Matthew Price, MD
Ellis & Badenhausen Orthopaedics
INTRODUCTION
Total hip arthroplasty (THA) has been a successful, increasing practice for caring for hip arthritis in the aging and active population. The advent of new techniques and efficiency has advanced the practice to one of the more reproducible and beneficial operations orthopaedic surgeons perform. Because of the increasing age of the American population, the need and number of hip replacements performed is expected to increase over the coming decades.1 With that in mind, surgeons have been advancing the practice of joint replacement in both the knee and the hip to accommodate the active lifestyles and demands of patients.2,3 More and more patients desire to be home in a timely manner and get back to work and daily activities as soon as they can tolerate. Several studies have shown the benefits and successful outcomes of an outpatient approach to joint replacement surgery.3-5
This article presents one surgeon’s experience with transitioning to outpatient total hip arthroplasty and the development of a successful outpatient program. Over the past two and a half years, the technique has evolved and patients were followed to determine whether this idea was plausible. The thought being that patients who are healthy enough and motivated to go home after surgery might recover just as well as those who had traditionally stayed in a hospital for two—sometimes three—days. Our practice has instituted an outpatient hip replacement model that has been used successfully in both the hospital and ambulatory surgery center settings.
This article presents one surgeon’s experience
with transitioning to outpatient total hip arthroplasty and the development of a successful outpatient program.
METHODS
Preoperative Evaluation
The discussion of any surgery can be an anxious and stressful time for patients. Setting the patient up for success starts with the in-office discussions. Oftentimes conversations are directed at finding and understanding their goals and expectations. Just like all procedures, we discuss the surgery in detail, including the risks and benefits. However, patients are often surprised to hear that they might be able to go home the same day as their surgery. As the reader knows, patients come with preconceived notions from the experiences of friends and family members, so hearing for the first time that outpatient surgery is an option can help alleviate some anxieties regarding surgery.
We have come to understand that the pre-operative discussions help set the patient up for the best possible outcomes. When a patient feels educated, they also feel empowered, and we spend a good amount of time discussing the advantages and disadvantages of a hospital stay versus going home. The discussion often focuses on comfort and control. Obviously, surgery can be a stressful experience, and the comforts of home can allow them to rest and recover in a more hospitable environment. Between the call lights, beeping IV equipment, other patients’ needs on the floor, nurses doing assessments at all hours of the night and unknown surroundings, it can be difficult for patients to even find an uninterrupted night of rest. Being able to have the comforts of home, literally, at their fingertips often dilutes some of the anxieties patients feel when discussing surgery. The ability to sleep in their own bed, use their own restroom facilities and sit in their favorite recliner eases the tension when surgery is in the future.
In addition to the discussion, we stratify patients whom we consider to be good candidates for outpatient surgery in partnership with our primary care and anesthesia providers. All patients are assessed pre-operatively by both services for proper clearances, lab studies and further work-up if needed. Patients with co-morbidities, which might lead to untoward events, are not considered for an outpatient procedure. ASA scores of three or greater are automatically marked as overnight stays. Patients with diabetic control issues are likewise deemed to be better hospital admits. Regarding diabetics, we typically will not scheduleany elective total hip unless hgbA1c levels are seven or less. Morbidly obese (i.e., BMI greater than 40) patients are set up with a dietician and bariatric surgery consult prior to surgery scheduling and return every three months prior to surgery while we follow trends in their weight loss. Patients who show consistent weight loss and are moving toward their goal weight with BMI less than 40 are considered for surgery. We have a strict cutoff for BMI less than 40 at the surgery center for all cases. Patients with prior complications of surgery or anesthesia are not scheduled as outpatient cases.
After stratifying patients for hospital versus surgical center-based surgery, we then have patients attend a pre-operative class designed for total joints. It is run by the hospital and includes topics to expect before, during and after surgery. It includes discussions on what to expect the day of surgery, anesthesia approach, ambulation protocols, wound care discussion, home care, pain control, follow up expectations and therapy protocols. The class was designed by our combined years of practice experience and common core practices, with input from pre-anesthesia nurses, physical therapy, social cares advisors and nursing staff. In addition to the pre-operative testing and the anesthesia evaluation, this class serves to answer basic questions patients have regarding issues they may experience at home. For instance, placement of rugs at home, the use of crutches or walker at home, or bath mats in the shower, to name a few, are discussed. Again, our approach is to educate the patient as much as possible before the surgery, so they know what to expect when the time comes for recovery. This limits anxious phone calls to the office, decreases unexpected case cancellations and empowers the patient to feel confident when preparing for their surgical experience.
