Pro: Im Still Doing It! My Patients Love It! Adolph V. Lombardi, - - PowerPoint PPT Presentation

Same Day Total Knee Arthroplasty:

Pro: I’m Still Doing It! My Patients Love It!

Adolph V. Lombardi, Jr., MD, FACS

Joint Implant Surgeons, Inc., White Fence Surgical Suites, The Ohio State University, Mount Carmel Health System, Midwest Training & Development Services, New Albany, Ohio

Adolph V. Lombardi, Jr. Disclosure

Consultant:

♦ Zimmer Biomet

Royalties:

♦ Zimmer Biomet; Innomed

Research Support:

♦ Zimmer Biomet; SPR Therapeutics

Investment Interest (minority):

♦ SPR Therapeutics, Joint Development Corporation, Elute, Inc.

Publications Editorial Boards:

♦ Journal of Arthroplasty; Journal of Bone and Joint Surgery - American;

Clinical Orthopaedics and Related Research; Journal of the American Academy of Orthopaedic Surgeons; Journal of Orthopaedics and Traumatology; Surgical Technology International; The Knee Boards:

♦ Operation Walk USA; The Hip Society; The Knee Society; Mount Carmel

Education Center at New Albany

Managing Patients Upfront: Indication vs Optimization

• 1. Diabetes: Hgb A1c if >7.9 delay and refer
• 2. Smoker: if YES then refer to smoking cessation
• 3. BMI: if >40 refer for counseling, metabolic consult
• 4. Anemia: if Hgb <12 in females and <13 in males, delay and refer for workup or blood management
• 5. Staph colonization: if in HC facility or HC worker or hx of MRSA, screen and decolonize
• 6. Narcotic dependence, manage upfront
• 7. Anticoagulation history or need perioperatively
• 8. Lack of supportive home environment

Is this patient indicated for surgery?

♦ Sufficient symptoms interfering with ADL, work or recreation, QOL ♦ Inability of alternative treatment to resolve symptoms ♦ Objective evidence of joint disease amenable to surgical correction

Develop a method to assess: Is this patient optimized for outpatient surgery?

♦ Should it be scheduled or delayed based on: ♦ Psychologically and medically fit for surgery ♦ Adequate support for home environment

Who’s a Candidate for Outpatient Arthroplasty at the ASC?

Does the patient have an ongoing medical issue that cannot be

• ptimized?

No

Does the patient have an organ failure?

Yes

Postpone surgery until medically

• ptimized

Yes

Patient is not a candidate for

• utpatient surgery and, if medically

stable, surgery should be performed at a hospital and the patient observed for 23 hours

No

Does the patient have adequate support upon discharge?

Yes

Surgery can be safely performed as an

• utpatient

No

Consider surgery at hospital

Medical Optimization: The Surgeon’s Role

Identify Organ Failure:

♦ Congestive heart failure ♦ COPD ♦ Chronic renal insufficiency ♦ Hepatobiliary disease ♦ Dementia / seizure disorder ♦ Hematopoietic disease ♦ History of anemia

Medical Optimization: The Internist’s Role

Make sure organ failure not missed… Medical Optimization:

♦ Referrals to specialists

• Cardiology, pulmonology, hematology

♦ Identify and optimize OSA ♦ Hemoglobin management ♦ VTE risk stratification ♦ Glycemic control/A1C ♦ Smoking cessation

Location of Surgery

A review process has been developed in collaboration with Orthopaedic Surgeons, Medical Consultants, and Anesthesia Initial triage is done at the time of visit with the Orthopaedic Surgeon Suitability for chosen facility is confirmed at the time of Preadmission Testing (PAT) Should the medical consultant feel that patient’s characteristics warrant change in location, this is communicated directly to surgeon and anesthesia

Outpatient Knee Arthroplasty Experience

Joint Implant Surgeons / White Fence Surgical Suites June 2013 – December 2016; 4 surgeons

♦ 2991 knee arthroplasties in 2373 patients

• 1344 partial knee arthroplasty
• 1589 primary TKA
• 58 revision TKA

♦ Gender:

• 43%

males (1014) : 57% females (1359)

♦ Mean Age: 59.4 years (SD 7.0, range 25-86) ♦ Mean BMI: 33.9 kg/m2 (SD 7.1, range 17-63)

