The Tenets of Total Joints

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Establishing a standardized care pathway and looking beyond current best practices will lead to long-term success.


Lee Rubin, MD, held his iPhone up to his computer’s webcam during a recent conference call to show the participants video proof of how well patients do after joint replacement surgery when advanced pain control practices meet minimally invasive surgical techniques. A short clip showed a woman with a walker moving with purpose through a hospital hallway. “This was 90 minutes after she had her hip replaced,” said Dr. Rubin, a hip and knee specialist at Yale Medicine and an associate professor at Yale School of Medicine in New Haven, Conn. “See how fast she’s walking? I had trouble keeping up.”

The woman was one of the hundreds of patients who’ve had their knees and hips replaced by Yale Medicine surgeons since 2018, when a building on the health system’s main campus was renovated and turned into a hospital outpatient surgery space dedicated to providing cutting-edge orthopedic care. 

Having the resources and experts on staff to develop innovations in outpatient surgery — and test their effectiveness through clinical research — keeps Yale Medicine at the forefront of what’s happening in same-day joint replacements. “Enhanced pain management protocols have empowered us — along with the minimally invasive techniques of surgeons and the incredible work of our physical therapists who work with patients in post-op — to discharge patients on the day of surgery,” says Jinlei Li, MD, PhD, Yale Medicine anesthesiologist and an associate professor at Yale School of Medicine.

 

Elements of the health system’s standardized care pathway for joint replacement patients provide a blueprint for launching and running a successful program. 

Patient selection. Surgeons must use pre-op clinic appointments to get a feel for which patients are candidates to have their joints replaced in the outpatient setting, according to Dr. Rubin. “They have to be motivated and enthusiastic about the prosect of being discharged on the day of surgery and have a strong support system in place at home,” he says.

To help quantify the appropriateness of a patient for same-day care, the Yale team developed a standardized Ortho Risk Score, a numeric rating based on the patient’s health history, current health status and comorbidities. The lower the number, the healthier the patient and the fewer risk factors they have. The care team uses the dashboard to help guide the patient selection process; patients with risk scores of five or below are greenlit for outpatient surgery. “The numerical score streamlines the medical decision made about where we operate on patients,” says Dr. Rubin.

Patients must still meet the health system’s strict criteria for undergoing outpatient surgery, and surgeons and anesthesia providers have collaborative discussions if questions arise about a patient’s candidacy. “It’s important to establish an appropriate forum for members of the care team,” says Dr. Rubin. “Their ability to communicate on the shared decision is crucial.”

Patients who are approved for outpatient surgery are assigned a nurse navigator, who coordinates the care plan among the multidisciplinary team of providers and communicates with patients to ensure they know what to expect before, during and after surgery — and understand the responsibility they have in working toward positive outcomes.

Pain management. About eight years ago, Dr. Li realized targeted pain relief — beyond the use of epidurals and continuous nerve blocks — was needed to decrease the lengths of stay of the health system’s joint replacement patients before the procedures could move to the outpatient arena. She added steroids to the anesthetics used in continuous nerve blocks and began mixing “Yale Cocktails,” concoctions of short-acting dexamethasone and long-acting methylprednisolone that are placed around nerve blocks to extend their analgesic effect — resulting in lower pain scores and less opioid consumption — for at least 48 hours in most patients and a day or two longer in some.

The steroid-enhanced nerve cocktails have been transformative, according to Dr. Rubin. “Hip replacement patients have essentially no pain and we’ve been able to cut the amount of opioids we prescribe by 50% or more from where we were just a few years ago,” he says. “One-third of total knee patients report experiencing no pain, and the other two-thirds have tolerable pain.”

HEALING AND HAPPY Patients who actively participate in their own care are more likely to achieve positive outcomes and recommend the procedures to their friends and family.

Surgeon expertise. Dr. Rubin is a proponent of employing the direct anterior approach during hip replacements, a technique that avoids cutting through muscle and allows patients to move functionally soon after surgery — leading to less post-op pain and more rapid recoveries. He says the anterior approach also allows for more accurate implant placement and reliable outcomes.

During knee replacements, Dr. Rubin has reduced tourniquet time — he applies one for about 20 minutes as he places cement around the implant at the end of the procedure — to lessen compression on the upper thigh, which can cause muscular injury or stasis. He makes bone cuts without the tourniquet inflated to perform dissection under hypotensive anesthesia, which allows for a meticulous hemostasis that lets him identify punctate bleeders around the joint and cauterize them as part of his surgical approach.

Dr. Rubin has also standardized the use of tranexamic acid (TXA) during knee and hip replacements to reduce intraoperative blood loss. He administers an IV dose at the beginning of cases and injects 100 ml into the knee or hip after closing the muscle layer at the end of procedures.

