Shoulder replacements were already moving strongly in the direction of outpatient facilities before the pandemic hit. Within the outpatient world, I've seen a steady move to freestanding centers as opposed to hospital-based outpatient departments (HOPDs). Now the pandemic is hastening these shifts even more, as we try to keep patients away from hospitals that treat COVID-19 patients.
I've done some elements of outpatient shoulder surgery since my career began in 2002, and we've come a long way. In the nearly two decades since, I've become much more comfortable performing shoulder surgeries inside ASCs, to the point where I now perform the vast majority of them at our centers. I'm quite confident at this point that almost all the procedures I perform as a shoulder surgeon can be done in an ambulatory setting provided the patients are medically appropriate.
If you're running a surgery center that performs shoulder surgeries, or thinking of opening one, let me share some clinical and business ideas that have been successful for us:
- Patient selection. You need to figure out which patients are most appropriate for your facility. We maintain strict exclusion criteria for our shoulder patients, with a particular focus on BMI and other significant comorbidities. For instance, a BMI of 40 or higher is a red flag. It doesn't necessarily exclude the patient, but does warrant further examination. We'll also instantly exclude a patient with a heart condition who might require a higher level of perioperative care, an extended hospital stay or potential readmission. Trying to comb out exactly how bad is too bad? is the next frontier for our practice. We're currently looking at ways to somehow increase safety in order to admit riskier patients. But if you're just starting out with outpatient total shoulders, you likely want to err more on the side of caution at least initially.
- Regional blocks. Place a heavy emphasis on regional anesthesia for your shoulder patients. Compared to 15 or 20 years ago, anesthesiologists have gotten much more efficient at performing regional, and the effectiveness and duration of these blocks are much better. It's become much more streamlined. We've been proactive in terms of trying to provide a multifaceted approach to perioperative pain control. We generally combine sedation with an interscalene regional anesthetic block in order to help lower morphine equivalents postoperatively.