How Ive Made Outpatient Total Hip Replacement the Rule and Not the - - PowerPoint PPT Presentation
How Ive Made Outpatient Total Hip Replacement the Rule and Not the Exception Keith R. Berend, MD Joint Implant Surgeons, Inc., White Fence Surgical Suites, Midwest Training & Development Services New Albany, Ohio Keith R. Berend, MD
Keith R. Berend, MD
Joint Implant Surgeons, Inc., White Fence Surgical Suites, Midwest Training & Development Services New Albany, Ohio
Keith R. Berend, MD Disclosure
Consultant:
♦ Zimmer Biomet
Royalties:
♦ Zimmer Biomet; Innomed
Research Support:
♦ Zimmer Biomet; Pacira Pharmaceuticals;
Orthosensor; SPR Therapeutics Development Partner: SurgCenter Development
The Future is Now
Average Length of Stay
1991-1992 ♦ Same protocol ♦ LOS: 5-7 days 1987-1990
♦ TKA: Robert Jones dressing ♦ THA: Charnley buttons ♦ All patients → Mini ICU ♦ LOS: 7-10 days
1993-1997
♦ Same protocol ♦ Acute setting: 3 days ♦ Adjacent SNF: 7 days
1997-2002
♦ Regional anesthesia (epidurals) ♦ Soft tissue injections ♦ Acute setting: 3-5 days ♦ Outside SNF: 7 days
2003-2004
♦ Single shot spinals ♦ Rapid recovery protocols ♦ Multimodal medications ♦ LOS: 2.5 days
2005-2011
♦ Minimally invasive surgery ♦ LOS: 1.5 days
2012-2013
♦ Liposome bupivacaine
suspension injection
♦ Same day surgery
Why Do Patients Stay in the Hospital?
Preoperative Education
Reduces Anxiety Decreases Pain Increases Satisfaction
Yoon et al., J Arth 2009 Mancuso et al., CORR 2008 Thomas & Sethares, Orthop Nurs 2008 Pietsch & Hofmann, Orthopade 2007 McGregor et al., J Arth 2004 NIH Consensus Statement on TKR, 2003 Sjoling et al., Patient Educ Couns 2003 Crowe & Henderson, Can J Occup Ther 2003 Liebergall et al., Clin Perform Qual Health Care 1999 Daltroy et al., Arthritis Care Res 1998 Claeys et al., Orthop Nurs 1998 Messer, Orthop Nurs 1998 Lin et al., Orthop Nurs 1997 Gammon & Mulholland, Int J Nurs Stud 1996 Livesley & Rider, Int Orthop 1993
Rooks et al., Arthritis Rheum 2006 Crowe et al., Can J Occup Ther 2003 Liebergall et al., Clin Perform Qual Health Care 1999 Daltroy et al., Arthritis Care Res 1998 Topp et al., PM R 2009 Brown et al., J Strength Cond 2009 Jaggers et al., J Strength Cond 2007 Coudeyre et al., Ann Readapt Med Phys 2007
Reduces anxiety Prepares patient for peri-operative protocols Decreases pain Improves outcomes
Know the route to get there
Meet the staff Allows patients and family to understand that its not a hospital
receive “real” medical care
Who’s a Candidate for Outpatient Arthroplasty at the ASC?
Does the patient have an ongoing medical issue that cannot be
No Does the patient have an organ failure? Yes Postpone surgery until medically
Yes Patient is not a candidate for
medically stable surgery should be performed at a hospital and the patient
No Does the patient have adequate support upon discharge? Yes Surgery can be safely performed as an
No Consider surgery at hospital
Medicare: there is no outpatient code for TKA or THA (PKA OK)
♦ Hospital/ASC ♦ Eliminates most over 65
♦ Different than PKA
In-network vs out-of-network
♦ May determine facility ♦ May change patient responsibility
Identify Organ Failure:
♦ Congestive heart failure ♦ COPD ♦ Chronic renal insufficiency ♦ Hepatobiliary disease ♦ Dementia/SZ disorder ♦ Hematopoietic disease ♦ History of anemia
Make sure organ failure not missed… Medical Optimization:
♦ Referrals to specialists
♦ Identify and optimize OSA ♦ Hemoglobin management ♦ VTE risk stratification ♦ Glycemic control/A1C ♦ Smoking cessation
Renal Disease
♦ Dialysis ♦ Severely elevated
serum Cr Gastrointestinal
♦ History of ileus ♦ Chronic hepatic
disease Genitourinary
♦ History of urinary
retention
♦ Severe BPH
Cardiac
♦ Prior revascularization ♦ CHF ♦ Valve disease ♦ Arrhythmia/Pacemaker
Pulmonary
♦ COPD ♦ Home O2
Untreated OSA BMI >40
– Chronic
Coumadin
– Coagulopathy – Anemia
– Thrombophilia
– CVA – Delirium/demen
tia
transplant
July 1, 2016 to Feb. 28, 2017 Our inpatient cases at Mount Carmel New Albany
♦ 1,543 Hip/Knee/Shoulder procedures:
)
)
)
)
)
)
)
)
)
)
)
)
)
Berend et al IMHS 2017
12/1134 (1.06% )
♦ 2.4%
♦ 0.2%
Demographics:
♦ 1 Male : 11 Females ♦ Preop Hgb 11.5 (9.3-12.7) ♦ EBL: 297 cc (50-900)
Berend et al IMHS 2017
Celecoxib 400 mg PO Pregabalin or gabapentin 600 mg PO
♦ 300 mg if >65 years old
Acetaminophen 1 gm PO Dexamethasone 10 mg IV Metoclopramide 10 mg IV Consider scopolamine patch Perioperative antibiotic TXA 1.4 gm PO 2 hours prior to incision Start crystalloid for resuscitation/hydration
Intraoperatively
Short acting spinal anesthesia Propofol short-acting sedation
± Short-acting inhalants
Ketamine 0.5 mg/kg IV Crystalloid 2 liters IV for resuscitation/hydration Periarticular injection
♦ 50 mL 0.5%
ropivacaine, 0.5 mL 1:1000 epinephrine, 30 mg ketorolac Ondansetron 4 mg IV
Surgical trauma
♦ Minimally/less-invasive techniques ♦ Efficient orchestration of the
procedure
Blood Loss
♦ Tranexamic Acid ♦ Tissue sealer device?
