In 11 years, surgeons at an Iowa ASC have performed 1,500 total joint replacements. The program has grown steadily, partly the result of positive word-of-mouth endorsement, mostly because of superior clinical outcomes.

“Our patients have a phenomenal experience. When you have more patients in your facility for longer periods of time, they will talk about how great their experience is when they tell family and friends,” says Michael J. Patterson, RN, MSN, FACHE, president and chief executive officer of Mississippi Valley Health in Davenport, IA. The organization is a multispecialty ASC that offers every surgical specialty except urology. Since 2015, the organization has partnered with UnityPoint Health–Trinity, a regional integrated healthcare delivery system, and Surgical Care Affiliates, a national ASC management company.

The ASC provides these total joint replacements: ankles, knees, hips, shoulders, and wrists.

Patterson offers the following suggestions for how ASCs can begin a 23-hour total joint replacement (TJR) program — at least in states that allow 23-hour stays:

• Recruit surgeons who are open to TJR in an ASC setting. Not all surgeons will adapt to the ambulatory surgery setting for surgeries they’re accustomed to performing in hospitals.

“If you have a surgeon who has a two-to-three-day length of stay in the hospital, to get him to do a 23-hour stay and discharge in the morning can be challenging,” Patterson says. “You will need to build a clinical pathway and have very clear patient selection criteria.”

Some physicians adapt well to the 23-hour stay model. They are the ones that believe patients are best off recovering at home, where there is less risk of infection, better sleep, and less risk of falls, he notes.

“We have four orthopedic surgeons who perform total joint surgery, and three do this routinely,” Patterson says. “They all require patients to have someone at home with them for a minimum of the first three days for 24 hours per day, and that’s the way patients get support while recovering.”

• Train staff in 23-hour stays and TJR. “Make sure the surgery center team is comfortable with total joint replacement,” Patterson advises. “All of our nurses have been involved in total joint replacement, and they understand the post-op patient’s needs and clinical pathway with TJR. We train them often, and if things change or technology changes or if the doctor uses a different medication or implant or a different post-op pathway, then we train again.”

Staff education is continuous. Surgical cases that warrant a patient to stay in an ASC for 23 hours tend to be more complex, Patterson notes.

“As a result of the increased complexity, the payment can be higher, in some instances, though it is still typically lower than what a payer or patient would pay for the same procedure in a hospital setting,” he adds.

One of the benefits to an ASC when expanding to 23-hour stays is that surgeons will perform a string of cases that accompany the 23-hour case, Patterson says.

“Also, we recognize that our ability to do 23-hour TJR has led other surgeons to realize the strength of our clinical staff, and they often bring cases to our facility because we perform on more complex patients and have excellent clinical outcomes,” he says.

• Make certain patients understand the expectations. Patients should be prepared for surgery and the discharge home on the same day or following day, Patterson says.

Mississippi Valley Health patients and their caregivers go through a “total joint boot camp” prior to surgery. The two-hour class is led by a surgery center health history nurse, a physical therapist, and, sometimes, a physician assistant or nurse practitioner from the orthopedic group who talk with patients about exercises, medication protocols, and what to do if there is a problem post-surgery.

• Work with vendors on pricing. “We’re constantly working with vendors to make sure we have the best pricing on implants and that surgeons have access to the types and brands of implants they feel are best for their patients,” Patterson says. “We have an annual review of all of our costs associated with total joint replacement program because ASCs are paid much differently from hospitals. We’re not paid for pharmacy or supplies, and often the implants and the overnight stay depend on the insurance payer. We get one payment, and we really have to manage our costs around that one payment.”

• Find the most efficient way to manage the 23-hour stay. The ASC started the 23-hour stay with TJR surgery and since extended it to spine surgery, ENT, and plastics, Patterson says.

“Some states don’t allow that, but Iowa allows patients to stay 23 hours and 59 minutes,” he says. “We have always given our patients the option of staying 23 hours, and some choose to go home the same day.”

One of the ways Mississippi Valley Health makes the 23-hour stay efficient from a staffing perspective is by keeping those surgeries in the middle of the week.

“When we started the program, it was hard to hire nurses to work one day a week. Now that we’ve grown our program over the last year, we have two to three nights a week with overnight nurses,” Patterson says.

Surgeons can fill an entire day with TJR surgeries.

“This way, they don’t feel like they’re having to go back and forth between two different settings,” Patterson adds.

Nurses must be flexible with their schedule. Typically, there are two overnight nurses and one LPN or patient care nurse when there are four or more patients receiving TJR. With three or fewer patients, two nurses can handle the job, Patterson says.

Physical therapists work with patients a couple of hours post-surgery and also work with them hours later, right before the next morning’s discharge, he says.

• Work with anesthesia providers. “You have to involve anesthesia providers, and they need to be comfortable with the techniques and procedures necessary to make sure the patient’s pain is well-controlled,” Patterson says.

“For instance, our patients are about two hours post-op and they’re getting out of bed and walking, and in the morning — usually about 12 to 15 hours later,” he adds.

• Create designated space. “We were fortunate when the building was built 21 years ago that we had six rooms that could accommodate overnight patients,” Patterson says. “Now, we’re in the planning phases of doing an expansion to provide more overnight capacity as we think long term.”

For instance, the ASC will prepare to handle Medicare TJR patients when and if Medicare changes its rules to permit a TJR procedure in an ambulatory surgical setting, he adds.

Patients who stay for 23 hours receive meals of their choice from local restaurants. Also, the overnight rooms contain televisions and recliners for family members.

“We make sure the patient’s experience and satisfaction are paramount in the process,” Patterson says. “We participate in the OAS CAPS survey, and we do a patient satisfaction survey with a separate survey just for overnight patients to find out if there’s anything we can be doing better,” he adds. “If we’re not getting a 10, we need to ask what we can do better.”