EXECUTIVE SUMMARY

Researchers found that a rapid recovery protocol works well with total joint arthroplasty cases, giving patients positive results in an ASC.

  • Investigators examined 1,000 total hip and total knee arthroplasties performed over more than two years.
  • The infection rate was less than 1%, and the readmission rate was 1.5%.
  • The rapid recovery protocol included mobilizing patients quickly and offering them a hospitality experience during their ASC stay.

As ASCs increasingly add total joint arthroplasty (TJA) to their services, administrators need to find ways to ensure patient safety and fast recovery. One recent study showed that a rapid recovery protocol works.1

With the rapid recovery protocol, TJA patients can achieve the same positive results in a same-day surgery setting as they would in a hospital, says Peter Daly, MD, study co-author and vice president, Summit Orthopedics in Woodbury, MN. “For example, on day one, patients in our study ambulated 300 feet,” he says. “The outcomes are very good.”

Daly and colleagues examined 1,000 primary, total hip, and total knee arthroplasties performed from March 2014 to May 2016. All patients were 66 years of age or younger and met ASC inclusion criteria. Patients were discharged within 24 hours after surgery to postoperative care suites. The results were a low infection rate of less than 1% and a hospital readmission rate of 1.5%. Early or unplanned access to care was 11.7%. Pain scores improved 71% for total knee and 81% for total hip patients.

“Outpatient total joints have resulted from a combination of multiple advances in medicine, not only surgical but also anesthesia advances, regional anesthesia, and better preoperative optimization of patients,” Daly observes. Patients are better prepared for total joint surgery, and there are more reliable rehabilitation methods, including immediate mobilization. The rapid recovery protocol mobilizes patients quickly and offers a hospitality experience during a brief, post-surgery stay at the center. The protocol works thusly:

Begin process preoperatively. “Rapid recovery begins on a preoperative basis, and that’s such an important point,” Daly says. “A lot of total joint programs have these two-hour, total joint classes with 20 patients having hip or knee replacement and having them meet someone to tell them what to expect. We did this on a one-on-one basis with a nurse practitioner, who does patient coordination for the total joint program.”

The nurse practitioner meets with each patient individually for one to two hours and explains all pre-op instructions, including what to expect from rehabilitation, what to expect on the first day, arranging outpatient medications, which family and friends would be helping the patient, and touring the facility.

Provide multimodal pain management program. The rapid recovery protocol calls for reducing pain and eliminating nausea. Patients take an anti-inflammatory on the day of surgery. They also take IV Tylenol and an IV medication to reduce bleeding, as well as appropriate regional nerve blocks and local anesthetics, Daly says. “Lastly, we inject Exparel, which is a long-lasting Novocain-type medication that dentists use,” he says.

Exparel’s ability to numb pain lasts for several days, instead of the typical eight to 12 hours. Using this agent helps reduce patients’ need for narcotics, he adds. “Patients aren’t lightheaded as they are with narcotics, so they can participate in rapid recovery right away. They’re also not nauseated or constipated from narcotic side effects,” Daly says. “This allows patients to participate in rehab and get up and move right away.”

Physicians also inject a regional anesthetic around the hip or knee wound area. “We want patients to walk 500 feet within five hours from the time of surgery, not the next day,” Daly explains. “Our anesthesia choice is general anesthesia instead of spinal anesthesia.”

With general anesthesia, patients wake up quickly and can begin to walk sooner than they would with spinal anesthesia, which takes longer to wear off. “We don’t want the patient to have a spinal anesthesia that does not wear off adequately, meaning the patient is unable to urinate in bags and attachments,” Daly says. “We want them to move right away.”

Put patients on their feet. “We get them walking as soon as they are awake and alert and can demonstrate sufficient balance and strength to move at three hours post-op,” Daly says. “We have the nursing staff ambulate the patient, and then we either discharge them to home or to our care suites.”

The protocol includes everything that might help a patient recover quickly and move sooner, including giving patients three liters of IV fluids within the first 18 hours. “If you’re dehydrated, you are more sluggish and can’t participate as well,” Daly says. “They receive the liters of fluids before and during surgery.”

Offer patients a recovery suite. Some surgery centers that handle total joint cases will discharge patients to a hotel with a private duty nurse and provide transportation to physical therapy sessions and to see the surgeon for follow-up appointments. But Summit Orthopedics’ model is to offer concierge service and a recovery suite that is separate but also housed within the facility, Daly notes.

“That’s a distinct differentiator of our same-day surgery program,” Daly says. “We want patients to have a hospitality experience, and we want to control the environment they’re in.”

Summit maintains a separate home healthcare licensure and a home health nursing licensure. The recovery suite is in the surgery center, but patients enter the suite through a separate entrance, as required by Minnesota licensure rules. When patients are discharged from the surgery center, they transition to a home health nursing site that is similar to a traditional care unit, except it cannot dispense medication (although patients arrive there with medications they need for that period), Daly explains. “They have a nurse available and a crash cart and back-up carts,” he says. “We encourage patients to stay overnight in our care suite.”

The hospitality part of the experience includes a large-screen television, a refrigerator with spring water, and a meal catered from a restaurant. “We want patients to feel well cared for,” Daly says. “We have safety and hotel-grade amenities in the suite.”

In the morning, a physical therapist reviews goals with the patient and reinforces their discharge instructions. “They leave in the morning when they get their things together,” Daly says. “We encourage patients to have a family member stay with them. If they can’t arrange that, then we have a nurse with them.”

Since the total joint cases are paid through a bundled price, the care suite stays are at no extra charge, he adds. Some physicians have asked Daly about how the ASC can provide the care suite experience at no charge without it affecting the bottom line. He tells them that it costs the center, but the expense is worth it because it is a great benefit for patients, leading to more satisfaction. “It pays us back multiple times with the good results we get,” he says. “We think it’s safer and provides higher quality medicine.”

REFERENCE

  1. Hoeffel DP, Daly PJ, Kelly BJ, Giveans MR. Outcomes of the first 1,000 total hip and total knee arthroplasties at a same-day surgery center using a rapid-recovery protocol. J Am Acad Orthop Surg Glob Res Rev 2019;3:e022.