TXA 1.4 gm PO 3 hours after initial dose Urecholine 20 mg PO for BPH/urinary retention Minimum 1 additional liter of crystalloid for resuscitation/hydration Ondansetron 4 mg IV PRN Promethazine 6.25 mg IV PRN Oxycodone 5-10 mg PO q 4 hours PRN Acetaminophen 1 gm PO prior to discharge Hydromorphone 0.5 mg IV q 10 minutes PRN
Celecoxib 200 mg PO QD for 2 weeks Aspirin 81mg PO BID for 6 weeks Antibiotics <24 hours Acetaminophen 1000mg PO TID for 48 hrs Oxycodone 5mg PO 1-2 q4-6 hr PRN Hydromorphone 2mg PO PRN breakthrough Hydrocodone/Acetaminophen 5mg 1-2 q4-6 hr PRN (beginning 48 hrs post-op) Ondansetron 10mg PO PRN Portable ambulatory calf pumps Cryotherapy motorized unit
Healthcare Costs Control of Care Patient Health System Surgeon OUTPATIENT Arthroplasty
Average Charges and Reimbursements
Category Outpatient Inpatient Total Hospital Charge $19,982 $23,087 Total Hospital Reimbursement $12,385 $13,950 Preop Physical Therapy Charges $203 $0 Preop Physical Therapy Reimbursement $134 $0 Postop 1 Week HH Nursing Charges $285 $0 Postop 1 Week HH Nursing Reimbursement $177 $0 Postop 1 Week HH Therapy Charges $149 $0 Postop 1 Week HH Therapy Reimbursement $99 $0 Total Billed Charges $20,619 $23,087 Total Reimbursement $12,795 $13,950
Bertin, CORR 2005
Outpatient Surgery Cost Reduction in THA
Observational, case-controlled 2008-2011 119 THA, DAA, single surgeon, outpatient Compared with inpatient controls (n=78) No different in: complications, EBL Cost:
♦ Outpatient:
$24,529
♦ Inpatient:
$31,307
Aynardi et al., HSS J 2014
Outpatient Arthroplasty at JIS
Joint Implant Surgeons / White Fence Surgical Suites (6/2013-12/2016)
♦
4820 arthroplasty procedures
♦
8.6% stayed overnight
)
nausea/vomiting; OSA precautions
(9/4820)
♦
98% patient satisfaction
Coronary Artery Disease (PTCA, CABG): 5% Obstructive Sleep Apnea: 15% VTE: 4% BPH, Urinary Retention: 18% COPD: 15%
5 (0.34% )
♦ 2 atrial fibrillation (both transferred) ♦ 1 postoperative anemia (transferred) ♦ 1 sudden R foot paresthesia ♦ 1 I&D wound dehiscence
Nonoperative Complications ≤90 Days
Death due to presumed PE @11 days Admit bowel issues @5 days Admit UTI/septicemia @7 days Admit for diverticulosis @40 days Fell & dislocated shoulder @3 days Foley catheterization @3 days ER for chest pain; negative PE @6 days
11 – Wound revision 3 - I&D of hematoma 2 - I&D for infection 4 - Periprosthetic femoral fracture 1 - Closed reduction @ 80 days
Postop Patient Calls to Clinic
198 procedures performed at musculoskeletal specialty hospital (MCNA)
♦ 72 patients (36%
) with 116 calls 126 procedures performed at outpatient surgery center (WFSS)
♦ 31 patients (25%
) with 76 calls (p=0.03) Most common reasons for calls:
♦ Pain control/pain medication refill ♦ Wound issue/swelling ♦ Orders for PT ♦ DVT prophylaxis/compression hose usage
April 2014-May 2017 76 Sites nationally Standardized, surgeon modifiable program >20,000 joint replacements LOS 4 hours 97% Home same day 0.4% Readmission rate 0.1% Combined Infection Rate
Eliminate the ”need” for a hospital
♦ Fear/anxiety, risk, side-effects
Regimented and structured perioperative program Multiple stakeholders share in reward 2.2% 90 Day readmission/complication 98% Good/Excellent Satisfaction