Outpatient total joint arthroplasty: A safe, cost effective perioperative pathway

Introduction: Same day surgery discharge (SDSD) S/P UKA,TKA, and THA allows for safe, cost effective care for the appropriately selected patient.

Several studies have outlined techniques of selecting patients suitable for this type of postoperative pathway. This abbreviated review outlines methodology for patient selection, insurance considerations, OR concerns, home assessment, data collection, preoperative and postoperative patient education, anesthetic approaches for pain control and postoperative rehabilitation.

Patient & ASC insurance contracting: It is critical to make certain that the insurance pre-approval process identifies any facility fee reimbursement issues as well as noncovered patient costs. It is not uncommon for some insurers to consider a TJA (total joint arthroplasty) at an ASC an "out of network" procedure as opposed to the local hospital. Credentialing of the ASC (ambulatory surgery center) to perform OP (outpatient) TJA is mandatory to obtain in advance. It is important to do a thorough pro-forma based upon payer mix and meet with each payer, and if possible, negotiate a bundled payment rate for each TJA procedure.

Preparing the ASC and staff: It is important for the staff to be well-trained in total joints to allow for efficiency in the operating room. With "error checking modules" and "staff training software" systems available, this allows for a simplistic method of educating the staff on each surgeon's preferences when performing the procedure.

Service line resources: The patient needs to understand that the success of the operation is dependent upon their personal hard work and cooperation with the postoperative rehabilitative team. The orthopedic group must be willing to have a home nurse visit the patient or the caregiver has to understand the requirements for postoperative care in the home which means an understanding of assisting the patient with activities of daily living throughout the day. If the home situation is not amenable to this type of home care, or a home healthcare nurse, or physical therapist cannot be employed in this setting, then SDSD should not be considered.

Service coordinator: There should be one nurse manager who is assigned as the "total joint coordinator." This individual's job is to make certain that all the surgeon's and patient's needs are being met as well as being the individual to make certain that the staff and service line resources have been coordinated successfully. Furthermore, someone in the billing and collections department of the group should be responsible for pre-approval for this type of procedure once the payer contracts are agreed upon.

Data collection: It is important to designate a lead physician and someone in the IT department to collect data on patients as part of this project. The vast majority of insurers define quality as outcomes/cost, thus data should be collected using postoperative subjective scoring systems such as WOMAC scores. There is considerable national data confirming that increased referrals from insurers to the orthopedic group may occur as a result of cost reduction and maintenance of quality when performing these procedures in the ASC.

Patient home assessment: The patient's social situation and home environment needs to be reviewed in advance and felt to be safe with a home caregiver present versus whether a home care nurse is required. A home healthcare nurse visit may be necessary for a wound check in the first week postoperatively as well as drain removal in the first 48 hours postoperatively. Home PT on a regular basis may be required to rehabilitate the patient at home until the patient is independently mobile.

Patient selection criteria: Specific criteria are considered mandatory for a patient to be a candidate for SDSD. Only ASA classes 1-3 should be considered. Some surgeons have an age cut off of 70 and BMI of 35. Others have expanded their indications to include older patients that are healthy and BMI's of <40. Only primary total joint procedures should be performed. A medical clearance must be obtained preoperatively. Patient expectations need to be thoroughly discussed with the patient and acceptable to that patient and their caregiver prior to considering SDSD. It is critical that the patient understands that this is going to be a difficult transition although with appropriate perioperative pain control, it is definitely doable and avoids the need for hospitalization. Ideally, either home PT or outpatient (OP) PT beginning one to two days postoperatively should be performed. If the surgeon and/or the patient feels that they have an inherently low pain tolerance, they should be excluded from SDSD.

Anesthesia: Adductor canal blocks are the procedure of choice for patients undergoing either TKA or UKA. Some groups continue to use femoral nerve blocks with indwelling catheters and knee immobilizers but the tendency to use adductor blocks has become more prevalent due to the complications associated with indwelling femoral nerve blocks. Short acting spinal blocks allow for rapid rehabilitation and decrease the risk of postoperative nausea and vomiting. Appropriately performed general anesthetics, either inhalation with isoflurane or sevoflurane using a laryngeal mask airway can be performed as an alternative to a short acting spinal block. Postoperative recovery includes the use of oral hyrdrocodone and intravenous fentanyl for breakthrough discomfort. Injection of the capsular structures by the surgeon includes one of various reported mixed anesthetic "cocktails" or the utilization of a bupivicaine liposome injectable suspension. Utilizing a postperativenarcotic oral medicine mixture technique, pericapsular injection techniques, and an adductor nerve block for TKA allows for the patient to be ambulatory within a few hours after surgery without significant ambulatory pain. Cold therapy has been shown to be beneficial in the early postoperative period and the majority of surgeons recommend its use for at least 48 to 72 hours postoperatively.

