According to Barnett, the best tool to help select patients for outpatient arthroplasty is the Outpatient Arthroplasty Risk Assessment (OARA). He pointed to a study, “Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the Outpatient Arthroplasty Risk Assessment Score” published in Journal of Arthroplasty in August 2017, which investigated the predictive ability of three scoring systems to select patients for outpatient arthroplasty, the OARA, the American Society of Anesthiologists (ASA) Class, or the Charlson Comorbidity Index (CCI). The OARA score was found to have the most precise predictive ability.
Barnett said, however, that the concern with the OARA is that it is a very long questionnaire with over 60 questions looking at various comorbidities, so it is significantly more time-consuming to complete than the other two scoring systems.
Creating a Protocol to Follow
For the best results, Barnett said you need a confluence of the right surgeon, the right institution and the right patient, such as an outpatient program at an inpatient facility with ambulatory surgery center-staffing, space and equipment, anesthesia modifications and appropriate patient candidates.
Barnett said that he and his colleagues at Hoag Orthopedic Institute used their in-patient experience, identifying the reasons patients were re-admitted and studying complication rates to create their own outpatient arthroplasty protocols.
First, they devote more time to the initial surgeon screening so they can make sure the patient meets the appropriate criteria including being active and motivated. They also use this time to inform the patient of the pathway and what they can expect.
Red flags that a patient is not a good candidate, Barnett said, include the 3 Ds—debilitated, demented and de-conditioned—and whether the patient is in a skilled nursing facility. Other factors to consider are whether the patient is overly anxious, has problems with pain management and/or has a non-supportive family. Barrett also doesn’t prefer to do outpatient arthroplasty on travel patients who are going to get on a flight right after surgery.
Next, patients identified as candidates for outpatient surgery must attend a mandatory pre-op education class which includes an orientation with physical therapy. And a “buddy” must attend and participate with them.
Barnett said that at his institution patients with any of the following are not a candidate for the outpatient pathway:
- ASA > II
- Unstable or poorly controlled chronic disease
- Hgb A1-C > 7%
- Chronic pain management
- BMI > 35
- Poor community ambulation
- History of pulmonary embolism or deep vein thrombosis
- Anxiety disorder
- Dementia
- No one to care for them in the first 72 hours post charge
“Physicians or med-level practitioners needs to discuss this with the patient prior to scheduling as outpatient,” he said.
