#LeadingVBHC – We talked to James Slover, MD from NYU after his presentation, Can Patients Have a Total Hip or Total Knee and Go Home the Same Day? Watch and see Dr. Slover share his secrets for success.
Breanna Cunningham: Hi. Bre Cunningham here with Dr. Jim Slover from New York.
James Slover, MD: Hi. How are you?
Cunningham: Doing very well. Thank you. Dr. Slover gave a fantastic talk today on outpatient total joints, which is all the rage these days for so many reasons, from the fact that it reduces cost to patients are getting younger, and joint replacement surgery probably at a younger age and they’re higher functioning beforehand. How long have you been in the business of outpatient total joints?
Slover: We’ve been doing them for about two years at NYU.
Cunningham: Your program has proven to be successful. If you could give me three things that you say are for an aspiring outpatient total joint program, what are three things you need to have in place in order to be successful as a team?
Slover: Well, I think the first thing, you have to have a physician and a team that’s committed to doing it. Everybody needs to be organized on the same page. It takes actually more work to do this than to do a traditional hip replacement. The patient needs a lot more education, a lot more resources need to be dedicated before the surgery to prepare them for this, and so everybody needs to be committed to do it. Safety, obviously, comes first as well. You have to protocols in place to make sure you’re doing it on the right patients for the right reasons.
Cunningham: What is your percentage of patients that wind up being readmitted to the hospital?
Slover: Our readmission rate is under 10%, somewhere between seven and 10%. For same-day surgery, what you’re maybe asking, is about one in 10 patients actually ends up staying overnight for one reason or another, either something happened in the surgery or they’re just not feeling well with the medicines, not reacting as well as we would like. We always want to build that in that it’s a possibility that we have the option, that if there’s anything going on, of course, safety comes first and we will just keep you overnight and take care of you whatever way we need to.
Cunningham: Is there one reason that you find that’s particularly more higher than others?
Slover: Not really. I think it’s just that you can never predict 100% how someone’s going to react to a major surgery and to anesthesia. We’re not going to send someone home that we don’t think is safe or that just isn’t feeling good enough to be at home. We have a very low threshold. If there’s any concern at all that this isn’t the best plan, then we just simply keep the patient overnight and get them all tuned up to go home the next day.
Cunningham: What is your triage process? You’re seeing your patient that is coming to you for osteoarthritis, you anticipate they may need a joint replacement. Before the patient actually comes in the room, do you have an inkling as to which track they’re going to go down, that inpatient or outpatient track?
Slover: Well, not so much before I go into the room. First of all, you can’t have any significant medical co-morbidities. Those are patients that you’re not going to feel comfortable sending home the same day of surgery. So, anyone who has any major heart or lung issues, then we’re not even going to consider the program. I think that’s a little bit harder to judge sometimes and it takes more of a conversation with the patient is what kind of support system do they have at home and how motivated are they about this. I think one of the biggest things to overcome is patients’ fear and anxiety about this.
We don’t want to put a patient in a position that they’re not comfortable with and we want to make sure that if we do send a patient home on the day of surgery that they have the support system at home to get through that without it being any type of safety issue for them. That takes a little bit more of a conversation with the patient, number one, about their own motivations, their own thoughts. There are a lot of patients that they come in for joint replacement now, they don’t feel like they’re sick and ready to spend a long time in the hospital, they just want to get this problem taken care of, and they’re anxious to go home. If they have the support system to do it and they’re healthy enough to do it, then it’s a good option for them and they can be more comfortable.
Cunningham: Sure. Now, is your prehab, right? That’s the trendy term these days. Your prehab program for your inpatient the same as those that are doing these outpatient?
Slover: Currently not, but we’re going to expand it because we have found that it’s so valuable and even for the patients that stay overnight. Many of them are going home the next day, so it’s not that much more of a time. The more prehab or pre-education. What our prehab actually is where we do some physical therapy and so the patients how they’re going to use a walker and things like that after surgery. We show them before surgery when they’re not under as much stress. I think it’s valuable for any patient who’s having a total joint replacement. The more of that we can do before the surgery, the better off they’ll be and the faster they’ll get out of the hospital and get moving, which is what they want and what we want.
Cunningham: Speaking of interdisciplinary approach, do you have the same people, the same care team, that are doing these same-day surgeries as doing the inpatient for like anesthesia and your extenders?
Slover: Well, it’s expanded to that, but when we first started off, we started off with sort of a champion in each area. It definitely a multidisciplinary effort. It’s not just the surgeon doing this and you can’t just do this without involving your whole team in this because anesthesia is definitely involved, physical therapy is definitely involved, nursing is involved, care management is involved. We started with a champion in each of those areas, but as the program has spread and now there’s 12 surgeons doing it and we’re going to expand it even further. All of the members of those teams have become familiar with these type of cases and so it’s less of a specialized thing and it’s more sort of the way we do business for many of these patients.
Cunningham: What is your favorite part about doing outpatient total joints?
Slover: My favorite part is when the patient comes back and tells me that they did well and that they were so happy that they could recover at home where they were more comfortable and they have a great result. That’s the best part about this for sure.
Cunningham: Do you see the similar functional outcome scores between the two patient populations?
Slover: Absolutely. We would not do this if we in any way were compromising patients’ outcome. We want safety first and we want quality outcomes. We do not want any change in that for sure. If we had any sense that we weren’t doing as well, we wouldn’t do that.
Cunningham: I have a final question for you and that’s who’s going to be the Jets quarterback next year?
Slover: I wish I knew. I wish I knew.
Cunningham: It’s a million dollar question, right?
Slover: I don’t think it’s going to be Fitzpatrick. I can tell you that.
Cunningham: Are you sure?
Slover: I’m not sure, but I don’t think it’s going to be him. Hopefully, he’s in college whoever it is.
Cunningham: I wish you the best of luck. It’s an important draft coming up for you guys. Thanks for all of your …
Slover: Always is with the Jets. Always is.
Cunningham: Thanks for having this outpatient total joints. It’s the way of the future and appreciate taking the time. We’ll be back with Dr. [inaudible 00:06:17].