How We Did Total Joint Replacement Surgery at Our ASC

Michele Mutchler, RN

If you think total joint replacement surgery is too complex and risky to be performed in ambulatory surgery centers, think again. At our center, we've proven that with a highly trained surgical staff, a well-thought-out perioperative plan, and a motivated patient, these procedures can be done successfully in an ASC - for about half of what they would cost in a hospital. In this article, I'll tell you the story of how we became the first ASC in Florida, and one of the first ASCs in the country, to perform total joint replacement surgery.

The Total Knee Replacement

The first joint replacement case at our center was a staged bilateral total knee procedure, performed in July 1997 (about a year before I joined the staff) by David Griffin, MD. The patient was a German man in his late 60s who had chosen to have the surgery done in the U.S. and planned to pay in cash, since he had no insurance. After deciding to proceed with the surgery, Dr. Griffin first called the local hospital, which was less than willing to take on an uninsured patient. They quoted him a price of $35,000, which did not include additional care should any complications occur.

The risk of complications, however, was rather low, since the patient had no major medical problems and was fairly young. Searching for a more cost-effective option, Dr. Griffin decided to explore the possibility of perfoming the surgery at our center. The center was equipped to serve as the surgical site, but since the patient would require round-the-clock post-op care for at least four days, we had to make arrangements to transfer him to another facility. Fortunately, HealthSouth Treasure Coast Rehabilitation, an acute care rehab hospital, was only two blocks away. The two facilities proposed a lump-sum fee that was less than half of the hospital's quoted price.

"Proper patient selection was very important in this case," says Dr. Griffin. "Performing the operation (in an ASC) on a really ill patient would have been inappropriate, but this patient had no potentially complicating conditions. Also, the surgical staff was willing to make the extra effort to procure the equipment we needed." One of Dr. Griffin's main concerns was whether or not to replace both knees in one day; he decided that a staged procedure, with a three-day interim period, was safer.

Over the next few weeks, the staff swung into action, assembling the instruments, sutures, sterile airflow hoods, dressings, and other equipment needed for the procedure. The only thing lacking was a laminar air flow circulation system, which would have been an extra precaution against infection, but was deemed unneccessary since the surgical team would be wearing sterile airflow hoods. The patient underwent a standard pre-op evaluation and predonated blood in case it was needed during the procedure.

At the rehab hospital, the nursing and therapy staff were also preparing for a new experience, since they normally see patients after a three- to five-day hospital stay. "We took extra steps to make sure the nursing and therapy staff were comfortable with the protocols," says Meg McNally, director of business development at the facility. "We made sure we communicated with the surgical staff and reviewed the pain medication and dressing change procedures in advance, so everyone felt prepared."

The surgery itself, in which the diseased knee joint was replaced with a metal prosthesis, was remarkably unremarkable. The team included Dr. Griffin, a physician's assistant who had worked with him on numerous other procedures, a scrub nurse who had assisted on total joint procedures in a hospital setting, and various other staff. Together, they completed the procedure in one hour.

Afterwards, the patient recovered for 90 minutes in the PACU before being transferred to the rehab hospital. Three days later, he returned for the second operation, which went as well as the first. After a short inpatient stay of 10 days at the rehab facility, he went home. He was scheduled for 12 rehab visits, but after 10 appointments he was doing well enough to forego the last two.

"Other than making sure the proper instruments and staff were available and having a backup plan in place (to transfer the patient to the hospital in case of an emergency), we didn't have to take any special measures to prepare, says Dr. Griffin. "If a similar situation came up, I would not hesitate to do this again."

The Total Hip Replacement

A similar situation did come up in October 1998, about five months after I became facility administrator. This time, the patient was a 67-year-old Scottish man in need of a bilateral total hip replacement. His surgeon, Omar Hussamy, MD, received a quote from the local hospital for $30,000. Together with HealthSouth Treasure Coast rehab, we offered a much lower lump-sum fee, which included the procedure, the inpatient stay, and 20 post-op recovery visits.

When we heard that we were going to do a total hip, we were extremely excited - we knew we were paving the way for how this surgery would be done in the future. The patient was a perfect candidate, who even took the time to visit the surgery center and the rehab facility a week before the procedure. He had a good attitude and he really wanted to have the surgery done in our facility. Plus, he had no other major medical conditions, so the risk of complications was low.

"I completed the procedure exactly as I would have in the hospital," says Dr. Hussamy. In fact, with the help of two experienced scrub nurses and his own assistant, he shaved 20 minutes off of his standard OR time, finishing in an hour and 10 minutes. After four hours in the PACU, the patient was transported to the rehab facility, where he stayed for one week. After six months, he returned to the center for the second hip replacement, which went just as well.

"The only potential downside of doing the procedure in a surgery center is not having laminar flow, but the rate of infection is so low that I don¹t consider this a real risk," says Dr. Hussamy. "I would do the procedure in ASCs for all appropriate patients if Medicare would reimburse it."

The Future of Joint Replacement in ASCs

Getting Medicare reimbursement may be the primary hurdle that ASCs need to jump in order to make total joints a viable revenue source. The patient population exists - in 1996, there were 138,000 total hip replacements and 245,000 total knee replacements performed, according to the 1996 Vital and Health Statistics report issued by the Centers for Disease Control and Prevention. "In the ideal situation, Medicare would allow surgery centers to work with rehab facilities," says Dr. Hussamy. "Under the current system, patients have to stay in the hospital for four to five days, and then go to a rehab center for another five days in order to get Medicare reimbursement. Performing the procedure in a surgery center would eliminate the hospital costs altogether."

"As long as they communicate with their rehab facilities and are sure of the proper therapies and medications, there's no reason why ambulatory surgery centers wouldn't be able to do these procedures," says Meg McNally. "It is a viable revenue source, especially for younger and healthier patients."

Performing total joint replacements has been an exciting and successful venture at our center for our surgeons, staff, and patients. If more centers like ours continue to offer lower prices and quality care, there's every reason to think that ASCs may someday become the venue of choice for this type of surgery.