Outpatient Joint Replacement, Dr. Michael Miranda

So again I’m Mike Miranda. Im going to be talking about the outpatient joint process that we’ve been working on over the years here.
First slides a video here.
We have right here today. You’re going to be going into surgery right. Correct. How long ago was your left hip done? about seven weeks ago. OK. Doing OK. Great. Back for another one right. Definitely. All right. And everything went fine last time and you’re walking. All right.
I will take that off the cane after you know do. All right. Great. And then so match up the other side. Sounds good. I’ll take good care. All right sir.
Some people are ready to do this within six weeks. I don’t know if that’s the smartest but they’re ready to go for it. There’s a nice guy we did two hip replacements on and they’re both outpatient and they’re about six seven weeks apart. And he was pretty happy with the process. He was he was trusting of us to do to go through with two of the two of those hips outpatient. Some of the things here most common surgeries in the United States number one cataract. Number two C-section number three is joint replacement hip and knee. Says it’s really prevalent in our country. Operating room procedures are performed. And during nearly 30 percent of hospital stays in 2012 and these stays account for about half of hospital costs so a lot of money being involved in joint replacements and surgeries in the hospital.
As we look at it over the years in 2015 over six hundred and fifty thousand total knee arthroplasties were performed the United States alone. There’s an expected increase over the next several years. Operating room procedures performed most frequently in 2012 diving in a little bit more into that. Number one was knee replacement and number four hip replacement or partial hip replacement which would be arthroplasty for a fracture. But you can see that of the top two of the top five we’re going to be discussing here. Numbers over 700.000 of the knees and about four hundred sixty-eight thousand four total hips. Again, numbers and these numbers are expected to rise as we go along here over the next five to 10 years. So what’s the future of this.
Well this is a little different than what we had planned it to be. As you can see with the I phone seven, I think we’re on 10 now, so we predict things we expect them to happen a certain way or we predict that they may occur in a certain pattern. But we really are sure of how the future what the future will hold. But what we do know is that patient centric care is changing our perception of these surgeries. Patients want a quick recovery and return to work and activity is as quick as possible. They want advanced technologies and techniques. They want minimal discomfort functional emulation an acceptable range of motion all at a low cost. So what is going to be our decision do we stay in the current and past or advanced to the future. 2006 to 2013 Medicare inpatient discharges decreased 17 percent and outpatient services grew 33 percent.
So there’s been a trend to increasing towards the outpatient side orthopedic projections assume that half of all elective hip and knee replacements will shift to outpatient setting over the next decade which would be 2016 to 2026. We’ve we’re getting there I don’t know that we’re there yet. So the benefits of total joint replacement outpatient there’s eliminated hospitals we eliminate the hospital stay potential for further fewer complications improve outcomes increase patient satisfaction and certainly the economics as we said which all provides value but to get there.
So how do we get there. Well I think this is kind of the approach that we’re taking, it’s kind of a threefold approach. We look at the surgical side of it pain management side and the rehabilitation and education for the patients. So on the surgical side we’re using minimally invasive procedures approaches for the knee midvastus subvastus approach hip replacement we’re using direct interiors or minimally invasive procedures for the hip replacement thing. It’s really important for meticulous hemostasis as we use more aesthetic agents such as tranexamic acid and we’ve eliminated use of drains we use advanced technologies such as robotic procedures here that here’s the Mako there’s several other things that we’re using for knee and hip replacement. Dr. Grayson’s going to be a little bit talking about robotics in the next presentation. There’s a couple of inter operative pictures of some of the equipment that we’re using for hip replacements the hand of table’s available this is the latest in the procedure of an anterior hip.
Here’s the setup for that. And one of ours for myself here on an anterior hip which are the patient’s head is to your right and feet is to the left we’re looking at a right hip there another setup here a little bit easier to see a right hip patient’s head would be your left, the foot to your right. And what that device there that the foot is looked into is enables us to move the leg around Texas different the acetabulum femur in different parts of the surgery. Again, another shot there with the patient’s hip all draped out. We use imaging interoperability to evaluate leg lengths and component positioning.
