This week’s Orthopaedic Crossfire® debate was part of the 35th Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “Outpatient TJA Surgery: The Best Sum of All Things.” For is Keith R. Berend, M.D., Mt. Carmel New Albany Surgical Hospital, New Albany, Ohio. Opposing is Alejandro Gonzalez Della Valle, M.D., Hospital for Special Surgery, New York, New York. Moderating is Fares S. Haddad, M.D., F.R.C.S. University College Hospital, London, United Kingdom.
Dr. Berend: The best sum of all things is really illustrated by my partner’s, Dr. Lombardi, experience. The length of stay in his practice starting in 1986 through roughly the teens of the 2000s gradually declined from over a week to where the majority, if not ALL patients, are simply staying overnight.
The fact is that we didn’t just decide to wake up Monday morning and send patients home the same day. We were looking at efficiencies. We were looking at safety. We were looking at protocols.
When we started looking at outpatient surgery, we really boiled it down to the three barriers: fear/anxiety; risk; and the side effects of our treatment.
I will predict that my opponent in this conversation is going to talk mostly about risks, side effects/complications. I’m a simple country bone doctor and I think what risk really boils down to is exposure to danger. What we need to do is mitigate that danger.
How do we do that? We don’t have a complex algorithm, we don’t have an app on the phone, we don’t have 45,000 different variables. It boils down to this question: does the patient have an ongoing medical issue that cannot be optimized? If they do then they shouldn’t have surgery at all, let alone outpatient surgery.
If the patient does not have any ongoing medical issues, then do they have organ failure? Yes? Then the patient is not a candidate for outpatient surgery.
If the patient does not have organ failure, then do they have adequate support at home to be safe at home after discharge? No? Then they probably need the support of a hospital system.
But if you answer, “Yes,” then the surgery can safely be performed as an outpatient procedure.
How simple is that?
No need to figure out whether they have this ASA score or that ASA score. We do need to consider the patient’s co-pays, their deductibles, things like that…because we don’t want to penalize the patient for having outpatient surgery.
We started our outpatient program conservatively. We used a “Go, no go” checklist. Now, after 5 years, we’ve eliminated things like prior revascularization, arrhythmia and pacemakers, BMI [body mass index] of over 40, if they’re on chronic coumadin, history of ileus and history of urinary retention.
The issue we continue to use on our “Go, no go” checklist is hemoglobin less than 13. That is a predictor of needing a transfusion, which is very difficult to do at a freestanding ambulatory surgery center.
Once again…no organ failure, hemoglobin greater than 13, good support at home, you’re having an outpatient joint replacement.
