Many patients eligible for speedy discharge after surgery

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with a podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. More and more people who need hip or knee replacements are going home the same day of their operation. To understand who's eligible and what's involved, I'm talking with two Upstate nurses. Lia Fischi is the orthopedic program manager, and Pete Jaskula, who's a nurse navigator. Welcome to "The Informed Patient," both of you.

[00:00:35] Lia Fischi: Thank you.

[00:00:35] Pete Jaskula: Thank you.

[00:00:36] Host Amber Smith: Do I understand correctly that Upstate offered one day hip or knee replacements to certain patients before Covid-19, but the numbers climbed during and since the pandemic?

[00:00:48] Lia Fischi: Yes, Amber, that is correct. Same day total knee and hip replacement is not new to us. We started these in about I want to say 2018. And before the Covid-19 pandemic, we were averaging about six (same-day) total hip or knee replacements per year. And then when the Covid pandemic hit, and when we were allowed to resume elective surgeries, we came up with a scoring system that would allow us to quickly identify those that would meet criteria for same-day hip or knee replacement surgery. And our numbers grew. In 2021, we then went up to 75 patients. In 2022, we went up to 226 patients. And in 2023, January through October, we're at 208 patients that are leaving same day after a total hip or knee replacement.

[00:01:45] Host Amber Smith: So let me ask you, are the criteria the same regardless of whether the person needs a hip or a knee replacement? Are you looking at the same criteria?

[00:01:54] Lia Fischi: We're pretty much looking at the same criteria. You know, the patient needs to be healthy. There's a number of things that the surgeon and the team look at, such as the body mass index of a patient. They pretty much have to be healthy. We look at certain things with diabetics.

The patient also has to be motivated and willing to pursue rehabilitation in a pretty much an outpatient level of physical therapy. And they also need to have a supportive system at home for same day discharges.

[00:02:29] Host Amber Smith: Well, what is different about a Swift hip or knee compared with a regular hip or knee replacement? I wonder, is the replacement joint the same?

[00:02:41] Lia Fischi: Yes, the surgery is the same. Patient care is the same. The difference is when the patient actually leaves the hospital, is discharged. So if they meet criteria to discharge the same day, a Swift means that they will be swiftly discharged, meaning the same day. So it's the timing piece of when they are discharged.

[00:03:05] Host Amber Smith: Well, let's talk about who qualifies for a Swift hip or knee operation. Is there an age cutoff?

[00:03:13] Pete Jaskula: Typically, age does not play a big factor. It's something that we assess for in our screening. The nurse navigators, we use a screening tool -- WSRR, which is willingness to discharge the same day, supports upon discharge, their RAPT (risk assessment and prediction tool) score and risk score of less than four, which is based on their medical history. So age does play a factor in that, but we have had successful swift patient patients at 80 years old.

[00:03:44] Host Amber Smith: Oh, interesting. Now you mentioned BMI, body mass Index. Is there a weight limit for this sort of procedure?

[00:03:51] Pete Jaskula: We factor in the BMI, as opposed to weight. Our inclusion criteria includes a BMI of less than 35 for diabetic patients and less than 40 for non-diabetic patients.

[00:04:03] Host Amber Smith: Now what about gender? Do you see more men or women that qualify for Swift?

[00:04:09] Pete Jaskula: I have not looked at the data, but gender does not impact on being a candidate.

[00:04:14] Host Amber Smith: What about previous history, if they've had previous knee or hip surgeries or other problems with the joint?

[00:04:23] Pete Jaskula: That really doesn't play that big of a role. Most of our patients have a history of joint pain, osteoarthritis, or rheumatoid arthritis, so they all have mobility issues. These factors are the reason why the patients are seeking having this procedure done.

[00:04:38] Host Amber Smith: Are there non-medical considerations?

[00:04:41] Pete Jaskula: Willingness to discharge the same day of surgery is the biggest non-medical consideration in qualifying for Swift, along with having a good support system at home because you will need those supports at home upon discharge to help you out. Without these factors, the success rate of our Swift program would probably be low.

[00:05:04] Host Amber Smith: So is there anyone who is not a candidate for Swift hip or knee?

[00:05:09] Lia Fischi: I'll speak on this. We do have exclusion criteria. So if the patient has a history of a deep venous thrombosis, that's a deep blood clot in the vein, if they have a bleeding disorder and if they have chronic comorbidities, if their medical history is extensive, these will be reviewed by the surgeon, anesthesiologist, and approved by the team for inclusion. So these patients are all reviewed, not just by the nurse navigator, but the whole entire team to make sure that the patient is a good candidate for a Swift hip or Swift knee.