Here’s the setup here we’ve got a double tiered table there. Rooms a little bit smaller but this is very helpful to store all the instruments rather than using the larger operating rooms in the hospital. And we can put all of all of our equipment on a table such as this. Here are some of the equipment that we’ve been using.
We try to tone down the number of instruments and trays that we use is obviously processing these will be an added cost for our outpatient facility but surgeons really only one part of the solution here is a shot of my children.
Several years ago, this was, so we’re a big soccer group. This was World Cup four years ago. Had a good result there and then this is a more updated picture here more recently of the World Cup this past summer comprehensive approach.
It’s important to involve everyone.
Education for the patient anesthesia team real rehabilitation team therapists home health care and support staff for the patient. So the next part of it will be pain management and really what we’ve gone to here is regional anesthetic spinal anesthetic limited use of narcotics anti-inflammatory is kind of a multi-modal approach. We use steroids and antiemetics blocks for the near typically the adductor nerve block and for the hip of fascia iliaca block or something similar to that and spinal anesthetics. And sometimes general what we’re trying to reduce the use of narcotics so that the patient can wake up an ambulance essentially right away interoperability where we’re trying to eliminate the narcotic use again we use the antiemetics and steroids and Periarticular injections to help with pain control. This is an example of one of the injections that we’re using. It’s a concoction of multiple different agents there and then rejecting it in various places in the knee around the joint as we do the procedure.
Here’s another picture we kind of inject the back of the knee before the components are in and after the resection of the bone is done. And then after we’ve cemented the knee we inject the remainder of the size the median lateral sides inside the arthrotomy and infiltrate all the local soft tissue so pain management post-operative again we take a multi-modal approach to this limited narcotics but we do have available for the patients they do need some form of narcotic typically but we use a combination of long acting in short acting these are prescriptions that we encourage patients to use only if needed. Patients are on anti-inflammatory as Tylenol and Gabapentin neurologic agents also found to be helpful. Education and Rehabilitation side of this patients all are seen in the office properly they’re indicated for surgery but then we have them come back and do a preoperative appointment which is probably a pretty lengthy procedure is probably about 30 minutes to 45 minutes with my myself or my physician’s assistant who’s educating the patient on the process. They will have been cleared by their primary care physician we have them either discuss and meet with the anesthesia team or phone conversation with them.
They’re given all their prescriptions and then we either have a phone conversation with the home health care team or they will have an assessment before their procedure.
The importance of this is that the patient once they go home. We don’t have eyes on them. They’re not in the hospital we want to make sure that everything is going understand well and they understand the process and we have the home health care team get out to the patient’s home to ambulate them assess them. The next morning and then we shoot for early outpatient physical therapy probably within about one to two weeks after their procedure think encompass the three aspects of this and the patients will. You can have successful outpatient joint replacement rapid recovery. So what is the current literature say here 2009. Mitch Berger in Chicago is really at the forefront of doing this looked at one hundred and eleven patients twenty-five partial knee replacements and 86 total New Yorker class these four patients had been readmitted two for anemia, one for a GI bleed, and one for DVT.
But they concluded that outpatient procedure was safe and effective procedure but screening was had to be done very carefully for all of these patients. Again Dr. Berger reported in in the international orthopaedic journal in 2014 one hundred and five outpatient partial knee replacements. One patient was readmitted in the first 12 weeks which for an infection required a surgery but again showing that this is an effective way of doing these outpatient twenty three hour versus inpatient tony arthroplasty says a study in clinical orthopedics CORE age is age average was fifty five BMI was thirty point eight and they looked at manipulations. If a patient goes home are they going to be aggressively doing therapy versus inpatient they found at the outpatient had a less percentage of patients that needed manipulation and a seizure 2 versus 4 for an inpatient group.
