Orthopedic Surgery in Ambulatory Surgery Centers During the COVID-19 Pandemic: Low Incidence of Infection Among Patients, Surgeons, and Staff.

Background and objective The coronavirus disease 2019 (COVID-19) pandemic has presented tremendous challenges to the healthcare systems worldwide. Consequently, ambulatory surgery centers (ASCs) have been forced to find new and innovative ways to function safely and maintain operations. We conducted a study at a large United States (US) private orthopedic surgery practice, where a universal screening policy and testing protocol for COVID-19 was implemented for patients and ASC personnel including surgeons, in order to examine the incidence of COVID-19 in patients scheduled for orthopedic surgery in ASC settings as well as the incidence among the surgeons and ASC personnel. Methods The universal screening protocol was implemented in the ASCs of the facility during the early stage of the pandemic for an eight-month period from April 28, 2020, to December 31, 2020. All ASC personnel including surgeons had their symptoms tracked daily and were rapid-tested every two weeks. All patients were screened and tested before they entered the ASC. Results A total of 70 out of 12,115 patients and 41 out of 642 ASC personnel tested positive for COVID-19, resulting in infection rates of 0.6% and 6.4%, respectively. Individual symptoms, age, the American Society of Anesthesiologists (ASA) scores, and comorbidities were documented, and no single factor was found to be common among positive (+) tests. Conclusions The implementation of universal screening and symptom-reporting procedures was associated with a very low rate of infections among ASC patients, staff, and surgeons, and it offers a reproducible framework for other facilities to continue to provide orthopedic outpatient operations in ASC settings during the ongoing iterations of the COVID-19 pandemic.

Opioid-Prescribing Practices Between Total Knee and Hip Arthroplasty in an Outpatient Versus Inpatient Setting.

ABSTRACT: Despite trends showing increases in the utilization of outpatient (OP) ambulatory surgery centers (ASCs) and decreases in the utilization of inpatient (IP) facilities for total knee arthroplasty (TKA) and total hip arthroplasty (THA), little is known about opioid prescribing for these procedures between each setting. This study evaluated differences in opioid prescribing and consumption between OP ASC and IP settings for elective TKA and THA surgeries over a 1-year period. Data collection also included pain and satisfaction of pain control postsurgery. In an OP ASC, analysis revealed a significant decrease in pills prescribed (p < .001, p < .001) and consumed (p < .001, p < .001) for TKA and THA, respectively. There was a significant decrease in the morphine equivalence units prescribed (p < .001, p < .001) and consumed (p < .001, p < .001) for TKA and THA, respectively. For TKA, pain was significantly lower (p = .018) and satisfaction of pain control was significantly higher (p = .007). For THA, pain (p = .374) and satisfaction of pain control (p = .173) were similar between the settings. Benefits of performing these surgeries in an OP ASC setting are patients having similar or lower levels of pain and having similar or higher satisfaction of pain control. Patients are also prescribed and consume less opioids. This has important implications for healthcare systems.

Implementation of formal prescription guidelines reduces the economic cost of unused opioids after orthopedic surgery.

BACKGROUND: Prior literature has reported on the concerning emergence of opioid overprescribing, yet there remains a lack of knowledge in understanding the cost of waste of this over-prescription and underconsumption of opioids. As such, further investigating the cost of waste of opioids following orthopedic surgery is of interest to patients, providers, and payors. In one of the largest private orthopedic practices in the United States, opioid prescribing and consumption patterns were tracked prior to, and after the implementation of, formal prescription guidelines. OBJECTIVES: To (1) establish the cost of waste of unused opioids before the implementation of formal prescription guidelines and (2) examine how the cost of unused opioids may be reduced after implementation of formal internal prescription guidelines. METHODS: Two separate phases (Phase I and Phase II) were implemented at different time intervals throughout a two-year period. Implementation of prescription guidelines occurred between Phases I and II, and data from Phase I (pre-implementation) was compared to that from Phase II (postimplementation). Data collection included type, dosage, quantity of opioids prescribed and consumed after elective outpatient procedures in ambulatory surgery centers, in addition to patient interviews/surveys within two weeks after surgery to measure consumption. From these data, the cost of waste was calculated by taking the total cost of prescribed opioids (sum of each prescription × Average Wholesale Price (AWP) minus 60%) per 1,000 patients, and subtracting the total cost of consumed opioids per 1,000 patients, calculated in a similar manner. Further analysis was performed to describe differences in the cost of waste of individual opioids between each of the phases. RESULTS: In Phase I, prior to implementation of formal internal prescription guidelines, there was a sizable cost of waste of unused opioids (per 1,000 patients, AWP minus 60%) of $11,299.51. The cost of waste in Phase II, after implementation of formal internal prescription guidelines, was $6,117.12, which was a significant decrease of 45.9% ($5,182.39) from Phase I (P < 0.001). Furthermore, both the average number of morphine equivalent units prescribed and consumed per patient decreased from Phase I to Phase II (294.6 vs 187.8, P < 0.001; and 144.9 vs 96.0, P < 0.001, respectively). Finally, in describing individual medications, there was a significant decrease in cost of waste (per 1,000 patients, AWP minus 60%) between Phases I and II for- Hydrocodone with APAP 5/525 mg (P< 0.001), Oxycodone CR 10 mg (P< 0.001), Morphine CR 15 mg (P=0.001), and Tramadol 50 mg (P = 0.014). CONCLUSIONS: The results of this study suggest that there is a significant cost of waste associated with differences in prescribed versus consumed opioids following elective orthopedic surgery. This cost of waste was significantly reduced following the introduction and implementation of formal prescription guidelines. DISCLOSURES: This study was funded internally by Revo Health and Twin Cities Orthopedics. Giveans reports consulting fees from Medtrak, Inc., and Superior Medical Experts. The other authors have nothing to disclose.

Opioid Prescribing Practices and Quality Improvements Within an Outpatient Orthopedic Practice.

Background During the last several decades, the opioid epidemic throughout the United States has been recognized as an increasing problem. The aim of this study was to identify and implement processes throughout a single private orthopedic practice and managed ambulatory surgery centers to reduce opioid prescription pill quantity and strength, while also reducing consumption. Methodology A baseline assessment along with the development of four separate phases was implemented. Data collection included type, dosage, and quantity of opioids prescribed after elective outpatient procedures as well as patient interviews/surveys within two weeks after surgery. Quality improvement implementation included: (a) presentations on opioid prescribing at an individual physician level, (b) internal prescription guidelines, (c) required Prescription Monitoring Program registration, and (d) patient narcotic education pamphlets after surgery. The average opioids prescribed and consumed were compared between different time points. Results Analysis revealed a highly statistically significant decrease in both pills and morphine equivalent units (MEUs) prescribed (p < 0.001, p < 0.001) between the baseline assessment and four subsequent phases, as well as consumed (p < 0.001, p < 0.001) between phases one through four. Even though patients were consuming less pills and MEUs than they were prescribed on average across all phases, overall pain levels increased between phases one through four (p < 0.001), and overall satisfaction of pain control decreased between phases two through four (p < 0.001). Conclusions Over a 24-month time frame, a single private orthopedic practice set a goal of reducing prescribing habits and with successful implementation of various measures, a significant reduction in opioids prescribed and consumed was accomplished. Interestingly, pain level and satisfaction of pain control worsened even though patients were continuing to be prescribed more opioids on average than they were consuming. Therefore, it may be normal to see these results when attempting to set the expectation for some level of pain and reduced consumption of opioid medications post-operatively. Overall, these results can be useful to healthcare administrators and surgeons looking for ways to combat the opioid epidemic.