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Northwoods Surgery Center’s Total Joint Replacement Program White Paper

BACKGROUND

Advancements in total and partial joint replacement surgery have resulted in the migration of these higher acuity procedures, previously confined to acute care hospitals, to ambulatory surgery centers (ASCs). Surgeons at Northwoods Surgery Center — which opened in Woodruff, Wisconsin in 2008 — seized this opportunity by including a joint replacement program as part of the services the center offered.

PATIENT SATISFACTION

To gauge the program’s success, look no further than the program’s patient satisfaction rate, says orthopedic surgeon Kevin Tadych, MD. “We have 98 percent satisfaction. ASCs typically achieve high patient satisfaction rates because they’re such efficient and highly service-oriented settings. The staff is always at the top of their game. Patients come in, have their surgery and leave on the same day. They are able to go home to recuperate, and they have decreased risks of hospital acquired infections. Several of my patients had one knee replacement performed by me at the local hospital and subsequently underwent a replacement on the other knee at Northwoods Surgery Center; they all said their experience at Northwoods was better.”

Orthopedic surgeon Mark Balas, MD takes pride in the program’s many success stories. “There was a patient who, after undergoing a total hip replacement, stood on that leg and bounced up and down with his arms waving in the air in his first hour of recovery. Another patient had both hips replaced a couple years apart, and both times —within two hours of his surgery — walked into Culvers without a cane, ordered a cheeseburger and sat down. A knee replacement patient, who had been unable to ride a bike for a decade due to his knee pain, rode his bike nearly four miles to the clinic for his two week post-operative visit.”

These stories are not unusual. Cheryl Olsen, 64, a nurse at the surgery center had her hip replaced by Dr. Balas in May 2013. “Before the procedure, I couldn’t put my socks on. I couldn’t bend over. I couldn’t keep up with my grandchildren. After speaking with Dr. Balas and the ASC’s anesthesia provider, they determined I was a good candidate for the surgery.”

She continues, “Following the procedure, I had in home physical therapy for four weeks. Six weeks after surgery, I was walking my dogs a mile. By July 4, I was in good shape. I’m now able to play with my grandchildren and fully participate in the activities I love. I’m even taking a weightlifting class. That’s also why I’m still nursing at this age. I feel I’m still able to carry my weight.”

“We have 98 percent satisfaction. ASCs typically achieve high patient satisfaction rates because they’re such efficient and highly service-oriented settings. The staff is always at the top of their game. Patients come in, have their surgery and leave on the same day. They are able to go home to recuperate, and they have decreased risks of hospital acquired infections. Several of my patients had one knee replacement performed by me at the local hospital and subsequently underwent a replacement on the other knee at Northwoods Surgery Center; they all said their experience at Northwoods was better.”

Dr. Kevin Tadych, MD

Marty Somerville, 74, a retired nurse, underwent a partial knee replacement performed by Dr. Balas in January 2013 following many years of dealing with a bad knee. “I was familiar with total knee surgery, but not the partial knee,” she recalls. “Dr. Balas showed me x-rays and explained the surgery. The fact that I could undergo the procedure at the surgery center made it that much better. In the back of my mind, I knew I would be able to go home, which is very comforting. The ASC is a lovely facility. It was apparent that everyone in the center liked where they were working, and the whole team really helped each other.”

Somerville’s surgery was a success. “I’m really amazed at how well it went,” she recalls. “I completed my therapy without a problem. I walk several miles a day, and my knee is now straight in pictures. Health care has come such a long way, and surgery centers truly represent 21st century medicine. I felt incredibly comfortable when I was there.”

“Following the procedure, I had in home physical therapy for four weeks. Six weeks after surgery, I was walking my dogs a mile. By July 4, I was in good shape. I’m now able to play with my grandchildren and fully participate in the activities I love. I’m even taking a weightlifting class. That’s also why I’m still nursing at this age. I feel I’m still able to carry my weight.”

Cheryl Olsen, a Nurse & Patient

It is stories like these that demonstrate to Dr. Balas the tremendous value of joint replacement surgery in the outpatient surgery center. “I’m really happy when I see these individuals one year, five years, and 10 years later and they’re still able to do what they want to do.”

SURGICAL APPROACH

Such impressive outcomes require the surgeons performing total and partial joint replacement to use advanced techniques that take a significant number of factors into consideration.

“We know that when we don’t violate the tendons in the knee or the hip, there’s a lot less pain,” Dr. Tadych says. “The tendons carry a lot of nerve endings. Our approach to the knee — subvastus or midvastus — does not cut into the quadriceps tendon. When surgeons have to cut the quadriceps tendon, patients experience more pain.”

Dr. Balas notes the minimally invasive approach he uses to perform joint replacement allows significant muscle preservation. “I firmly believe a true subvastus approach has benefits. If there’s less trauma and the muscles are not being violated, patients experience less inflammation, less pain and their joint stabilizers are not being taken apart. I am able to leave their muscle envelope intact which assists me in my attempts to preserve the patient’s native anatomy.”

Another important component of outpatient joint replacement is the use of different pain control techniques. “We give patients pre-emptive analgesia,” Dr. Tadych says. “I give them Celebrex beforehand, then a combination of Ropivacaine, Toradol and Clonidine are administrated intraoperatively. Studies have shown that through the use of this special mixture, post-operative pain is cut drastically, and that’s been my experience.”

