How I’ve Made Outpatient Total Hip Replacement the Rule and Not the Exception Keith R. Berend, MD Joint Implant Surgeons, Inc., White Fence Surgical Suites, Midwest Training & Development Services New Albany, Ohio
Keith R. Berend, MD Disclosure Consultant: ♦ Zimmer Biomet Royalties: ♦ Zimmer Biomet; Innomed Research Support: ♦ Zimmer Biomet; Pacira Pharmaceuticals; Orthosensor; SPR Therapeutics Development Partner: SurgCenter Development
The Future is Now 1987-1990 1997-2002 ♦ TKA: Robert Jones dressing ♦ Regional anesthesia (epidurals) ♦ THA: Charnley buttons ♦ Soft tissue injections ♦ All patients → Mini ICU ♦ Acute setting: 3-5 days ♦ LOS: 7-10 days ♦ Outside SNF: 7 days 2003-2004 ♦ Single shot spinals Average Length of Stay ♦ Rapid recovery protocols ♦ Multimodal medications ♦ LOS: 2.5 days 2005-2011 ♦ Minimally invasive surgery ♦ LOS: 1.5 days 2012-2013 ♦ Liposome bupivacaine suspension injection ♦ Same day surgery 1991-1992 1993-1997 ♦ Same protocol ♦ Same protocol ♦ LOS: 5-7 days ♦ Acute setting: 3 days ♦ Adjacent SNF: 7 days
Why Do Patients Stay in the Hospital? 1. Fear/Anxiety Unknown Pain 2. Risk Co-morbidities Medical complications 3. Side-effects of our treatment Narcotics/anesthesia Blood loss Surgical trauma
An unpleasant emotion caused by the belief that something is dangerous, likely to cause pain, or a threat
Preoperative Education Reduces Anxiety Decreases Pain Increases Satisfaction Yoon et al., J Arth 2009 Mancuso et al., CORR 2008 Thomas & Sethares, Orthop Nurs 2008 Pietsch & Hofmann, Orthopade 2007 McGregor et al., J Arth 2004 NIH Consensus Statement on TKR, 2003 Sjoling et al., Patient Educ Couns 2003 Crowe & Henderson, Can J Occup Ther 2003 Liebergall et al., Clin Perform Qual Health Care 1999 Daltroy et al., Arthritis Care Res 1998 Claeys et al., Orthop Nurs 1998 Messer, Orthop Nurs 1998 Lin et al., Orthop Nurs 1997 Gammon & Mulholland, Int J Nurs Stud 1996 Livesley & Rider, Int Orthop 1993
Pre-Arthroplasty Rehabilitation Reduces anxiety Prepares patient for peri-operative protocols Decreases pain Improves outcomes Topp et al., PM R 2009 Rooks et al., Arthritis Rheum 2006 Brown et al., J Strength Cond 2009 Crowe et al., Can J Occup Ther 2003 Jaggers et al., J Strength Cond 2007 Liebergall et al., Clin Perform Qual Coudeyre et al., Ann Readapt Med Phys 2007 Health Care 1999 Daltroy et al., Arthritis Care Res 1998
Fear: Familiarity Site Visit/Tour Know the route to get there ♦ Not worried they will be late Meet the staff Allows patients and family to understand that its not a hospital ♦ But they know that they will receive “real” medical care
A situation involving exposure to danger
Does the patient Who’s a Candidate have an ongoing medical issue that for Outpatient cannot be optimized? Arthroplasty at the ASC? No Yes Does the patient Postpone have an organ surgery until failure? medically optimized No Does the patient have adequate support upon discharge? Yes Patient is not a candidate for outpatient surgery and if No medically stable surgery Yes Consider should be performed at a Surgery can be safely surgery at hospital and the patient performed as an hospital observed for 23 hours outpatient
Insurance Status Medicare: there is no outpatient code for TKA or THA (PKA OK) ♦ Hospital/ASC ♦ Eliminates most over 65 • Helps with determining health status ♦ Different than PKA In-network vs out-of-network ♦ May determine facility ♦ May change patient responsibility
Medical Optimization: The Surgeon’s Role Identify Organ Failure: ♦ Congestive heart failure ♦ COPD ♦ Chronic renal insufficiency ♦ Hepatobiliary disease ♦ Dementia/SZ disorder ♦ Hematopoietic disease ♦ History of anemia
Medical Optimization: The Internist’s Role Make sure organ failure not missed… Medical Optimization: ♦ Referrals to specialists • Cardiology, pulmonology, hematology ♦ Identify and optimize OSA ♦ Hemoglobin management ♦ VTE risk stratification ♦ Glycemic control/A1C ♦ Smoking cessation
Start Conservatively Cardiac Hematologic Renal Disease • ♦ Prior revascularization ♦ Dialysis – Chronic Coumadin ♦ CHF ♦ Severely elevated – Coagulopathy ♦ Valve disease serum Cr – Anemia ♦ Arrhythmia/Pacemaker Gastrointestinal ♦ History of ileus • Hbg <13.0 Pulmonary ♦ Chronic hepatic – Thrombophilia ♦ COPD disease ♦ Home O2 Neurological • Genitourinary – CVA Untreated OSA ♦ History of urinary – Delirium/demen BMI >40 retention tia ♦ Severe BPH Solid organ • transplant
