Same-Day Success Is a Multi-Person Effort

An orthopedic attending got the ball rolling for us. "Listen, I believe that we can become the first academic medical center in New York City to implement a same-day hip replacement program," he told our facility's leadership team. That was in 2015, and we haven't looked back since.

Of course, we'd been preparing ourselves to move in that direction long before that attending made the official ask. For one thing, the constant changes in the rates at which insurance companies will reimburse facilities for inpatient total joint procedures made exploring the option of a same-day program a virtual necessity. We knew back when we started thinking about same-day discharge that Medicare would eventually remove total joints from the inpatient-only list, and we wanted to be ahead of the curve when they did.

Plus, there are the metrics. Research shows that when hip and knee patients are discharged same-day, they tend to be more satisfied, and less prone to infection and readmission.

All in all, a successful same-day joints program offers an opportunity to both give patients better surgical outcomes and post-op recoveries. Since rolling out our same-day total joints program in 2015, we've achieved a 94% same-day discharge success rate for procedures that normally require a 2-to-3 night stay (total hips) or a 3-to-4 night stay (total knees). Plus, only 1% of our same-day patients are readmitted, and they outperform non-same-day patients in each of the 11 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) benchmarks.

If you're considering implementing a same-day joints program at your facility, here's what you should know.

Get the key players involved early

We can't overstate the role your physician-champion plays in the process, but you need to get buy-in from all of your key players right from the get-go. We knew early on that the success of our same-day joints program, pardon the pun, hinged on a lot of different disciplines working together as seamlessly as possible. On top of our surgeons, nurses and anesthesiologists, pre-admission testing and acute services departments played a critical part for us. We mapped out everything everyone does — day in and day out and in as much detail as possible — to ensure staff understood the processes, workflow and protocols for each and every patient we identified as a same-day discharge.

But with so many people involved, it's easy for things to slip through the cracks or for redundant messages to cause confusion or, worse, delay things from getting done on schedule.

Our solution? Appointing a dedicated coordinator to oversee the clinical management of the program and to ensure communication reaches all care team members. Plus, we created an interdisciplinary workgroup to give everybody from clinical (surgeons, nurses, OT/PT) and administrative staff (security, patient registration, patient experience) timely, consistent and, most importantly, relevant updates on same-day workflow, patient education materials and process changes — like the opioid-sparing protocol we piloted on our same-day patients.

While there are a number of factors you can't control with a same-day procedure — like unexpected complications — one thing you absolutely can control is how prepared your same-day patients are for not only their surgery, but also their post-op recovery.

We require each of our same-day patients and their adult coach — a friend, family member or neighbor that agrees to spend a minimum of 2 days pre-op and 2 days post-op supporting the patient — to attend a 2-hour pre-hab class on their procedure. For the first hour of the class, the patient and coach talk with a nurse from our care management team about everything they can expect with a same-day procedure — from the moment they arrive at the hospital to the days and weeks following the surgery. While this section covers general info that applies to all same-day patients — such as proper hydration, post-op DVT prophylaxis and cath pumps — it's also tailored directly to the individual patient, so they learn how things like their medical history and any present co-morbidities could affect their outcome.

Patients spend the next 30 minutes of the class with a physical therapist going over the use of post-op equipment, such as crutches and walkers. The class covers all types of scenarios and post-op equipment, so whatever patients wind up using, they're at least familiar with it. For the final 30 minutes, an occupational therapist shows the patient how to maneuver with an impacted extremity and address all questions related to post-op home care: How will you get into and out of the shower? How will you sit on your toilet? How will you get into and out of bed? Your car? The class covers mock-ups of all of these scenarios.

Our anesthesia providers modified their approach to accommodate same-day discharge. For starters, they minimized the use of general anesthesia in favor of spinal blocks. They also started using a liposomal bupivacaine injection (Exparel) to help with pain control. Together, blocks and a local anesthetic went a long way toward making our total joints program a success.

In terms of the surgical process, a small change for total-hip replacements garnered big results. Most of our same-day patients undergo a tendon-sparing anterior approach, which helps mobilize patients earlier and decreases their post-op pain.

Early on, we ran into some problems same-day discharging patients who experienced post-op nausea or vomiting. So we ramped up our patient monitoring and changed our protocol for patients with a history of PONV. If our same-day candidates had any history of PONV, we'd pre-emptively give them a scopolamine patch. We also adjusted our algorithm for treating PONV. Instead of treating with just 1 medication, we now have 3 potential medications — the anticholinergic scopolamine, and antiemetics Zofran (ondansetron) and Reglan (metoclopramide) — that we use in a tier of first, second or third choice.

We also adjusted some of the more conservative candidate criteria as we got more accustomed to the program. Initially we capped the program at age 65, but then we realized our older patients were doing really well, so we asked, "Should age really be a limitation if a candidate met all the other criteria?" So we slowly pushed the envelope with patient age and, as of right now, our oldest same-day patient was 80 years young.

You won't be able to pinpoint all of the issues with a same-day discharge program until you go live with it.

Finally, we used our same-day initiative as a pilot program of sorts for other organization-wide initiatives. And it happened completely by accident. We noticed our same-day medication regimen was very opioid-heavy — with both the primary and the secondary meds being hydrocodone and oxycodone. So we decided to test an opioid-sparing protocol for our same-day patients where they started with only non-opioid pain meds — such as acetaminophen — combined with non-pharmacological treatments like ice therapy and moved up to opioids based on pain level. The protocol was so successful that we soon rolled it out to our non-same-day patients, too. We've now implemented our opioid-sparing protocol across our entire total joints population.

In the end, our move to a same-day total joints program was all about quality, about providing our patients with better outcomes. And by taking a pre-emptive approach, we created and fine-tuned a program that was the first of its kind in our city. OSM