Lots of Moving Parts Required
According to Edwards, there are a lot of factors that go into successfully participating in same-day discharge including teamwork, nutrition counseling, education, communication, collaboration, early mobilization and fluid management.
He said though that it really hinges on enhanced recovery through all the phases: preoperative, intraoperative and postoperative.
He explained that a team-work approach is essential, that it takes a lot of moving parts, a lot of people to participate and make it happen, including a hospitalist consultant, mid-level providers, social workers, RN coordinators and physical therapists.
“The key here is education to the patient and to the family and a strong social support system so they can understand what is happening and agree to the plan,” he said.
“Discharge planning begins in the office. Expectation is always set as DC postoperative day 1 (POD#1). The first time I meet with them in my office for hip or knee replacement we talk about when they can expect to go home and the expectation is always set as DC POD#1.”
“If there is a medical reason to keep them, we can talk about it and keep those patients longer, but we initially start out those conversations with DC POD#1 prior to 11 a.m.”
Patients are also expected to take a hip and knee class before their surgery. Attendance is mandatory and their “coach” is also expected to attend. The class usually lasts one or two hours and covers dressing care, disposition (home), physical therapy and any durable medical equipment (DME) that might be needed.
At his institution there are two pathways to preoperative medical clearance:
- Healthy, controlled hypertension, stable cardiac with routine cardiology follow-up and cardiac clearance, diabetes (DM) with minimal health complication—cleared through the Musculoskeletal Service Line by a non-operative ortho M.D.
- Aggressive anticoagulant, renal disease, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), rheumatoid arthritis (RA), uncontrolled diabetes mellitus (DM), history of deep vein thrombosis/pulmonary embolism (DVT/PE)—cleared by an internal medicine M.D.
Their exclusion criteria includes:
- BMI > 40
- Hgb A1c > 8.0
- Active smoker
- Active use of narcotics
- Skip hip and knee Education Class
Edwards said that they also write up an agreement for the patient to sign for accountability. They want the patient to read and understand what the purpose of the surgery is and what they can expect to happen. That way if patients come back and say they were never told that they were getting discharged on POD #1, the surgeon has the paperwork to show that they did talk about it.
