He got his knee replaced at a Toronto hospital. A few hours later he was climbing stairs
Just a decade ago, knee-replacement surgery would have involved a hospital stay of up to a week.
Women’s College Hospital is revolutionizing the way knee-replacement surgery is done. It is starting to provide the procedure as an ambulatory service. Patients can go home from hospital four hours after having the surgery. In some other hospitals knee replacement surgery patients have to stay as long as 4 days.
It’s been less than four hours since Greg Nemez underwent knee-replacement surgery and the 56-year-old Mississauga man is already on his way home from hospital.
This past Monday, he became the fifth patient at Toronto’s Women’s College Hospital to undergo the outpatient procedure, which normally requires a hospital stay of two or three days.
“I’m happy … You have that freedom of movement from before. It’s like wow,” he said on the elevator as he was leaving the hospital.
After years of being unable to hold his leg straight, the real-estate agent can finally do so. A 20-year-old football injury had left him with severe arthritis and pain.
Ontario is making strides in the provision of outpatient — also called ambulatory — orthopedic surgery. The Ottawa Hospital also has a same-day program and a small number of other centres across the county offer such procedures as well.
It’s the desire of the Canadian Orthopedic Association for ambulatory joint replacements to become the norm in the country for a subset of fit, active patients. And it’s the goal of Women’s College to show that it is very doable.
Women’s College is Canada’s only independent, academic, ambulatory hospital. It has no overnight beds. If it was going to do joint-replacements, same-day surgeries were the only option.
Nemez’s surgery is part of a pilot project undertaken by the Women’s College Hospital Institute for Health System Solutions and Virtual Care. Described as a “living lab for ideas to heal health care,” the institute looks for ways to improve health services in Ontario, Canada and beyond.
“The reason we are doing this is we are seeking to transform the health system. Right now, we have a very good health system but it has problems,” explained Dr. David Urbach, surgeon-in-chief at Women’s College. “In the system, there are a few bottlenecks and one of the biggest bottlenecks is hospital beds.”
The issue of crowded hospitals has been making headlines across Canada. Same-day orthopedic surgery — including hip replacements — can help address the problem by freeing up beds for other patients, he continued.
A Dec. 2017 article in the CMAJ describes such outpatient procedures as an “evolution” in orthopedic surgery. It notes that many Canadian hospitals are often at overcapacity and that they not infrequently must cancel surgeries because of bed shortages.
“With more than 50,000 hip and knee replacements conducted every year in Canada, the potential to liberate hospital beds is considerable,” the article states.
Hospital stays have been getting shorter over time because of advances in surgical techniques and anesthesia. Just a decade ago, knee-replacement surgery would have involved a hospital stay of up to a week.
Same-day joint-replacement surgery was pioneered in the United States where insurance companies were looking to cut health-care costs.
But this kind ambulatory surgery is not for everyone, cautioned orthopedic surgeon Dr. David Backstein who operated on Nemez.
“It is a very select patient population we can do this on,” he said, explaining it best performed on active, healthy, fit patients and not on those who are frail, inactive or obese. “There is always going to be a need for in-patient joint replacement.”
Nemez proved to be the ideal candidate. Aside from an arthritic knee, he’s healthy. And he was eager to get out of hospital as quickly as possible.
“I think I will recover faster at home,” he said, explaining that he wanted to be in the comfort of his own home and eat his own food. He has family around to help him. The same-day surgery program, which will become permanent at Women’s College, requires a chaperone.
There are many additional benefits to outpatient orthopedic surgery. Money saved from shorter hospital stays can be reinvested into providing more joint replacement surgeries. That, in turn, reduces waiting lists.
The Ontario Hospital Association estimates the average cost of a one-day stay in an acute care hospital is $1,300.
“Using the same dollars to perform more operations helps reduce wait times by increasing the supply of surgeries,” Urbach said. “Surgeons and patients would prefer this trade-off.”
Dr. John Antoniou, president-elect of the Canadian Orthopaedic Association, said it’s important to find such efficiencies so that the nation’s “publicly funded health system can grow and flourish,” particularly with increasing demands for a growing and aging population.
He said eventually such procedures will be standard for those patients who can tolerate them: “The goal is to shorten hospital stays overall and do it in the most efficient and safe way to benefit the patient and the system.”
Anthony Dale, president of the Ontario Hospital Association, said the province’s hospitals are constantly evolving and transforming to improve efficiency and provide high quality care: “In our highly complex and interconnected health care system, innovative solutions, such as new models of care, are central to meeting growing demand and helping our hospitals continue to deliver the quality of care that Ontarians have come to expect.”
But Antoniou conceded that it has been somewhat of a challenge to get more “hospital buy-in” to same-day discharges. Hospitals don’t want patients to feel as though they are being discharged too quickly just to save a buck.
“It’s a delicate balance … We do not want to make it appear like we are kicking them out … It’s a mindset. Home is better in many circumstances,” Antoniou said, noting that hospital patients are at risk of picking up “nasty pathogens” such as C. difficile. Patients also tend to sleep better in their own beds, he noted.
Even though such programs save money, they require initial start-up investments and training of health professionals, particularly anesthesiologists, Antoniou continued.
Anesthesiologists play a key role in making same-day orthopedic surgery doable. They give just enough anesthesia to keep patients comfortable, but not enough to prevent them from being mobile soon after surgery.
“The two things that keep patients in hospital are pain and nausea and that’s what we’re mitigating with our techniques,” explained Dr. Richard Brull, chair of ambulatory anesthesia at Women’s College.
Traditionally surgical patients are given narcotics such as morphine to control pain. But morphine causes nausea, so it is withheld when patients feel sick. But when they start to feel pain again and the morphine is reinstated, and the cycle continues.
Instead, Brull starts out by giving Nemez “preventative anesthesia,” in the form of anti-nausea and pain medications, but no narcotics. Then he gives nerve block injections in the lower spine.
“We’re fooling the brain into believing they are not having surgery … If the pain sensation never makes it from your knee to your head, you don’t need morphine,” Brull said
Patients are prescribed oral opioids to take at home as needed after surgery.
Three hours after being wheeled out of the OR, Nemez is on his feet. A physiotherapist guides him in using a walker and crutches. Then she has him climbing stairs.
Two days after the surgery, Nemez said he doing well. An app developed by Women’s College allows him to stay in regular touch with the hospital via an iPad. Hospital staff ask him about his pain levels and answer any questions. An alarm on the app reminds him when to take his medications.
He has been given a set of exercises that he does. He plans to follow up with his family doctor in a couple of weeks.
Nemez said friends and family were initially surprised to hear he would be having his knee replaced as an outpatient.
“I questioned it as well. I didn’t know there was this revolution or whatever you want to call it,” he said.
“It shocked a lot of people, but I think it’s great. I’m living proof the system is working.”
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