Author: Moira McCarthy
More knee and hip replacement surgeries are being done on an outpatient basis, especially in this COVID-19 era.
Surgeons say the fact patients are at home forces them to move around more and do their physical therapy, speeding their recovery.
They note that the outpatient surgery isn’t for everybody. A patient needs to be motivated and have the right attitude.
The orthopedic surgeon had just set the date for my much-needed total knee replacement, and I was pumped and ready.
Until he said this:
“You’ll be going home the same day. We’re going to do this outpatient.”
What the what?
My immediate reaction was terror. How could a surgery of that magnitude be done in an outpatient format? I thought everyone stayed for days and days? Would I be safe? It sounded crazy.
That surgeon, Dr. R. Scott Oliver, the chief of surgery at Beth Israel Deaconess Plymouth and president of Plymouth Bay Orthopedics in Massachusetts, talked me through it.
I was otherwise healthy, active, and relatively young. I’d have a visiting nurse meet me when I got home, and his personal cell phone would be my emergency outreach.
“This is your choice,” Oliver told me. “But you’ll be fine. You’re a perfect candidate for this.”
Doubtful, curious, but a bit more open to the concept, this being the age of COVID-19, I agreed. I’ll admit I was anxious about it up until the day.
But I’m here 4 weeks post surgery to tell you this:
For the right person, outpatient surgery for total knee or hip replacement can be an option.
Outpatient surgery for total knee or hip replacement is relatively new.
Across the country, more orthopedic groups are putting the system in place and finding that it not only reduces costs but also has better outcomes for patients.
“My belief is this: When you do a surgical integration, especially a quality of life one, we want to disrupt the patient’s life as little as possible,” Dr. Steven B. Haas, the chief of knee service for the Hospital for Special Surgery in New York and Florida, told Healthline.
The hospital began its shift toward outpatient surgery for joint replacement nearly 4 years ago, one of the first in the nation to do so.
Haas said they were driven by cost cutting, but more so by how they believed this would improve both the experience and outcome for the people undergoing the surgery.
“There is no doubt there were multiple drivers,” he said. “But if you look at the bigger picture, this really hits the sweet spot of decreasing costs while improving care and the patient experience. It’s the right thing to do.”
How does it work?
Oliver began working toward outpatient joint replacement surgery at the start of this year before COVID-19 was a reality.
He planned on launching in early spring, but when the pandemic shut down most surgeries at Beth Israel Deaconess Plymouth, that plan got put on pause.
That, he said, may have been a good thing.
Oliver said the months of surgical shutdown gave him time to research more and, most importantly, build a strong and cohesive team for the new outpatient practice.
“I had been seeing patients [in the hospital] the day after surgery and they had almost no pain,” he said. “It just seemed unnecessary.”
At his monthly Joint Pathway Committee meetings, Oliver began floating the idea. Once COVID-19 hit, he amped up the planning, holding biweekly meetings and bringing a full team together as a cohesive group.
“So much of this is just plain good communication,” he said.
Setting up protocol with across-the-board acceptance were keys to success.
“I had to have buy-in and buy-in is tough to come by with a whole new concept,” he said.
But the shutdown allowed Oliver time to make that happen.
When the medical center let Oliver and other surgeons know that they could begin elective surgeries again for outpatients, he knew it was time to start.
Oliver and his team launched with a first group of people who had already had a knee or hip replacement in the past.
“They would know what to expect, and we knew their outcomes from the past,” Oliver said.
From there, it was about what doctors say is the most important part of the success: choosing the right patient.
In difficult times, you need to be able to turn to experts who understand and can help strengthen your mental well-being. We’re here for you.
“There is no doubt there are people who are a good choice for this and those who are not,” said Haas. “I don’t envision 100 percent of [total joint replacement patients] going home the same day. That’s never going to happen.”
So, what makes one a viable candidate for outpatient?
There are guidelines, Oliver said, but it’s nuanced as well.
For his practice, they are looking for patients who are:
- under 70 and otherwise healthy
- have a good support system at home
- have a workable physical environment at home (for instance, a second- or third-floor walk-up would not do)
And most of all, Oliver said, “have that spirit within.”
“I’m talking about people who are game,” he said. “Some people walk to the foot of the mountain, look up and say, ‘Oh, I absolutely can do this’ and hike to the top, no matter what it takes.”
