March 2, 2022

Earlier ambulation with reduced opioid use drives safer same-day growth.

Thanks to the ever-increasing use of multimodal pain management protocols, an increasing number of total joints patients are walking out of facilities on the same day as their procedures. Proponents of multimodal protocols cite patients' improved outcomes, earlier ambulation and greater satisfaction, as well as a reduced need for opioids, as proof that these approaches work.

"Multimodal pain management has been absolutely crucial to our joint replacement practice," says Tad L. Gerlinger, MD, director of the adult reconstructive fellowship and an associate professor of surgery at Rush University Medical Center in Chicago. "It has allowed us to perform the procedures on an outpatient basis." In the four years since Dr. Gerlinger started performing outpatient total joints procedures, his patients' post-op pain medication use has plummeted from six or more weeks to just three weeks.

Dr. Gerlinger lauds multimodal regimens not just for their effectiveness but also because, through strategic modification, they can turn patients who couldn't be safely treated as outpatients due to other medical issues into candidates for outpatient total joints. "For example, we might place an epidural that can be re-dosed versus a single-shot spinal as part of their regional anesthesia, or go straight to using a general anesthetic to facilitate a longer procedure," he says.

The development of comprehensive multimodal regimens requires strong communication with patients as well as good working relationships between surgeons and anesthesia providers. "It's only in the last decade or so that anesthesiologists and orthopedists have worked closely together to manage pain," says Dr. Gerlinger. "The roles are less siloed now, and that's allowed us to improve outcomes for patients."

Dr. Gerlinger expects to see more joint revisions and longer surgeries shifting to outpatient ORs due to the use of opioid-sparing, multimodal regimens. "That's going to lead to cost-effective care and better outcomes," he says.

While waking up pain-free from joint replacement surgery improves patient satisfaction, Dr. Gerlinger believes limiting post-op pain provides other intangible benefits that are difficult to quantify. "Once a patient experiences pain, it's harder to manage than it would have been to stay ahead of it," he says. The key, he notes, is to proactively address post-op pain, which multimodal protocols are ideally suited to do. With excellent pain management in place, patients are better equipped to begin postoperative therapy.

Be mindful of these issues when launching a new program.

Adolph V. Lombardi, Jr., MD, FACS, president of JIS Orthopedics in New Albany, Ohio, performs an average of 10 joint replacements a day at the two-OR White Fence Surgical Suites. He recently discussed what it takes to succeed in same-day joint replacement surgery.

What are your patient selection guidelines for outpatient total joint replacements?

We have an independent third-party doctor evaluate patients' entire health histories to greenlight them for surgery. The internal medicine physician evaluates their blood pressure and level of diabetic control, and determines if they have underlying lung disease, gastrointestinal problems, urinary issues or sleep apnea. We don't have automatic BMI cutoffs. We focus on their underlying health concerns instead. We strongly encourage them to quit smoking, if only for a short time before and after their surgeries, to help with wound healing and reduce the risk for post-op infection.

How long should patients wait between their first and second knee or hip surgery?

While some research suggests there should be a three-month gap between the procedures, we generally wait a minimum of six weeks. We came to this conclusion based on other published studies, and our own results showed no appreciable difference in outcomes in patients who waited less than six weeks, six weeks or more than six weeks before they had the second procedure. We'll sometimes do the second surgery four weeks after the first one in younger, healthy patients with an urgent need to get back to work.

How do you address staph bacteria?

We employ a hybrid approach that involves screening high-risk patients for methicillin-sensitive staphylococcus aureus (MSSA) or methicillin-resistant staphylococcus aureus (MRSA). This population includes those on renal dialysis, residents of nursing homes, healthcare workers and individuals with indwelling catheters. We also screen patients who have had a staph infection in the past or who report having had an infection of mysterious origin. Patients who test positive for MSSA or MRSA are treated with mupirocin nasal ointment and shower with chlorhexidine gluconate (CHG) antiseptic skin cleaner for five days leading up to their procedures. All patients' surgical sites, meanwhile, are wiped with CHG on the day of surgery.

What is the best physical therapy regimen for total joints patients?

I prefer that my patients attend traditional, in-person PT sessions. The experience is better and getting to and from the facility is valuable therapy itself. Patients are forced to move and ambulate simply by getting dressed, getting in and out of their car and walking into the facility. This level of basic activity can help speed their recoveries.

If a patient has COVID concerns, or is otherwise resistant to scheduling traditional PT sessions or having a therapist visit their home, there are apps on the market that provide virtual rehab sessions patients can view on their phone or computer. Home-care PT is the least desirable option, as physical therapists visit patients at their houses, which likely lack adequate workout equipment, yet charge the same amount as if the patients went to a fully equipped PT facility. I believe that patients get better faster if they attend their PT sessions at a rehabilitation facility.

What steps do you take to prevent deep vein thrombosis (DVT)?

We have patients wear compression socks and take two 81mg baby aspirin daily. Patients with a history of DVT or who are morbidly obese might need additional measures, such as an oral blood thinner for 14 days after surgery. Sometimes we'll give them a half-dose for the first three days to reduce the risk of a surgical wound bleed. Individuals cleared for outpatient surgery, however, are inherently at a lower risk for DVT because they are often healthy enough to ambulate in recovery and able to continue to move around hours after they've been discharged.

What is a typical pain management plan?

Patients and providers no longer carry expectations of pain-free surgical recoveries. We used to prescribe patients high doses of painkillers and were quick to provide refills, but now we employ multimodal pain regimens instead. We explain that their post-op pain will be treated with ice, acetaminophen and an anti-inflammatory. If narcotics are still needed as a last resort, we prescribe appropriate amounts for mild, moderate or severe pain.

