Outpatient surgery and early discharge is the hottest topic in hip and knee arthroplasty and will continue to be in the coming years: It is expected that over 50% of all hip and knee arthroplasties will be performed in the outpatient setting by 2026. Currently, a central text that encompasses all of the unique aspects of performing hip and knee arthroplasty in the outpatient setting does not exist. Furthermore, as surgeons across the US and abroad are incentivized and encouraged by government and commercial payors, as well as patients, to perform these surgical procedures in the outpatient setting, the educational material must be available to disseminate the unique perioperative and surgical strategies and techniques accordingly.
This book is unique in that it will address all the essential elements and considerations to promote surgeon success in this endeavor and enhance patient safety through the transition of hip and knee arthroplasty into the outpatient setting, as well as how to implement such a program into practice. Topics discussed include patient selection, medical optimization and risk management, anesthetic surgical techniques, pain management protocols, and postoperative physical therapy. Later chapters cover practical issues surrounding outcome metrics, discharge criteria, minimizing patient readmissions, financial considerations, and additional implications for hospitals, ASCs and payers.
Filling a glaring gap in the literature on this popular new topic, Outpatient Joint Replacement is an ideal resource for orthopedic surgeons, notably hip and knee specialists, as well as residents, fellows and supporting clinical staff.
Author(s): R. Michael Meneghini, Leonard T. Buller
Publisher: Springer
Year: 2023
Language: English
Pages: 193
City: Cham
Preface
Acknowledgements
Contents
Chapter 1: Patient Selection for Same-day Discharge: Medical and Surgical Risk Assessment
Introduction
Medical Evaluation and Patient Selection
General Medical
Hematological
Cardiac
Endocrine
Gastrointestinal
Neurological/Psychological
Renal/Urology
Pulmonary
Infectious Disease
Perioperative Optimization
Barriers to Early Discharge in TJA
Conclusion
References
Chapter 2: Medical Optimization and Risk Mitigation for Readmission
Introduction
Modifiable Versus Non-modifiable Risk Factors
Patient Modifiable Risk Factors and Current Evidence
Diabetes
Obesity
Malnutrition
Smoking
Vitamin D
Staphylococcus Aureus Screening
Inflammatory Arthropathies
Antibiotic Prophylaxis
Conclusion
References
Chapter 3: Surgical Appropriateness for Outpatient TJA in an ASC
Introduction
Ambulatory Surgery Center Versus the Hospital
Selection of Patients
Selection of Cases
Educating the Patient
Anesthesia and Pain Management
Postoperative Care and Follow Up
23-Hour Observation and Transfer Agreements
Conclusion
References
Chapter 4: Essential Components of Preoperative Education and Planning
Introduction
Influence of Bundled Payments on the Patient Experience
Traditional Preoperative Joint Replacement Education
The Effect of the Migration Towards Outpatient TJA
Setting the Foundation of Patient Expectations
Addressing Patient Anxiety Preemptively
Understanding Patient Comprehension and Limitations
Family/Caregiver Preparedness
Evolution of Education Techniques
Conclusion
References
Chapter 5: Multimodal Pain Management Protocols for THA and TKA
Introduction
Anti-Inflammatories and Acetaminophen
Gabapentinoids
Steroids
Opioids
Neuraxial Anesthesia
Peripheral Nerve Blocks
Periarticular Injections (Pais)
Conclusion
References
Chapter 6: Surgical Techniques and Protocols to Minimize Blood Loss and Postoperative Pain
Introduction
Blood Management
Preoperative Optimization
Intraoperative Blood Management Strategies
Postoperative Pain
Tourniquet Use
Tranexamic Acid
Incision Length and Surgical Technique
Conclusion
References
Chapter 7: Anesthesia for Outpatient TJA: Anesthetic Techniques and Regional Blocks
Preoperatively
Patient Optimization
Multimodal Pain Control
Intraoperatively
Spinal Anesthesia
General Anesthesia
Regional Anesthesia for the Hip
Regional Anesthesia for the Knee
Anesthesia Adjuncts for Pain Control
Fluid Management
Blood Loss
Intraoperative Treatment of Nausea
Postoperatively
Pain Management
Nausea and Vomiting
Urinary Retention
Sample Outpatient TJA Anesthesia Protocol
Appendix 1: Indiana University Health Saxony hip and Knee Center Call Orders for Postoperative Urinary Retention
Criterion for Oliguria Indication
Appendix 2: Indiana University Health Saxony hip and Knee Center Multimodal Perioperative Pain Protocol for Outpatient Arthroplasty
Prior to Arrival for Surgery
Preoperative Unit
Intraoperatively
References
Chapter 8: Threats to Same Day Discharge: Prevention and Management
Introduction
Poor Pain Control
Urinary Retention
Hypotension and Tachycardia
Hypoxia
Nausea and Vomiting
Unable to Safely Meet Physical Therapy Discharge Criteria
Conclusion
References
Chapter 9: Is there an Optimal Place for Outpatient TJA: Hospital, ASC, or “Other”?