So another benefit early mobiles of earlier immobilization. Outpatient surgery as means of cost reduction total hip arthroplasty. This was a study reported that the direct anterior approach was an effective procedure. They looked at hospital admits outpatient four of the and nineteen were were evaluated but in the emergency room but not readmitted. And there’s the four things listed there they had to elect this this was one diagnosis they were evaluated in the E.R. and then discharge EKG changes they didn’t readmit but they said they’re deep seated 72 hours so I would kind of consider that admission. Then there were two fractures there that were treated on operability so kind of a couple ways of doing this. You can do hospital replacements inpatient and outpatient and ambulatory surgery center which would be strictly an outpatient procedure.
What we’re kind of really discussing here is outpatient replacements and ambulatory surgery center. What I found we’ve tried to transition this from patients that had surgery in the hospital to doing outpatient procedures in the hospital and sending the patient home and then moved forward to doing the procedures at a freestanding AC where the patients have to go home.
And what we found is that the difference between the two is in the in the hospital there’s not that urgency to get the patient moving and get them out quicker.
So the process is delayed a good bit in the ASC everyone’s functioning and working to get everyone discharged for that day so there’s a higher acuity and we move the patients along better so I have been most happy with the patients that are done in the ASC setting and then they go home and I think the patient satisfaction reflects as well because if they’re in the hospital and the procedure is done in the hospital the staff doesn’t work the same way that the ASC works so they’re kind of like lingering around it’s taking a little longer and patient satisfaction goes down as the patient remains at the facility longer. So here’s a study comparing the outpatient procedure of means of cost reduction total hip arthroplasty and you can see that the hospital costs were about seventy eight thousand dollars difference between outpatient cost.
So what’s our experience so I didn’t get the data from 2018 but we have seven surgeons that are within our group doing these procedures and we’re we have unique departmental new arthroplasty total knee and total hip. And the numbers at the end of 2007 were about two hundred roughly two hundred thirty-eight cases and we had had one DVT considered a complication but patient wasn’t admitted. I think now we’ve probably we’re near around the 400 mark for procedures that are ASC again still doing well as far as our readmissions.
But I have to look back at the 2018 numbers to complete that. So this is just a graph. What we started in 2013 and you can see there’s a little dip there towards the end but that’s because that wasn’t complete for the year. The data but you can see is an hour over the years over I guess that three or four year period numbers are really in decline with a big jump between 2015 and 2016.
So what’s our protocol. Patient meets with myself and my physician’s assistant.
They have to be cleared from their PCP or internist anesthesia conversation as I mentioned we look at their past medical history and essentially somebody that’s really obese has a history of cardiac disease pulmonary disease is an automatic exclusion for the procedure to the thing I put hemoglobin in creatinine if these are abnormal that’s a no go for me to patients has to be done in the hospital those are abnormal they receive their medications properly we give everybody Celebrex the oxycodone was reviewed the short acting pain medicate. This is before the procedure I’m sorry Celebrex and anti-inflamed inflammatory before the procedure day of surgery we are going back and forth with the narcotic before the procedure. As I said we’re kind of finding if that’s really necessary and we’ve found that we may not need to do the pre narcotic before the procedure but we’re using scopolamine patches and the nerve blocks are really key for this procedure adductor again for the total knee and the fact that family act for the hip and then we’re using spinal or general anesthetic. Anesthesia gives decadron to reduce the nausea vomiting side effects. Again narcotics as we discuss trying to minimal narcotic use and then patients have Reglan or Zofran that they get interoperative leave from the anesthesia team. Interoperable we were doing X Pro which is local injection or pain cocktail deep into the soft tissues and bupivacaine superficially and then everybody gets trained examined trying exam acid to reduce the bleeding interoperable and post-operative one gram during the procedure and one gram of closure. Post-operative medications are Tylenol Celebrex or some form of anti-inflammatory Zofran and stool softener is some of the devices and things that we use for the patients so they had venous compression stockings mechanical compression devices Walker cryotherapy and knee immobilizer.