The administration of TXA is confirmed during pre-procedure time outs and discussed during post-op debriefings. “It’s important for the care team to have these types of conversations before and after surgeries to ensure no element of the patient care protocol is missed,” says Dr. Rubin.

He has access to computer navigation technology and uses it selectively to plan surgeries for patients with complex joint disease. Another hospital within the Yale health system has invested in two robots that are used for outpatient knee replacements. “Any technology that enhances the accuracy of component placement has the potential to give the surgical team more confidence in their ability to get patients up and walking sooner after surgery than they did in the past,” says Dr. Rubin.

Monitored recoveries. During recoveries from hip and knee replacement surgery, patients spend about an hour with members of the nursing team and another couple of hours with physical and occupational therapists before discharge. It’s a structured process based on positive reinforcement. Dr. Rubin says Yale providers reworked the language of the joint replacement program’s protocols to provide guidance on what should be done instead of what must be avoided.

We moved away from prohibitive education, because studies show it doesn’t benefit patients.
— Lee Rubin, MD

“We moved away from prohibitive education, because studies show it doesn’t benefit patients,” says Dr. Rubin. “It actually causes more anxiety and doesn’t reduce rates of complications.”

For example, patients are reminded to ask for assistance before getting out of bed thanks to the effectiveness of Dr. Li’s pain management cocktails. (Remember Dr. Rubin’s phone video?) “They feel so comfortable that they forget they just had major surgery,” she says. “We don’t want them to fall.”

Yale Medicine partnered with a home health company that sends nurses to patients’ homes the day after their discharges and the health system’s nurse navigators contact patients to check on their recoveries. Patients return 10 to 14 days after surgery for a wound check with a physician assistant and schedule a full follow-up appointment with their surgeon around six weeks post-op. At any time during their recoveries, patients can call a hotline to reach a nurse navigator if they have concerns or questions that need an immediate response.

Dr. Rubin points to the emergence of telemedicine and patient communication apps as a significant development in the post-op care of joint replacement patients. Yale Medicine’s EMR platform has a module that allows patients to send messages to residents, nurse coordinators, nurse navigators and physician assistants, who can quickly reply. Patients can also send pictures of their wounds if they have questions about the healing process or how the dressings look. They receive reassurance that all is well or are asked to come into the clinic for follow-up care.

“Joint replacement programs need to provide multiple avenues for patients to communicate with providers,” says Dr. Rubin. “Patients who need follow-up care shouldn’t end up in the ER. Being able to manage patients remotely improves their outcomes in a more cost-effective way.”

The pandemic has normalized virtual communication between patients and their providers. Yale Medicine recently surpassed one million telemedicine visits since the start of the pandemic in early 2020 after not previously offering the service. “Patients expect to interact with their providers through some form of technology,” says Dr. Rubin. “Virtual communication platforms are evolving into the standard of care. Giving patients multiple ways to reach out is an essential calling card for today’s providers.”

Future developments

CONSTANT CONTACT Today’s joint replacement patients expect to have multiple ways to interact with members of their care team before and after surgery.

Yale Medicine’s surgeons, nurses, anesthesia providers and health system pharmacists are collaborating to update the standardized protocols of the joint replacement program so it can be used across the health system’s 10 hospitals. “Having a standardized evidence-based program in place means we can roll it out to new facilities,” says Dr. Rubin. “We’ve shown through data and published research that our protocols are best practice, which allows more patients to benefit from the care we provide. We’re going to bring these best practices to their communities.”

Providers across the country have worked hard to normalize same-day joint replacement surgery and increasing numbers of patients are expecting to head home soon after their procedures. That will continue to increase the already high demand for outpatient care. Insurance companies are also pushing patients to undergo the more cost-effective treatment option, so the momentum of moving cases to the outpatient arena shows no signs of slowing down.

“Patients who have a positive experience and feel very little pain are enthusiastic about the experience, and their enthusiasm drives the next group of patients who want to have their joints replaced in the ambulatory setting,” says Dr. Rubin.

Dr. Li encourages providers to look beyond current best practices as demand for the procedures continues to climb. “I know better is the enemy of good,” she says, “but sometimes you have to realize there are ways to improve patient care.”

Progress in outpatient joint replacements will be incremental, according to Dr. Rubin, who points to the slight but game-changing improvement Dr. Li made to Yale Medicine’s pain management practices. “She got the dosing just right and the result has been like magic,” he says. “Change doesn’t happen in a vacuum. It’s small steps along the way made by a team of dedicated providers.” OSM

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