Doug ouglas las A. D Denn nnis is, M , M.D. Adjun junct ct - PowerPoint PPT Presentation

SA SAME D DAY T TKA: A: A ARE RE Y YOU OU CRAZ RAZY? MY PATIENTS A TIENTS ARE W E WELL C CARED F ED FOR Doug ouglas las A. D Denn nnis is, M , M.D. Adjun junct ct Prof ofes essor or, Dept. t. of Bio iomed edical al Engine neer ering ng Univ iversity ty of Tenne nnessee Assista tant nt Clin linical al Prof ofes essor or, Dept. t. of Orthop thopedic c Surgery Univ iversity ty of Color lorado o Heal alth th Scien ence ces Cente nter Clini linical cal Dir irec ecto tor Roc ocky Mtn. Muscul culos oskel elet etal al Resear arch h Laborator ory Denver er, Color orad ado

DISCLOSU DISCLOSURE RE  Consu onsult ltant nt : Dep epuy uy  Royalties: s: • Depuy puy / Innome Innomed / / Wol Wolte ters K s Kluw uwer  Lab Labor oratory Rese esearch Sup uppo port • Depuy puy • Por orte ter A Adve dventi ntist Hospi st Hospita tal  Ow Owners rship In Inte tere rest: Jo Joint t Vue ue

ADOLPH ADOLPH  Yo You’ve Be ’ve Been en Wor Working ing Much Much Too H oo Har ard  Yo You’r ’re Asl e Asleep eep At At Th The W Wheel eel On On This his One One !!

THIS THIS I I KNOW !! KNOW !!  Many ny Sm Small all Stud Studie ies D Demon onstrat ate Outp Outpat atien ient T t TKA C A Can B Be D Done Sa one Safely ly In A n A Se Sele lect cted Gr Group oup Of Of Pa Patie ient nts  I Still H Still Have A A Lot Lot Of Of Que Questio ions ns  JUS JUST B BECAUS USE IT CA IT CAN B BE DO DONE NE, IS IS IT THE IT THE B BEST TR TREATMENT METHOD F HOD FOR O OUR P PATIENTS ? TIENTS ??

OUTPATI PATIENT T ENT TKA  If 250 50 Outp Outpat atie ient T t TKA Pa A Patie ient nts A Are e Perfo rforme rmed S d Safe fely & y & One Pa One Patie tient D t Dies ies Or Or Has A A Majo jor C Com omplic lication ion & If & If The he Pa Patie ient nt W Were H Hosp ospit ital aliz ized ed & & Em Emer ergency cy T Trea eatm tment nt W Was Admin inis ister ered ed M Mor ore Pr e Prom omptly ly, Le Less ssening ing T The M he Magnit itud ude Of Of The he ion, IS IT IS IT WORTH RTH IT ?? IT ?? Com omplic lication

OUTPATI PATIENT T ENT TKA  Many ASCs Are Not On A Hospital Campus  Is There An Intensivist On Site ?  How Long Will It Take ?? • Ambulance To Arrive • Patient Transport To An Acute Care Hospital

OUTPATI PATIENT T ENT TKA  Numer umerou ous R Repor eports ts S Show ow Similar C lar Comp mplicat icatio ion & Readm admis ission ion R Rates tes Between etween Outpatien tpatient & Inpat npatien ient C t Coho ohort rts  Cohorts Are Rarely Matched • Outpatient Subjects Typically Younger, Healthier, & More Psychologically Prepared

OUTPATI PATIENT T ENT TKA  IF S F STUDI DIES WE WERE DON DONE OF OF MATCH MA CHED COH COHOR ORTS ( (AGE GE, MOR MORBIDI DITIES, E ETC. C.) DON DONE INPATIE INPATIENT VS NT VS OUTPATI UTPATIENT, ENT, WOU WOULD COMP LD COMPLI LICA CATIONS & & READM DMISSION ONS R RATES S STILL LL BE T THE SAME ME??

OUTPATI PATIENT T ENT TKA  A Lot Lot Of Of Out Outpat atie ient nt Knee Knee Arthro Arth roplasty D asty Data ta In Invo volve ves UK s UKA  Will Will Similar imilar R Res esult ults Be e Ob Obtaine ained Wit With h Out Outpat atie ient nt TKA KA • Especi pecially ally I In Medicar care e Aged P d Patien tients ts ? ??

OUTPATI PATIENT T ENT TKA  Whe When Com Comparing Variabl iables O es Of Similar ilar Incidence, L cidence, Large rge C Cohor ort t Size Size Is Req Is Required T To Detect S ct Small D ll Differences erences

OUTPATI PATIENT T ENT TKA Are The Idea Are The Ideal Cand Candidates For For Outpatient patient S Surger gery C Clear early ly Identif ntified I ied In Studies dies I Involv olving ing Thou Thousand nds O Of f Pat atient nts ? ??

