Upload
others
View
14
Download
0
Embed Size (px)
Citation preview
Outpatient Total Joints
The ASC is not your Hospital OR
OutpatientHospital
OutpatientASC
<24 HrsHospital
ReduceLOS
OutpatientHospital
OutpatientASC
<24 HrsHospital
ReduceLOS
2012
2013
2018
Tipping Point
TOTAL
JOINTS
INPATIENT
TIPPING POINT
CHEAPERBETTERPATIENTS WANTSURGEONS WANT
TIPPING POINT
OUTPATIENT
Patient Selection
Stick to Protocols
Start in Hospital
TIPPING POINT
SAFE TRANSITION
ASC
2016: Hospital
94% Home Same Day
70% Home <6 Hrs
2% Stayed unexpectedly
If you are healthy enough for a total joint…Our Philosophy:
You are healthy enough to go home the same day.Our Philosophy:
Medicare CMS Data
Jan 3, 2018Lowest LOS in
US
0.65 Days
Work on Protocolsin Hospital
Collect Data
Scrutinize Results
Institute A Change
Collect Data
Scrutinize Results
Institute A Change
Reclaim Control
2018
Hospitals High CostsInefficiencyAdministrator
Control
Low Satisfaction
Scores
Surgery Centers Low CostsEfficientSurgeon
Control
High
Satisfaction
Scores
COST SAVINGS
MORE
EFFECTIVE
LESS COST
No Differences
Readmissions
Re-operations
ER Visits
Phone Calls
112
2685
FAILURESSUCCESS
Dizziness/Hypotension
Pain
Patient Preference
Ambulatory Issues
Urinary Retention
9
6
5
2
1
24 %
Failure
Failure is Not Possible in ASC
FAILURE (is a GIFT)
+Analysis
=
Improve
Pain
Volume
Nausea
Blood Loss
80% of worlds narcotics
prescribed in US
“JCAHO’s enforcement of its
Pain Management Standards and its
widespread misinformation campaign
about the safety of opioids has also
led to an over-prescribing of opioids”
West Virginia cities filed suit in
US District Court - November 2017
By Eric Eyre Staff Writer Nov 2, 2017
Qualify for surgery: 7/10 Intensity
What is acceptable pain in the PACU ?
When patients arecomfortable enough
to go home…
PAIN
7/10
PAIN
3/10
PAIN
EXPECTATIONS
ACCEPTABLE UNACCEPTABLE
PAIN EXPECTATIONS
PAIN
PYRAMID
REASONABLE
TOLERABLE
TERRIBLE
EDUCATION
NON-NARCOTIC
RESCUE
PATIENT
EXPECTATIONS
Our
Multi-modal
Protocol
P
A
I
N
Acetaminophen
NSAIDs
Pregabalin
Ketamine
Dexamethasone
ACB- block*
Infiltration x 3
7 layers
MMAPMulti – Modal Analgesia Protocol
Multiple
Unique abilities
Complementary
Synergistic
A Team of Super-Heroes
Narcotic Side Effects
• Nausea/ Vomiting
• Dizzy/Weak
• Respiratory Depression
• Sedation
• Urinary Retention
• Addiction
Inadequate Pain ReliefCurr Opin Anesthesiol 2017, 30:458–465 Opioid-induced hyperalgesia in clinical anesthesia practice:
Actually
Makes
Pain Worse !!
Opiate
Induced
Hyperalgesia
Pre-Op
Cocktails
In Surgery
PACU
Floor
Tylenol/Motrin
No Morphine
Ketamine
Therapy
Protocols
Multi-Modal
VOLUME
Preoperative Drinking:
• – Phillips S1, Hutchinson S, Davidson T.
• Br J Anaesth. 1993 Jan;70(1):6-9.
Gastric Contents
Preoperative Drinking:
• – Phillips S1, Hutchinson S, Davidson T.
• Br J Anaesth. 1993 Jan;70(1):6-9.
pH Fluids
Preoperative Drinking:
• – Phillips S1, Hutchinson S, Davidson T.
• Br J Anaesth. 1993 Jan;70(1):6-9.
Aspiration
Preoperative Drinking:
• – Phillips S1, Hutchinson S, Davidson T.
• Br J Anaesth. 1993 Jan;70(1):6-9.
Regurgitation
Dehydration enhances pain-evoked activation in the human brain compared
with rehydration.
• –Anesth Analg. 2014 Jun;118(6):1317-25.
Ogino Y1, Kakeda T, Nakamura K, Saito S.
DEHYDRATED PATIENTSHURT MORE…
PAIN
NPO Status
No solids after midnight
Clear liquids/Gatorade
Encouraged till
arrival to ASC
Timer Starts:PACU
< 4Hours Deal with:Family Expectations
Hypotension
4 HoursHypotension
Nausea
Pain
Ambulation
Families
Traditionally Adversarial Roles
Surgeons Anesthesiologists
Anesthesiology
Same Teams
Same Protocols
Demand in ASC
Spinal Doses
Fluid Mgmt
Nausea Mgmt
Narcotic Use
Hypotension
PRE-OP OPTIMIZATION
+
=HYPOTENSIVE
ANESTHESIA
+TRANEXAMIC
ACID
Must know
Hb Prior
One Month
Assume 3 g/dl
Drop in Hb
No More Post-op Blood Checks
Hospital to ASC
Same Surgeons
Same Anesthesia
Same OR Staff
Same Equipment
Same Implants
Avoid
Change
QUALITYSUPERIOR OUTCOMES
FEWER COMPLICATIONS
HIGH PATIENT SATISFIACTION
VALUE
COST
Financial Pressure
Recruit New Surgeons
Cheaper Anesthesia
Less OR Staff
Cheaper Equipment
Cheaper Implants
Quality
Is King
ASC Capability
SPD
OR Space
Implant Stock
Instrument turnover
Number of Cases
Less Capacity
Smaller
Less Options
Reduced
Reduced
PACU
How many rooms?
Where patients walk ?
How much narcotic ?
How long can they stay ?
Overnight capability ?
KEY TO SUCCESS
Thank You