Q: What sparked your interest in launching a total joints initiative?
Dr. Stoeckl — My background is in sports medicine, and the knee replacements I performed were primary an inpatient procedure. I was curious if they could be done safely and effectively in our practice's surgery center. I met with the center's clinical and business leaders to put a plan in place to make it happen.
Q: So it was a gradual evolution?
Dr. Stoeckl — Absolutely. I focused on a select group of knee replacement patients who I operated on at the local hospital — the ones who were doing really well post-op day 1 — and envisioned what we'd have to do to ensure they could be cared for in the outpatient setting.
Q: What's the first building block of a successful program?
Dr. Stoeckl — It's essential to first identify patients who are good candidates for outpatient joint replacement. You must assess their comorbidities, the amount of support they'll have at home during the post-op recovery phase and whether or not they're narcotic naïve.
Q: What type of patients are prime candidates?
Dr. Stoeckl — Patients receive anti-inflammatories and we place abductor canal blocks, which provide good analgesia and let patients retain good motor function. Injections of bupivacaine liposome at the joint have been a huge part of our pain control success. We also administer tranexamic acid to decease hemarthrosis, which in turn lessens post-op bruising and swelling at the joint.
Ironing out the pain control plan and figuring out patient selection are the relatively easy steps. The hard part is managing all the behind-the-scenes details.
Q: So how do you manage patients' pain?
Dr. Stoeckl — Great teams know you have to practice together as a team, because you have to learn how to anticipate each other, you have to understand each other's body language and you have to understand how people are thinking. Great athletes don't practice on their own. They practice as a team. And great musicians practice as a team. The whole point with great sports teams and great orchestras is they work together so they can function effectively as a team. We don't do that in health care.
Q: Do surgeons need to change their surgical technique?
Dr. Stoeckl — Surgeons need to evolve, and that comes from experience. They have to be confident that they can perform the procedures in a timely fashion without causing a lot of trauma to the joint. If the patient is a perfect candidate in terms of comorbidities and family support, but they have a knee deformity that raises concerns about post-op pain and swelling, surgeons should pick more vanilla cases to be sure you can do them quickly and efficiently without causing a lot of trauma.
Q: More and more patients will need their joints replaced in the coming years. Are you seeing that demand at the local level?
Dr. Stoeckl — Patients are just beginning to seek me out for the surgery. That means interest is growing and my case volume has the potential to increase, but that's a double-edged sword. Some of the patients who want same-day joint replacement aren't candidates to have it done. Approximately 15% of the patients I see in clinic can have their procedures done in the surgery center. You must be honest with patients who don't quality for having the procedure done in the same-day setting. A lot of boxes need to be checked, and the surgeon needs to trust his gut.
Q: Why is now the time to get an outpatient joint program off the ground or enhance one that's already in place?
Dr. Stoeckl — There are great programs out there that help people learn how to speak to others respectfully and handle conflict effectively, but you can't just give people a course. You've got to do something on a regular basis. Maybe once a year take your entire OR staff somewhere and work on communication skills, and then maybe come back together as a group once a month and practice, and work through issues, practice doing dialogue. Create scenarios and give people positions and have them work through how to do conflict. It helps to have a facilitator who can provide feedback.
Q: From a practice management standpoint, what does it take to run a successful program?
Dr. Stoeckl — It takes a total team effort to get a patient to the facility, through surgery and recovered safely and effectively. At the same time, surgeon champions need to push the cause and make it happen. They need to make the clinical team confortable with the concept, and staff energized and excited about it. If it weren't for the people around me getting behind the idea of moving joints to our surgery center, I'd still be talking about it and performing the procedures at the local hospital.
Q: What's been the biggest challenge?
Dr. Stoeckl — It's easy to come up with the notion to add total joints, but it takes a couple years to make it happen the right way. Ironing out the pain control plan and figuring out patient selection are the relatively easy steps. The hard part is managing all the behind-the-scenes details. Sharing our experiences and advice about that part of the equation is where we'll be able to provide huge value during the conference's workshop.
Q: What has adding outpatient total joints meant to your career?
Dr. Stoeckl — It's been a lot of fun to be a part of the evolution. It's also been energizing and exciting, and personally satisfying, to bring the procedures to our community.