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Early Discharge: Same day or overnight
surgery for THR or TKR
H Yang
Professor & 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
Pain Control
Financial
• Decrease wait times
• Improve operational
efficiencies
• Improve accessibility
Multimodal
analgesia
Regional analgesia
Surgical techniques
Demand for TKR
• ↑ Wait Lists
• ↑ hospital pressures
• Aging cohort
Outpatient TKR
MIS procedures
Inclusion Criteria
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•
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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
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•
•
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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 noncardiac surgery in 329 hospitals in 2000 & 2001
• 782969 patients, 663635 without contraindications to βblockers
• 13454 mortality (2%)
• Number of RCRI factors
–
–
–
–
0: 313969
1: 76983
3: 15655
≥ 4: 1416
Perioperative Mortality
541297
(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
Lindenauer et al. NEJM 2005; 353:349 - 61
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
Effect of β-blockers in Postop Hip & Knee Replacements
PMI (n=77)
No PMI (n=5081)
Class I
28 (36.4%)
4502 (88.6%)
Class II
32 (41.6%)
502 (9.9%)
10 (6.1–17)
Class III
15 (19.5%)
63 (1.2%)
38 (19–75)
Class IV
2 (2.6%)
14 (0.3%)
23 (5.0–106)
Anesthesiology 2009; 111(4): 690-4
OR
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%
Remote
Care Plan
Manage
medication &
activities
Patient
Messaging &
Clinical Notes
Exchange
Monitoring
Reporting
Analysis
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