Early Discharge: Same day or overnight surgery for THR or TKR H Yang Professor & 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 Control Multimodal analgesia Regional analgesia Surgical techniquesMIS 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 & patients, without contraindications to β- blockers mortality (2%) Number of RCRI factors – 0: – 1: – 3: – ≥ 4: 1416

Lindenauer et al. NEJM 2005; 353: Perioperative Mortality (did not receive  -blockers) (1.98%) RCRI Factors ≤ 1RCRI Factors ≥ (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): 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