When you look at a community based hospital, do you see an ambulatory surgery center? Maybe if you squint?
Most tertiary care facilities, for example community-based hospitals, do not offer same-day arthroplasty procedures. Should they? Could they?
A team from Brigham Health in Boston, Massachusetts has just published a review titled, “Team Approach: Same-Day Discharge of Patients Undergoing Total Joint Arthroplasty” in the June 2020 edition of The Journal of Bone and Joint Surgery: Reviews.
Co-author Alexander Crawford, M.D., a third year orthopedic resident explained the genesis of this study and subsequent paper to OTW, “Over the past several years we have seen a transition to rapid recovery for patients undergoing total joint arthroplasty [TJA]. Given the paucity of this rapid recovery being performed at tertiary care centers across the country, we wanted to share our protocol that successfully allowed this to occur.”
Bottom line, said Crawford, “In a short period of time, we transitioned from doing very few outpatient total joint arthroplasty procedures to doing them regularly. A team-based approach was integral to creating this change.”
The key issue, of course, is patient management and the Brigham team relied in part on Michael Meneghini’s Outpatient Arthroplasty Risk Assessment (OARA) metric1. The OARA metric adds up points assigned to various conditions (for example, body mass index) within organ systems (general medical, hematological, cardiac, etc.).
The Brigham team used other measures as well. “The OARA score is just one tool we can use in addition to clinical judgment and patient discussions. We also use two criteria to filter patients who are medically safe enough for same-day discharge: an American Society of Anesthesiologists (ASA) score of three and BMI [body mass index] of ,40 kg/m2. Those who fit these criteria are considered for TJA same-day discharge. Importantly, age is not a filter. Patients in our practice have successfully undergone same-day discharge without postoperative complication from the age of 30 to 89 years.”
Lots of Patient Optimization and Communication
According to Crawford, “The most important conclusions of our article were twofold. First, outpatient total joint arthroplasty is becoming increasingly feasible due to advances in anesthesia, physical therapy, surgical techniques, and perioperative protocols. Second, we believe a team-based approach to each phase of care is vital to creating an effective and safe outpatient total joint arthroplasty program. If this is not achieved patients do not get a unified message and often are not comfortable with discharge home on the day of surgery.”
“Physical therapy preparation begins with confirming expectations set in the surgeon’s office with the patient, specifically that the patient will be discharged home on the same day as the surgical procedure. We do this approximately one week prior to the surgical procedure during our preoperative telephone call… The plan for the day of the surgical procedure is reviewed in detail with the patient, including arrival at the hospital, the surgical procedure, postoperative care, physical therapy treatment, and discharge home.”
“The physical therapist assesses the patient’s readiness for discharge home by verbally confirming that the patient understands that he or she is going home in the afternoon or evening of the surgical procedure, verifying his or her ride home, identifying support in the home, ensuring the home is prepared prior to the surgical procedure, and confirming the patient’s plan with regard to picking up prescription medications on the way home.”
“We have found that the time invested in these telephone calls has provided us with a wealth of knowledge as to the readiness of the patient, as well as an opportunity to mitigate issues that may impact a timely discharge.”
“A surgical team member calls patients the night before the surgery, telling patients when to arrive and reviewing what the patient should anticipate. The goals are threefold: 1) Maximize the number of “touches,” so that the patient does not feel isolated as they go through this experience, 2) Streamline the day of surgery. The authors noted that they have found that fewer patients arrived late after they began making this call, 3) Give patients a final chance to ask any questions.” The authors state that many of their patients have later noted that this call was “reassuring and made them feel more ready for their surgical procedure.”
Recommendations are….
Co-author Vivek M. Shah, M.D., director of outpatient arthroplasty at Brigham Health, summarized the teams recommendations with regards to community hospital based same day arthroplasty surgeries to OTW, “The most practical recommendations from this work are the importance of communication between team members and the importance of following a protocol based approach. All members of the same-day discharge team must be compliant with a standard pathway, and there are many pathways available in the literature today.”
“As the push for value-driven healthcare and the incidence of total joint arthroplasty continues to grow, outpatient arthroplasty will likely become more prevalent and increasingly incentivized. With this article, we hope to convey a proven method that has allowed us to significantly ramp up our outpatient total joint arthroplasty program. We would also add that this was created and accomplished despite some of the significant hurdles that accompany a large tertiary care center.”
References
1. Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo P. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “Outpatient Arthroplasty Risk Assessment Score”. J Arthroplasty. 2017 Aug;32(8): 2325-31. Epub 2017 Mar 14.