[00:05:51] Host Amber Smith: So do you ever have the situation where someone comes in fully expecting to go home the same day with a Swift hip or knee, but something comes up in the surgery or they're not really recovering like they should? Do you ever have to have them stay longer?

[00:06:07] Lia Fischi: That's the beauty of this program is that these surgeries are done in our surgery center that's connected to the hospital. It's still part of the hospital. So we have the safety net of the hospital. So if the patient, for whatever reason, you know

sometimes your blood pressure might just dip a little bit, so we want to continue to watch you. So they will go then be moved to the floor, the unit, and stay overnight.

[00:06:35] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking about Swift knee and hip replacement surgeries with two Upstate nurses, Lia Fischi and Pete Jaskula.

Let's talk about what happens after a person and their surgeon decide to move forward with a Swift hip or knee. What sorts of testing is done ahead of time?

[00:06:58] Pete Jaskula: I'll answer this. The patients have to go for medical clearance with their primary care provider. They may also need additional clearances such as a cardiac clearance or pulmonology clearance. So any clearances would need to be obtained prior to surgery.

There's usually blood work that is done to get a baseline data such a complete blood count, basic metabolic panel, type and screen for surgery. And they also would screen for MRSA prior to the patient having surgery, to help reduce their risk of an infection with surgery.

[00:07:32] Host Amber Smith: What is MRSA?

[00:07:34] Pete Jaskula: MRSA is methylicillin resistant Staph(ylococcus) aureus. So it is a type of bacteria that's out there in society that is resistant to certain types of antibiotics. So if a patient were to test positive for that, the surgeon is going to treat them with an antibiotic ointment that they would apply to their nostril twice a day for five days before surgery to reduce that bacteria, to reduce their risk of infection with surgery. And we would also know which antibiotic to treat with, prophylactically.

[00:08:07] Host Amber Smith: So that sounds like a lot of the kind of standard for pre-op for any sort of operation. Is there anything specific for Swift hip or knee? Do they have to talk with physical therapists beforehand?

[00:08:21] Pete Jaskula: Well that's a good question. All the patients do meet with their nurse navigator two weeks prior to surgery to get them prepared for surgery, make sure they have all their support systems in place. And we also have a joint class that all patients are attending, and they will meet with a physical therapist on that. And physical therapy does go over a PowerPoint presentation with them, getting the patients prepared. They talk about their precautions and exercises and the importance of "prehab," which is one to two physical therapy sessions before surgery.

And they're going to get educated on mobility, how to properly use their DME (durable medical equipment), how to safely do stairs, some of those common asked questions, so that way when they're here in the hospital, we're focusing more on getting the patient safely discharged home and not doing the education piece while they're here.

During the class the nurse navigators also do a PowerPoint presentation to go over what to expect on the day of surgery, what to expect afterwards. It's a lot of education ahead of time to get the patients prepared for surgery.

[00:09:27] Host Amber Smith: And you said DME. That's durable medical equipment?

[00:09:30] Pete Jaskula: Yes.

[00:09:30] Host Amber Smith: Which would be, what, crutches or...?

[00:09:32] Pete Jaskula: Typically a rolling walker. Sometimes it is crutches. But typically it's a rolling walker. They may also need, like, a raised toilet seat or a tub bench shower chair. So these are all things that the nurse navigators discuss with the patients at our risk assessment appointment.

And we go over all these medical equipment and what is typically covered and not covered by insurance companies and advise patients what's going to be best for them so they can maintain their independence and adhere to their precautions after surgery.

[00:10:07] Host Amber Smith: So what is the day of the procedure like? How early do patients arrive?

[00:10:12] Pete Jaskula: The day of the procedure, the patients arrive two and a half hours prior to their surgery time. At this time, the patients get registered. They'll go over to the surgery center, meet with their nurse there. They'll get prepared for the OR ( operating room), get an IV started. They'll meet with their anesthesiology team member at that time, as well, to go over the anesthesia procedure as well. And then they get all prepped for surgery and then go in and have the procedure itself, which typically takes about an hour and a half.

Then after surgery, the patient will go over to the recovery room. Time in the recovery room is, on average, I'd say about an hour or maybe two hours. And then they will get transferred over to the surgery center. And from the surgery center they'll work with PT (physical therapy) at that time to determine if the patient can safely ambulate, walk, climb stairs, do all these with their support systems.

