Optimizing Patients for Superior Total Joints Outcomes

Rely on data for planning and team building for results.

Optimal total joints outcomes require a multidisciplinary approach that begins long before the day of surgery.

This all-hands-on-deck commitment can only be achieved with strategic, advanced planning.

At Constitution Surgery Center East in Waterford, Conn., we perform more than 1,000 total joints cases each year. We have six surgeons, many of whom are fellowship trained, who perform robotic and non-robotic total joints. Here are the processes and protocols that are integral to our total joints program.

Data rules everything

Everything we do is outcome-driven. We rely heavily on the data we gather from patient-reported outcome measures (PROMs), the standardized questionnaires that patients use to report their health status and experiences with their health care. To optimize patients for their upcoming surgery, we rely on this multipronged strategy for success:

• Patient education. All our providers go through a goals and outcomes list with the patients. We ask questions aimed directly at what they ultimately want to achieve — Do you want to be able to run a marathon? Play pickleball? Walk with your grandkids again?

Patient education is vital to the success of these cases. Total joints are major surgeries, and patients need to be informed of what to expect. We ensure this by requiring a mandatory total joint education session for every patient who has a total knee or a total hip done at our center. It’s all or nothing. If a patient does not attend, their surgery is canceled. There is zero tolerance for non-attendance.

The classes are offered twice a week at the surgery center. A couple of our other nurses and I run the sessions. The class is usually about 90 minutes long. While we briefly touch on the anatomy of the affected knee or hip, most of the time is spent talking about what happens leading up to surgery, what to expect on the day of the procedure and, most importantly, what to expect after surgery.

That’s the big one. Patients need to understand that there will be some pain, and that they will need to put a lot of work into their physical therapy to ensure a smooth recovery. We stress to patients that they must be an active participant in their own rehabilitation. And that rehabilitation starts virtually right away: Within 30 minutes of hitting the recovery room, we get them out of bed and they are standing and walking to a chair.

• Multimodal pain management. In the past, providers prescribed opioids more freely than they do today because we were taught that the fifth vital sign is pain. If you didn’t ask about pain and treat it over-aggressively, you were viewed as negligent, so we prescribed opioids as the patient’s primary means of pain control.

A multimodal pain management program is based on finding effective non-opioid alternatives. We use a long-acting nerve-blocking agent that numbs the nerves around the knee for 12 to 18 hours postoperatively. For further pain management, we administer an extended-relief nerve-blocking agent, liposomal bupivacaine, that can provide pain relief for up to 36 hours postoperatively. With total knees, we can go a step further by offering cryoneurolysis treatments. Interested patients come in a week or two before surgery and the anesthesiologist uses an ultrasound-guided device to freeze the six genicular nerves on the anterior portion of the knee. This numbs the front of the knee for about 90 days, and there is no surgical incision pain, although some patients still experience posterior capsule pain in the back of the knee.

Our multimodal techniques have resulted in a significant decrease in opioid usage among our total joints patients. Using these techniques, we eliminate a large percentage of the pain so patients can better participate in physical therapy. Our patients are hitting their range-of-motion points faster, which ultimately improves their overall outcomes.

Managing patients’ pain is probably the single greatest thing you can do to create successful total joints outcomes.

• Physical therapy. Early on in our program, we partnered with a physical therapy company. We coordinate directly with their physical therapists who visit our patients at their homes. This coordination is comprehensive. Because our patients are discharged same-day, the physical therapist is waiting in their driveway when they get home. Their sole purpose on that day is to assist the patient into the house, get them settled and perform an initial assessment.

Preventing surgical site infections

ACTIVE PARTICIPANT Preoperative education must center on the patient’s own role in preparing for and recovering from total joint surgery.

Infection prevention plays a pivotal role. The first step is proper prepping of the skin. Our multistep skin prep process is thoroughly discussed in the preoperative patient education class, where we provide patients two packages of antibacterial chlorhexidine gluconate (CHG) wipes. We go over instructions on how to use the first package of wipes the night before surgery, after they take a shower, to cleanse their entire body to aid in the decolonization of any staph. Patients are instructed to use the second package of wipes the day of surgery. This way, by the time they walk through our doors, they’ve already had two steps of decolonization with CHG wipes. Once they arrive at the center, we prep the patient in our preoperative room with more CHG. They are prepped again with CHG in the OR by the surgeon prior to incision.

When our total joint patients come in for surgery, they get crop-dusted with antibiotics. Our surgeons’ favorite is cefazolin. Ample data shows that intraosseous administration of antibiotics can reduce periprosthetic infections and help reduce side effects. The intraosseous antibiotic most of our total joint surgeons use is vancomycin.

Anesthesia expertise

Anesthesia is an invaluable resource when you are trying to make improvements to your total joints line. We are fortunate to have a team of four anesthesiologists and four nurse anesthetists who work exclusively at our facility; they’re not part of a larger group, and they don’t work at the hospital.

On the day of surgery, they meet the patient the moment they enter the pre-op area, introduce themselves and do their assessment. There is always an anesthesiologist stationed in the OR and another elsewhere in the perioperative area. For the nursing staff, there is always an anesthesiologist when needed. There is no delay in any type of care.

We employ regional nerve blocks and general anesthesia for total hips and knees. Our length of stay in the recovery room for a total joint patient is about an hour and 45 minutes to two hours. When patients come out of the OR and into recovery, they’re already awake, and we get to work right away. We start the rapid recovery process upon arrival to PACU.

Village mentality

It really does take a village to make it all work. We have five ORs, a staff of more than 70, and we move up to 40 patients a day through our facility. That type of throughput doesn’t happen without a highly efficient, dedicated team. Everybody is vested in this, and what makes it all work is clear communication across the board.

We use an electronic medical record, and everyone from the referring offices to the anesthesiologists has encrypted access to it. Nurses go through every single chart to ensure each patient meets our admission criteria.

Cross-training helps immensely with communication. It’s something I am very insistent upon. The hardest thing to prevent in an ASC is compartmentalization of staff. If your team is compartmentalized, you won’t get the right level of communication and buy-in. Many of our nurses work in pre-op but also as circulating nurses in the OR. When you are hired as a pre-op or PACU nurse at our facility, you are required to float between the two departments. Staff are rotated daily and weekly. It fosters an appreciation for the vital role everyone plays in the process and keeps things from getting stagnant or stale.

Room for improvement

We’re incredibly proud of our total joints program, but we know there’s always room for improvement. It all goes back to a team approach. Making sure that nothing is an authoritative function, that everyone operates as a team — that is how you continue to improve and how your patients achieve optimal outcomes from start to finish. OSM