Overnight Stays / Acute Transfers

2755 (92.1% ) discharged same day 10 (0.3% ) transferred to acute hospital 226 (7.6% ) stayed overnight

♦

74 (2.5% ) stayed for convenience

♦

154 (5.1% ) stayed or transferred for a medical reason

• 43 respiratory issues
• 24 OSA
• 29 nausea / vomiting
• 7 urinary related
• 4 pain control
• 8 muscle strength
• 6 difficulty waking up
• 7 wound issues
• 4 arrhythmia
• 3 blood pressure control
• 4 cardiac
• 2 cerebrovascular
• 13 other (in 12 patients)
• 4 traumatic falls
• 3 antibiotic administration
• 1 pseudoseizures
• 1 dizziness
• 1 patient - bilateral TKA (2)
• 2 difficult history

Major Co-Morbidities

1. Coronary artery disease 2. Valvular heart disease 3. Arrhythmia 4. History of venous thromboembolism 5. Obstructive sleep apnea 6. Chronic obstructive pulmonary disease 7. Asthma 8. Frequent urination 9. Renal disease

Preoperative Major Co-Morbidities

0% 10% 20% 30% 40% 50% 60% 70% CAD Valvular Arrhythmia VTE OSA COPD Asthma Frequent Urination Renal Disease

≥1 Major CM

6% (174) 1% (15) 18% (531) 5% (147) 16% (474) 18% (531) 11% (333) 19% (569) 3% (81) 58% (1729)

Overnight Stay or Transfer for Medical Reason by Preoperative Major Co-Morbidities

200 400 600 800 1000 1200 1400 1600 1800 CAD Valvular Arrhythmia VTE OSA COPD Asthma Frequent Urination Renal Disease

≥1 Major CM

(109 of 1729)

12% (20 of 174) 13% (2 of 15) 8% (40 of 531) 3% (5 of 147) 7% (32 of 474) 8% (42 of 536) 10% (32 of 333) 6% (33 of 569) 7% (6 of 81) 6%

No Stay or Convenience Ovenight or Transfer for Medical

Risk of Overnight Stay for Medical Reason by Major Co-morbidity

Major Co- Morbidity Overnight Medical with vs without CM Relativ e Risk 95% CI P value Odds Ratio 95% CI P value CAD 11.5% vs 5.5% 2.41 1.6-3.8 0.0001 2.60 1.6-4.3 0.0002 Valvular 13.3% vs 5.1% 2.83 0.7-12.5 0.1677 2.86 0.6-12.8 0.1693 Arrhythmia 7.5% vs 4.6% 1.50 1.1-2.0 0.0043 1.68 1.2-2.4 0.0066 VTE 3.4% vs 5.2% 0.65 0.3-1.6 0.3334 0.64 0.3-1.6 0.3295 OSA 6.8% vs 4.8% 1.33 1.0-1.8 0.0778 1.42 1.0-2.1 0.0868 COPD 7.8% vs 4.6% 1.57 1.2-2.1 0.0011 1.78 1.2-2.6 0.0021 Asthma 9.6% vs 4.6% 1.96 1.4-2.7 0.0001 2.21 1.5-3.3 0.0001 Frequent Urination 5.8% vs 5.0% 1.13 0.8-1.6 0.4288 1.17 0.8-1.7 0.4354 Renal Disease 7.4% vs 5.1% 1.47 0.7-3.3 0.3542 1.49 0.6-3.5 0.3542 Any 6.3% vs 3.6% 1.24 1.1-1.4 0.0001 1.82 1.3-2.6 0.0010

Major Complications within 48 Hours

26 (0.9% ) including 10 patients transferred to acute

♦

2 CVA (both transferred)

♦

2 atrial fibrillation (both transferred)

♦

3 pulmonary issues (all transferred)

♦

2 EKG changes (transferred, negative for MI)

♦

1 possible ileus, continuous N/V (transferred)

♦

1 postoperative anemia

♦

4 trauma secondary to falling (3 inpatient, 1 at home)

♦

4 pain control post discharge

♦

2 confirmed VTE

♦

3 to ER for VTE symptoms with negative testing

♦

1 allergic reaction to medication

♦

1 I&D for hematoma / wound dehiscence

Unplanned Care after 48 Hours, within 90 days

22 (0.7% )

