In an age when “patient-centered care” is the watchword, more providers are channeling eligible candidates toward lower-hassle medical services. Joint replacement surgery is a prime example.
According to Gregory Polkowski, M.D., an associate professor of orthopaedic surgery at Vanderbilt University Medical Center, for patients with no major medical conditions, same-day joint replacement surgery is attractive for all involved – patient, provider, employer and insurance carrier. “If the patient doesn’t require in-patient hospital services, staying over for one or two nights doesn’t add value, and may increase the risk of complications,” he said.
Vanderbilt added same-day joint replacement as a bundled service through its program, MyOrthoHealth, in late 2020, making it available to Vanderbilt employees and over 18,000 Metro Nashville Public Schools employees and dependents. In addition, four other MyHealth Bundles were introduced over the past year: MyMaternityHealth, MyWeightLossHealth, MySpineHealth and MyHearingHealth.
The Outpatient Experience
The eleven operating rooms at the Vanderbilt Health Belle Meade and Vanderbilt Surgery Center outpatient facilities are state-of-the-art and equipped to handle any complication that might occur during a surgery center procedure.
Consistent with newer protocols across surgical specialties, Polkowski and colleagues use short-acting spinal anesthesia during most procedures, and follow up with alternatives to narcotics in many cases. Following a typical two-hour surgery, the patient spends two or three hours in the recovery room before getting up and walking around. “At that point, unless they have an unexpected response like nausea, they are ready to go home with their family members,” Polkowski said.
Operating outside a hospital setting drives efficiencies, he explained. The surgical staff at an outpatient facility draws from a smaller pool of employees, so the teams generally have more experience working together.
“When we are scheduling a patient, it is incredibly important that we make a fully-informed decision about whether the patient is totally appropriate for this venue.”
“There is an inherently slower pace at a hospital, partially because services and supplies are spread out geographically. It takes longer to get the room ready and to get the instruments into the room,” he said.
“The outpatient center teams are accustomed to moving a higher volume of the same kinds of surgeries through the system, so we have a more high-throughput mindset.”
Before recommending same-day joint replacement, Polkowski says the outpatient surgeons carefully scrutinize the patient’s medical history. “When we are scheduling a patient, it is incredibly important that we make a fully-informed decision about whether the patient is totally appropriate for this venue,” Polkowski said.
Comorbidities do not preclude same-day surgery, however, and Polkowski says the team works with patients and their providers ahead of time to qualify them for the procedure. If the patient has diabetes, the outpatient team makes sure the patient’s blood sugar levels are well controlled. If the patient has hypertension, the team ensures that the patient is on the right medications before surgery.
“We have all the resources we would have at the hospital to deal with many chronic, stable medical conditions such as diabetes or hypertension, for example,” he said. “On the other hand, if a patient has significant heart problems, poorly controlled diabetes or certain respiratory conditions, the hospital may be the best place for their procedure so they can be observed overnight.”
“When you tell a patient that they’re going to be back on their feet quickly, and that they will do well, it can become a self-fulfilling prophecy.”
Setting Expectations for Success
While COVID-19 has lowered elective surgery rates, it has increased the popularity of same-day outpatient versus in-hospital surgery. In 2020, these procedures at Vanderbilt ran between 80 to 90 percent of the prior year’s volume, Polkowski said, which is high for an elective procedure during the pandemic.
Polkowski says one of the learning points over the years is about setting expectations with each patient. “The message that we try to convey is that we’re replacing your joint, but that doesn’t make you sick,” he said. He added that particularly in an outpatient setting, results are better all-around when the patient doesn’t fall into a dependency role.
“The sooner they get up and moving after the procedure, the less muscle deconditioning they have, and the lower the chance of blood clots,” he said. “Thankfully, in most cases, when you tell a patient that they’re going to be back on their feet quickly, and that they will do well, it can become a self-fulfilling prophecy.”