IC24-L: Wide Awake Hand Surgery: Strategies to Implement ...

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IC24-L: Wide Awake Hand Surgery:

Strategies to Implement It in Your Practice

Moderator(s): Asif M. Ilyas, MD

Faculty: Ryan Garcia, MD, Kristofer S. Matullo, MD, and Jonas L. Matzon, MD

Session Handouts

Saturday, October 03, 2020

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

Ryan Garcia, MD

Non-CME Services: Integra Lifesciences

Wide Awake Hand Surgery: Strategies to Implement it in Your Practice

Ryan Garcia, MD

Charlotte, NC

Disclosures

•Integra LifeSciences - Consultant

Outline

•Dedication to WALANT•Office Space

•Equipment

•Medications

•Staff

•Graduated Comfort Level

•Financial Considerations

Dedication to WALANT


•Office Space•Dedicated Room for WALANT

•Durable Equipment• Gurney

• Overhead Light

• Side Table

• Storage


•Cost of Durable Equipment

• Gurney

• Overhead Light

• Side Table

• Storage

$500 – $1000

$500 – $1500 $100

$400 – $2000


•Equipment Needs

• “Hand Trays”

•Various Sutures

•+/- Towels / Drapes

•Dressings

Estimated “Facility Cost” per Case - $35


Medications

25 Gauge1 Inch Needle

10cc Syringe

Medications

Phentolamine

Epinephrine Reversal Agent

Controversial Use

Expensive / Short ½ Life

Medications

Dental Equivalent – Intraoral Submucosal Injection

Off-Label Use

Cost$100 / 10 Vials

•Dedicated “In Office Procedure” Staff Member

-vs- Medical Assistant

•Room Set Up

•Patient Prep

•Room Cleaning / Turn-over

•Equipment Sterilization

Dedicated Training of Staff

Staff

• “Buy-in” to the Process

• New / Exciting

• Enjoy being a Part of Surgery

• New Form of Engagement in Patient Care

• Patient Interaction throughout the Procedure

• Valuable Experience

• Incentivization

Staff

Graduated Comfort Level


Break the Mold of Traditional Teaching

•Forbidden to Use of Epinephrine in

End Organs • Hand and Fingers

• Multi-center Prospective Trial

• 3110 Patients with Low Dose Epi (1:100,000) Injections to the Fingers and Hand

• No Incidences of Digital Ischemia

• No Cases of Phentolamine Use



•Start Simple – Start Easy

• Trigger Thumb before Trigger Fingers

• All Dorsal Hand Procedures


•Start Simple – Start Easy

• Trigger Thumb before Trigger Fingers

• All Dorsal Hand Procedures

• Mass Excisions

• EDC Tendon Repairs

• Easy Pretendinous Dupuytren Cord Excisions

• Carpal Tunnel Releases in the Elderly / Atrophic Patient


Case Courtesy of Donald Lalonde, MD

Financial Considerations

Monday Tuesday Wednes Thurs Friday

AM

PM Loeffler Garcia

2016 WALANT Procedure Room Utilization

<150 Total Cases per Year



AM Gaston

PM Loeffler Garcia



<300 Total Cases per Year


AM Gaston Gaul Chadderdon Gantt Ward

PM Loeffler Gart Lewis Garcia


>1400 Total Cases per Year


ASC ReimbursementCarpal Tunnel Release

In Room

Transfer Patient to OR Table 1 Minute

Start MAC Anesthesia, Tourniquet Placed 3 Minutes

Start Local Anesthesia 1 Minute

Patient Prep / Surgeon Prep 3 Minutes

Tourniquet up to Tourniquet down 5 Minutes

Hemostasis, Suture Closure, Dressing 3 Minutes

Awaken Patient, Transfer to Stretcher 2 Minutes

Out of Room

Turn Over

Breakdown, Clean, Set Up 12 Minutes


ASC Reimbursement for Carpal Tunnel Release

Average Collections $600 - $1,000

Overhead Costs ???

__________________________________________

Net $700

30 Minutes per Case

7am – 5pm 20 Cases

__________________________________________

$14,000 / day


Outpatient Total Joint Arthroplasty Reimbursement

Average Collections ???

Overhead Costs ???