“Dr. Balas showed me x-rays and explained the surgery. The fact that I could undergo the procedure at the surgery center made it that much better. In the back of my mind, I knew I would be able to go home, which is very comforting. The ASC is a lovely facility. It was apparent that everyone in the center liked where they were working, and the whole team really helped each other.” I’m really amazed at how well it went. I completed my therapy without a problem. I walk several miles a day,”

Marty Somerville, Retired Nurse & Patient

To provide the patient with immediate pain relief, the surgeons use femoral nerve blocks. “They work so well with indwelling catheters,” Dr. Tadych says. “Patients can go home with them and are able to get pain relief automatically via a spring-loaded pump. In my 22 year career of performing joint replacement surgery, the improvement in pain management capabilities has been extraordinary.”

Dr. Balas adds, “We also aggressively use anticoagulation therapy to minimize blood clots and complications. We have a home health practitioner go to the patient’s home to conduct a blood draw. There is constant communication between the ancillary staff working with our patients and my office.”

PATIENT EDUCATION

While good surgical outcomes are largely determined by the performance of the surgical team, Dr. Tadych notes the education that goes into preparing patients for their surgery and what they need to do during recovery plays an important role as well.

“Patients must be prepared ahead of time so everything they need to begin their recovery is already in place at their home,” he says. “All of their prescriptions have been filled. They have already been taught how to properly use crutches, a walker or a motion machine. There’s no running around last minute to locate equipment or move furniture. Patients receive clear timelines that explain the process and necessary preparation. People who are well informed and prepared experience a lot less anxiety.”

Dr. Balas adds, “It really boils down to giving them the tools they need to succeed, and instilling confidence that they will experience a great surgical procedure and recovery. On my total hips, there are really no postoperative restrictions besides impact sports. There are no limitations on what that total hip or knee patient can do day one. Patients need to have an immediate, positive post-operative experience, so we have them walk on that hip or knee to see what it’s like without any of the arthritic pain in there. I also give patients an opportunity to kick me once in the recovery room to show the muscle in their knee still works.”

Sometimes patients have fears that cannot be entirely alleviated prior to the procedure, Dr. Tadych says. In these scenarios, there are steps the ASC takes to provide comfort to patients. “We give patients the option of going to a rehabilitation facility and having home health come and check on them,” he says. “For patients with no one at home to watch them, we set up home health ahead of time, look at a rehabilitation facility as an option or we just see them more frequently postoperatively. Patients also have the option of staying 23 hours at Northwoods Surgery Center. All of these options are already in place which assists us in offsetting the bulk of patient fears. We always take it case by case.”

“Patients must be prepared ahead of time so everything they need to begin their recovery is already in place at their home. All of their prescriptions have been filled. They have already been taught how to properly use crutches, a walker or a motion machine. Patients receive clear timelines that explain the process and necessary preparation.”

Dr. Kevin Tadych, M.D.

PATIENT SELECTION

Many patients in need of joint replacement surgery are strong candidates for the Northwoods program,” Dr. Balas says. “Typically, we are able to see anyone who does not require an overnight stay in the ASC. The only patients I admit to the hospital are those where Medicare or other third-party payors require the procedure to be performed on an inpatient basis or when a patient may have health issues that require a hospital admission. There are always outliers which require inpatient care.”

“Still, a lot of Medicare-aged people are good ASC candidates,” Dr. Tadych says. “We always carefully screen and select our patients. We won’t treat anyone in the outpatient setting with extensive co-morbidities, such as a major heart issue. We’re looking at people who are healthy and independent.”

OPTIMAL SETTING

For appropriate patients, the ASC provides the best setting for joint replacement surgery, Dr. Balas says. “What’s great for patients around here is they get state-of-the-art surgery in rural America with a very personal touch. We are delivering an excellent patient outcome, but we also control so many of the variables around the surgery. We’re basically limiting patients to seeing a select team of people who deliver this care time and time again. A very consistent group interacts with you.”

He adds, “There’s a big plus in being small, personalized and innovative where the outcome and safety is important to every person that interacts with that patient. We are significantly below the national average infection rate.”

Many patients in need of joint replacement surgery are strong candidates for the Northwoods program. Typically, we are able to see anyone who does not require an overnight stay in the ASC. The only patients I admit to the hospital are those where Medicare or other third-party payors require the procedure to be performed on an inpatient basis or when a patient may have health issues that require a hospital admission.

Dr. Mark Balas, M.D.

Another significant benefit of performing joint replacement in the ASC comes in the form of cost savings. “Fifty percent of normal weight Americans and two-thirds of overweight patients need a total knee,” Dr. Tadych says. “The needs are significant and growing. ASCs are well positioned to offer these surgeries at a much lower cost compared to hospitals. We are able to save both the patient and their insurance carrier substantial money.”

He continues, “With Obamacare, there’s an increased focus on reducing costs. Moving forward, ASCs are going to be the answer for a lot of the care patients need. I love to perform my operations at Northwoods Surgery Center. ASCs are a positive health care option in our country.”

Download Northwoods Surgery Center Total Joint Replacement White Paper