Recovery Game Changers
Barnett said that making changes to anesthesia and patient diet also help patients recover quickly making them better candidates for same-day discharge.
“The complications that keep people overnight are not cardiac issues or pulmonary issues. It is basically related to anesthesia, spinal anesthetic issues and a big one is nausea. This was a game changer for us, changing our anesthetic and our diet,” he said.
“We tell patients they can have carbohydrate drinks up until an hour before surgery to decrease post-operative nausea and vomiting (PONV), insulin resistance, thirst, hunger and anxiety.”
Patients are allowed water, apple and cranberry juice, Gatorade and sports drinks, clear broth, Jello, coffee and tea without milk. Prohibited items include milk or dairy products, citrus juices, prune juice, juices with pulp, and alcoholic beverages.
Then in the recovery room they advance the patient’s diet immediately and start them back on regular food as soon as possible in order to reduce insulin resistance and decreases PONV and infection risk.
Patient Safety Must Be First
As of this past summer, the Hoag Orthopedic Institute had discharged 524 outpatient arthroplasty patients (16%) out of 3,259 total arthroplasty patients including hips and knees.
Of their 524 outpatient THA, two patients were readmitted, 1 for peri-prosthetic fracture and 1 for anemia. And while 80.9% of those selected for the outpatient surgery did go home same day, 18.4 % ended of spending the night in the hospital and 0.7% stayed in the hospital for 2 days.
“We have gotten more comfortable with this new pathway since it started in 2015 and are starting to include more patients,” he said. “And as of this summer when it comes to ASA scores between their outpatients and inpatients, 17% of their outpatients were ASA 1, 76% ASA 2 and only 7% were ASA 3. None were ASA 4. When it came to inpatients, 71% were ASA 2, 29% were ASA 3 and 0.4% were ASA 4. Patients in the outpatient program also had fewer comorbidities (3 vs 7).”
He added. “We have made a significant effort to keep people out of skilled nursing and acute rehab because by our own data, the readmission rate for any patients who go to any extended care facility goes up to 5 or 6-fold. We counsel patients strongly that they need to go home.”
“Patients who live alone, I strongly urge them to get somebody to stay with them for a few days, but even with that we do have 8-9% who go to extended stay facilities.”
The goal he said is to prevent readmission and emergency department visit after surgery, because not only does it increases cost, but it also negatively impacts patient safety and outcomes, which should be of paramount importance.
Dr. Barnett at the Direct Anterior Approach Hip Course
Barnett’s presentation, ““Outpatient Arthroplasty: I Want to Be Selective and This is Why” was originally presented at the International Congress for Joint Reconstruction’s 6th Annual Direct Anterior Approach Hip Course in 2017.
His presentation on outpatient arthroplasty was also on the agenda for the 7th Annual Direct Anterior Approach Hip Course which will be held September 27-29, 2018 in Houston, Texas.
The conference is designed for orthopedic surgeons and allied health professionals looking to learn the latest in orthopedic technology and optimum patient care when using the direct anterior approach to hip arthroplasty.
For more information, click here. (https://icjr.net/meeting/2018-7th-annual-direct-anterior-approach-hip-course) Or watch the live broadcast from the meeting here.
