Downside of Outpatient Arthroplasty? Higher Surgeon Workload

Like a lot of things that sound inherently positive, outpatient total joint surgery can have a downside. One of which, says new research, is the shift of responsibility away from the hospital to the surgeon.

The new study, “Rapid Discharge and Outpatient Total Joint Arthroplasty Introduce a Burden of Care to the Surgeon,” appears in the July 2019 edition of The Journal of Arthroplasty.

Richard A. Berger, M.D. of Midwest Orthopaedics at Rush, who has just performed his 10,000th outpatient (OP) joint replacement surgery, was a co-author on the study. He really spelled out the difference between inpatient and outpatient total joint arthroplasty in terms of the surgeon responsibilities to OTW, “When someone is in the hospital for several days there are numerous interactions, including those with nurses, PAs, doctors, etc. They tell the patient, ‘If your knee is a little red and a little warm then that’s fine…that is normal.’ Basically, a lot of information is transferred as a normal part of being in the hospital. On occasion, this is a formal transmission of information; at other times, less so.”

“But, when patients go home three hours after surgery, they have the same questions as those who remain in the hospital. They have a need for information that is no longer being addressed by the hospital. Someone has to help these patients lest they be—and feel—abandoned.”

Dr. Berger and his colleagues reviewed 103 primary total joint arthroplasty (TJA) patients, all of whom were discharged either within five hours or on the morning after surgery. The team assessed all phone calls and office visits during the first seven days after surgery. Any patient contact was defined as a “touch.”

The authors wrote, “…There were 253 touches required, averaging 2.5/patient. One hundred sixty were outgoing phone calls by the surgical team and 93 were incoming calls from patients. The average duration of each call was 4.74 minutes. The entire group required 19 hours and 35 minutes of telephone contact. After including specialized education time, this cohort required 83.1 hours of clinical time, or 48.4 minutes per patient.”

“Due to this shift to the physicians,” says Dr. Berger, “we now have to give more information up front. We used to tell inpatients, ‘Look for infection, a red or warm knee, etc.’ and the nursing staff would be around to help them determine what is normal. Now you’ve discharged 100 patients who are at home and wondering what is normal red versus infected red…and many of them are calling you. With OP joint surgery, before they leave the hospital you really need to show patients a picture of what is normal.”

“Also, the fact is that three hours post-discharge we are having to spend more time with patients to reiterate everything we told them two weeks ago. In a hospital a nurse will round on patients 3-4 times per day. But for outpatients there is no one. In our group we have made it a practice to call the patient the night of surgery, the next day and one week later. This contact is critical as patients have questions…anything normal and then, for example, ‘My dog jumped on my leg and bit it. Should I worry?’”

“Our goal was to quantify how much additional work an outpatient total joint surgery is for surgeons. I’m surprised how poorly we have done with preop instructions thus far, with the majority of them being quite vague. We surgeons have traditionally relied on the hospital to firm up those endpoints. For example, if the patient is in the hospital for four or five days then they see what a normal bit of redness or swelling looks like and take that as a baseline to go home. In an OP situation they don’t have a baseline and they assume it’s infected and either run to the ER or call the physician.”

“We are going to see a massive shift in the next few years from inpatient to outpatient,” says Dr. Berger. “I just want to help ensure that we are as ready as possible.”