One of the hottest topics in 2014 was the rapid gain of momentum for outpatient joint replacement.
In prior years, the conversation was full of skepticism with many reasons of "why not" to do OJR. Today, that conversation still starts with "why not" but goes on to say "why not develop a joint replacement program in the outpatient setting? Why not build a program that is 'as good or Better' than an inpatient program? And why not develop protocols and processes that deliver patient safety, predictable outcomes and a superior patient experience so that patients can recover safely in their homes?"
With advances in anesthesia protocols, pain management and mobility, inpatient programs are demonstrating that a short length of stay is not only safe but reasonable for the right patient. This is good news. But before we take this practice to the outpatient setting, it is important that all providers (surgeons, ambulatory surgery centers (ASCs) or hospital outpatient departments) understand that not only is the setting changing but that a successful move to OJR actually requires a change in thinking of a few other fundamental components.
Here are four quick summaries that illustrate the new starting point for surgeon, procedure, patient and setting for outpatient joint replacement.
1. The surgeon: It takes more than interest or the desire to be an innovator to succeed at OJR. The right surgeon is one who consistently achieves predictable superior outcomes such as low blood transfusion rates, minimal complications, few readmissions and length of stay of consistently below two days. This surgeon must also utilize anesthesia and pain management protocols that produce a "well patient" who is alert, able to eat and drink and mobilize with physical therapy within hours after surgery. Without these achievements, patients will not be able to be safely discharged to home on day of surgery.
2. The procedure: Advances in surgical technique support shorter surgery times. A cut to close time of less than 75 minutes is desirable as an entry point for OJR. Longer times have been shown to increase blood loss leading to complication risks that must be avoided in the outpatient setting.
3. Patient selection: presently there are three factors impacting patient selection for OJR. 1) The patient must meet strict clinical patient selection criteria (usually ASA 1 and only selective ASA level 2 co-morbidities); 2) the patient must have insurance coverage that covers the procedure; 3) and lastly the patient is mobile and has a competent and available caregiver to assist in recovery. Adding to these factors is your community's degree of acceptance of OJR as a safe and good option for their care.
At this time, achieving alignment of all of these factors narrows the pool of good candidates; it is important for surgeons and ASCs to realize this so that you can set appropriate expectations for volume growth.
4. The setting: most OJR programs are setting up in freestanding ASCs. With OJR typically being a new procedure for these centers, there is often a fairly big investment upfront to prepare the OR for these procedures (i.e.: purchasing new equipment, training OR staff and ensuring SPD can handle the processing and storing of the additional trays and equipment, etc). Additionally ASCs have less on-site resources to handle complications, perform blood transfusion, or to provide physical therapy or specialty consults. ASCs must develop new partnerships and protocols to meet these needs.
Understanding these key differences will help you evaluate your readiness and starting point for outpatient joint replacement. Careful planning and adopting a service line approach for standardization of your program will set you up for success as you venture forward with this alternative to traditional inpatient joint replacement surgery.
Lori may be reached at lori.brady@stryker.com or 1.800.616.1406
As a Senior Director for Stryker Performance Solutions, Lori draws upon her 30 years of experience as an orthopedic nurse to guide clients through the process of becoming a Destination Center of Superior Performance®. Lori's team of project managers helps hospitals achieve both the process change and knowledge transfer needed to realize sustainable results.
Lori spent 15 years caring for patients at Anne Arundel Medical Center in Annapolis, MD, where she helped create orthopedic sub-specialty programs to meet the educational, emotional and physical needs of surgical patients and their families. She went on to play a pivotal role in developing Destination Center programs for joint and spine, as well as their respective outcomes programs, and developed one of the first comprehensive joint centers in the country, which later became known as “Joint Camp.”
She has also implemented more than 150 Destination Centers of Superior Performance across the country, and continues to open new centers while managing implementation and program development services for Stryker Performance Solutions. Lori has a Bachelor of Science degree in Nursing from York College of Pennsylvania.