assessed

• Project appropriate level of assistance needed upon discharge

• Communicate home assessment results with all providers

• Call patient Monday of surgery to address final questions

Preoperative Evaluation – Home Health



Communication day of surgery

– Advanced Center for Surgery updates Home Health with patient’s

progression

– 30 minutes prior to discharge Home Health notified

• Allows nurse to be at home when patient arrives

• Discharge instructions include last does of antibiotic, IV pain

medication, etc.

Nurse and PT meet patient at their home

– Assist patient out of the car and into home

– If clinician worried about safety during assessment, a third

clinician will be at home

Day of Surgery – Home Health



Nurse completes admission assessment and education

• Hemovac drain (knees) or Q-pump (hips)

• Pain medications, side effects, use of ice, S& S of infection, DVT,

fall prevention, TEDhose and pneumatic compression device

Administer IV

• antibiotic approximately 8 hours after first dose in Pre-op

• pain medications as needed

Ensure patient has all medications ordered

Physical Therapy

• completes evaluation

• Supine AROM TKA exercises

• Measure AROM/AAROM

Day of Surgery – Home Health



POD1Nursing

• Completes full assessment

• Assesses Hemovac drainage (knees) or On-Q pump (Hips)

• Administers last IV dose of antibiotics and discontinues IV lock.

• Obtains a CBC

Therapy

• Start seated AROM exercises

• Continue supine AROM

• Measure AAROM

·

Postoperative – Home Health

Postoperative – Home Health

POD 2Nursing

• Completes full assessment

• Removes Hemovac drain (knees) or On-Qpump (hips)

• Obtains CBC only if day 1 Hg <10.5 or excessive drainage from

incision

• Ace bandage removed

• Silver lon dressing (if used) left on for 7 days and then removed

Therapy

• Start standing exercises with walker

• Continue with all others

• Start stair training if able

POD3Therapy

• Increase all exercises difficulty (repetit ions) depending on tolerance

NursingEducate patient and family members

• Fall prevention, pain control, S&S of infection and DVT

• Importance of regular bowel movements

• Medication and their side effects

• Importance of ice/ elevation

Complete full system assessment

Check incision

Edema measurements • Document findings on communication sheet in folder

• Allows subsequent clinician visits has an established baseline.

Post-Op Daily Assessments – Home Health

Patient responsibility• Instructed to complete exercises three times a day

• Ice and elevate with heel prop after each session

• Ambulate once an hour

Therapy• Each session includes bed mobility, gait training and

transfer training Focusing on safety using muscular strength and

normalization to avoid compensatory techniques.

• Progress patient to SPCfrom WW and eventually to no

AD when gait is with minimal or no pain.

• Progress patient to exercises with Theraband when

appropriate.

Post-Op Daily Process – Home Health

Same Day Surgery OutcomesHips Average Average Ave SN Ave Therapy

LOS Age Visits Visits28.3 56 9 14.3

Knees Average Average Ave SN Ave TherapyLOS Age Visits Visits

17.3 59.6 6.3 9.5

Hospital 30 days 60 daysREADMISSIONS 0% 0%

Advantage Home Health Risk Assessment Overview

Preoperative Evaluation - Anesthesia

Execute Care Pathway Process

Physical Evaluation of the patients – Is a MUST-7-10 days out

– Pre-Operative Testing

– Coexisting Diseases

Airway, Airway, Airway

Anesthetic Technique Considerations– Post Op Pain Control

Educate Patients and Family

Intra-operative

Implement Care Pathway

OR Preparation– Surgical Equipment– Disposables, – Implants– Staff

Standard operating procedures implemented– Proper patient identifiers – Time Outs– Positioning preparation– Anesthetize patient– surgical prepping– Reduction in OR traffic – Infection Control Reduction

Hemostasis considerations and techniques

Minimize operative insult and duration– Minimally Invasive– Efficiency

Postoperative

Implement Care pathway

Rapid and Safe recovery from anesthesia– discharge under 4 hours

– Phase I/II Nursing Staff Trained in Rapid TJR Discharge

Early Ambulation and Gait Training/ Transfers

Post Op Pain Management

Post Op N/V Management

Educate Patient , Family and Home Health of Special Needs

Home Pharmaceuticals in place

Reimbursement – Same Day TJR

Payer Limitations•Medicare Exclusions “Inpatient Only” procedure; ASC Covered

procedures

•Commercial payers dependent on Medicare coverage policies

Licensing Restrictions•Approved procedure exclusions of Total Joint Codes

Participating Payers •Highmark Blue Cross/Blue Shield

ACS Facility Reimbursement•Negotiated Fee for Service (Procedure Based) plus Cost carve

outs for Implants

Physician Reimbursement• Incentive Based Fee for Service (Procedure based payment

increases based on Episode Quality and Cost Performance)

Under Development •Retail Bundled Pricing

Cost Per Episode

• ASC v. Hospital– Clinical advancements and cost efficient protocols are generally portable

and can be applied in a hospital based setting.

– Hospitals conceptually recognize the need to adapt and share with consumers lower unit costs

– Convincing Hospitals to pass cost savings to the consumer in terms of lower pricing or out of pocket expenses remains a challenge

•Health Insurers recognize that narrow networks improve

cost and quality performance predictability

•Desirable networks include physicians who practice

evidence based medicine AND utilize cost effective

facilities

•The gateway to earning payment incentives for

physicians is quality, and the means for insurance

companies to fund the incentives is lower facility cost.