So the idea and the knee immobilizer is that patients going home the same day I put a put the patients that have a knee replacement and a hip replacement in a knee immobilizer because of the nerve block. Okay so you’re doing adductor. Sometimes the medication can leak up proximal in the nerve sheath and take out the femoral nerve. So we found that’s really beneficial and the conversation with the patient is you’re going to go home in the knee immobilizer or you can take it off later tonight if you feel that your leg is come back and the effect of the nerve block has worn off or safest thing to do is leave it on to the next day. I haven’t seen any effect in patients losing their range of motion by leaving on the knee mobilizing for the first 24 hours on the hip side.
They get a fascia iliaca block which incorporates the femoral nerve. So those patients can also have some quad weakness and have a tendency to fall. So we keep them in a knee immobilize for the hips as well for the same instructions are given to the patient. There evaluate their vital signs their pain’s controlled. We have an ambulance before discharge and then essentially, they’re ambling to the restroom to avoid and then they’re able to head out of the facility. We have home health care assess the patient post-op day one in the morning subsequent nursing and P.T. visits later that week and we try to get the patients to early outpatient therapy within about seven to 10 days. I was initially bringing all the patients back within a week to evaluate them because I want to see how they’re doing but I found that that really wasn’t necessary and we moved more towards the two to three-week protocol.
It’s just hard for the patients to get up and mobilize and then come and sit in the office for a bit within the first seven days. So when we’re starting a program we want to make sure that we’re evaluating and recording how these patients are doing which we’re in the process of doing we’re trying to collect some scoring systems to evaluate the patients so that we can report on it. And these are just some of the examples. But in developing an outpatient total join our capacity program I think it’s important to analyze the cost instruments disposable implants and negotiate with providers cost of these things and try to minimize collectively all of it.
So the benefits are eliminating hospital stay fewer complications improve outcomes the increased patient satisfaction. Now just a little bit of an update for everybody here just recently on the twenty sixth of June the bill the Florida bill 843 was passed which is allowing patients to stay overnight in an ambulatory surgery center.
Prior they would have to leave the same day. Things have really changed and how much impact this is going to have on us. We’re not sure yet. But it’s pretty exciting thing that you’re be able to keep the patients overnight if they have any problems. It may also open up the doors a little bit for some patients that we were a little hesitant to do outpatient go home the same day we can monitor them overnight and then they can be discharged the next day. Next day it’s gone into effect July 1st. But obviously there’s a lot of planning that has to be done and we would probably a year or so maybe more away from getting facilities ready to accommodate those type of patients that was required overnight stay. Currently Medicare allows for unicompartmental arthroplasty only. So we’re doing some of those but you cannot do a Medicare patient for a total near total hip at the ASC.
You can’t do them in the hospital and go home the same day. But only the units are available from a Medicare standpoint to do at the surgery center and then the it varies per insurances whether or not they’ll be authorized to have. A procedure outpatient. So my recommendations are it’s really important to train the staff have the right equipment and really educate and discuss with the patient. This process and you have to be selective. So just a couple of things here. There’s a hip replaced hip replacement candidate patient looks pretty good pelvis looks good though. Be a good candidate. I think pretty relatively straightforward arthritis there. This dislocated hip requiring revision obviously not a good patient to do at the surgery center again.
Here’s another one. The right side there we’d be OK with the left. We would not. It’s a dysplastic chronically dislocated hip. Yeah this is a patient that you would hopefully not have to do a hip replacement on but certainly not an outpatient candidate.
So we try to avoid patients that are morbidly obese have very stiff musculature on the hips and mesomorphic males hip fractures obviously they’re in the hospital so they’re not done outpatient. We get patients age and bone quality and type C bone which would be a weaker bone. We avoid doing. The risk is higher here so we avoid that now patient setting. So in summary the patient selection is very important patient education surgical procedure pain management comprehensive approach approach and a perfect execution is. What we look for. So people say time changes things but you actually have to change them yourself. This is the patient that we did. She’s about, that’s her first post op. SO she came in she was pretty happy. That was about ten days out so thank you very much.