Same Day Total Joint Replacement A Byproduct of Synergy from a Comprehensive Approach. Disclosures. Just 25 Years Ago

Transcription

1 Total Joint Replacement A Byproduct of Synergy from a Comprehensive Approach Richard Berger, MD Rush Medical Center Chicago, IL Disclosures Zimmer, Inc Microport, inc Just 25 Years Ago Arthroscopic ACL inpatient procedure 2-3 night hospital stay Total joint pathway Decreasing from 14 days to 10 days 1

2 2001 TJA Heraclitus (6th century BC) Nothing endures but change Joint Replacement Started in 2001 Same Day THA Patient From

3 Total Hips and Knees Total Hips and Knees Total Hips and Knees 1,200 Joint Replacement 1, ,200 Joint Replacement 1, Overnight Joint Replacement 1,200 1, <1 Night Overnight

4 Total Hips and Knees Total Hips and Knees Joint Replacement 1,200 1, <1 Night 3,667 Overnight Patients Since ,587 Patients 0 Joint Replacement 100% 1,200 90% 1,000 80% 70% % 50% % % 20% % 0% 0 <1 Night 3,667 Overnight Patients Since ,587 Patients Synergy of a Comprehensive Approach Same Rapid Day TJA 4

5 Synergy of a Comprehensive Approach Minimally Invasive Pain Management TJA Rehabilition & Education Changing Our Perception of TJA 1 Patients want a quick recovery Changing Our Perception of TJA Patients Apprehensions Pain & Unknown Dependent & Complications 5

6 Changing Our Perception of TJA Patients Apprehensions Pain & Unknown Mild Dependent & Complications Changing Our Perception of TJA Patients Apprehensions Pain & Unknown Mild Dependent & Complications Independent the day of surgery Changing Our Perception of TJA 1 Patients want a quick recovery 2 Many good techniques 6

7 Changing Our Perception of TJA 1 Patients want a quick recovery 2 Many good techniques 3 is only part of the solution Synergy of a Comprehensive Approach Minimally Invasive Pain Management Rapid Rehabilition & Education Changing Our Perception of TJA 1 Patients want a quick recovery 2 Many good techniques 3 is only part of the solution 4 Comprehensive approach 7

8 Synergy of a Comprehensive Approach Minimally Invasive Rapid Synergy of a Comprehensive Approach Minimally Invasive Rapid Pain Management Synergy of a Comprehensive Approach Minimally Invasive Pain Management Rapid 8

9 Synergy of a Comprehensive Approach Minimally Invasive Rapid Pain Management Rehabilition & Education Synergy of a Comprehensive Approach Minimally Invasive Pain Management Rapid Rehabilition & Education Synergy of a Comprehensive Approach 20% Minimally Invasive Pain Management Rapid Rehabilition & Education 20% 20% 9

10 Tissue Trauma Perioperative Medications Hypotension & Nausea / Malaise Imposed & functional restrictions Difficulty with Rehabilitation Tissue Trauma Perioperative Medications Hypotension & Nausea / Malaise Imposed & functional restrictions Difficulty with Rehabilitation Tissue Trauma Effect Perioperative Medications Anesthesia Effect Hypotension & Nausea / Malaise Imposed & functional restrictions Rehabilitation / Education Effect Difficulty with Rehabilitation 10

11 Changing Our Perception of TJA 1 Patients want a quick recovery 2 Many good techniques 3 is only part of the solution 4 Comprehensive approach 5 Significantly reduced recovery Length of Stay CORR 2003 Length of Stay 70% CORR

12 Length of Stay Problems: Hypotension Nausea CORR 2003 Length of Stay Problems: Hypotension Nausea Less: Hypotension Nausea CORR 2003 Length of Stay CORR

13 Length of Stay Better Patient Education CORR 2003 Length of Stay CORR 2003 Rehabilitation Protocol Hospital Mandated Milestones Independent transfer To and from bed to standing To and from chair to standing Ambulate 100 ft without assistance Ascend & descend a full flight of stairs 13

14 TKA - Day of Standardized Protocol Patient education with rapid discharge Pre: Cox-2 (400mg) & OxyContin (10mg) Muscle Sparing TJA with epidural Intraop: hydration, antiemetic, & Bupivacaine Post: Cox-2 (200mg) & OxyContin (10mg) Immediate PT & FWB 150 Hip - First Case / IRB Study Better Patient Education 14