JIS Inpatient Experience July 1, 2016 to Feb. 28, 2017 Our inpatient cases at Mount Carmel New Albany ♦ 1,543 Hip/Knee/Shoulder procedures: 733 TKA (47.5% ) 13 Reimplant TKA (0.8% ) • • 401 THA(25.9% ) 13 Reimplant THA (0.8% ) • • 52 TSA (3.3% ) 12 Radical TKA (0.7% ) • • 138 PKA (8.9% ) 7 Radical THA (0.5% ) • • 89 Rev TKA (5.7% ) 14 I&D TKA (0.9% ) • • 55 Rev THA (3.6% ) 13 I&D THA (0.8% ) • • 3 ORIF Hip (0.2% ) • Berend et al IMHS 2017
Transfusion in Primary THA & TKA 12/1134 (1.06% ) ♦ 2.4% of all primary THA (10 of 401) ♦ 0.2% of all primary TKA (2 of 733) Demographics: ♦ 1 Male : 11 Females ♦ Preop Hgb 11.5 (9.3-12.7) ♦ EBL: 297 cc (50-900) Berend et al IMHS 2017
Side-Effects A secondary, typically undesirable effect of a drug or medical treatment
Preoperatively Celecoxib 400 mg PO Pregabalin or gabapentin 600 mg PO ♦ 300 mg if >65 years old Acetaminophen 1 gm PO Dexamethasone 10 mg IV Metoclopramide 10 mg IV Consider scopolamine patch Perioperative antibiotic TXA 1.4 gm PO 2 hours prior to incision Start crystalloid for resuscitation/hydration
Intraoperatively Short acting spinal anesthesia Propofol short-acting sedation ± Short-acting inhalants Ketamine 0.5 mg/kg IV Crystalloid 2 liters IV for resuscitation/hydration Periarticular injection ♦ 50 mL 0.5% ropivacaine, 0.5 mL 1:1000 epinephrine, 30 mg ketorolac Ondansetron 4 mg IV
Efficient Performance of an Operative Procedure Skillfulness in avoiding wasted time and effort-Does not mean “MIS”
Side-Effects : Surgical Trauma/Blood Loss Surgical trauma ♦ Minimally/less-invasive techniques ♦ Efficient orchestration of the procedure • Includes surgeon and team Blood Loss ♦ Tranexamic Acid ♦ Tissue sealer device?
Postoperatively TXA 1.4 gm PO 3 hours after initial dose Urecholine 20 mg PO for BPH/urinary retention Minimum 1 additional liter of crystalloid for resuscitation/hydration Ondansetron 4 mg IV PRN Promethazine 6.25 mg IV PRN Oxycodone 5-10 mg PO q 4 hours PRN Acetaminophen 1 gm PO prior to discharge Hydromorphone 0.5 mg IV q 10 minutes PRN
Discharge Medications Celecoxib 200 mg PO QD for 2 weeks Aspirin 81mg PO BID for 6 weeks Antibiotics <24 hours Acetaminophen 1000mg PO TID for 48 hrs Oxycodone 5mg PO 1-2 q4-6 hr PRN Hydromorphone 2mg PO PRN breakthrough Hydrocodone/Acetaminophen 5mg 1-2 q4-6 hr PRN (beginning 48 hrs post-op) Ondansetron 10mg PO PRN Portable ambulatory calf pumps Cryotherapy motorized unit
Multiple Driving Factors and Stakeholders Healthcare Control of Costs Care OUTPATIENT Arthroplasty Surgeon Patient Health System
Average Charges and Reimbursements Category Outpatient Inpatient Total Hospital Charge $19,982 $23,087 Total Hospital Reimbursement $12,385 $13,950 Preop Physical Therapy Charges $203 $0 Preop Physical Therapy Reimbursement $134 $0 Postop 1 Week HH Nursing Charges $285 $0 Postop 1 Week HH Nursing $177 $0 Reimbursement Postop 1 Week HH Therapy Charges $149 $0 Postop 1 Week HH Therapy $99 $0 Reimbursement Total Billed Charges $20,619 $23,087 Total Reimbursement $12,795 $13,950 Bertin, CORR 2005
Outpatient Surgery Cost Reduction in THA Observational, case-controlled 2008-2011 119 THA, DAA, single surgeon, outpatient Compared with inpatient controls (n=78) No different in: complications, EBL Cost: ♦ Outpatient: $24,529 ♦ Inpatient: $31,307 Aynardi et al., HSS J 2014
Outpatient Arthroplasty at JIS Joint Implant Surgeons / White Fence Surgical Suites (6/2013-12/2016) ♦ 4820 arthroplasty procedures 1559 THA • 3128 UKA/TKA • 1289 UKA • 48 TSA • 83 Rev TKA/THA • 1 Rev TSA • 1 TAA • ♦ 8.6% stayed overnight Convenience / travel (35% ) • Most common medical issues: urinary retention; • nausea/vomiting; OSA precautions NOT UNCONTROLLED PAIN 0.2% (9/4820) • ♦ 98% patient satisfaction
Not Everyone Has to Be Perfectly Healthy Coronary Artery Disease (PTCA, CABG): 5% Obstructive Sleep Apnea: 15% VTE: 4% BPH, Urinary Retention: 18% COPD: 15%
ER/Admissions within 48 Hours 5 (0.34% ) ♦ 2 atrial fibrillation (both transferred) ♦ 1 postoperative anemia (transferred) ♦ 1 sudden R foot paresthesia ♦ 1 I&D wound dehiscence
Nonoperative Complications ≤90 Days 0.6% Death due to presumed PE @11 days Admit bowel issues @5 days Admit UTI/septicemia @7 days Admit for diverticulosis @40 days Fell & dislocated shoulder @3 days Foley catheterization @3 days ER for chest pain; negative PE @6 days
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