It takes the entire OR team, including surgeons, anesthesiologists, nurses and OR staff to work together to complete these complex surgeries.

As total joints procedures continue to take hold in the outpatient surgery environment, OR teams work closely together to make these surgeries a success. Close attention to qualifying patients for the surgeries along with strategies regarding techniques and technologies utilized in the ambulatory surgery setting combine to provide safe and efficient surgeries. We spoke to Dr. Alyssa Hamman, an anesthesiologist from Denver, Colorado who is a consultant with Stryker, to get her thoughts about the role of the anesthesiologist in an orthopedic ASC.

Q: Does the role of the anesthesiologist differ from a hospital setting in an ASC?
While the role of the anesthesiologist is always to safely provide expert preoperative, intraoperative and postoperative care, there are some distinct differences between the hospital and ASC. Most notably, the ASC demands meticulous patient selection to ensure a successful and safe surgery. Anesthesia technique may also differ to ensure an expedient but appropriate PACU discharge.

Q: Do outpatient surgeries, including total joints and other complex surgeries, require special planning by the surgical team?
Absolutely. The more complex the surgery, the more the anesthesiologist needs to communicate and plan with the surgical team. Specific considerations include planned operative time and plans for post-operative pain management. Longer operative times usually result in longer PACU times, which can affect the flow of the ASC. Post-operative pain management can also affect PACU time, so regional anesthesia techniques and other narcotic-sparing techniques are important tools in the outpatient setting. However, certain anesthesia techniques commonly used in orthopedic procedures, such as spinal anesthetics, are usually not appropriate in the ambulatory setting given the prolonged recovery time and the risk of urinary retention. Overall, consistency and communication within the team will result in a smooth experience for the patient and the surgical team.

Q: What has changed for anesthesiologists in the outpatient setting since you started working there?
The breadth and depth of procedures have increased, and we are also seeing patients with more comorbidities and complex medical histories in our ASCs. When I first started working in an ASC during residency, orthopedic cases mostly consisted of quick arthroscopies. Now, total joint replacements are becoming the norm. Whereas a bilateral mastectomy used to require a 2- to 3-day hospital stay, now we do these surgeries in the outpatient setting. Neurosurgical procedures such as ACDFs are commonplace in the ASC, and hysterectomies can go home the same day. Innovations in both surgical and anesthetic techniques have allowed us to expand what we can do in an ASC. Overall, most surgeons seem to really enjoy working in an ASC setting and will often "push the envelope" to try and avoid taking a case to the hospital! ASCs are more efficient, surgeons can't be "bumped" for an emergency (which happens often in the hospital), surgeons know and trust the smaller staff at an ASC, and patients are usually eager to go home. As an anesthesiologist, part of my job in the ASC is to balance surgeon preference with reasonable patient selection.

Q: From an anesthesia perspective, how critical is patient selection when surgeons are making the choice to operate in an outpatient setting?
Patient selection is absolutely critical to a successful ASC. We often don't have preoperative diagnostics (such as EKGs and labs) in an ASC, so those items need to be evaluated and optimized before the patient walks in the door. Intraoperatively, we need to ensure that we can safely care for patients given the equipment and technologies we have at the ASC, which may be different from the hospital. And lastly, careful patient selection should result in fast and safe PACU discharge. For example, a patient with severe OSA might do well intraoperatively, but if he stays in the PACU for 6 hours due to hypoxia and hypoventilation issues, then that can interrupt the flow of patients and staffing for the entire center.

Q: How do you think the migration of surgeries to the outpatient setting is beneficial for patients?
Outpatient surgery is beneficial to patients in terms of cost, comfort and avoidance of hospital specific complications. If it's safe, most patients would prefer to recover in the comfort of their own home surrounded by family or friends. Patients get more rest at home, and familiar surroundings can be critical to older patients to help avoid postoperative delirium and perhaps longer-term neurocognitive issues. Avoiding hospital acquired infections is also a bonus.

Q: How can anesthesiologists get more comfortable in the ASC or HOPD?
Experience in a well-run ASC is crucial to increase anesthesiologist comfort. Additionally, working as a team with the surgeons and administrators can ensure that the anesthesiologists' concerns are being addressed so that she can provide the best anesthesia care possible. The Society for Ambulatory Anesthesia (SAMBA) is also a great resource. As a member you can access many clinical practice guidelines and connect with other ambulatory anesthesia colleagues.

Q: What is your favorite part of being on the surgical team in an ASC or HOPD?
Ambulatory anesthesia is an evolving and challenging skill, and one that I see will continue into the future. I enjoy working with my team to achieve a common goal: safe, successful surgery that gets the patient home quickly and back to enjoying life in good health!

Dr. Alyssa Hamman is a consultant of Stryker. The opinions expressed by Dr. Hamman are those of Dr. Hamman and not necessarily those of Stryker.

After completing training at Stanford University, Dr. Alyssa Hamman has been working in private practice throughout the Denver metro area. She has worked in a variety of settings and group models and has found her niche in ambulatory anesthesia. She now practices exclusively in the outpatient setting and works with a wide range of specialty surgeons ranging from orthopedics to fertility specialists.

Note: Whether you're building a new ASC or expanding and renovating an existing ASC, Stryker's ASC business can help you build and grow strategically. By giving you access to our world-class portfolio of wall-to-wall capital, head-to-toe implants, ASC specialists who understand your unique challenges and ongoing support, we deliver everything your ASC needs to win today – and tomorrow. To learn more about Stryker's ASC business visit https://www.stryker.com/us/en/care-settings/asc.html