early discharge: same day or overnight surgery for thr or tkr h yang professor & chair...
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Early Discharge: Same day or overnight surgery for THR or TKR
H YangProfessor & 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
Outpatient TKR
Demand for TKR• ↑ Wait Lists• ↑ hospital pressures• Aging cohort
Financial• Decrease wait times• Improve operational
efficiencies• Improve accessibility
Pain ControlMultimodal
analgesiaRegional analgesia Surgical techniques
MIS procedures
Inclusion Criteria
• 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
• 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 non-cardiac surgery in 329 hospitals in 2000 & 2001
• 782969 patients, 663635 without contraindications to β-blockers
• 13454 mortality (2%)• Number of RCRI factors
– 0: 313969– 1: 76983– 3: 15655– ≥ 4: 1416
Lindenauer et al. NEJM 2005; 353:349 - 61
Perioperative Mortality541297
(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
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
Anesthesiology 2009; 111(4): 690-4
Effect of β-blockers in Postop Hip & Knee Replacements
23 (5.0–106)14 (0.3%)2 (2.6%)Class IV
38 (19–75)63 (1.2%)15 (19.5%)Class III
10 (6.1–17)502 (9.9%)32 (41.6%)Class II
4502 (88.6%)28 (36.4%)Class I
ORNo PMI (n=5081)PMI (n=77)
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%
Patient
Remote Care Plan
Monitoring Reporting Analysis
Messaging & Clinical Notes
Exchange
Manage medication & activities
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