Patient Mindset
Differences in Cost
Recommendations for Same Day Discharge
Outcomes
Conclusion
References
Chapter 10: Navigating the Limitations and Obstacles of TJA in a Free-Standing ASC
Patient Selection
Space—A Different Frontier in an ASC
Instruments
Sterile Processing
An ASC is an Island
Everything Moves Faster
Anesthesia
Physical Therapy
References
Chapter 11: Same-Day Discharge in the Hospital: Resources and Program Elements
Introduction
Reasons to Consider Outpatient TJA in Hospital Setting
Implementation of Outpatient TJA in Hospital Setting
Experiences with Outpatient TJA in Hospital Setting in the Literature
Conclusion
References
Chapter 12: Discharge the Day of Surgery: Strategies to Optimize and Discharge Criteria
Preoperative Visit
Patient Selection
Anesthesia and Pain Management
Surgical Technique and Coordination in the Operating Room
Postoperative Care and Physical Therapy
Medical Discharge Criteria
Post-Discharge Follow-Up
Conclusion
References
Chapter 13: Staying Connected with the Patient after Discharge: Strategies and Resources
Introduction
Options for Staying Connected
Role of Telemedicine and Electronic-Based Follow-Up
Conclusion
References
Chapter 14: Physical Therapy Following Same-Day Discharge Total Joint Arthroplasty
Introduction
Critical Factors for Successful Same-Day PT and Discharge
Role of Prehabilitation
Day of Surgery Physical Therapy Protocols
Post-Discharge Physical Therapy Protocols
Conclusions
References
Chapter 15: Strategies to Minimize Patient Anxiety, Emergency Room Visits, and Readmissions Following Outpatient Total Joint Arthroplasty
Introduction
Anxiety and Patient Outcomes
Reducing Patient Anxiety
Reducing Caregiver Anxiety
Reducing Surgeon Anxiety
ER Visits and Hospital Readmissions
Reducing ER Visits
Reducing Readmissions
Useful Tools for Reducing Anxiety, ER Visits, and Readmissions
Apps for Patients and Caregivers
Assessment Tools for Surgeons
Conclusion
References
Chapter 16: Making the Transition to Outpatient: Resources and Pathway Changes
Introduction
Patient Selection
Preoperative Optimization/Clearance Pathways
Education
Anesthesia
Same-Day Discharge Criteria
Staying Connected
References
Chapter 17: Outcome Metrics: What to Measure Now and in the Future
Introduction
Assessing Success: Patient-Report Outcomes and Satisfaction Scores
Assessing Safety: Complications
Assessing Failure: Readmissions
Assessing Costs: Healthcare Costs in the CJR Era
Conclusion
References
Chapter 18: How to Mitigate Risk for Surgeons, Institutions, and Patients
Introduction
Reducing Patient Risk
Reducing Surgeon Risk
Reducing Institution Risk
Conclusion
References
Chapter 19: Financial Considerations for Surgeons in the Outpatient Setting: Costs and Ownership Models
Introduction
Develop a Business Plan
Specific Steps Required to Develop a Comprehensive Business Plan for TJA
Creating and Meeting with the Implementation Team
Sources and Uses of Funds
Initial Proforma
Refinement of the Projections
Technology and Evolution
Conclusion
Chapter 20: Outpatient Hip and Knee Arthroplasty: Implications for Hospitals, ASCs, and Payers
Introduction
Implications for Hospitals
Implications for ASCs
Implications for Payers
Conclusion
References
Index
