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Discharging suitable patients the day after THR can become routine
Caveats: The treatment team must make appropriate preparations and not all patients will qualify. Large savings are possible.
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To gain the full benefits that minimally invasive total hip replacement can offer, orthopaedists and the entire surgical team must make significant changes to the care infrastructure, rather than just the surgery itself, according to one British orthopaedic surgeon.
A recent series of patients undergoing minimally invasive THR demonstrated some of these changes, showing good results when patients went home after only one day in the hospital.
“In my view, there is much more to total hip replacement than just an operation,” said Hugh D. Apthorp, FRCS, orthopaedic consultant at Conquest Hospital in Hastings, England. “Minimally invasive surgery using the conventional infrastructure likely makes little difference to the outcome of the patient. It’s like trying to drive a Formula 1 car in London.”
Apthorp said THR is a product of teamwork involving the surgeon, the patient and all the support staff involved from the initial consultation through the follow-up visits. The entire team needs to make changes in order to positively affect the outcomes.
“The general principle is to give as much care in the outpatient setting as possible, and only use inpatient facilities where they are absolutely necessary,” he said.
Next-day discharge
For suitable patients, minimally invasive surgery can lead to hospital discharge the day after surgery, Apthorp said. However, he only recommends this program for patients with a body mass index under 40 and for patients younger than 72. It is also important that patients live somewhat close to the surgical center.
Building patient confidence and enforcing treatment consistency are vital aspects of the next-day discharge program, he said. Apthorp gives a booklet to his patients at the initial consultation outlining the schedule prior to, during and after the operation. It is vital to stick to this schedule as closely as possible, he said, which helps builds confidence in the patient so that he or she feels confident enough to go home the day after surgery.
To deem patients ready for discharge the day after the arthroplasty, orthopaedists must regard the day of surgery as the first postoperative day, he said. Several hours after the operation, patients can be mobilized with the help of physical therapists and crutches. The anesthetic chosen for the operation is also important: spine anesthetic wears off quickly, allowing motor function within several hours, but its analgesic effects last much longer. This can help significantly with pain management and in early mobilization.
Pain management
Apthorp described a series of 43 patients who underwent this program with the goal of going home the day after surgery. He used a posterior approach and a harmonic scalpel as a way of minimizing soft tissue trauma and blood loss.
“If people don’t have pain, there is very little reason to stay in the hospital, so I really work on pain management,” he said. Patients use a pain pump at the hospital before they are discharged, which the patients can take home to use after the operation.
Patients in this series had an average hospital stay of 1.2 days compared to 5.7 days in a control group who did not participate in Apthorp’s program. Visual Analogue Scores were very good in the program group, but these data were not available for the control group.
Implant alignment was similar for the two groups, with no dislocations or infections. There was one periprosthetic fracture due to a fall down the stairs.
Apthorp said he does not make the final decision to discharge the patient; this is left to the nurses. To be discharged one day after THR, patients should be able to get out of bed, climb stairs with crutches and sustain adequate pain control and a dry wound.
“There’s got to be more to minimally invasive surgery than just a pretty wound or a small wound,” Apthorp said. “[We] can achieve high levels of patient satisfaction, but infrastructure changes are necessary to achieve these results.”
For more information:
- Apthorp HD. Gaining the benefit from minimally invasive total hip replacement — development and evaluation of an overnight stay programme. Presented at the British Orthopaedic Association Annual Congress. Sept. 20-23, 2005. Birmingham, England.