♦

4 pain control post discharge

♦

6 confirmed VTE

♦

6 allergic reaction (5 to medication; 1 unknown cause)

♦

1 urinary tract infection

♦

1 urinary retention

♦

1 chest pain

♦

1 constipation/ileus

♦

1 cellulitis of the foot & ankle

♦

1 panic attacks

Surgical Complications Requiring Treatment Days 3-90 30 (1.1% )

♦ 15 wound revisions ♦ 9 I&D for hematoma or early infection ♦ 1 two-staged exchange for infection ♦ 2 periprosthetic fracture ♦ 2 arthroscopic removal of loose bodies ♦ 1 revision UKA to TKA for instability

90-Day Mortality

2 patient deaths within 90 days

♦ 1 (POD 33) cause unknown – seen at ER POD 7

for severe pain with “pop” from bending

• ver, negative for fracture or dislocation

♦ 1 (POD 48) cause unknown – seen at 6 week

postop office visit & was doing well

Musculoskeletal Specialty Hospital (MCNA) 30-day Readmissions

2015 2016 Total Primary Total Hip 1.0% (6 of 604) 1.5% (9 of 598) 1.2% (15 of 1202) Primary Total Knee 0.8% (8 of 977) 0.7% (8 of 1082) 0.8% (16 of 2059) Total 0.9% (14 of 1581) 1.0% (17 of 1680) 1.0% (31 of 3261)

Outpatient TJA

In medically optimized patients, despite a large proportion of comorbidities, outpatient TJA is associated with a low rate of medical and surgical complications Presence of major comorbidity was associated with need for extended observation / overnight stay Patient education, medical optimization, and multimodal program to mitigate side effects and reduce narcotic need results in ability to safely perform outpatient TJA in a large proportion of patients without need for a standardized risk assessment score.

Preoperative Care

0% 20% 40% 60% 80% 100%

If yes, did the nursing staff clearly explain… Were you contacted by our staff prior to…

98.4% 97.3%

Yes No 0% 20% 40% 60% 80% 100%

My waiting time prior to surgery was reasonable and as expected. The registgration and business staff were courteous and helpful. The directions to the facility were clear and accurate. Prior to my visit, my financial responsibilities were discussed and my…

75% 84% 74% 54% 17% 14% 18% 27%

Excellent Good Average Fair Poor

Nursing Care and Staff Performance

0% 20% 40% 60% 80% 100%

My homecare instructions were clear. Kept you informed of any delays. The nursing staff was competent and knowledgeable. Staff respect for your privacy. My pain level was as expected and well controlled. The nursing staff was concerned for my comfort. The nursing staff was reasonable and as expected.

78% 83% 90% 90% 86% 91% 92% 16% 12% 9% 9% 11% 8% 7%

Excellent Good Average Fair Poor

Facility and Overall

0% 20% 40% 60% 80% 100%

Comment added

62% 5% 33%

Positive Neutral Negative 0% 20% 40% 60% 80% 100%

Would you recommend WFSS to your family and friends? How would you rate your experience at White Fence overall? Overall cleanliness and appearance.

89% 85% 92% 9% 13% 8%

Excellent Good Average Fair Poor

Outpatient TJA: Here & Now

The reasons TJA “need” to be in hospital

♦

Fear, risk, side-effects Program to eliminate that “need”

♦

Education

♦

Identify appropriate patients

♦

Mitigate side effects Safe and efficient for certain patients and procedures

♦

All Medicare UKAs are outpatient

♦

As of January 1, 2018, Medicare TKA will be considered

• utpatient

♦

70%

• f non-Medicare THA, TKA & TSA can be done as outpatient

Significant cost savings for patient, hospital, and health care system

Take Home Message

As evidenced in over 2000 patients, knee arthroplasty is feasible in the outpatient setting Patient satisfaction and safety:

♦ #1 priority ♦ The ultimate report card

Standardization is required

♦ Efficiency – office/ASC ♦ Evidence based medicine ♦ Ongoing review to develop best practices

The Ultimate Report Card

Doug, Tom wanted me to tell you that we’ve come a long way from this! Change is good. We are moving forward with vigor, enthusiasm, and a sense of

• ptimism.