Early Discharge: Same day or overnight surgery for THR or TKR

H YangProfessor & Chair

Department of Anesthesia

Objectives

• To understand the theory and organization behind early discharge after TKR

• To understand some of the potential concerns of early discharge

• To understand the limitations of current risk stratification methodology

• To understand the remote patient monitoring system

It takes a Team!

• Susan Madden BScN MEd APN• Geoffrey Dervin. MD MSc, FRCSC Orthopedic

Surgeon• Alan Lane, MD, FFARCSI Anӕsthetist• Holly Evans, MD, FRCPC Anesthesiologist• Timelines

– Pathway implemented 2008– Pathway revised 2011

It takes a Team!

• Fred Beauchemin, Tina Alverez West, Lynn Cuerrier, Physiotherapist;

• Ray Vallee, Kevin Babulic & Lila Brooks, CCCAC; • Sonia Mathieu, SDCU RN• Barb d’Entremont, Clinical Pathway Coordinator; • Barb Crawford Newton, Kirsten Dupuis, Jackie Mace

Orthopedic Nurse Manager; • Dr Peter Thurston, Orthopedic Surgeon• Sarah Plamondon, Kyle Kemp, Orthopedic Research

team

Outpatient TKR

Demand for TKR• ↑ Wait Lists• ↑ hospital pressures• Aging cohort

Financial• Decrease wait times• Improve operational

efficiencies• Improve accessibility

Pain ControlMultimodal

analgesiaRegional analgesia Surgical techniques

MIS procedures

Inclusion Criteria

• City of Ottawa• ASA 1 & 2• Accept same day discharge• Motivated • Good understanding of care concepts

– anticoagulant self-injections, multimodal analgesia, continuous nerve block: effects, limitations, care of numb extremity, Quad weakness, ambulatory pump function

• Appropriate resources at home (responsible care giver, for 3-4 days limited stairs ~ 5, bathroom / bed on same level)

Exclusion Criteria

• ASA III – V• Chronic pain or opioid

consumption• Residence outside the catchment

area of home care services

Multimodal Analgesia

• Spinal without long acting opiods• Peri-articular local anesthetic

injections• Acetaminophen 975 mg 2 hrs pre-op;

then 650 mg PO Q4H while awake• Celecoxib 400 mg PO 2 hrs pre-op;

then 200 mg Q12H for 2 weeks• Pregabalin 50 – 75 mg PO 2 hrs pre-op;

then 50 mg Q8H for 10 days ; 50 mg taken HS before surgery

• Hydromorphone 1 – 2 mg po q4h prn

Potential Gaps in Early Discharge

• 45.8% of PMI occurs after POD 2• Postop pneumonia defined at 48 hrs postop• Fatal PE peaks between POD 3 – 7• In major arthroplasty

– 3.1% PMI, CVA, rhythm irregularities, DVT, others– 43% have 1 – 2 of the 4 factors for metabolic

syndrome

Periop β-blocker & mortality after major non-cardiac surgery (Propensity Analysis)

• Retrospective cohort of patients undergoing major non-cardiac surgery in 329 hospitals in 2000 & 2001

• 782969 patients, 663635 without contraindications to β-blockers

• 13454 mortality (2%)• Number of RCRI factors

– 0: 313969– 1: 76983– 3: 15655– ≥ 4: 1416

Lindenauer et al. NEJM 2005; 353:349 - 61

Perioperative Mortality541297

(did not receive -blockers)

10771 (1.98%)

RCRI Factors ≤ 1 RCRI Factors ≥ 2

8443 (1.73%) 2328 (4.23%)

78% of all mortality 22 % of all mortality

Database Results

• HHSC Chart Audit 1996 – 1997 elective THR & TKR– 679 charts– 38/49 (77.5%) cardiac complications in Detsky 0 or 5

• LHSC Referral Consults– 2035 patients– 95/130 (73.0%) of MI, unstable angina, CHF, or death in Detsky

stratum 1

• TOH 2002 – 2006 elective THR & TKR– 5158 patients in Data Warehouse

Anesthesiology 2009; 111(4): 690-4

Effect of β-blockers in Postop Hip & Knee Replacements

23 (5.0–106)14 (0.3%)2 (2.6%)Class IV

38 (19–75)63 (1.2%)15 (19.5%)Class III

10 (6.1–17)502 (9.9%)32 (41.6%)Class II

4502 (88.6%)28 (36.4%)Class I

ORNo PMI (n=5081)PMI (n=77)

Transition Points

• 46% of medication errors at admission or discharge

• 23% medicine patients experienced at least 1 adverse event after discharge– Adverse drug events 72%– Therapeutic errors 16%– Nosocomial infections 11%

Patient

Remote Care Plan

Monitoring Reporting Analysis

Messaging & Clinical Notes

Exchange

Manage medication & activities

Summary

• Early Discharge – after TKR is reality– after THR is imminent– Multi-disciplinary team work essential– MIS & multimodal analgesia

• Potential Gaps– Timing of complications– Limitations of risk stratification tools

• Remote Monitoring– NIBP, SpO2, HR, BS, pain, activity advice– Real-time remote support – Smooth post-discharge transition