Given Medicare’s addition of several orthopedic procedures to its fee schedule, an increasingly graying population and a post-COVID effect that has predisposed...
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How the Perioperative Team Can Optimize Arthroplasty Outcomes
By: Jennifer Parrott, RN
Patient selection, standardization and ERAS protocols help ensure successful results for each and every patient.
Sure, a successful surgery in the patient’s eyes means waking up and knowing they will soon have their mobility and, essentially, their quality of life back. However, for a successful surgery and an optimal patient experience to occur, the process begins well before the patient hits the operating table.
Identifying the right candidates is the first critical step. Once the patient is approved for surgery in our outpatient surgery center, we spend ample time educating the patient and their caretaker, so they know what to expect the day of their procedure, immediately after it and during the recovery process. In this article, we will peel back the curtain to show you how we at OrthoTennessee optimize our arthroplasty outcomes for every patient who comes through our doors.
Our pre-admission nurse is responsible for communicating with the patient to discern if they meet our selection criteria. We utilize a standardized patient selection questionnaire that is located in our electronic charting system. The development of the questionnaire was a collaborative effort among nurses, anesthesia and our governing board. Patients are not approved for total joint surgery here unless they meet all our criteria. For example, for our total joint patients, we have a BMI limit and ask questions about related comorbidities. We also discern if the patient is diabetic. If they are, is it under control? To get a better picture of the patient’s lab values, we request their hemoglobin A1C. In addition, we take anemia into account. We need to find out if the patient is anemic and if so, are their values less than 10? If the answer is yes, they cannot have surgery at our ASC.
In addition to the above-mentioned exclusion criteria, a patient will not be a candidate for surgery if they have a history of malignant hyperthermia or any other comorbidities that places them into an ASA IV classification. We also take into account a patient’s current illnesses; history of COVID-19; alcohol, tobacco or drug consumption; and the medications they are currently taking. Also, the pre-admission nurse will ask the patient if they have a history of difficult intubation. Depending on how they answer, some patients may require an anesthesia consult. The consult can range from a phone call to the patient coming into the facility and meeting with the anesthesiologist and pre-admission nurse. These are just a few of the requirements and questions that the pre-admission nurse will discuss with the patient.
Some patients might feel embarrassed or scared to answer these questions truthfully; however, we always encourage them to be as honest as they can. We clearly communicate with our patients that we do not judge. We just need to know if they smoke, drink or do drugs so we can give the proper anesthetics. We want them comfortable, we want their pain controlled and we want them to have a good outcome. Sometimes it feels like pulling teeth, but if you educate the patients and explain why we need to know this information, they will often open the line of communication and be honest.
Once the pre-admission nurse has the patient’s pertinent information, we send them several forms via secure email that include what to do — and what not to do — before surgery, what happens the day of surgery and what to expect after surgery. We attempt to answer every question our patients may have, and our standardized forms include most or all of the information that people want to know.
In addition, our patients have a 1:1 pre-habilitation appointment with a physical therapist at the surgeon’s office. The therapist educates the patient on all the before, during and after teaching — the same information they receive in their packet from us. The therapist and staff will review physical therapy scenarios and also give them an antiseptic soap to use the night before their surgery. We ask that they go NPO the day of surgery, but we do allow clear liquids up to six hours before their procedure. Keeping patients as hydrated as possible helps to prevent nausea. Many patients do not understand why we ask them to go NPO the night before surgery and think it’s unnecessary; however, we ensure they have a thorough understanding that it helps to decrease the incidence of aspiration. There are also studies that show that patients benefit from having clear liquids in multiple ways, including an improved mental state on the day of their surgery.
Standardization and Enhanced Recovery After Surgery (ERAS) protocols are critical to a patient’s safety and surgical outcome.
Every patient also takes a walker or other assistive device to their pre-habilitation appointment. The physical therapist educates the patient on how to use it properly, so that all they need to do on the day of surgery is bring it with them. It is so important that the patient is prepared prior to the day of surgery so they don’t arrive fearful, anxious or confused.
Our physicians prefer to utilize one pharmacy for our patients’ medication needs. The pharmacy is staffed with experienced professionals who will contact the patient prior to surgery. The patient will either get the medications delivered to their home or the pharmacy staff will deliver them the day of surgery to the patient’s family members. This takes the hassle and stress away from the family and patient trying to get medications filled after surgery. Licensed professionals will also go over all the medications and provide all the instructions that are needed.
Anesthesia and pain control
Standardized anesthesia and post-op pain control protocols are a major component of a patient’s arthroplasty success. We employ a well-considered combination of analgesics and anesthetics that helps our outpatient knee and hip patients be on their way home about four hours after they arrive. We utilize adductor canal and IPACK blocks, the latter of which infiltrates a local anesthetic in the space between the popliteal artery and the capsule of the knee, which works wonders for our knee arthroplasty patients. About 90% of our patients receive spinal anesthesia using a localized numbing agent such as ropivacaine, which greatly reduces the risk for PONV. In addition, we use a combination of IV and PO medications, which include, but are not limited to, alpha blockers, antiemetics, analgesics, NSAIDS and steroids.
When the patient arrives in the PACU, a nurse takes over to monitor their vital signs and administer fluids, antibiotics and analgesics. A cold therapy unit is applied as soon as they get to recovery, which they get to take home with them, that greatly helps with swelling and pain. Once their spinal anesthesia has worn off, the goal is to get the patient up and walking around. For our hip replacement patients, we perform an X-ray to confirm implant placement and scan for any complications. Patients are asked to walk a few different distances with their walkers with the assistance of our trained nursing staff. We also have them walk up and down a few stairs, because everyone has at least one or two stairs somewhere at home.
Every patient receives comprehensive discharge paperwork that details necessary precautions to take, physical activity do’s and don’ts, proper wound care guidelines and medication instructions. The paperwork also notes when their follow-up appointment and physical therapy appointment are scheduled and when they last took their pain medication so they know when they can take another dose. The patient’s caretaker must sign the form, as does one of our nurses, before they can head home.
Standardization is key
Standardization and Enhanced Recovery After Surgery (ERAS) protocols are critical to a patient’s surgical outcome because they improve patient safety by minimizing risk of errors, enhance efficiency of care and boost communication.
Standardization can also decrease cost and waste, which is beneficial to the patient and the facility. Standardized care prevents items and supplies from being opened when they are not needed, keeps the patient from being charged for unused items and relieves the facility from accruing higher costs. The process to approve a patient for a total joint operation may seem daunting, but it is critical that no shortcuts are taken. You wouldn’t want a mechanic to rush while fixing the brakes on your car, would you? By taking all the necessary precautions upfront, we can help ensure optimal outcomes for each and every patient. OSM
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