Overview

Capital City Surgery Center (CCSC) is a multispecialty ASC serving central North Carolina with seven operating rooms and four procedure rooms. The freestanding facility located on WakeMed Health & Hospitals’ Raleigh Campus is associated with the hospital and local physicians. NAPA’s anesthesia team, comprising a chief, eight physician anesthesiologists, and 13 certified registered nurse anesthetists (CRNAs), is fully integrated into the center’s highly collaborative culture. Their contributions to standardizing procedures helped CCSC produce outstanding results and earn a prestigious dual AAAHC Center of Excellence certification.

This case study describes NAPA’s leadership in CCSC’s transition to move total joint procedures safely and efficiently to the outpatient environment. By decreasing variability and applying best practice protocols from pre- procedure optimization through recovery, the team defined standardized patient pathways for orthopedic care. That enabled the surgery center to significantly increase volume and patient satisfaction while reducing costs and the use of opioids. Following evidence-based processes implemented over a six-year period, CCSC’s excellent clinical outcomes were recognized with Newsweek’s “Best ASC” for North Carolina in 2021 and 2022.

CCSC Highlights

• Ranked #1 ASC in North Carolina by Newsweek, 2021 and 2022
• Only ASC in North Carolina, and one of only five nationwide, to earn dual, three-year AAAHC Advanced Certification for Orthopaedics & Spine Surgery
• 100 percent patient satisfaction for total joint (TJ) and complex spine programs in 2020 and 2021
• 69 percent decrease in TJ procedures requiring overnight stays at estimated $3,000 per patient night saves over $150,000 annually in operational costs
• Robust PAT and ERAS program increases case volume
• Standardized ERAS protocols reduce narcotic use for pain management to near zero
• Moving TJ procedures from hospital to ASC settings represent 40-45% overall cost savings, per national estimates
• Performing TJ procedures at CCSC generates revenue for WakeMed and frees hospital ORs for other surgeries

Situation»

CCSC opened in 2012, offering orthopedic, ENT, urology, ophthalmology, neurology, and general surgical procedures. Robert E. Seymour III, MD, a former president of the North Carolina Society of Anesthesiologists who had previously served for three decades at a Level I trauma center, soon joined the ASC. He continues to serve there as NAPA chief of anesthesia. 

In 2016, CCSC sought to expand its orthopedic service line by moving total joint (TJ) procedures from WakeMed’s Raleigh hospital to the ASC setting. Gradually, a mix of WakeMed and community orthopedic surgeons began working with the center’s administrators and anesthesia department to develop criteria for case appropriateness. However, each surgeon had inconsistent anesthesia needs, making standard protocols difficult. A commonality was found in all TJ patients being admitted for 23 hours, requiring an anesthesiologist in-house overnight to monitor patient recovery and unanticipated emergencies. As TJ case volume increased, CCSC saw the opportunity for consistent TJ best practices.

Solution»

CCSC and NAPA share a commitment to promoting a collaborative work environment, where all administrative, medical, and anesthesia staff play a critical role and are valued for individual contributions. Thus, a strong foundation existed for this transformative, group-driven initiative.

In 2016, robust pre-admission testing (PAT) and enhanced recovery after surgery (ERAS) programs were created by NAPA anesthesiologists and CRNAs, CCSC administrators, perioperative staff, surgeons, and an orthopedic nurse navigator. Seymour and the anesthesia team worked with all stakeholders to develop and implement a consistent, safe, efficient, and reproducible anesthetic plan, which are utilized by all the TJ surgeons. It leveraged regional anesthesia and narcotic-sparing tools, multimodal medications, and a standardized post-operative pain management care plan. Prescribing less or no opioids enables patients’ early ambulation and regained cognitive ability, allowing most patients to leave the facility within two to three hours after arriving in the PACU. Ongoing benchmarking continues to enhance the program.

Results»

Standardized TJ protocols produced meaningful clinical and financial outcomes. In 2021, CCSC’s outstanding patient safety and quality metrics were awarded with a rare dual AAAHC Advanced Certification for Orthopaedics & Spine Surgery, and the distinction of Best ASC in North Carolina. These efficiencies and enhanced trust in their anesthesia team have improved surgeon satisfaction.

At an estimated operational cost of $3,000 per patient night, reducing 23-hour TJ admissions from 87 ($261,000) in 2018 to 27 ($81,000) in 2021—and two ($6,000) in the first quarter of 2022—had a positive fiscal impact for payors and patients. Same-day discharge with little pain also drove patient satisfaction to 100 percent in 2020 and 2021. Successful and compassionate treatment at CCSC has led patients to seek future care at CCSC. Moreover, NAPA’s patient-first mindset supports the center’s collaborative culture of safety, which encourages clinician recruitment and retention so CCSC and partners like them can better serve their communities.

To learn more about NAPA, please visit napaanesthesia.com.