Day of Surgery Pre-op
As with most surgeons, the legwork before surgery depends on a dedicated team of medical assistants, schedulers and nursing staff committed to providing the best experience for the patient as possible. By the time the day of surgery comes, patients have been properly evaluated and educated on expectations, have had their questions answered and are confident when they arrive.
Most patients receive the same anesthesia care for our total hip replacements. What started in 2014 as spinals for all patients has evolved to the use of epidurals with catheters. Our facility happens to be the largest infant delivery center in the state, and thus, the anesthesia providers are quite proficient at both spinals and epidurals. After careful consideration, and discussion, we have chosen the epidural route for a couple of reasons. First, the ability to perform in the pre-operative area allows the flow of surgery to proceed more smoothly throughout the day. With two surgical suites available, this process allows the anesthesia team to remain ahead of the day’s schedule and requires less room coordination. Second, the ability to re-dose an epidural has several advantages. With a spinal, cases need to be more strictly coordinated to be performed within the two-hour surgical window. Also, in the event of uncontrolled post-operative pain, a re-dosing of the epidural in the post-anesthesia unit is possible. As with both spinal and epidural anesthesia, the potential for urinary retention is possible, and we have instituted the use of 0.4 mg of Flomax (tamsulosin hydrochloride) one week prior to surgery for patients 50 years of age and older. In addition, our anesthesia team uses a multimodal approach for pain control the day of surgery, which includes 200 mg of Celebrex, 300 mg of Gabapentin, and 400 mg of IV Acetaminophen.
Intra-Operative
All cases are performed with the same team involving the room nurse, surgical scrub tech and a first assist. At the hospital, we use two rooms with two teams, while at the surgery center we have one room for these procedures. All cases are performed using the Hana® table, and we utilize the modified Smith-Peterson approach described by Matta et al.6 The preferred instrumentation is the Novation® Crown Cup and the Alteon® Tapered Wedge Stem. In addition, we use an intra-operative fluoroscope to assist with abduction angle, medial placement and ante-version of the cup, as well as determining proper leg length and abductor offset with overlaying radiographs while in the surgical suite. The patient is transferred to post-anesthesia recovery with a cooling device placed over the dressing intended to be started in recovery and without any use of abduction pillows or bracing.
Goals to be accomplished before discharge are: ambulating greater than 75 feet, ability to perform and climb stairs (we have a stair model in recovery) and ability to void urine before discharge.
Post-Anesthesia Recovery and Transition to Home
Once in the recovery unit, the patient is almost immediately encouraged to sit up in bed. The nursing staff first will determine the patient’s level of pain and begin oral pain medications as soon as they are consciously aware to drink and eat. They will begin to allow the patient to begin the process of eating more solid foods and sitting at the side of the bed. In addition, the Physical Therapy team is notified of the patient’s arrival, and our goal is to have them ambulating within one hour of transfer to post-anesthesia care. We encourage the use of crutches after surgery for ambulation. In coordination and discussions with our physical therapy providers, it was decided that we use crutches instead of a walker, when feasible, reducing the awkwardness and difficulty of managing a walker in the home and transportation. However, patients are assessed for coordination and comfort of both devices before discharge. Goals to be accomplished before discharge are: ambulating greater than 75 feet, ability to climb stairs (we have a stair model in recovery) and ability to void urine before discharge. The team is instructed that the accomplishment of these goals is paramount to their discharge, and in some cases a second round of therapy before discharge is undertaken.
As discussed, the pre-operative assessment and plan upon discharge has been discussed with the patient prior to arriving at the hospital. Our office’s pre-operative nurse and social services team have coordinated an in-home nurse to meet them at the house on the day of discharge. This allows the patient to have access to coordinated care, and addresses any questions should the need arise on the day of surgery. Oftentimes, this visit serves to answer any lingering questions after surgery as well as asses the home for any possible transfer or ambulatory issues (such as chairs and rugs) which might prove challenging for their recovery. In addition, we utilize in-home physical therapy on post-operative day one. Our goal is to have the patient transitioned to an outpatient therapy center as soon as they feel comfortable to be out of the house more consistently.
Post-Operative Follow-up
All patients are followed up in our office four weeks after surgery for wound check and radiographs. Most questions of pain and renewal of medications are handled by our office nurse. Patients are anti-coagulated with 325mg of enteric-coated Aspirin twice daily for 21 days. Those patients with prior history of chemotherapy, DVTs, PEs, etc. are usually prescribed 2.5mg of Eliquis twice daily. This is all pre-determined by our office and their primary care providers, and usually the therapy is concluded before the first office visit. As discussed, the use of crutches versus a walker is made prior to discharge, and many patients have transitioned to a cane or no assistive device by the time of follow-up. Patients with wound care concerns are brought into the office sooner, and coordinated with our office nurse handling those calls. Patients will then follow-up at the three-month interval for radiographs and activity assessment. If recovery has proceeded smoothly, they are then seen again at their one-year appointment.
