Authors: Mark Hamilton MD, Charles DeCook MD, Deanna Whitacre PT, Christine Seligman RN, Emily Arce RN, Mikayla McGrath
Abstract
Introduction
It is projected that by 2026 over 50% of arthroplasties will be performed as outpatient procedures1. The term “Outpatient” has been used to include discharge from a hospital or an Ambulatory Surgery Center (ASC) anytime up to a 23- hour stay. We use Same Day Discharge (SDD) to indicate discharge the day of procedure. For 2020, CMS removed Total Knee Arthroplasty (TKA) from the in-patient only category. Total Hip Arthroplasty (THA) was removed for 2021. In response to COVID, elective surgeries, particularly those requiring overnight admissions have been limited and patients have been reluctant to have surgery in hospitals. These factors have resulted in an abrupt increase in ASC arthroplasties. We present our 2019, 2020 and 2021 data on 3,074 consecutive arthroplasties performed in our Free-Standing, Arthroplasty-Exclusive ASC, all SDD.
Methods
Our preparation for ASC arthroplasty began in 2014, when tasked with developing peri-operative protocols and procedures to support routine SDD in the hospital setting. In 2018, as a multidisciplinary team, we accomplished 98.2% successful SDD for 1,978 in-hospital THA/TKA patients2. We then transitioned these protocols to our new ASC.
Key components to successful ASC Arthroplasty:
• Surgical Skill: Our surgeons are exclusive arthroplasty surgeons.
• Effective Anesthesia / Analgesia: Analgesia with minimal hypotension, PONV, weakness, Post-op Urinary Retention (POUR), and residual sedation.
• Education: Comprehensive education and preparation for patient and care giver.
• Teamwork and Protocols: This is a coordinated team process. Excellent communication and cooperation can result in efficiency and value.
With one surgeon and 2 ORs, we can routinely complete 15 arthroplasties with all patients being discharged by 4 pm. The concept of Multi-Modal Analgesia (MMA) has revolutionized arthroplasty care3. Historic reliance on narcotics has frequently resulted in inadequate analgesia, prolonged parenteral narcotics, sedation, PONV, POUR and opiate induced hyper-algesia. Using a comprehensive MMA Protocol, we not only decreased reliance on, but nearly eliminated our need for narcotics. We strictly adhere to our MMAP and maximize all agents prior to the patient’s arrival in PACU. Recent studies have highlighted the advantages of using neuraxial anesthesia for arthroplasty. Over 98% of our cases are under spinal anesthesia. We record, track and evaluate data specific to discharge delays and complications, and adjust protocols.
Current protocol:
Mandatory Education for all patients and their designated caregivers.
Preop: NPO: Electrolyte clear liquids until 2 hours preop Pregabalin 75 mg PO Rapaflo (silodosin) 8 mg PO for all males >50 yo TKA: ACB- Liposomal Bupivacaine 10 ml (off label use) + Bupivacaine 0.25% 5 ml iPACK- Bupivacaine 0.25% w/ epi 1:200,000, 20 ml
Spinal Anesthesia: Isobaric Mepivacaine (33-45mg) Preload with ~500 ml IV Fluids and Zofran 4 mg IV (Spinal And Blocks placed in Pre-op)
Intra-operative:
Acetaminophen 1,000 mg IV Dexamethasone 0.15 mg / kg IV
Ketorolac 15 mg IV Ketamine 0.25 mg / kg IV
Methocarbamol 750 -1000 mg IV Benadryl 5 mg IV (hold in males > 50 yo)
Patients on chronic narcotics, consider Methadone 0.1 -0.2 mg/kg IV
Otherwise, no narcotics pre-op, intra-op, in blocks or for sedation
Peri-articular injection by surgeon- Bupivacaine 0.5% w epi, 1:200,000, 22 ml
PACU: for Pain rated > “reasonable”/“tolerable”, Fentanyl, titrated 25 mcg IV
Post-discharge: continue MMA with:
Acetaminophen 1,000 mg and Ibuprofen 600-800 mg PO TID X2 weeks
Pregabalin 75 mg PO qhs X 2 weeks , Oxycodone 5 mg PO as rescue
Results
Number of Arthroplasties:
2019- 476 (46% knees) 2020- 911 (61% knees) 2021- 1,687 (53% knees)
PACU arrival to discharge time:
2019- 2 hrs. 17 min 2020- 2 hrs. 10 min 2021- 2 hrs. 13 min
Patients discharged with foley catheter:
2019- 2/476 (0.42%) 2020- 1/911 (0.11%) 2021- 4/1,687 (0.24%)
Infections:
2019- 3/476 (0.63%) 2020- 4/911 (0.44%) 2021- 4/1,687 (0.24%)
30-day readmissions:
2019- 6/476 (1.3%) 2020- 7/911 (0.77%) 2021- 10/1,687 (0.59%)
Education class attendance- 98.3%
Post-spinal headaches, epidural blood patches, Transient Neurologic Syndrome-0/3,074
Readmission for pain- 0/3,074 Transfusions- 1/3,074
Physical Therapy works with the patient within 1 hour of PACU arrival- 76%
Reasons for PT clearance delay: Prolonged spinal- 8.2% POUR- 10.9% Excess sedation- 3.7% Pain- 1.7%
For patients who were not on narcotics pre-operative: 85% received no narcotics in the ASC
For those who required narcotics, ~50% required only 25 mcg and less than 20% required >50 mcg fentanyl
Post-operative narcotic use, POD 1-7:/
TKA - oxycodone 5 mg tabs - Average 0.6/day. Pain satisfaction 96%
THA - oxycodone 5 mg tabs - Average 0.5/day. Pain satisfaction 95%
Discussion
After developing our protocols to accomplish routine SDD in a hospital setting, we were able to smoothly transition to our free-standing ASC, performing over 3,000 arthroplasties in the last 3 years. Keys to our success: Specific and strict MMAP combined with Spinal Anesthesia by protocol, Comprehensive patient preparation and education, Collaborative teamwork with staff led by Surgeon-Anesthesiologist partnership. We have accomplished: Average PACU to discharge times of 2 hours 13 minutes, Very Low narcotic requirements: 85% discharged having received ZERO narcotics, Post-op narcotic use averages 2.5-3.0 mg oxycodone/day for POD# 1-7. Foley Catheter required at discharge 0.2%. Surgical complication rates well below national averages. Efficiency and value.