J. David Evanich, MD, partner at Flower Mound, Texas-based Orthopedic Associates and board president of Texas Health Orthopedic Surgery Center Flower Mound, an affiliate of Surgical Care Affiliates, discusses lessons learned about outpatient total joint replacement in ASCs and how he thinks the procedure will grow in the future.
Question: How did your total joint replacement process and protocols change when transitioning cases from the hospital to the ASC? How are they similar?
Dr. J. David Evanich: We use the same preoperative, operative and anesthesia protocols at the surgery center that we use at the hospital. This provides treatment consistency based on well-tested, proven protocols. The difference is in the accelerated postoperative protocol. Surgery center patients receive 1:1 or 1:2 nursing care to aid in expediting their recovery. All surgery center joint replacement patients are walking within two to three hours of surgery. These patients are independent in bed transfers, ambulation, washroom self-care and a home exercise program at the time of discharge, which occurs approximately eight hours after surgery. The patients then start outpatient physical therapy the day after surgery. Further need for therapy is assessed at the first postoperative clinical follow-up appointment. Many patients, especially hip patients, are independent in PT by this time.
By comparison, hospital patients usually require some aspect of the full services of the hospital and stay there for one to two nights. Once discharged, most hospital patients utilize home health PT for two weeks prior to starting outpatient PT.
Q: Since beginning to perform total joints in the ASC, how have you refined the protocols? What is the most important lesson you've learned?
JDE: We have decreased the amount of oral narcotics prescribed, both in quantity and strength. This decision was based on multiple patient reports indicating that they did not need their pain medicine after a relatively short (~2 week) time period.
We have also relaxed the medical condition and body mass index restrictions. Those motivated patients with stable, well-controlled medical conditions are often good candidates for outpatient joint replacement. Initially, we had weight limitations with a BMI less than 30. Now, the decision for surgery is based more on body habitus and anticipated difficulty of surgical exposure rather than a strict BMI threshold.
We have learned that multimodal anesthesia and a strong home support network are the two most important, non-surgeon dependent factors in the success of outpatient joint replacement. A comprehensive multimodal anesthesia program with preemptive analgesia, targeted nerve blocks, long-acting local anesthetic infiltration and limited narcotics is likely the single most import factor that has allowed outpatient joint replacement to be possible. Also, in our experience, motivated patients with a strong social support system are more confident, have less pain, and progress more quickly in their recovery, making them excellent candidates for the outpatient venue. Successful application of these two factors contribute to the high patient satisfaction levels seen in outpatient joint replacement.
Q: How does your ASC approach patient selection and education for total joint replacements?
JDE: Most of the screening for outpatient joint replacement happens preoperatively in the clinic. Each patient's medical history, personal motivation and social support are assessed by the surgeon for outpatient suitability. Those patients who qualify are offered the outpatient surgery option. These patients are then referred to their primary care physician for medical clearance. In most cases, the clearance reaffirms their appropriateness for outpatient joint replacement. These patients then meet with the surgery center nurse coordinator for an educational class, preoperative instructions, a surgery center tour, and a Q&A session. The patient’s primary social support person is required to attend these sessions as well to improve communication, provide patient reassurance, and decrease the risk of postoperative ER visits with readmission due to misunderstanding.
Q: Where do you see the biggest opportunity for the ASC's total joint replacement program to grow in the future?
JDE: Outpatient joint replacement appeals to the busy patient who desires to recover quickly to get back to what they love to do, whether that be work or play. As more outpatient joint replacement cases are completed nationwide and the benefit of an accelerated recovery with an extremely low complication rate becomes more publicized, we believe more patients will request the outpatient option.
Outpatient joint replacement also satisfies the triple aim of healthcare in improving the patient experience while improving health of the population and decreasing cost. The personalized and focused approach of outpatient joint replacement along with its accelerated recovery program improves the patient experience. The health of the population is improved by the joint procedure itself, which has been shown to increase quality of life, mobility and functionality. Finally, outpatient joint replacement patients only utilize the resources they require and have a low complication rate, thereby decreasing the overall comprehensive cost of joint replacement surgery. In an era of cost reduction and improved patient satisfaction, outpatient joint replacement will likely become the norm for the relatively healthy and motivated patient with a severely damaged joint.