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Getting Comfortable with Outpatient Spine Surgeries
By: John Caruso, M.D., F.A.C.S.,
Parkway Neuroscience & Spine Institute, Hagerstown, Maryland
Considering the Move to Outpatient?
It is well known that increasing numbers of spine surgeries are handled on an outpatient basis. Overall, outpatient spine surgical rates are in the 10-15% range, but, in some parts of the country, outpatient spine treatments are becoming more the rule than the exception. By 2015, it is predicted that outpatient treatments will be nearly as common as inpatient. For many years, “bread-and-butter” spine procedures like lumbar decompressions and cervical operations have been handled in ambulatory spine centers (ASCs) and other outpatient facilities. Today though, even more complex and involved cases, including multilevel ACDFs and extensive decompressions, can be safely handled outside of hospitals.
In some quarters, however, outpatient spine surgeries are less prevalent, and there appears to be lingering reluctance to make the transition. A number of factors account for this slower rate of adoption. They include local surgical biases and geographic standards of care, the influence of hospitals and payers, and physician misconceptions about patient preferences and the relative risk of inpatient vs. outpatient procedures. Based on my discussions with colleagues, I believe that many spine surgeons are interested in making the transition, but are not clear about the best approach.
I count myself as an advocate for outpatient spine surgeries. I have been performing these in an outpatient hospital department setting for more than 12 years and now I have performed 130+ cases in my spine ASC in over one year. Operating in an outpatient environment and, specifically, in an ASC where I am an owner, works at every level. It is a more satisfying and comfortable experience for patients and surgeons. I have more control over the work environment. I know, trust and hired the staff I am working with and have confidence in their skills and knowledge. I collaborate more closely with anesthesiologists, which also helps my inpatient practice as well. The economics make more sense for the patients, the payers, and surgeons. The bottom line: I prefer to handle as many cases as possible at my spine ASC.
As for making the transition, I think it is primarily a matter of comfort and confidence. Obviously, I am comfortable doing spine procedures in an outpatient basis. But how did I get there? What lessons have I learned in making the transition? For me, focusing carefully on patient selection and ensuring that I had the right support team in place were key factors.
Patient Selection & Education
Patient selection is the number one determinant for ensuring success in outpatient environments. Every patient must be evaluated on a case-by-case basis, starting with age and general health. Obesity, surgical approach or positioning issues, a history of recent respiratory illness, and sleep apnea are the first factors to examine.
The point of careful patient evaluation and selection is to minimize the risk of co-morbidities and unique surgical and anesthetic challenges. Of course, you also need to have a plan of action in case complications arise. The more complex the procedure, the more there is to think about.
Assuming the patient is physically fit for outpatient surgery, a bit of psychological preparation may also be very helpful for him or her. The goal is to ensure that patients and their families have confidence in being treated outside hospitals in an ASC setting. Their confidence is directly linked to yours as the surgeon.
Patient selection is critical for ensuring success with outpatient spine cases.
Patient perceptions are also affected by the perceptions of referring physicians, primary care providers, RNs, PAs, and all other medical staff employees they come in contact with. It is important that all these people support the idea of outpatient spine surgery. They are critical links in patient education and satisfaction.
I have patients visit our facility before their surgery. It helps them understand all the benefits in terms of convenience and easy access. If your facility is run well, staff will be noticeably more upbeat and helpful than in a typical hospital environment. Patients appreciate knowing exactly where to go and who to talk to when they arrive for surgery, especially if the staff is familiar and has smiling faces. In this case, familiarity breeds comfort and significantly reduces anxiety about the impending surgery. Their confidence in the center and the surgeon makes the “sell” of the ASC surgical experience an easy one.
Handling pain procedures and conservative/nonsurgical attempts at the ASC is another way to gain the confidence of patients. Often these techniques allow patients to understand the tempo and unique experience of ASC operations. The procedures are handled quickly and recovery time is short. This establishes the center as an integral part of their spinal care experience.
