EXECUTIVE SUMMARY

Joint replacement patients who meet criteria can be discharged the same day after surgery through a program at NYU Hospital for Joint Diseases.

  • Criteria include healthy patients with no cardiac issues who do not take anticoagulation medication or have obstructive sleep apnea, and have a body mass index less than 40.
  • Patients and their caregivers attend a mandatory educational session that includes information on what to expect the day of surgery and after discharge, how to use assistive equipment, and what symptoms to watch for at home.
  • During the educational session, patients receive their post-surgical prescriptions with instructions to fill them before surgery, and choose a home health provider for physical therapy in the home for two weeks.

At NYU Hospital for Joint Diseases, patients who meet medical criteria, have a caregiver at home, and attend pre-surgical training may be discharged to home the same day they have joint replacement surgery. About 90% of the patients who meet the criteria go home the day of surgery.

The program began in late 2014 with a six-month pilot project spearheaded by orthopedic surgeon Roy Davidovitch, MD, including only his patients who received total hip replacements. The program was expanded in 2015 to include all surgeons and patients receiving knee replacement surgery as well, says Deserie Duran, RN, BSN, assistant director of care management at the New York City hospital.

“The patients get a lot of hand-holding and a lot of attention before, during, and after their surgery. Our team works together to make sure that patients have everything they need for a successful discharge,” Duran says.

A multidisciplinary team including clinical care coordinators, physical therapists, occupational therapists, and physicians collaborated on program development. The team developed criteria for patients who would qualify for the program, and brainstormed ways to ensure patients could be safely discharged on day 1. They worked together to set expectations for the team and the patient and to create the education patients would need, and designated a core group of clinicians to work with patients in the program.

“We wanted to streamline the process and create an ambulatory-like experience in the hospital setting. Not everybody who has joint replacement surgery can be in the program. It’s at the surgeon’s discretion, and there are criteria that patients must meet,” Duran says.

Patients who qualify for the program are generally healthy with no cardiac issues, according to Meghan Rockey, RN, clinical care coordinator. They are not taking anticoagulation medication and do not have moderate-to-severe obstructive sleep apnea. Their hemoglobin must be more than 12 and body mass index less than 40. They must want to go home the same day as surgery and have a caregiver/coach at home who is willing to participate in an education session. The orthopedic surgeons screen the patients and notify the case management department when patients who meet criteria for the program have surgery scheduled.

The key to the success of the program is educating patients and family members or caregivers before surgery on what to expect and what they will need to do after discharge, Rockey says.

Patients who meet criteria for the program attend a two-hour educational session with Rockey — the clinical care coordinator who will see them in the hospital — a physical therapist, and an occupational therapist. The educational session is scheduled on the same day that patients come in for pre-admission testing, usually seven to 10 days before surgery

“We require that the caregiver, who will act as a coach, is present and engaged, understands the process, and will be available during the entire episode of care,” Rockey says.

During the educational session, the clinical care coordinator goes over the timeline for the day of surgery and discusses the medication the patient will be taking and potential side effects.

“We talk about the two main issues that cause problems for joint replacement patients: blood clots and infections. This leads to a discussion of the medication regime, why it is important, and what symptoms and signs indicate that the patient should call the doctor or go to the emergency department,” Rockey says.

They educate the caregiver on what to expect when they are taking care of the patient at home. “Patients and families usually have a lot of questions. We answer all of them and encourage the patients to get back to their regular way life as soon as possible after surgery,” Rockey says.

The physical therapist, who sees the patient after surgery, instructs the patient on how to use the walker or other assistive device and how to use the portable compression device prescribed by the surgeon for prevention of deep venous thrombosis.

Before the patient leaves, the team takes care of discharge details such as giving patients prescriptions for their post-surgical medication and instructing them to get them filled before surgery, and making sure the patient has identified his or her preferred home care agency.

Surgery for patients in the program is scheduled early in the day to give the staff time to prepare the patient for discharge.

In order for patients to be alert shortly after surgery, the surgeons use regional anesthesia and a local anesthetic that gives patients pain relief for 24 to 36 hours without narcotics.

The clinical care coordinator follows the patient throughout the day and coordinates the care and equipment the patient will need at home. The care coordinator calls patients after they get home to ensure the needed equipment was delivered, and to answer any questions or concerns. Patients can call the clinical care coordinator at the hospital or the surgical coordinator from their physician’s office if they have any questions.

Patients have physical therapy in the home for about two weeks, and begin outpatient physical therapy after the follow-up visit to the surgeon.

If patients have any issues with the potential of preventing a safe discharge, they stay overnight as a precaution, Rockey says.

“We make sure they are medically safe and if they need to stay over, we keep them,” she adds.