__________________________________________

Net $8,000 – $11,000

3 Hours per Case

7am – 5pm 3 Cases

__________________________________________

$24,000 - $33,00 / day


•WALANT Eligible Hand Surgery Cases

• Insurers and Physicians can be Incentivized

• Not as Profitable in an ASC as Outpatient TJA or Spine


Strategies to Impliment WALANT in Your Practice

Dedicate an Effort Towards it

Start Simple and Move to More Complex

Financially You Can WIN

Conclusion

Future of Hand Surgery

WALANT

THANK YOU

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Strategies to Implement WALANT2020 ASSH IC 24

WALANT Economics

ASIF ILYAS, MD, FACSProgram Director of Hand Surgery Fellowship

Rothman InstituteProfessor of Orthopaedic Surgery

Jefferson

DISCLOSURES

• Speaking• Depuy Synthes

• Consulting• Globus• AxoGen• Acumed

• Royalties• Globus

• Research Support• Pacira• AFSH• Acumed

• Exsomed

• Boards• Rothman Institute

• PA Ortho Society• JOMI

OBJECTIVES

•ECONOMICS of WALANT

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ECONOMICS

• ECONOMICS of WALANT

Chatterjee et al – Ann Plast Surg 2011

•CLINIC vs OR – ECTR / OCTR• Profit Margin• Opportunity Cost

ECONOMICS



•CLINIC vs OR : Profit Margin• Endo CTR: $2710 v $1140• Open CTR: $1180 v ‐$650

ECONOMICS



•CLINIC vs OR : Opportunity Cost • Endo CTR: $2710 v ‐$1560• Open CTR: $1180 v ‐$3350

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ECONOMICS



•CLINIC vs OR : Opportunity Cost • Endo CTR: $2710 v ‐$1560• Open CTR: $1180 v ‐$3350

Doing CTR in the Main OR loses money

ECONOMICS


Leblanc et al – HAND 2007

• Survey of Canadian Plastic Surgeons•Practice Pattern of Performing CTRs

•Cost Analysis of performing CTRs in OR vs Clinic

ECONOMICS



• Survey of Canadian Plastic Surgeons

• 104 surveys returned from 250 members

• 42% response rate

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ECONOMICS



•Practice Pattern of Performing CTRs

• 18% exclusively perform CTRs in main OR• 63% use main OR for some CTRs• 37% exclusively perform CTRs in the clinic• 69% use clinic for >95% of CTRs• 73% of surgeons use WALANT for CTRs

ECONOMICS




• In 3 hour block, 4 CTRs can be done in main OR versus 9 CTRs in Clinic

•Main OR CTR is 4x more expensive than Clinic CTR(assuming local only)

ECONOMICS




• In 3 hour block, 4 CTRs can be done in main OR versus 9 CTRs in Clinic

•Main OR CTR is 4x more expensive than Clinic CTR(assuming local only)Doing CTR in the Main OR is

costlier and less productive

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ECONOMICS


Alter et al – PRSJ 2018

ECONOMICS


•PURPOSE•WALANT surgical costs in US Surgicenters.

•HYPOTHESIS•WALANT will result in decreased surgical costs.


ECONOMICS


•METHODS• Retrospective review of consecutive mini‐open CTR procedures.

• 136 sedation only• 54 local only


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ECONOMICS


• RESULTS


Same OR time

Same Surgical time

PACU time: 84 v 7 min

ECONOMICS


• RESULTS


MAC $1320 more‐ Anesthetist‐ PACU time

ECONOMICS

• ECONOMICS of WALANTAlter et al, PRSJ 2018

• CONCLUSION

• WALANT savings: $1320• PreOp costs• Anesthesia fees• Recovery room fees


$1320

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SUMMARY

SUMMARY

• WALANT Economics:

• Performing WALANT CTR in the Clinic versus the main OR:

• Is cheaper• More efficient

• A WALANT CTR in a Surgicenter is at least $1320 cheaper per case than a MAC CTR.

THANK YOU.