RESULTS
We only considered and defined outpatient surgery as those patients discharged the same day as surgery. While developing this protocol, we started to follow our average length of stay in the hospital. Prior to developing our outpatient program, in 2014 our average length of stay in the hospital was 2.3 days. We performed one outpatient total hip in that year. In 2015 we performed a total of 147 primary total hip replacements. Of those, 27 (or 18%) were performed on an outpatient, same day as surgery, discharge basis. In addition, in the first full year of actively scheduling outpatient hip replacements, our average length of stay in the hospital dropped to 1.7 days. In 2016 we performed 167 primary total hip replacements. Of those, 56 (or 34%) were performed on an outpatient basis. In 2016 our average length of stay for those admitted dropped again to 1.3 days. The length of stay data was only recovered for total hips that were admitted. In 2015 we had no re-admissions from our outpatient population. In 2016 we had one re-admission for urinary retention issues while at home.
DISCUSSION
The transition to performing outpatient total hip replacements is an evolving process. My senior partner performed the first total knee and total hip in our state back in the 1970s. After spending time with Maurice Edmond Mueller in Bern, Switzerland, he returned and began performing the procedure in our local hospitals. At the time, patients would stay admitted to the surgical floor for 5-7 days, followed by an extended stay in the therapy unit. Oftentimes patients were not allowed to ambulate fully weight bearing for the first 1-2 weeks, and abduction braces were occasionally utilized, for fear of dislocation. We have come a long way since the 1970s.
Prior to developing our outpatient program, our average length of stay in the hospital was 2.3 days. In 2015 the first full year of actively
scheduling outpatient hip replacements, our average length of stay dropped to 1.7 days.
In 2014 we performed the first outpatient total hip at one of our facilities. By
chance, the patient had a prior total hip replacement on the opposite side, was healthy and very active. He requested and inquired if it was possible we might let him go home after the procedure. After his first procedure, he was walking the hallways that night on the hospital floor, independently climbing stairs and went home the next morning. He relayed that he could not sleep well in the hospital and that he did not like being around patients that might be sick. That got us thinking, and after careful consideration and evaluation by both his primary care providers and the anesthesia team, we scheduled our first total hip as an outpatient procedure. That experience led us to begin developing a pathway of protocols for developing an outpatient experience for total hip replacements.
As a fellow in Nashville, it was not rare to have patients discharged on post-op day one. However, they weren’t listed, nor expected, to be discharged unless they had met certain discharge criteria. While developing this protocol, we started to follow our average length of stay in the hospital. Prior to developing our outpatient program, our average length of stay in the hospital was 2.3 days. In 2015 the first full year of actively scheduling outpatient hip replacements, our average length of stay dropped to 1.7 days. The following year in 2016, our average length of stay dropped again to 1.3 days. That data was for all total hips, which were full admits to the hospital. We found that in conjunction with the development of outpatient total joint program, our scheduled overnight admissions stayed for shorter periods. In addition, the number of outpatient procedures went up. We believe that as expectations went up for those expected to go home on the same day, so too did the expectations rise for those being admitted to the hospital.
We have recognized that most of the success of this program starts in the office. When patient’s expectations are met with their surgeon’s expectations, the results changed and improved regarding admissions. If a patient is expected to get up and ambulate on the same day as surgery, most of the time they will accomplish that goal. One of the keys to that success is reiterating your desires and goals for patients with the nursing staff and physical therapy teams. We meet regularly (once a month) to review protocols, discuss challenges, make changes when necessary, and adjust plans if patterns that do not work are identified. In addition, in the age of rising medical care costs, increased patient insurance premiums and demand, the discharge of patients in a timely manner will help decrease the overall burden on the system.
The author believes that outpatient total hip replacements have a place in the realm of total joint arthroplasty. The development of that process takes time and effort to coordinate and execute. Our next step will be to include VAS as well as Harris Hip scores, and specifically stratifying those patients who have experienced both an inpatient and outpatient surgery. We also would like to assess the cost savings to the system and compare inpatient and outpatient costs, as has been done in other studies.7 With time, outpatient total joint replacements may become the norm. After all, it was not too long ago when patients were admitted for months on end.
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