15 150 Hip - First Case / IRB Study Selected Patients (2003 to 2004) Patient education with rapid discharge Pre: Cox-2 (400mg) & OxyContin (10mg) Muscle Sparing TJA with epidural Intraop: hydration, antiemetic, & Bupivacaine Post: Cox-2 (200mg) & OxyContin (10mg) Immediate PT & FWB CORR Hip - First Case / IRB Study Selected Patients (2003 to 2004) 150 (100%) D/c home same day CORR Hip - First Case / IRB Study Selected Patients (2003 to 2004) 38 Delayed pathway intervention 12 Nausea Reglan & Zofran 9 Nausea / Hypotensive Fluid & Reglan 10 Hypotensive Fluid 7 Oversedated 6 Observation / 1 Narcan CORR

16 150 Hip - First Case / IRB Study Selected Patients (2003 to 2004) 131 Walked without an assistive device 26 D/c with nothing 105 D/c with cane 18 D/c with crutches 1 D/c walker (preop balance) CORR Hip - First Case / IRB Study Adjusted Our Pathway Patient education with rapid discharge Pre: Cox-2 (400mg) & OxyContin (0-10mg) Muscle Sparing TJA with epidural (Marcaine) Intraop: hydration, antiemetic, & Bupivacaine Post: Cox-2 (200mg) & OxyContin (0-10mg) Immediate PT & FWB TJA Done by Noon: Hips & Knees Feasibility of TJA: 245 cases in agreed to be in study (91%) Less selective 213 (95%) D/c home same day 16

17 111 Knees Done by Noon Feasibility & Problems of TJA (94%) D/c home same day Selection open to all PT with FWB 103 Walked without assistive device»37 D/c with nothing»66 D/c with cane CORR Knees Done by Noon Feasibility & Problems of TJA Stayed over night D/C Next day 4 Pain 1 Chest pain 1 Nausea 1 Patient s choice CORR Knees Done by Noon Feasibility & Problems of TJA Patient education with rapid discharge Pre: Cox-2 (400mg) & OxyContin (0-10mg) (0-20mg) Muscle Sparing TJA with epidural Intraop: hydration, antiemetic, & Bupivacaine Post: Cox-2 (200mg) & OxyContin (0-10mg) (0-20mg) Immediate PT & FWB Re-transfusion drain 17

18 Current Protocol Preoperative Preparation Preoperative Class Explain the surgery & recovery Emphysize rapid recovery Review discharge day and time Address special needs & concerns coordinate post op care & services No pre-op PT Current Protocol Pain control- Preemptive and Bridge Gaps Preoperatively Morning of OxyContin 0-20mg Anti-inflammatory Lyrica 50 mg Scopolamine patch Current Protocol Pain control- Preemptive and Bridge Gaps - Avoid narcotics Epidural: Marcaine only Minimize sedation and other agents Injection: Marcaine/Epi (RR bridge) Tranexamic acid & diffuse hemostasis Room - Start to tailor program OxyContin (0-20mg) Avoid IV & IM narcotics 18

19 Total Hips and Knees Current Protocol Pain control- Preemptive and Bridge Gaps Home - Tailored program OxyContin 0-20mg tapered over 5 days Break through pain Norco or Ultram or Tylenol Anti-inflammatory BID for 3 months Lyrica 50 mg BID for 2 weeks Current Protocol Rehabilitation Protocol No Pre-op PT In Hospital PT with FWB Frist walk with nothing, when use cane D/c with cane use if pt wants Knees: ROM with flexion & extension Home PT for 1 week: Amb and ROM Outpatient PT for 3-4 weeks Progress as rapidly as tolerated All Primary Total Joints 1,200 1, <1 Night 3,667 Overnight Patients Since ,587 Patients 0 19

20 Total Hips and Knees 100% 1,200 90% 1,000 80% 70% % 50% % % 20% % 0% 0 All Primary Total Joints 3%: < 1 night 60% <1 Night 3,667 Overnight Patients Since ,587 Patients Heraclitus George Bernard (6th century Shaw BC) Progress Nothing is endures impossible but without change change, and those who cannot change their minds cannot change anything. George Bernard Shaw Progress is impossible without change, and those who cannot change their minds cannot change anything. Andy Warhol People say time changes things, but you actually have to change them yourself 20

21 Synergy of a Comprehensive Approach Minimally Invasive Pain Management Rapid Rehabilition & Education Thank You 21