The thought of outpatient total hip replacement would have been unbelievable just a few years ago, when the surgery lasted 2 to 3 hours and the post-op hospital stay was measured in days, not hours. But today we routinely discharge patients 3 hours after their surgery so that they're home in time for dinner.

The well-choreographed day of surgery looks like this. The patient meets for about an hour in the morning with a nurse to review the surgery, medications and home care. The surgery takes about 45 minutes, then there's recovery and a 40-minute walking-light therapy session. Many facilities arrange for a patient to spend the first post-op night or two in a nearby hotel, but we let the patient recover at home, where nurses and physical therapists will visit. How do we make this happen? Here are 3 keys to success with same-day hips.

1 Follow a set day-of-surgery routine

At our facility, we conduct up to 4 to 6 total joint surgeries at a time, but we generally have several other procedures scheduled as well, so it becomes crucial to have a set plan that surgeons, nurses and administrators are clear on, and ready to carry out.

A day of surgery starts with a patient arriving 90 minutes before his scheduled start time. We schedule all of our total hip and knee procedures for the morning. Our doors close at 5 p.m. and we want to give patients adequate time to recover following the surgery before they have to go home.

Our patients have already met with many of the team members — including the surgeon, anesthesia provider, a nurse and home therapy helpers — in earlier consultations, so they're comfortable with the staff members and more at-ease the morning of surgery.

In the pre-op meeting, a nurse explains to the patient exactly what the procedure entails, including what medications we'll prescribe for him and what physical therapy exercises he'll need to do in the coming days. The nurse's goal in this step is to make the patient feel as comfortable and confident as possible going into surgery.

The nurse also assures our patients that they'll likely be going home within 3 hours following their procedure. Creating that expectation not only lets the patient know it's possible, but also leaves them feeling like they ?should ?be leaving the center soon. Our goal is to rid patients of the myth that total hip surgeries require at least a full day's stay in the surgical facility.

After meeting with the nurse, the patient goes into surgery, which lasts for about 45 minutes to 1 hour. In PACU following the procedure, nurses act as both nurse and physical therapist, helping the patient start to move as his anesthesia begins to wear off. The nurse helps the patient get in and out of chairs, walk across a flat surface, and walk up and down a flight of stairs. The exercises together last for about 40 minutes, after which nurses contact the home nursing agency and prepare to send the patient home for surgery — all within a few hours of them arriving.

2 Plan out the procedure

You can make sure your total hip operation is far more efficient by planning out a roadmap of the procedure. Our facility does this with the help of orthopedic digital templating. We take the standard X-ray of our patient's hip and put it into our templating computer program. The program comes with all sizes of implants already in its system, letting us fit an implant against a picture of the X-ray to decide on the general size of the implant. It also lets us visualize where to make our cuts and determine the anteversion and abduction of the acetabular component of the implant.

Using digital templating to estimate implant size can be remarkably accurate. A 2016 study that used digital radiographs to retroactively template total hip replacements found that the digital system predicted the accurate prosthesis within 1 cup size in 96.6% of cases and within 1 stem size in 97.8% of cases.

I often hear from surgeons who want to take an X-ray in a surgery center but that it's difficult to organize because of space. You need an X-ray processing machine or a C-arm, which can be both expensive and difficult to store. Your center should decide whether the investment is cost-effective for your facility. Templating orthopedic procedures will save you an enormous amount of time in the OR, as you'll know the right implant — often within 2 mm of the implant you end up using — and where to make your cuts

3 Non-opioid pain control

Managing a patient's pain is a huge part of making your total hip procedures more efficient, especially in an outpatient setting. The less pain a patient feels following a surgery, the more ready he is to return home within hours. However, I try to avoid opioids like hydrocodone and oxycodone and instead give my patients tramadol for breakthrough pain. I've found that opioids are not entirely necessary for hip replacements, and that tramadol acts as a more moderate, non-narcotic pain reliever.

Discharging a patient in 3 hours? Yes, at first we were skeptical about the concept of hip replacement without a hospital stay.

For my practice, pain management starts in the office when I meet with patients for a consultation day around 2 to 3 months before their procedures. I ask each total hip patient what medications he's currently taking for pain, to rank his pain on a 1-10 scale and I ask whether his medication helps reduce that pain. Those simple pre-operative questions can give you a strong sense of how to handle your patient's pain following the procedure.

For example, if a patient ranks his hip pain as a 7 and says that ibuprofen controls that pain, I'll suggest he continue taking ibuprofen — rather than a prescription painkiller — following the procedure. I've found that whatever the patient takes for his hip pain before the operation generally controls his post-op pain as well.

On the day of surgery, we give patients several preemptive pain medications, including 1 g of acetaminophen and 400 mg of celecoxib, both given orally. We stopped giving intrathecal narcotics such as morphine, as they can lead to nausea and urinary retention — conditions that often delay discharge.

Of course, there's always a risk of nausea following major surgery, so we've started giving dexamethasone to patients pre-operatively. We'll administer a 10 mg injection of the corticosteroid just before surgery and the home health nurse will administer another 10 mg injection the next morning. A 2011 article that examined the effects of dexamethasone on post-op nausea and vomiting found that it prevented early and late vomiting in adults in every 1 out of 7.1 cases and that dexamethasone was equal to or better than other antiemetic drugs in preventing PONV.

Outpatient total hips?

At first we were skeptical about the concept of hip replacement without a hospital stay. Discharging a patient in 3 hours who just underwent a bloody and painful surgery that usually requires 2, 3 or more days in a hospital is pretty ambitious. But like most things, we've found our success by focusing on the fundamentals: patient education, a structured surgical day, physical therapy and home nursing care. OSM