TKA Can Be an Outpatient Procedure for Select Patients
With the arrival of bundled funding, surgeons need to create safe models of practice that are financially sustainable. During the practice management session of the 2014 AAOS meeting, Canadian surgeons reported that they made primary total knee arthroplasty (TKA) an outpatient procedure for carefully selected patients by piloting the new approach on inpatients.
“Most surgeons are very reluctant to do this,” Dr. Geoffrey Dervin said in an interview with ICJR. “They see this as taking on a lot more risk than they need to. There has to be a process where they can go at it slowly.”
At the University of Ottawa, Dr. Dervin and his colleague Dr. Brendan O’Neill created an accelerated inpatient TKA clinical pathway by combining their hospital’s standard TKA clinical pathway with its pathway for unicompartmental knee arthroplasty. Components of the novel pathway include preoperative patient education, multimodal analgesia, and a subvastus approach with early mobilization.
Drs. Dervin and O’Neill applied the new pathway to surgeries on 30 inpatients (17 female, mean age 64). “The first group of patients were certainly not going to be admitted,” Dr. Dervin told ICJR. “But we had to do everything as if they were going to go home, so we would learn, in particular, what their analgesic requirements were going to be—that was the biggest thing. We were able to see how quickly they mobilized, look at their wound drainage—and discovered that they didn’t need any needles for pain.”
“They had to be ASA 1 or 2, they had to live within 30 minutes’ drive of the hospital, and they had to have support at home, at least one adult caregiver,” Dr. Dervin continued. “And obviously, they had to be open to the concept, because it was voluntary. I wouldn’t call this pathway experimental, because a number of centers have published on this, particularly in Chicago with Dr. Rich Berger. But it’s still a very, very small sliver of patients.”
The first 20 inpatients received intrathecal morphine at the time of surgery and the last 10 did not. Patients in this initial group reported a mean pain score of 3 on a 10-point scale and consumed between 3 and 5 mg of oral hydromorphone a day in the first 7 days. Satisfaction with pain control was high, with a mean rating of 8.5/10 after the first 7 days.
Subsequently, Drs. Dervin and O’Neill used the protocol for 15 carefully selected patients (11 male, mean age 59) who were scheduled as the first procedure of the day with a plan for same-day discharge after they met a number of performance criteria. Most patients received a combination of spinal and local anesthetic (pericapsular infiltration).
The analgesic use and pain scores of patients in this second group were comparable to the findings for the inpatient group. Four patients experienced a vasovagal episode early in the process, requiring a more formal protocol of volume replacement. However, all patients were discharged on the day of surgery. There were no readmissions or any serious medical or orthopedic complications.
A multidisciplinary team approach is what makes early discharge possible, Dr. Dervin said. “You have to have anesthesia working in the same direction – strength of the anesthetics, spinal anesthetics that wear off quickly – so the patient can be up and mobilizing quickly. The nurses have to be on board, too, advising the patients both before surgery and immediately afterwards, and getting them ready to go home. Physiotherapy needs to come down and see the patients both before surgery and after some 4 to 5 hours afterward. The last one is the home care. In Canada, most jurisdictions have a coordinated home care program that ensures that the patient gets a visit from a nurse and then a physiotherapist the day following surgery. All those players have to be pulling in the same direction.”
Since the time that he submitted his AAOS abstract, Dr. Dervin said, he and his colleagues have been doing about one outpatient TKA procedure a week. “We’re still going at it slowly. I expect and hope to get to a day where it becomes more routine. My best guess is that up to one-third of patients could probably qualify.”
Dervin GF, O’Neill B. Development of an outpatient total knee replacement pathway. Presented at the 2014 Annual Meeting of the American Academy of Orthopaedic Surgeons; New Orleans, LA; March 11-15, 2014. Paper 145.