There are business and financial issues related to patient selection as well. Questions about payers’ in-network vs. out-of-network policies, and inpatient vs. outpatient reimbursement rate should be addressed long before operations take place. It is simple economics, as cases must be assessed in view of carrying costs and cost of operating the facility. The good news is that outpatient environments make more economic sense for patients, payers, and surgeons.
I’m a big believer in spine ASCs, not only because I am an investor/owner of one, but in terms of clinical quality, and surgeon efficiency and productivity. The difference between ASCs and hospitals are especially pronounced on routine spinal surgeries. We turn over our ORs in under 10 minutes, versus 60+ minutes at most hospitals. My experience mirrors the national experience of ASCs outperforming hospitals in patient satisfaction surveys and quality indicators.
Building the Right Team
Because a lot of legitimate concerns are related to outof- hospital sedation, anesthesiologists must develop their own comfort level in an ASC. They must feel confident working on patients for specific spinal procedures. If peri-operative concerns are expressed to me by my anesthesia colleagues and their comfort level is more in line with a case being performed in a hospital setting, I always defer to their judgment.
The same is true with our support staff, especially our RNs. They must be comfortable operating in an ASC, and be educated and trained for specific procedures as well as potential complications. Of course, outpatient environments (and ASCs in particular) provide surgeons with much more control over staffing decisions and placing the best trained personnel in the patient surgical experience.
Dealing with Complications
Carefully selecting patients and assembling the right team does not eliminate all the risks. A while ago, I was very concerned about operating on a colleague’s son. There were a number of potential complications to worry about, based on his past medical history and prior hospital experience, as well as the surgery to be performed – a four-level lumbar decompression. I considered operating at the local hospital. We took extra precautions and outlined the situation for the whole team before entering the OR. In the end, the patient came through without a hitch. He was up and home within three hours and was feeling great. Once again, planning and forethought were very helpful. He was my first extensive decompression, and his successful outcome validated my early confidence in what can be done in an ASC.
More recently, I faced a case that seemed tailormade for our ASC. The patient never mentioned his history of respiratory issues and sleep apnea, despite preoperative inquiry. After prolonged oxygen desaturation in the recovery room, he had to be checked in to the hospital for a 12-hour stay for aggressive pulmonary care. We had a plan in place and our staff executed it once the transfer to the hospital was deemed best, despite the patient’s desire not to go. This case did nothing to shake my confidence in outpatient spine surgery and even validated our set policy for transfer arrangements should the need arise in the future.
I share these incidents to show an irony regarding the transition of spine surgeries to outpatient centers. Most surgeons get much more comfortable with outpatient surgeries once they manage of few complex cases and complications. Such cases will always arise, no matter where you operate. But in my experience, if you choose patients carefully, plan ahead and establish the right team, the complications are quite manageable in the outpatient setting. You deal with them, learn from them, and move on, applying the lessons as you go.
Looking Back & Looking Ahead
What is interesting relative to spine surgeries is that, fundamentally, they have not changed all that much. Many of the treatments are the same today as they were 20 years ago, just more refined. The anatomy and pathology of nerve root compression have remained constant and presented the same medical and surgical challenges over the years. Surgeons considering the transition to outpatient environments should take comfort in that.
On the other hand, how we conduct those procedures has changed considerably, and for the better. There is better technology, instrumentation and pharmacological agents, along with vastly improved surgical techniques. The incisions are smaller and you do not have to devascularize, deinnervate, and disturb the tissue as much. All of these factors add up to less trauma for patients and make more treatments suitable for outpatient settings.
Technology will only improve. There are dozens of companies developing advanced implants, delivery systems, and instrumentation to make the surgeon’s job easier. That competition is good as it charts a forward course to achieve better treatments – such as motion preservation devices and nucleus pulpulpus replacements – and thus improved outcomes for patients. I have no doubt that the trend to outpatient care will continue to grow and evolve.
It is easy to get caught up with questions about technology and the latest treatments, but in truth, patient selection and building the right team are the real difference makers when it comes to successful outpatient spine surgeries. These factors are the first steps that help surgeons achieve the necessary level of comfort and confidence. Once they do, however, handling spine surgeries on an outpatient basis becomes second nature and a rewarding experience for both patient and surgeon alike.