Surgical procedure: It is critical to try to avoid significant blood loss and bleeding at the time of surgical intervention. Some outpatient total joint surgeons avoid using a tourniquet completely during a TKA but have the tourniquet in place in case any untoward bleeding during the procedure ensues. Ideally a shorter incision for TKA and a relatively smaller incision should be utilized if the posterior approach is employed for a THA or the anterior approach is utilized for a THA. If the surgeon uses a tourniquet for a TKA, it is important to release the tourniquet prior to closure and coagulate all major bleeders prior to soft tissue injection of either bupvicaine liposomal injection or one of the anesthetic "cocktails."

Postoperative recovery: The postoperative recovery phase is critical and must be set up ahead of time to allow for rapid rehabilitation subsequent to TJA. Ideally, home physical therapy should be instituted on day one or two. If "in home" PT cannot be set up, then OP PT should be instituted within 48 hours after the surgery. PT should consist of ROM exercises, quadriceps strengthening, hamstring strengthening and weight bearing as tolerated with an external aid consisting of a walker, crutches or cane(s). If the therapist is not trained in drain removal, or a home healthcare nurse is not seeing the patient daily, then the patient should return to see the surgeon within 48 hours after the surgery. In some practices, the home care nurse sees the patient on postoperative days one, two and three. If "in home" PT is available, progression to activities of daily living can begin on day three. The patient should return to see the surgeon in one week after the surgery to perform wound check. Assuming that the postoperative course is unremarkable, in-home or outpatient physical therapy must be continued three times per week for a minimum of three weeks or until the patient has reached a minimum of 90 degrees of knee flexion, is able to walk independently with crutches or a cane, and is independent in their home setting without a caregiver present. Most surgeons continue high dose aspirin for a minimum of 4 weeks postoperatively, monitor the use of warafarin or prescribe enoxaparin for two to four weeks post-op.

Cost effective care considerations: Implant cost considerations are critical determinants for SDSD. "Stable technology implants" (STIs) differ from generic implants when considering their usage in the SDSD setting. STIs by definition have a minimum of 10 years of survivorship data whereas generic implants are simply "copies" of existing implants without long term survivorship data. STIs have been used throughout the United States and Europe and registry data in many cases reports survivorship data as high as 98 percent at 15 years. Usage of these implants in a "repless system" with an intraoperative "error checking" platform and "surgical nurse training module" can result in dramatic savings for both the surgeon's ASC and/or the hospital supply chain when utilized. Implant companies are developing methods to employ these models in the United States and Europe. SDSD with or without an overnight stay in the postoperative recovery room area in an ASC versus an overnight stay room adjacent to the ASC facility results in significant savings to the insurer. Some groups are utilizing hotels with RN monitoring or short or long term care centers for postoperative care.

Summary and further considerations: SDSD after total joint TJA has significant advantages. Many patients are averse to staying overnight in a hospital. It allows for surgery to be performed at ASCs that might not otherwise allow for an overnight stay. Pain control and the treatment of nausea must be aggressive in order to prevent delay in discharge, postoperative admissions or emergency room visits. Utilizing peripheral blocks and soft tissue anesthetic injections surrounding the hip and knee joint have dramatically reduced pain symptoms. There is a significant decrease in cost utilizing this approach especially if STIs with an intraoperative error checking system are utilized. It is important to make certain that the patient's health insurance covers home PT and a home healthcare nurse. Appropriate patient selection and education is essential. The patient must understand that they are going to have to be responsible to perform their therapy at home with assistance or in an outpatient setting. They will need a caregiver with them at home for the first 48 to 72 hours. Ideally a home care nurse should be utilized as well as a home physical therapist for the first two to four days after surgery. Subsequently, OP PT should be performed. At least four weeks of anticoagulation with full dose ASA should be utilized in healthy patients without a history of predisposing factors that would require more aggressive anticoagulation treatment.

Gondusky J et al. Day of Surgery Discharge after Unicompartmental Knee Arthroplasty: An Effective Perioperative Pathway. Jrn'l Arthroplasty 2014; (29): 516-519.

Lovald S et al. Complications, Mortality and Costs for Outpatient and Short-Stay Total Knee Arthroplasty Patients in Comparison to Standard-Stay Patients. Jrn'l Arthroplasty 2014; (29):510-515.

Kolisek F et al. Comparison of outpatient versus inpatient total knee arthroplasty. Clin Orthop Relat Res.2009; 467 (6):1438-1445.

Levin B et al. Blood Management Strategies for Total Knee Arthroplasty. Jrn'l Am Acad Orthop. 2014; Vol 22 (6): 361-371.

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