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Kristofer S. Matullo, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

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How to Gain Buy-in for Wide Awake Hand Surgery in the Operating Room

Kristofer S. Matullo, MD

Chief – Division of Hand Surgery, St. Luke’s University Health Network

Orthopedic Surgery Residency Director, St. Luke’s University HospitalAssociate Clinical Professor of Orthopedics: Temple University

ASSH Meeting, 2020, Saturday October 3, 2020ICL 24-L: Wide Awake Hand Surgery: Strategies to Implement it in Your Practice

St. Luke’s University Health Network

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Conflicts of Interest

• Reviewer for: Journal of Hand Surgery, Hand, Orthopedics• Committee member: American Society for Surgery of the Hand

• I have no conflicts related to this talk


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Use the Buzz Words to Gain Administrative Attention• Patient Safety• Patient Comfort• Staff Safety• Decreased Staff Utilization Requirements• Increase Case Volume with Increasing Efficiency• Decreased Late Hour/After Hour Requirements• Money saver


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Patient Safety

• Consistent communication with the nursing team• Same nurses pre and post

op• Aware of all things needed

pre and post op• Decrease chances of things

slipping through the cracks


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Patient Safety

• Mask on at all times• No risk of aerosolized droplets

due to sedation or anesthesia• Diabetic patients can eat and

can control their blood sugar


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Patient Safety• Hustedt, et al. 2017• Evaluation of the American College of Surgeons National Surgical Quality

Improvement Program registry looking at 30 day complication rates depending on anesthesia type• 4614 – Local no sedation• 3527 local with sedation• 18900 general anesthesia

• Complications • Serious in 1%• Any in 2.1%• Superficial SSI 0.71%• Sepsis 0.32%• Transfusion 0.25%• Deep SSI 0.21%• UTI 0.2%


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Patient Safety

• Hustedt, et al. 2017• All patients – compared to local had Odds ration 1.59 of

complication with general anesthesia• Patients 65+ had a OR of complication of 3.07 with sedation and

3.26 with general


Complication (%) Local Local/Sedation General P valueSepsis 0.02 0.17 0.42 <0.001Septic Shock 0 0.03 0.18 0.001Ventilator >24 hours

0 0 .20 <0.001

Intubation 0.04 0.03 0.13 0.04SSI 0.43 0.80 0.76 0.02Pneumonia 0.04 0.03 0.15 0.02Transfusion 0.04 0.06 0.34 <0.001Serious complication

0.59 0.60 1.21 0.002

Any complication 1.28 1.76 2.40 <0.001

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Patient Comfort

• Patient arrives to pre-op holding• BP, pulse and O2 checked• Glucose check of diabetic patients• Patient keeps clothing on• Gown placed over patient to protect

clothing from prep• Arm cleaned with chlorhexidine wipe


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Patient Comfort

• Patient injected 30 minutes prior• Food and drink offered• Blanket placed over patient’s

clothing to keep clean• Patient brought back to OR on

stretcher• Eliminates climbing on the OR table• Sitting forces patient to watch, lying

gives the option


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Patient Comfort

• Arm table placed under stretcher• All prep and surgery

done on the arm table


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Patient Comfort

• Patient brought back to same pre-operative bay• Check of BP, pulse and O2• Food and drink offered• Patient receives instructions

• Patient leaves


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Patient Comfort

• Can eat the day of surgery• Can drink the day of surgery• Can take all meds as scheduled the day of surgery• May be able to drive themselves• Get the instructions multiple times throughout the day• Door to door in 90 minutes


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Door to door in 90 minutes…..

• Codding, et al. 2017• Consecutive cases of TFR with MAC vs WALANT• 31 MAC and 47 WALANT• OR time was 27 minutes with MAC, 25 with WALANT• Surgical time equal at 10 minutes• Recovery time after surgery 73 minutes with MAC, 30 minutes with WALANT


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Staff Safety

• No lifting of heavy patients• No risk of aerosolized droplets

due to anesthesia• No violent arousals from

anesthesia


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Decreased staff utilization requirements

• 2 staff members in the room• Scrub tech/nurse• Circulating nurse

• Preps patient• Sits near head of bed to watch patient and

complete charting at same time• Talks to patient to keep them calm and

entertain the nurse


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Decreased staff utilization requirements

• Anesthesia machine nearby but not used• No monitoring patient during surgery

unless higher risk• No Anesthesia staff present• No third staff member


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Increase case volume with increasing efficiency• A case every 30 minutes as compared to every 45 – 60.• Easier turnover• No anesthesia machine or equipment turnover

• An extra case every 1-2 performed• CTR, TFR, dQR, masses, etc.• Pre WALANT – 8 cases by 3• Post WALANT – 13 by 3


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Increased efficiency• Maliha SG, et al. 2019• Retrospective study between 2012 and 2017• 39 patients with Local and 37 with standard procedure (62% local, 30% MAC,

