During the COVID-19 pandemic, I've consulted many times with patients and referring physicians about postponing "non-essential" surgeries. While safety considerations continue to be top of mind for all of us, delaying important procedures can leave patients stranded with pain and mobility issues that will impact them now and for the rest of their lives.
As an orthopedic surgeon who spends most of my waking hours replacing joints and relieving patients' pain, when I hear the words "non-essential," I always think, "non-essential" to whom? Non-essential isn't "non-essential" when postponing a recommended surgery or procedure that negatively affects a patient's daily life.
A Replicable Model: Outpatient Orthopedics
In COVID-19, many people have become fearful of the potential risks of undertaking medical procedures for conditions they don't perceive as life-threatening. Plus, depending on location and the strain on hospitals and staff, it can be challenging to schedule "non-essential" surgery in a hospital. But when a delay can have a critical impact on a patient's long-term well-being, we physicians need to be proactive in finding alternatives.
More than a decade ago, The Anderson Clinic created a model to reduce hurdles for patients receiving life-changing joint replacements. This model led our team to develop an outpatient surgical center, which has since served as a patient-friendly and effective model of care. Well before COVID-19, we were already conducting a significant portion of joint replacements on an outpatient basis at both , with the goal of keeping qualified patients out of the inpatient setting and in the comfort of their own home.
Amid the new pandemic normal, even more patients are willing to consider outpatient joint replacements. If there are any positive aspects to the pandemic, greater patient and physician confidence in outpatient surgeries is one.
Patients who come in for replacement surgery at 7 a.m. are frequently out of the operating room and home before lunch. In an effort to facilitate this, we practice minimally invasive surgical techniques -- taking careful measures to minimize muscle, tendon, or soft tissue damage. Anesthesia and pain management protocols have also changed tremendously for outpatient replacements. We now rely on utilizing multiple non-narcotic medications as the mainstay for pain management, which we believe results in patients being more alert, less nauseous, and more comfortable following surgery. Early mobilization (walking) has also proven critical for success in the outpatient replacement realm.
Over the years, we have developed an efficient process for the patient. They get up and walk with a therapist less than 2 hours post-surgery. This early mobilization provides patients with the boost of confidence we want them to have prior to going home. Our practice has done thousands of outpatient procedures and has proven the safety of this type of care in both hospital and surgery center settings. is safe, effective, and allows the patient to recover in the comfort of their own home.
For hip replacements, physical therapy can also be entirely touchless and home-based. Nearly all of the resources our recovering patients need are delivered through an online patient-engagement platform. They receive daily updates on everything from expectations to incision care to how to take medications to therapy exercises. If there is a complication -- and there will be occasional complications -- our app allows us to catch the issue early. A patient can send an immediate message if they don't feel well, want to know if something is abnormal, or if they simply need reassurance. We can then make a quick phone call and address their concerns.
Prior to the pandemic, we were already discharging surgical patients the same day, focusing on rapid recovery protocols, and performing touchless care through our patient-engagement platform -- and the pandemic has only further validated that outpatient replacement surgery works for patients. This approach ensures patient safety without further compromising a patient's quality of life. Other than adding COVID-19 testing, our process has not changed and offers a model for other practices to follow. It's time for a big shift in orthopedics.
Best Practices for Implementing Outpatient Surgery
When other surgeons visit us to learn about setting up an out-patient surgical center, we make the following suggestions:
- Begin by setting up your outpatient practice inside a hospital setting. Do not jump into a surgery center right away. You will feel more secure at first with the resources available in a hospital.
- When you begin treating outpatient patients, accompany them to their initial bedside physical therapy. If you feel comfortable that they are stable and pain-controlled, send them home from the hospital floor on the same day as the surgery.
- After you have successfully completed a number of outpatient surgeries, have patients perform their initial PT in the recovery room instead of going to the floor. That will closely mimic how things will work in a surgical center. When you are comfortable, start discharging from the recovery room.
Robert Axel Sershon, MD, is a fellowship-trained hip and knee replacement surgeon at The Anderson Orthopaedic Clinic.