Postponing ‘non-essential’ procedures isn’t the only option

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During the COVID-19 pandemic, I have repeatedly consulted with patients and referring physicians about postponing “non-essential” surgeries. Although safety considerations continue to be a priority for all of us, delaying important procedures can leave patients stranded with pain and mobility issues that will affect 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” for whom? Non-essential is not “non-essential” when postponing a recommended surgery or procedure that negatively affects a patient’s daily life.

A reproducible model: ambulatory orthopedics

In COVID-19, many people have begun to fear the potential risks of undertaking medical procedures for conditions they do not perceive to be life-threatening. Additionally, depending on the location and pressure on hospitals and staff, it can be difficult 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 must be proactive in seeking alternatives.

Over a decade ago, the Anderson Clinic created a unique outpatient practice model to reduce barriers for patients receiving life-changing joint replacements. This model led our team to develop an outpatient surgery center, which has since served as a friendly and efficient model of care. Long before COVID-19, we were already performing a significant portion of joint replacement surgeries on an outpatient basis in surgery centers and hospitals, with the goal of keeping qualified patients out of the hospital 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 positive aspects to the pandemic, greater patient and physician confidence in day surgery is one.

Patients showing up for replacement surgery at 7 a.m. often leave the operating room and go home before lunch. In an effort to facilitate this, we practice minimally invasive surgical techniques – taking careful steps to minimize muscle, tendon or soft tissue damage. Anesthesia and pain management protocols have also changed dramatically for outpatient replacements. We now rely on the use of several non-narcotic medications as a mainstay of pain management, which we believe makes patients more alert, less nauseous and more comfortable after surgery. Early mobilization (walking) has also been shown to be critical to success in the field of outpatient replacement.

Over the years, we have developed an efficient process for the patient. They get up and walk with a therapist less than 2 hours after surgery. This early mobilization gives patients the confidence boost we want them to have before they go home. Our practice has performed thousands of outpatient procedures and has proven the safety of this type of care in hospital and surgical centers. Ambulatory joint replacement is safe, effective and allows the patient to recover in the comfort of their own home.

For hip replacements, physiotherapy can also be completely non-contact and at home. Almost all the resources our recovering patients need are provided through an online patient engagement platform. They receive daily updates on everything from expectations to incision care to how to take medication to therapy exercises. If there is a complication – and there will be occasional complications – our app allows us to catch the problem earlier. A patient can send an immediate message if they are not feeling well, if they want to know if something is wrong or if they simply need reassurance. We can then make a quick phone call and address their concerns.

Before 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 their quality of life. Other than adding COVID-19 testing, our process has not changed and provides a model for other practices to follow. It’s time for a big change in orthopedics.

Best Practices for Implementing Ambulatory Surgery

When other surgeons visit us to inquire about setting up an outpatient surgical center, we make the following suggestions:

  • Start by setting up your outpatient practice in a hospital setting. Don’t jump into a surgery center right away. You will initially feel safer with the resources available in a hospital.
  • When you start treating outpatients, accompany them to their initial bedside physiotherapy. If you feel comfortable that they are stable and the pain is controlled, send them home from the hospital floor the same day as the surgery.
  • After successfully completing a number of outpatient surgeries, have patients perform their initial TP in the recovery room instead of going to the floor. This will closely mimic how things will work in a surgical center. When you are comfortable, begin to exit the recovery room.

Robert Axel Sershon, MD, is a hip and knee replacement surgeon at Anderson Orthopedic Clinic.

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