Speaker: Patient exclusion criteria for same-day TJR better than inclusion criteria
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NEWPORT BEACH, Calif. — Patient factors that can impact outcomes after same-day total joint reconstruction should be modified, if possible, and patients who cannot be optimized should be excluded from same-day surgery, a presenter said.
“The key in whatever we do is that we have to have great surgeons, great anesthesia, great team and a great facility with the equipment so that we can provide safety to the patients,” Leopoldo Rodriguez, MD, MBA, FAAP, FASA, SAMBA-F, an anesthesiologist and immediate past president of the Society for Ambulatory Anesthesia (SAMBA), said at the Interdisciplinary Conference on Orthopedic Value-Based Care.
One approach physicians use to indicate patients for same-day TJR that is supported in the literature is to use Charlson Comorbidity Index and American Society of Anesthesiology scores as inclusion criteria for patients undergoing same-day TJR to help ensure they can be safely discharged the day of surgery, he said.
Rodriguez said, “As an anesthesiologist working for a large organization and also representing two large academic or professional organizations, such as SAMBA, ... I’m always asked, ‘What is your patient selection criteria for surgery?’ First, my answer is, I don’t have patient selection criteria. I have patient exclusion criteria, because you cannot be dogmatic – saying, ‘I’m going to do this, this, this and this, no matter what.’ Instead, you should say, ‘I’m not going to do this, this, this and that.’”
Contraindications for same-day TJR
Rodriguez said patients who have cirrhosis, end-stage renal disease or significant coronary heart failure should always be excluded from same-day TJR. “Those are not candidates for outpatient surgery centers to have a total joint replacement.”
In addition, patients with frailty should not undergo TJR at an outpatient facility “because their outcomes are worse and their hospitalization and transfer rate to a hospital with high-level care is higher, and they’re people who lack social support,” according to Rodriguez.
Age is a relative contraindication, he said.
“So when we talk about rapid optimization of a patient, we have to look at what reasons cause a patient to be admitted to a hospital after they have a surgery,” Rodriguez said. After these patient risk factors are examined, physicians can work on these to determine what is reversible or can be improved upon to prevent readmissions within 30 days, he said.
Target, manage primary risk factors
“In general, substance abuse, Staphylococcus infection or colonizations, a high BMI, those are the things that come up as a primary target, Rodriguez said.
He said the NYU Langone Readmission Risk Assessment Tool published in 2015 is helpful for grading patients preoperatively and setting targets to improve the risk of hospital readmission within 30 days of hospital discharge. “It is a good work. It touches on all the things we’ve mentioned today. So rapid optimization is the training of the body for surgery. The majority of patients are not ready for a large procedure, and we have to modify the risk factors. The things that we can do is do the pre-admission testing early,” Rodriguez said, noting he usually recommends this testing be done 1 month before surgery to provide enough time to evaluate the results.
He assesses patients for malnutrition, high hemoglobin a1c levels, vitamin D deficiency and low testosterone levels, all of which can be managed preoperatively.
“Smoking cessation, substance abuse, those sorts of things we have to do. It takes a while, 6 to 8 months, to get rid of those bad habits,” Rodriguez said. Any social barriers the patient has should also be addressed through psychology and psychiatry, as well as ensuring the patient has a support system, he said.
References:
Rodriguez L. Rapid patient optimization for same-day surgery. Presented at: Interdisciplinary Conference on Orthopedic Value-Based Care; April 29-30, 2022; Newport Beach, Calif.
Boraiah S, et al. J Bone Joint Surg Am. 2015;doi:10.2106/JBJS.N.01196.
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Rodriguez L. Rapid patient optimization for same-day surgery. Presented at: Interdisciplinary Conference on Orthopedic Value-Based Care; April 29-30, 2022; Newport Beach, Calif.
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