5% LMA, 3% GET)• Case length local 21 minutes vs 23 with standard• Turn over time 31 vs 65 minutes• OR cost $994 vs 3,304• TAKE HOME – use a procedure room and WALANT

• Leblanc, et al. 2007• WALANT in Canada yielded 9 cases in a 3-hour block• OR with anesthesia yielded 4 cases in a 3-hour block


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Increased efficiency

Caggiano N, et al. 2015• 566 cases on 501 patients comparing GET vs. MAC vs. Local• All patients:

• Room turnover was 16 vs 15 vs 12 minutes• Presurgical time was 17 vs 13 vs 11 minutes• Post surgical time was 8 vs 6 vs 2 minutes• Nonsurgical time 41 vs 32 vs 24 minutes

• ECTR• Room turnover 18 vs 15 vs 12 minutes• Presurgical 16 vs 12 vs 11 minutes• Post surgical 7 vs 6 vs 2 minutes• Total nonsurgical time 43 vs 32 vs 25 minutes


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Decreased late hour/after hour requirements

• Get done before second shift• Saves overtime• Increases patient and surgeon satisfaction• Less likely to get delayed or bumped

• Typically I put locals first to get through the day• Longest case after lunch to end the day and prevent loosing the room• Can switch as the local patients can eat


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Money saver

• Increased cases = more money• Less cost• No IV• No anesthesia equipment• No recovery room use (no delays or PACU holds)

• Less OR down time = less wasted funds• Childers, et al. 2018. Each minute in the OR is $37

• Patients like it and refer their friends and family


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Money Saver

• Rhee P, et al. 2017• Prospective cohort study with 100 clinic based WALANT procedures• Performed at a military medical center from 1/2014 – 9/2015• Questionnaire to patients for satisfaction• 34 CTR and 33 TFR, 14 ROH or FB, 9 CRPP Phalanx, 4 DeQ• Cost savings was 85% with CTR (1,111 vs 7386) and 70% (1,960 vs 6,565) with

TFR and 84% 1,329 vs 8276) with DeQ• CTR, TFR and DeQ release saved $393,100 in cost• 94% patients would do again


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• Kazmers, et al. 2018.• Total direct cost of CTR compared to WALANT in outpatient setting


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References• Caggiano NM, Avery III DM, Matullo KS. The effect of anesthesia type on nonsurgical operating room time.

The Journal of Hand Surgery. 2015 Jun 1;40(6):1202-9.• Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA surgery. 2018

Apr 1;153(4):e176233-. • Codding JL, Bhat SB, Ilyas AM. An economic analysis of MAC versus WALANT: a trigger finger release surgery

case study. Hand. 2017 Jul;12(4):348-51.• Hustedt JW, Chung A, Bohl DD, Olmschied N, Edwards SG. Comparison of postoperative complications

associated with anesthetic choice for surgery of the hand. The Journal of Hand Surgery. 2017 Jan 1;42(1):1-8.• Kazmers NH, Presson AP, Xu Y, Howenstein A, Tyser AR. Cost implications of varying the surgical technique,

surgical setting, and anesthesia type for carpal tunnel release surgery. The Journal of hand surgery. 2018 Nov 1;43(11):971-7.

• Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada. Hand. 2007 Dec 1;2(4):173-8.

• Maliha SG, Cohen O, Jacoby A, Sharma S. A cost and efficiency analysis of the WALANT technique for the management of trigger finger in a procedure room of a major city hospital. Plastic and Reconstructive Surgery Global Open. 2019 Nov;7(11).

• Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures. The Journal of hand surgery. 2017 Mar 1;42(3):e139-47.


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Safety of Wide Awake Hand Surgery

Jonas L. Matzon, MD Rothman Orthopaedic Institute

Hand, Upper Extremity, and Microvascular SurgeryAssociate Professor of Orthopaedic Surgery

Thomas Jefferson University

Jonas L. Matzon, MD

Speaker has no relevant financial relationships with commercial interest to

disclose.

Lidocaine with epinephrine is SAFE in digits

LESSON 1

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2007

• More reported cases of digital infarction involving local anesthesia WITHOUT epinephrine than in those with epinephrine

2007

2007

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2007

• Procaine has a high rate of toxicity due to acidity

2007

• Procaine has a high rate of toxicity due to acidity

• Procaine is currently a restricted drug (NOT for human use)

2007

• Not a single case report of digital infarction using lidocainewith low‐dose (1:100,000) epinephrine

• …..