TKA MORT TKA MORTALITY  May Mayo Regi Registr try Anal Analysis • 7 7 Day Day: 0.1% 0.1% • 30 30 Day Day: 0.2% 0.2% • 90 90 Day Day: 0.4% 0.4% Singh ngh & & Le Lewallen, J J Arthr thropl oplast sty 2 y 2012

TKA MORT TKA MORTALITY  Power A wer Analy nalysis is • Stat C t Chan ange ge: – 0.2 .2% To 0 To 0.4 .4% • 9,425 S 425 Subject jects R Requ quired ired  Studies udies N Not ot Avail ailab able le To D Detect tect Subtle D btle Differen erences ces I In M n Mort rtality ality

OUTPATI PATIENT T ENT TKA  Some Out ome Outpat atie ient nt T TKA KA Prot otocols ocols “S “Send nd T The he Hos ospit ital al Home Wit ome With T h The he Pat atien ient” • Visiting RN, HHA, PT  Are They Really Saving $$$ Or Just Cost Shifting ??

 Early D Disch charg arge N e Not ot Assoc ociated iated Wit With ↑ Readmis eadmissio ion B But ut Exc Excess ssiv ive Post Postoperative ve ER ER Visits its E Encou countered ered  Cos Cost Sa Savin vings Vs Vs Shif Shifting ? ??

OUTPATI PATIENT T ENT TKA  Many Many Out Outpat atie ient nt S Sur urgic ical l Cent Center ers Are P Phy hysicia ician Ow Owne ned • Surgeons Potentially Economically Incentivized To Take Patients To Outpatient Surgical Centers

OUTPATI PATIENT T ENT TKA  Will Will Some S ome Sur urgeon on Ow Owne ner Make A Mak A Poor oor Decis Decisio ion n Reg egarding ing P Pat atien ient Sele election ion Due Due To o Sec econd ondary E Economic conomic Be Benef efit t An And d Adver Adverse Pa se Pati tient t Event ents Occ Occur ur ? ??

OUTPATI PATIENT T ENT TKA  Anes nesthe hesio iolog logis ist Fear Fears • Fa Falls lls: Li Ling nger ering ng A Anes nesthes esia Ef a Effec ects ts • Postop Postop B Blee leeding ng (A (Ant ntic icoag agula lant nts) • Urin inar ary R Ret eten ention ion → Readmi dmissi ssion • Epidur ural H al Hematom oma • Cardi rdiac A Arrh rrhyt ythmi mia • Respi spira ratory D ry Depre pressi ssion • Pa Pain in C Contr ontrol A l After er B Blo lock ck C Cessation ion

OUTPA PATI TIENT T ENT TKA: OTHER ER R RIS ISKS  Posto top R p Respirato piratory Depr pres ession ion • Obstr Obstruc ucti tive ve S Sleep A p Apne pnea – Inc Incide denc nce Repor ported To B To Be As s Hi High gh As s % In ♀ / 49% In % In ♂ 23.4% In – Ma Many OS ny OSA Undi Undiagnose gnosed ! !! – Risk sk Of Of Respi spirator tory C y Compl omplicati tions ons In In OS OSA Subj ubjects C s Consumi onsuming ng Opi Opiods ods For For Postop P ostop Pain n Contr ontrol ol Is S Is Substa ubstanti tial – Risk sks: s: Hypoxi Hypoxia / P / Pne neumoni umonia / / Death

OUTPA PATI TIENT T ENT TKA: OTHER ER R RIS ISKS  Pos ostop op Urinar inary R Ret etent ntion ion • If U Undiagn ndiagnosed ed & & Not T ot Treat eated ed In In A Timely ely F Fashio ion, n, U Urinar rinary Reten etentio tion C Can n Result ult I In Perman manen ent B Bladd adder D er Damag age, e, Hydro droneph ephro rosis is, , Chro hronic U nic UTI’ I’s, , Etc. c.

SUM SUMMARY ARY  Can Be Be Done Sa Safe fely In Se Selected Pa Pati tients  Larger Stu Studi dies R Requ quired To To Defi fine Pr Prope per Patient ient S Select lection ion & Safet ety  FEARS: EARS: • Major C r Comp mplicati cations @ ASCs Locat ated ed D Distan tant From om A A Major or H Hos ospi pital • Surge geon O Owne nershi hip p → Po Poor Pa r Patie tient Se Select lectio ion • Increa reased Resourc rces es R Required red Not A t Availab able e To A All Su l Surg rgeo eons  Not ot Yet R t Read eady For For W Wides espread ad U Use ! se !!

THAN THANK K YOU YOU