•Physicians practicing quality medicine in high cost

venues will end up in those network tiers that will require

the patient to pay an increased cost to access them

•Today, low costs and high value trump provider choice

Partnering with Payers“It’s like bringing Moneyball to health care”- Brett Morris, President of Health Net of Arizona

Same Day Surgery Recipe for Success

Featuring VISIONAIRE™ and JOURNEY II BCS™

Dr. Chris McClellan and Dr. Ken CherryAdvanced Center for Surgery

Altoona, PA

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JOURNEY™ II BCS

A Rationale for Guided Motion

Performance to patient expectations

Only 14% were

satisfied with squatting

• 2 Arms (TKA v Normal Knee)

• Age and Gender matched armsClin Orthop Relat Res. 2005 Feb;431:157-165: Noble PC, Gordon MJ … Mathis KB

• 243 TKA Patients v 257 individuals

• Performance to expectations was poor

Performance/Satisfaction of TKA’s v THA?

• Post THA: sports activities increased

from 36% to 52%

• Post TKA: sports activities decreased

from 42% to 34%

The Ulm Osteoarthritis Study- K Huch

• Up to 20% of patients are not satisfied

with the outcome following total knee

replacement

• Only 82% to 89% of primary TKA

patients are satisfied

J Bone Joint Surg Br. 2010 Sep;92(9): Scott CE, Howie

CR, MacDonald D, Biant LC

Clin Orthop Relat Res. 2010 Jan;468(1):57-63: Bourne

RB, Chesworth BM, Davis AM, Mahomed NN, Charron

KD

Conventional TKA limitations

Non-anatomic (abnormal) motion yields muscular inefficiencies

• Paradoxical motion (anterior sliding)

• Limited external rotation (hinge)

Normal Knee Conventional Knee - Fixed

Conventional TKA limitations

Non-anatomic shapes and position yields poor kinematics

• Abnormal proprioception

• Promotes paradoxical motion

Posterior sulcus

position to gain deep

flexion

Symmetric joint-

line to manage

inventory (left/right

inserts)

Improve Kinematics to Boost

Performance

PHYSIOLOGICAL MATCHING™:Normal motion

PHYSIOLOGICAL MATCHING™Restoring anatomy and motion

Restores anatomic 3°varus joint line

Medial:Prominent posterior medial

Normal A/P sulcus position

Normal convexity

JOURNEY™ II TKA

Conventional TKA

PHYSIOLOGICAL MATCHING™:Stability Throughout a Range of Motion

Mid-line Sulcus Anterior Cam Posterior Medial

Lip/Horn

Posterior Cam

™Trademark of Smith & Nephew. Certain marks Reg. US Pat. & TM Off. All Trademarks acknowledged.

Confidential – For internal use only by Smith & Nephew employees and sales force. Do not publicly distribute.

0° 0° - 20° 60° - 155°20° -

60°

Kinematic

Options

BCSC

R

JOURNEY™ II TKA: A Complete

System

Femur/Tibia

Bailout

Options

Seamless

Primary ->

Revision

Revisio

n10 AP Sizes

Same AP Box

Primary Stem

Options

Revision Stem

Options9 proven anatomic sizes (L/R) 8 sizes (L/R)

High-Level Experience

• First Period of Implantation: Dec.

2011

• Total Implantations to Date: 7,606

(US)

• Total Implantations beyond 3 mos:

5,342

• Total Implantations beyond 6 mos:

4,141

• Total Implantations beyond 1 year:

1,856

• First Patient Enrolled: June 21,

2012

• Go/No Go Decision Target (100):

• Cases to date: 473 (715 Group)

• 1st Case: December 2011

• > 1 year follow-up = 171

• Avg length of stay – 1.6 days

(20 last 3 months as outpatient)

• Avg. ROM @ discharge 107°• Total PT sessions = 8.2

(ROM > 110 & independent

ambulation)

• Complications:

- ITB Pain – 0

- Dislocation - 0

- Manipulation - 1

Personal Clinical ExperienceP

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tats

“Happiest post-op patients I’ve ever had in my 20 year

career”

•Disposable TKA cutting guides designed to match the patient’s

anatomy

•Utilizes preoperative MRI and full-leg X-Ray

•Based off the gold standard of mechanical axis alignment

VISIONAIRE Cutting Guides

•Reduces OR time by eliminating a number of steps in the surgical technique*

Alignment, sizing, and rotation are included in cutting guides

• Improves alignment and sizing by using computer generated images of the patient’s

anatomy to determine bone cuts, and implant positioning preoperatively

•Eliminates need to violate the IM canal, reducing blood loss and complications from

fat emboli

•Reduces sterilization due to less instruments required for surgery

VISIONAIRE

Instrumentation v standard TKA

Standard TKA VISIONAIRE instrumentation

Pre-op plan allows me to know exactly what to

expect with every surgery

Less invasive to patients (No IM rod, Less Ligament

releases)

Better patient outcomes

More efficient OR (Less trays & instruments)

S&N has reduced the instruments and implant sets

at my hospital

It makes me a better surgeon

VISIONAIRE™ My Experience

VISIONAIRE™ Surgeon Benefits

Know exactly what to expect with each case

Can anticipate intra-op problems before they

happen

Ability to customize each plan specific to patient’s

anatomy

Dedicated engineer

Reduced instrumentation in the OR

OR Staff loves it

My patients are happier (Increases patients

confidence)

VISIONAIRE™ Patient Benefits

Patients have:

• Less pain

• Shorter hospital length of stay

Preop X-Ray

Post-op 1 Month

Post-op X-Ray

•Less physical therapy

•Less blood loss

Contact Information

mailto:[email protected]





same day surgery live webcast - amazon web services€¦ · · 2014-12-11–convincing hospitals...

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