Published 8/1/2019
Kerri Fitzgerald

Taking Joint Replacement to the Outpatient Setting: AAOS Course Sets You on the Right Track

On Oct. 18, AAOS will host a new single-day course, “AAOS Outpatient and Rapid Recovery in Total Joint Replacement,” which will address the increasing demand for same-day discharge after total joint replacement (TJR). Expert faculty will provide tips for safely implementing an outpatient rapid recovery program in your own institution or practice.

The course will feature focused lectures and interactive panel discussions, during which faculty will share how they successfully transitioned their procedures to the outpatient setting, while keeping patient safety and satisfaction at the forefront.

R. Michael Meneghini, MD, of the Indiana University School of Medicine, and William G. Hamilton, MD, of the Anderson Orthopaedic Clinic in Alexandria, Va., are the course directors. They spoke with AAOS Now about what attendees can expect and gain from participating either in person or virtually.

AAOS Now: Can you discuss the growing push for same-day discharge after TJR? What are the considerations for all stakeholders: patients, surgeons, and payers?

Dr. Meneghini: The growing trend comes from multiple external forces, even outside the profession, including the need to reduce the cost of joint replacement for the healthcare system. In almost every setting, outpatient joint replacement is less expensive than inpatient, even within the same health system. It’s the only thing that I have seen where the government, payers, and many surgeons are all aligned. Even surgeons who aren’t “fully aligned” right now know that it’s coming and that it’s the right thing to allow medically and psychosocially appropriate patients to recover at home.

We presented data at the Mid-America Orthopaedic Association’s 37th Annual Meeting in April, which showed that for patients who stay overnight, there are a negligible number of tests or interventions during the night they are in the hospital. So, for healthy patients, there’s not really a need to keep them in the hospital. It’s somewhat of an antiquated model. There is a growing acknowledgment within the orthopaedic community that it’s actually safer for patients to be discharged home early.

Dr. Hamilton: I agree completely, and I think it’s a natural evolution like many surgical procedures that have come before this one. There’s a natural movement toward doing procedures in the outpatient setting. It happens once the surgical techniques are optimized; once we determine the appropriate anesthesia; and once we convince patients, surgeons, and every stakeholder that the safety is appropriate. There are so many benefits to moving in this direction, and cost is just one. Patients prefer not being admitted to the hospital. Surgeons benefit from having patients at home and from the efficiency of the outpatient atmosphere. As this is implemented and becomes more popular, we must ensure that patient safety is optimized so we can maintain the trust of our patients.

AAOS Now: How can physicians safely implement an outpatient rapid recovery program at their institutions and practices?

Dr. Hamilton: All factors have to be taken into account. Surgeons must be able to confidently perform the procedures efficiently. To do this with same-day discharge, it’s more challenging with prolonged surgical times or increased blood loss. The procedures need to allow for early weight-bearing and activity. It’s helpful to team up with your anesthesiologist to develop appropriate perioperative protocols so anesthesia and pain management are optimized. All team members—anesthesia, nursing, and physical therapy—need to be on the same page to avoid confusion, optimize efficiency, and avoid giving the patients mixed messages.

This requires planning; you have to meet often with the various stakeholders ahead of time to explain the rationale and goals of the program so all parties collaborate on how best to get there. It does take some planning and preparation, but it can easily be achieved.

Dr. Meneghini: We now know that we can safely do this. Right now, it’s happening at selective centers. It’s up to us now to start to teach others how to do that, so they can go back to their institutions and try and put those programs and protocols in place.

It’s a complicated and involved process to put the whole program together, but it’s not that different from 10 to 15 years ago when we were putting total joint programs together. It requires education. People who are already doing this need to show that it can be done safely and teach others those techniques.

AAOS Now: What are the patient safety considerations for performing TJR in the outpatient setting?

William G.Hamilton, MD
R. MichaelMeneghini, MD

Dr. Meneghini: You need a motivated patient with good home support and minimal medical comorbidities. If patients do have medical comorbidities, they need to be optimized. If the patient wants to sit in the hospital for three days, it’s going to be really hard for us to motivate that patient, especially if the insurance carrier will pay for it.

Dr. Hamilton: You need to monitor outcomes and adverse events. Evaluate your own data to make sure you’re safely implementing this in your own patient population. Just because it has been done safely in another center, that doesn’t mean the same will happen at your own. Start simple with patient selection and monitor outcomes and graduate from there.

AAOS Now: Can you give an overview of what will be discussed during the course? What can attendees or online viewers expect to learn?

Dr. Hamilton: We will review all of the important components of implementing a successful outpatient surgery program. We’ll start with patient selection, anesthesia protocols, and perioperative modalities. Then we’ll have a layered discussion on some of the more complex issues, such as financial implications, national policy and government implications, and what the future holds. There will be question-and-answer sessions and discussions for both audiences.

AAOS Now: Are there any differences in what one might learn or experience online versus attending in person?

Dr. Meneghini: The live course offers the ability to interact with the faculty outside of the more formal, didactic discussion.

Dr. Hamilton: Having the ability to interact offline over coffee or during breaks can sometimes be when you learn some of the more valuable things. Obviously, there are pros and cons for both options. Staying home and being able to participate online has an upside, but I think attending in person will be a more robust experience.

AAOS Now: Do you have any final thoughts about the course?

Dr. Hamilton: Outpatient surgery is coming whether you like it or not. Over the next 10 to 15 years, I think we’re going to see a fairly significant rise in outpatient TJR. Whether you adopt this today or in the near future, this is coming. I think there are significant upsides to learning these protocols and techniques. Even if you didn’t radically increase your percentage of outpatient surgery, there are still tips and tricks that will enhance even your inpatient population.

Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at kefitzgerald@aaos.org.


Course details: ‘AAOS Outpatient and Rapid Recovery in Total Joint Replacement’

Attend in person at the OLC Education & Conference Center in Rosemont, Ill., on Oct. 18 from 7 a.m. to 5:30 p.m. C.T., or live-stream the course online. Both registration options include the course recording to rewatch lectures anytime, anywhere for 90 days following the event.

To register for the course:

  • Visit aaos.org/3265A
  • Call AAOS Customer Service at 800-626-6726 from 8 a.m. to 5 p.m. C.T.
  • Print the registration form at aaos.org/3265A and mail to AAOS, 9400 W. Higgins Rd., Rosemont, Ill. 60018, or fax to 847-823-8125.

This activity has been approved for 6.5 American Medical Association Physician’s Recognition Award Category 1 Credits™.