Robotic surgery represents an evolutionary turning point in surgical care. Robotic platforms support minimally invasive procedures associated with lower infection rates, faster recoveries, and increased patient satisfaction. These surgical programs are also enabling critical access hospitals to expand the services they provide to their communities.
Becker's Hospital Review recently spoke with two leaders from Clara Barton Hospital and Clinics in Hoisington, Kan., about lessons learned from launching a da Vinci surgery program:
- Jim Blackwell, CEO
- Kim Tutak, Director of Surgical Services
Question: How has your perception of da Vinci and critical access hospitals changed over time and what has surprised you about this journey?
Jim Blackwell: The da Vinci platform has become much more functional over time. When Intuitive engineered the da Vinci platform used by our institution, they made it much more user friendly for general surgeons. I say "general surgeons," because we don't have full-time OB-GYN or urology services in our facility.
When those procedures shifted to da Vinci surgery, we lost patients to larger tertiary care centers with urologists and other specialists on staff. After Intuitive introduced its next generation of technology, it became something that was very important for us to adopt. We wanted to keep patients at our rural critical access hospital instead of losing them to tertiary care centers.
Q: Why did Clara Barton make the decision to invest in da Vinci surgery? When investing in one of these programs, how does critical access hospital certification to receive cost-based Medicare reimbursement support?
Kim Tutak: When Intuitive approached us, we already had a strong general surgery program and we had a great opportunity to transition traditionally open as well as laparoscopic cases to the da Vinci robotic platform. In addition, we forecasted incremental case volume growth with patients who would stay at Clara Barton with robotic surgery as an option. Jim and I agreed that this was something we could do very well here and that has proven itself out over time. In large facilities, robotics teams often don't have the capacity to offer robotics 24/7. We do, because we've trained our whole team on the da Vinci robotic platform and our surgeons have access to it 24/7.
JB: When you connect your general surgeons with a capital asset like this that improves their skill set, it challenges them to use alternate approaches. They can take on cases that would have gone to larger care centers and handle them at a level that's appropriate for a hospital of our size. We're also now able to recruit new surgeons coming out of residency robotically trained and seeking out facilities with a da Vinci robot.
The Medicare share for the cost of the platform will vary for every institution. Instrumentation costs are higher for laparoscopic cases compared to traditional open surgery and additional reimbursements can follow that. Medicare cost-based reimbursement can help support the da Vinci programs in critical access hospitals, and the increased reimbursement for outpatient robotic hernia surgery mitigates increased costs of open hernia procedures.
Q: What are barriers to success in robotics and how can others overcome these obstacles?
KT: It's not just the ability to perform da Vinci robotic surgery. You must also consider instrumentation, sterilization processes and the electrical infrastructure. Each da Vinci component, including the patient cart, vision tower and console, needs its own electrical circuit.
Since our low-temperature sterilizer and ultrasonic cleaner weren't appropriate for da Vinci instrumentation, we upgraded those systems. We also purchased a special bed that pairs with the da Vinci robotic system. When surgeons reposition patients, they don't have to unlock the robot and delay their case. Although these factors were challenges, they weren't barriers.
Q: What does an efficient, financially sustainable da Vinci robotic program look like and what are the metrics that define success? What measures of value are weighed against the potential return?
JB: Obviously, you want to look at cost. Many of the benefits, however, are indirect. For example, good patient outcomes are a clear advantage to robotic surgery. When you bring procedures back to the institution, it drives additional revenue — even if increased instrumentation costs offset that. Competitive edge was another reason we adopted a the da Vinci program.
Q: How have you translated the value of da Vinci into patient benefits?
KT: We analyzed infection rates for open inguinal hernia procedures, and we see much lower infection rates with da Vinci surgery compared to open procedures. We also looked at narcotic use. We use TAP blocks in our hernia program and we administer fewer narcotics to those patients. Post-operative narcotic use in robotic inguinal hernia procedure patients is astoundingly low; those patients don't have the post-op pain. The prescriptions we send home have been cut in half.
Q: How have da Vinci robotics resulted in a better care team experience at Clara Barton?
KT: When we looked at this program, we solicited input from our general surgeons. We also worked closely with anesthesia and PACU nurses. Our surgical techs and physician assistants attended intensive da Vinci training. All of us worked together to ensure the success of the da Vinci robotics program and everyone had a stake in the process. I truly think that is why the team has been so successful.
Conclusion
The Clara Barton Hospital and Clinics team believes that other critical access hospitals can benefit from da Vinci surgery programs, but organizational buy-in is essential. "Do the research, but also do the work to inform and educate everyone about the advantages of a da Vinci surgery program. Once everyone gets behind it, it's thrilling to see," said Mr. Blackwell.
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