And once the patients are medically stable, they pass their PT evaluation, tolerating their pain medications, we do like the patients to urinate before they leave as well. And once they meet all that criteria, the patient will be discharged home.

[00:11:19] Host Amber Smith: What have you seen the first night at home be like for most patients?

[00:11:24] Pete Jaskula: Most patients the first night at home, it can vary, vastly because patients typically get a regional nerve block, which is a peripheral nerve block where they numb the operative leg for pain control purposes. And the duration of that can last anywhere from four to 24 hours. It's really dependent on many factors. So typically the first day is not so bad, that first night because that nerve block is in effect. It's more, the next day is when that nerve block wears off and patients start experiencing that postoperative pain.

That's what we were preparing the patients more for is how to deal with that pain after that nerve block wears off. So we advise the patients that they should avoid overactivity, as that can increase the pain and aggravate those muscles after that nerve block wears off. And we advise them to kind of routinely take their pain medications for the first day or so. That way at least there's pain medication in their system already, pre-medicating them, because if that nerve block wears off and there's no pain meds in their system, it's going to be a lot harder to control the pain at that point. So we want to intercept that pain ahead of time.

[00:12:37] Host Amber Smith: So once they get the pain sort of managed, or under control, let's talk about what other postoperative red flags the patient and their loved ones are supposed to look out for.

[00:12:50] Lia Fischi: I'll talk on that. So I want to say, I just want to mention that the support system from the nurse navigators is huge, contributes to the success of the Swift program. So, like Pete was mentioning about the pain elevating the nerve block wearing off on day one, the day after surgery. That's when our nurse navigators will contact the patient and kind of support them and kind of help them with their pain control, give them tips and strategies.

As far as red flags, what's expected? I would say some pain is expected. A little swelling is expected.What's unexpected is: a fever; pain that doesn't go away with the prescribed medication; swelling, like significant swelling or redness, that could indicate an infection; difficulty breathing, shortness of breath, chest pain. That would indicate, call 9 1 1 for that. Calf pain or swelling could indicate a blood clot. And so call, definitely. Numbness or tingling, joint instability. Some red flags are wound issues, if you have increased drainage, sudden weakness or inability to move. Those are things to call or call 911.

[00:14:16] Host Amber Smith: I know you said when they're in the recovery room, they go to the surgery center, and you said they walk before they leave, which is amazing. It wasn't that long ago hip and knee replacement patients were in the hospital for a week, and now they're walking just hours after the surgery. It's pretty amazing. When do they start regular physical therapy, where they are working on certain exercises?

[00:14:45] Pete Jaskula: As soon as possible. Typically, like you said, they will work with physical therapy while they're in the hospital, and that's usually within two hours of the patient getting to the surgery center, where we get up and mobilize them. But as far as, like, outpatient PT, their first appointment for our Swift patients, we like them to go and start that two days after their surgery.

[00:15:05] Host Amber Smith: So pretty quickly.

[00:15:07] Pete Jaskula: Yes. Mobility is key to success with a joint replacement.

[00:15:12] Host Amber Smith: Long-term, do Swift hips and knees work as well and last as long as those implanted through regular open surgery?

[00:15:21] Pete Jaskula: Yes. I honestly feel that our Swift patients probably typically do better than the inpatient population. These patients are highly motivated to leave the same day of surgery and prepare themselves for success by leaving the same day. The patients have to mobilize once they're home, and early mobilization has been proven to be a key factor in a successful joint replacement.

[00:15:44] Host Amber Smith: Can listeners who are interested to see if they qualify, can they make an appointment on their own or do they need a referral from a primary care provider, and how do they go about doing that?

[00:15:55] Lia Fischi: , We only need a referral for VA (veterans administration) and Tricare (insurance for active duty military) patients, but they can request an appointment by calling, and I'll give a phone number: (315) 464-8600. Or, going to the website of upstateorthopedics.com.

[00:16:16] Host Amber Smith: Very nice. Well, I appreciate both of you making time for this interview, Mr. Jaskula and Ms. Fischi.

[00:16:22] Lia Fischi: Thank you.

[00:16:23] Pete Jaskula: Thank you for having us.

[00:16:24] Host Amber Smith: My guests have been Nurse Lia Fischi, the orthopedic program manager at Upstate, and nurse navigator, Pete Jaskula. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too, and you can rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.