Author: Ajai Raj
A high-volume community hospital has succeeded with routine same-day discharge for knee and hip replacements by using a multimodal analgesia protocol (MMAP). Researchers from Northside Hospital, in Atlanta, reported that their MMAP relies on opioids for analgesia only on an as-needed basis.
|Table. MMAP for Joint Replacements at Northside Hospital, 2017|
|ATC, around the clock; PO, orally; PRN, as needed|
Proving the Same-Day Model
Mark Hamilton, MD, an anesthesiologist at Northside Hospital and the study’s first author, said the study, which was presented at the 2018 annual pain medicine meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 6038), was prompted by colleagues at conferences who had expressed skepticism that routine same-day discharge for joint replacements using an opioid-sparing protocol was feasible. The research began as a pilot study with two surgeons in 2015, and was expanded to include all 10 orthopedic surgeons at the hospital in 2017.
Dr. Hamilton emphasized the necessity of a committed multidisciplinary team led by a strong anesthesiologist–surgeon partnership.
“Surgeons, anesthesia, physical therapy, business, the admissions people, preoperative and postoperative nurses—everyone has to be invested in making routine same-day discharge a reality,” he said. “That means following the data and refining protocols to control pain and eliminate side effects that would prevent discharge. That’s where everybody has to start.
Dr. Hamilton added that the protocol is subject to ongoing revision in response to evidence. “We continually evaluate our outcomes and look for improvements. For example, in mid-2018, after an evaluation, we added iPACK [interspace between the popliteal artery and capsule of the posterior knee] blocks to our standard protocol for knee replacements. This required an adjustment of our local anesthetic doses for our other combined injections.”
Emily Lin, MD, MS, a regional anesthesiologist at Memorial Sloan Kettering Cancer Center in New York City, who was not involved with the study, called the findings “compelling. Performing joint replacements on an outpatient basis is an exciting yet relatively new phenomenon. While some centers are able to provide same-day care, there are few that do so with great numbers,” she said. “With such a high percentage of reported same-day discharges and minimal readmissions for pain, that may be enough reason for those with a robust joint replacement service to consider implementing a similar analgesic regimen.”
“This is happening throughout the anesthesia world, and it’s necessary,” Dr. Hamilton agreed. “There’s a push throughout the anesthesia world for opiate-free analgesia. This is the new frontier.”