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2017

• Key Point: None had phentolamine reversal attempted

2017

Margin of Safety• Phentolamine

– Competitive antagonist of alpha‐receptors

– Serves as the catecholamine vascoconstriction antagonist

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Margin of Safety• Phentolamine

– Competitive antagonist of alpha‐receptors

– Serves as the catecholamine vascoconstriction antagonist

– Recommended dose: 1‐2mg in 1‐5mL normal saline

• Methods:– 22 subjects (18 hand surgeons) injected with 1.8 mL of 2% lidocaine with 1:100,000

epinephrine over distal palmar crease, base of P1 and base of P2 in 1 finger in each hand

– 1 hr later: • 1 hand injected with 1mg phentolamine in 1 mL saline (1 mg/mL)• 1 hand injected with 1 mL saline

• Results:– Time for injected finger to return to normal color:

• Phentolamine: 85 min• Saline: 320 min

– Length of anesthesia: 549 min

2003

Margin of Safety• Low‐Dose epinephrine (1:100,000)

– Excellent track record of safety

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• Review of 59 cases of finger injections with high dose epinephrine (1:1,000)

• 27 received treatment:– 13 phentolamine– 4 nitropaste– 2 phentolamine and nitropaste– 2 terbutaline– 2 terbutaline and nitropaste– 1 iloprost– 1 nifedipine– 2 unknown

2007

32 NO treatment

• Review of 59 cases of finger injections with high dose epinephrine (1:1,000)

• 27 received treatment:– 13 phentolamine– 4 nitropaste– 2 phentolamine and nitropaste– 2 terbutaline– 2 terbutaline and nitropaste– 1 iloprost– 1 nifedipine– 2 unknown

2007

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• No cases of finger infarction!

2007

• Results:– 2 of the authors injected their own fingers

with 1:1,000, 1:10,000, and 1:100,000 epinephrine with no effects after 10 wks

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Margin of Safety– My Experience• I’ve injected 1% lidocaine with 1:1,000 epinephrine

– No finger infarction, skin necrosis, or tissue loss

• I’ve injected 1% lidocaine with 1:100,000 epinephrine with 8.4% sodium bicarbonate in a 1:10 ratio– No finger infarction, skin necrosis, or tissue loss

• Need to have a standardized process for drawing up medications appropriately

Lidocaine with epinephrine is SAFE in practice

LESSON 2

• Prospective study of 3110 consecutive cases performed over 2 yrs by 9 hand surgeons in 6 cities– Finger and hand procedures

• Results: – No cases of finger infarction, skin necrosis, or tissue loss– No cases required reversal with phentolamine

2005

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• Retrospective study of 4287 consecutive procedures performed over 4 yrs by 2 hand surgeons at 1 institution– Finger, hand, wrist, forearm, and elbow procedures

• Results: – No cases of finger infarction, skin necrosis, or tissue loss

– No cases required reversal with phentolamine

Accepted

Wide awake surgery is safe with minimal patient monitoring

LESSON 3

History• Lidocaine with epinephrine has an excellent track record

• IV lidocaine has proven safety record as antiarrhythmic agent– IV bupivacaine can be cardiotoxic

• >60 yrs of millions of doses in dental offices without patient monitoring

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July 2020

• Most cases occur in surgical center or hospital– Only 24% of members performed WALANT in outpatient clinic / procedure

room

July 2020

• Most cases occur in surgical center or hospital– Only 24% of members performed WALANT in outpatient clinic / procedure

room

• 45% of members reported that anesthesia staff were required to be present for WALANT cases at their institution

July 2020

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Monitoring – My Experience• Retrospective study of 1771 consecutive procedures

performed over 2+ yrs by 2 hand surgeons at 4 ASC– 2 ASC: scrub tech/nurse, circulating nurse (925)– 2 ASC: scrub tech/nurse, circulating nurse + monitoring nurse (846)

• Results: – No intra‐op or immediate post‐op complications in either group – No cases required conversion to general anesthesia– No cases required IV or medications intra‐op– No cases required transfer post‐op

Safety Lessons• Lidocaine with epinephrine is

SAFE in digits

• Lidocaine with epinephrine is SAFE in practice

• Wide awake surgery is SAFE with minimal patient monitoring

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IC24-L: Wide Awake Hand Surgery: Strategies to Implement ...

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