Same-day Total Joints Set to Surge

Orthopedics

By: Jared Bilski

Published: 7/14/2020

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Efforts to keep patients out of hospitals during the coronavirus pandemic could ultimately increase outpatient demand.


Outpatient total joints currently account for about 3% of all joint replacements performed in the U.S. That percentage is projected to grow to 30% to 50% over the next five years, according to Ritesh R. Shah, MD, chief of orthopedic surgery at Advocate Illinois Masonic Medical Center in Chicago.

Although the coronavirus halted elective surgeries earlier this year and fears of a second wave have created an uncertain future, Dr. Shah believes the pandemic and its aftermath could accelerate the growth of same-day joint replacements as surgeons, patients and payers realize it's best to spend as little time as possible in healthcare facilities.

"The COVID-19 crisis should provide a push for what was already happening across the country," agrees Steven B. Haas, MD, chief of the knee service at the Hospital for Special Surgery (HSS) in New York City. "The number of cases outpatient facilities take on will only increase."

Facilities that want to capitalize on the expected influx of cases by adding a same-day total joints program or expanding the number of procedures they're already performing should focus on the following elements to build programs set up for long-term success.

  • Appropriate candidates. The most important component of a successful same-day joint replacement program is patient selection, according to Dr. Shah. The right candidates often emerge by identifying patients with comorbidities — such as obesity, smoking and diabetes with an A1C greater than 7% — who are unsuitable to safely undergo outpatient procedures.

Selecting candidates for surgery should also involve assessing a patient's physiological status and social support structure to ensure they have the mental fortitude and help they need to recover at home.

Dr. Haas is also a big proponent of putting patients on comprehensive prehab programs and optimizing their pre-op nutritional status to prepare their bodies for the trauma of major surgery and improve their abilities to recover quickly. "Prehab is important because the better condition patients are in heading into surgery, the better condition they'll be in coming out," he says.

Plus, points out Dr. Haas, prehab programs typically involve ensuring patients have realistic expectations of how much pain they'll be in and how mobile they'll be after surgery, as well as demonstrations of the exercises they'll perform while rehabbing.

Dr. Shah, who has been performing outpatient total joint replacements since 2013, says his typical hip or knee replacement patient walks within 40 minutes of surgery and climbs stairs within 70 minutes. About half of his patients are discharged a few hours after their procedures and 90% are ready to head home within 23 hours.

Fledgling programs will likely realize much lower percentages of patients who are ready for same-day discharge. That's to be expected as surgeons and staff grow accustomed to new clinical pathways and make needed adjustments as they gain more experience in managing the entire episode of care.

ROAD TO RECOVERY Patients must be mentally ready and physically prepared to complete rigorous rehab regimens soon after their bandages are removed.

"When surgeons first start performing outpatient total joints, they should select healthier, more active patients and focus on perfecting their surgical techniques and overall program," says Dr. Shah. "As their skills improve and the facility's clinical pathways become more refined, the percentages of patients who are ready for same-day discharge will grow."

  • Skilled surgeons. If patient selection is the top consideration in the success of outpatient total joints, surgeon skill is a close second. Dr. Shah says surgeons need to understand and commit to an approach that prepares patients for same-day discharge. They need to implement blood-conserving techniques and operate efficiently to shorten the amount of time patients are anesthetized.

Surgeons must also use instrumentation designed to minimize muscle and tissue damage in the joint. "I use low-profile instruments and avoid pulling on or tearing muscle," says Dr. Shah, "I also focus on limiting how much tissue I grasp or pinch."

Dr. Haas has developed a surgical technique that involves operating through small incisions and eliminates the need to cut the quadriceps tendon, factors that limit post-op pain and help to prepare patients for same-day discharge. He also points to the tremendous strides orthopedic device manufacturers have made in the design and availability of numerous implants that are better anatomical fits for a variety of patients. Anatomically correct femoral and tibial components improve the post-op alignment of the knee, distribute load-bearing forces more evenly and share the stress and pressure placed on the joint with the patient's natural ligaments and tendons. These factors maximize joint mobility and function after surgery.

Running an efficient and successful outpatient total joints program requires building a group of hard-working professionals who work toward a common goal and are driven to achieve excellent outcomes, according to Dr. Shah.

Members of the nursing staff must understand the importance of direct and detailed communication with patients, and sterile processing professionals must oversee the management, sterilization and storage of large and complex instrument sets. Clinical leaders need to make sure patients move along the clinical pathway efficiently and safely. Facility administrators must manage staffing levels, coordinate the actions of the entire team and ensure they have the resources to do their jobs effectively.

Dr. Haas points out that anesthesia providers should be adept at placing regional blocks to help manage post-op pain. "We use an adductor canal block for the front of the knee, an IPACK block for the back of the joint and an additional periarticular injection to numb the entire area," says Dr. Haas. His patients also receive a spinal or epidural anesthetic.

  • In-house rehab. The quality of care that patients receive in the weeks and months after surgery and the amount of work they put into their rehab regimens are essential to ensuring they achieve the outcomes they expect. Interestingly, this is another area in which the coronavirus is likely to play a role moving forward as limiting in-person care becomes more of a focus for providers and patients alike.

Digital platforms now allow patients to follow prescribed physical therapy programs at their convenience and from the comfort of their homes. The platforms guide patients through personalized exercise routines, record the results of rehab sessions and send them to providers, who monitor the progress of patients and schedule virtual meetings to discuss the next steps of their recovery.

HSS launched a telehealth physical therapy program before the pandemic hit and used it for select patients. The facility has since expanded its use due to COVID-19. Patients go home, get online and work with a physical therapist remotely. HSS plans to expand the remote rehab program over the coming year and study its impact on post-op results.

Piece of the pie

While it may seem like same-day total joints is a massive undertaking that requires a tremendous amount of coordination between different departments, there's great potential for facilities that are up for a challenge. Even if the expected market growth ends up on the low end of the projected 30% to 50% increase, that's still a high volume of total joint cases that could be performed at your facility. OSM

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