Those, he said, are the right people for outpatient joint replacement surgery.
“We look at motivation as well,” Haas said. “If you are not a motivated patient, this is not for you. I tell every patient: This is a team effort, and I have the easiest part on that team. I give them the equipment. They have to use it.”
A motivated person, he said, is one who will do their at home physical therapy daily, stay up to speed on medications, and be willing to push themselves.
Dr. Bryan D. Springer, the fellowship director at the OrthoCarolina Hip and Knee Center and a professor of orthopedic surgery at Atrium Musculoskeletal Institute in North Carolina, agrees that finding the right patient is key.
“People really underestimate the resiliency factor that some patients have,” Springer told Healthline.
He agrees that home support and good health are key, but most of all is drive.
“If you pick the patient appropriately, it’s a win-win for everybody,” he said.
Oliver convinced me to go ahead, but it was hard to stay positive. Almost everyone I told about the plan was shocked and concerned.
It was only a decade or so ago, after all, that such a surgery would demand a full-week hospital stay.
“The public perception is very much that this is impossible to do outpatient,” Springer said.
Being able to explain the procedure to friends and family and ignore doubters is key.
So, I trusted my medical team and pushed forward.
Teamwork begins well before your surgical date.
Oliver, as most practices do, has a patient do a “pre-hab,” not only getting them ready for the walker or crutches they will use at home at first, but helping them build strength before the procedure.
There are many meetings, too. For me, a Zoom call on total joint replacement was required.
I also met with an admitting nurse, a surgical nurse at my orthopedics’ office, another hospital nurse, and an anesthesiologist, among others.
I also had phone calls ahead of time with the visiting nurses and visiting physical therapists. I was given a list of things to have ready at home, too.
By surgery day, the house was ready (throw rugs removed, sleeping area on main floor), all my prescriptions were in the cabinet, and my “spirit within” was amped up.
My husband dropped me off on surgery morning at 9 a.m. The new COVID-19 rules meant he had to leave me at the door. He was allowed in after surgery to get instructions and bring me home.
I was whisked into the pre-op area and from there, the team took over.
I was assigned a lead nurse to follow me from start to finish. The anesthesiologist reminded me that because I was having a spinal block and sedation, I would wake up less groggy than past surgery experiences I had.
By early afternoon, I was awake and walking up and down the hall with the aid of a walker.
Once I’d eaten solid foods without nausea, shown I could stand and move around without feeling dizzy, and my blood pressure and other stats were on target, it was time to go home.
Less than 8 hours after arriving, I was making my way to the couch and greeting the visiting nurse.
Nurses visited that first night and then biweekly for 3 weeks. Physical therapists came to my home two to three times a week.
Other than some brief struggles with a few medications, it was relative smooth sailing.
Haas believes part of the reason this works is that at home, people must get up and do things.
“If you lay someone down for a day, they will want to lay down the next day too,” said Haas. “At home, you have to get up and do things that seem hard, but once you do them, you see you can.”
He was right. During my first saunter to the restroom, I was nervous and made my husband stay by my side.
But once mastered, I got braver and moved around more. My doctor’s orders were that every hour I had to be up and moving and doing some of my physical therapy.
The first 2 days were a breeze.
Days 3 through 5, however, were rough. The nerve block wears off and your joint begins to “wake up” again.
Physical therapy kept me on track, though, and by the end of week 2, I was off the walker and on a cane.
Now, 4 weeks in, I’m moving better every day. I’m cleared to drive and to begin outpatient physical therapy where, Oliver warned me, I’ll be pushing through some pain.
I have my eye on the the moderate slopes at the ski resorts this winter.
Oliver is happy with my progress. He believes part of my early success is skipping the hospital stay.
Is it the future of joint replacement? Yes, but maybe only to a point.
Springer, who is an active member of the American Academy of Orthopaedic Surgeons, said more of these procedures are even being done at surgical centers.
That’s great, he said, but again: for the right patient.
He pointed out that as this becomes more popular, insurers may begin to push for the outpatient surgeries as a cost savings.
“We need to be cautious there,” he said. “We feel strongly it should be physicians who should decide the proper point of care, not insurance. We are the best judge of where and it’s a slippery slope.”