Outpatient Joint Replacement

Mike Berend, MDMidwest Center for Joint Replacement

Indianapolis, Indiana

Clinical InnovationCost savings, early return to function and work,

higher satisfaction

Medicine is Dynamic • EMR• “Meaningful” use• Payer and Hospital 

mergers• Payment advisory board• Medicare reductions• Regulatory “oversight”

SpeakingOf dynamicChanges…

New Beginning

www.mcjr.com

Timeline of Arthroplasty Length of Stay

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Ave

rage

Length

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Stay

1991-1992♦Same protocol♦LOS: 5-7 days

1987-1990♦TKA: Robert Jones dressing♦THA: Charnley buttons♦All patients → Mini ICU ♦LOS: 7-10 days

1993-1997♦Same protocol♦Acute setting: 3 days♦Adjacent SNF: 7 days

1997-2002♦Regional anesthesia (epidurals)♦Soft tissue injections♦Acute setting: 3-5 days♦Outside SNF: 7 days

2003-2004♦Single shot spinals♦Rapid recovery protocols♦Multimodal medications♦LOS: 2.5 days

2005-2011♦Minimally invasive surgery♦LOS: 1.5 days

2012-2013♦Liposome bupivacaine suspension injection♦Same day surgery

From Keith R Berend, MD, JIS, Inc

Why Do Patients Stay in the Hospital?

1. Fear/Anxiety Unknown Pain

2. Risk Co-morbidities Medical complications

3. Side-effects of our treatment Narcotics/anesthesia Blood loss Surgical trauma

Hospital Environment Not Ideal

• “limited resources”• Multiple agendas• Resistance to change • Increased infection risk• Higher cost• Staff don’t report to

Surgeons…• Regulatory

environment Indianapolis Star Newspaper

Patient Selection for OutPt Arthroplasty• Medical screening program• “Acceptable” Cardiac History• Hgb > 12• Function Independently with Walker• Pre-op Visit and Physiotherapy Evaluation

– Pre-op Education & Equipment– Written Materials– Family Support at home

• Live within 1-2 hours of the center– 23 hour stay capabilities helpful but not

mandatory < 2%

Postoperative Care

– FWB: Walker or Crutches

– Cryotherapy– PT options

1. Home PT2. Outpatient3. Patient HEP

– 23 hr obs prn– ATI coordination of

care2 hrs s/p PKA

It’s Safe, It’s Better for Us and Our Patients, and It’s Here Now

• Actually spend more time with the patients and family in a more friendly environment– Typical Day: 6-8 Outpatient TJA– Average 9 interactions with patient/family

– Phone calls down

Clinical Experience Out-Pt Knee

• Began Sept 2011, Currently: > 80 %• 2 year data Q1 13’ to Q1 15’• 2,055 Knee Arthroplasties (CHKS/JIS)

(~ 50%)– 1,037 PKA– 983 TKA– 35 Rev TKA

• 98 % home DOS

Summary

• Future may reveal ideal marriage- All Arthroplasty and Outpatient Space

• MCJR national leaders in this space

• Focused on patient, their family, experience-‘Less is More’ ~ big scope

- We believe in Individualized Care for the patient and their care team

Thank You

www.mcjr.com