Total joint replacement (TJR) same day discharge has become more common over the last few years for several reasons. First, COVID gave it a good push as a way to get patients out of the hospital faster to decrease the chance of infection. (No one wants a side of COVID with their TJR). It was also a way for hospitals to catch up from the large backlog of elective surgeries canceled due to the pandemic
Second, financial pressures to lower healthcare costs and offset slashed reimbursement rates pushed hospitals to make same day discharge the norm. Lastly, more patients are asking to leave the day of surgery. Can’t say I blame them. I mean who sleeps that well in the hospital? I’d rather recover in my own house and bed too.
Same day discharges definitely have benefits, however it’s not without challenges to implement them successfully. PTs are usually the ones who have to overcome those challenges. No surgical team, no surgeries. I get that, but I’d be prepared to argue PT has the most influence on the actual success of total joint day-of discharge. And is it just me or is that influence sometimes a little overlooked?!
I’ve outlined three ways PTs can make day-of discharges a success for the patient and decrease the obstacles that sometimes come with it. We’ll discuss the specific challenges and some potential solutions. These steps result in a win for patients who get to go home without sacrificing good surgical outcomes. They’re a win for healthcare systems who both reap the financial benefits and have happy customers. And finally, a win for PTs to reduce day-of discharge challenges and increase recognition of the integral role we play in their success.
This will hopefully result in more acknowledgement of our value and more seats at the table for us when making decisions about the systems we work in, which sounds pretty damn good to me.
#1. Committee with Surgical Teams
Many of the hurdles with same day discharge have to do with how or when the actual surgery takes place. This doesn’t mean it’s completely out of our hands. The surgical team obviously has a very important job, but sometimes doesn’t realize how decisions made in the OR can affect our work or likelihood of the patient leaving that day.
For example, certain nerve blocks can cause the patient to be more numb or numb for longer making them unable to safely get up soon after surgery. The anesthesia can also play a role in nausea and alertness for the patient to tolerate mobilization. And of course, all goes better if the patient gets into surgery earlier versus later in the day to let anesthesia and blocks wear off, get pain under control, and get more opportunity for early mobilization prior to discharge.
Like I said though, the surgical team may not know this unless it’s communicated to them. Having regular open communication with surgeons and their teams would give an opportunity for change. I would go as far as to suggest any health system performing total joint replacements should have a committee with regular meetings between surgeons, PTs, and other heads of essential personnel involved in total joint care.
Routine meetings with surgeons would also be a time to align values and visions and help better prepare patients. If the surgeon tells them in their pre-op visit to expect PT soon after surgery, then things go a lot better when we actually get there since at that point the patient is expecting us.
Or if the surgeon educates the patient prior to surgery day that someone will need to go home with them, they might need to get their own walker, or how much pain at discharge can be expected – these are hopefully things that DON’T come up when trying to discharge.
Some may be wondering how to start this committee. My advice would be to start with your DOR and suggest it. There’s likely a VIP meeting they go to where it’s appropriate to bring it up. Worried either they or the surgeon team won’t be for it? I’d say it’s highly unlikely. Administrators and surgeons have a large stake in same day discharge. They’re likely to support anything that may help its success.
#2. Patient Prep and Education
Patient education is key in what we do, but maybe even more so with total joint replacements. Pretty much everywhere doing TJRs, same-day discharge or not, has a patient education packet at the least. Whether or not the patient actually reads it becomes the question . . .
I know many hospitals offer pre-total joint replacement classes to educate patients on post-op expectations, exercises, pain control, equipment needs, and mobility needs. Some even have patients practice with a walker or teach them how to navigate stairs. All great info, but there are some issues implementing this type of patient prep.
For one, what’s the actual attendance of these classes? The classes undoubtedly have good info, but it’s not helpful overall if the patient doesn’t go. I’m curious, are more hospitals and total joint centers making it mandatory for their pre-op patients to attend a class? What’s your facility doing? Share in the comments section.
The second barrier is the use of staff for these classes, which are usually run by PTs. Again, the classes are good, but it does take us away from patient care. Unfortunately for us, administrators and insurance just see less billed units which means decreased reimbursement and department revenue (Insert rant I could go on but won’t because this would turn into the never-ending blog post.)
So how do we successfully do some kind of patient education course where we get attendance without creating a burden on existing staff? One idea I had was to have an online module or course. There are several YouTube videos out there for this. Most are for specific hospitals or surgical centers so some information is unique to them. Still not a bad resource. Again, I’m curious how many patients are directed to the link and how many actually watch it.
I’m sure a program like this exists out there for purchase. Total joint programs could also make their own course. Yes, that would likely take PTs away from patient care, but maybe just once to make the course versus multiple times over.
As far as attendance goes, I would propose total joint programs make it a privately accessed module where they can track completion. I would say it’s fair to require patients to complete this post-op education if they’re going to discharge on the day of surgery.
What do you think? Any other ideas on how to effectively educate patients prior to total joint replacement? What does your program do? Share below in the comments section!
#3. Clinical Pathways
My final suggestion pertains to our actual treatment. We all have our own way of treating and most of the time I think that’s a good thing! However, when it comes to TJR there are big ticket items patients need to be able to do or need to know. The creation of clinical pathways can help standardize that process so essential skills and in aren’t missed.
These pathways could help departments as well. There are usually surgeon-specific goals to meet or specific info required by Joint Commission for documentation. The pathways would serve as a reminder to look at these goals and metrics.
Clinical pathways could be as simple or as in-depth as a department wants them to be. It could just be a checklist of mobility skills and education points that need to be achieved. PTs could refer to the list to make sure no critical mobility or education is left out. It could also go as far as to create session outlines where the mobility areas and education are spread to between two sessions. This can help to organize sessions into digestible parts from a physical and educational standpoint and make sure everything gets addressed.
What are your hospitals and joint teams doing to improve TJR success? I’ll go first. We get a total joint weekly preview. When there is a same-day discharge it will be on the preview. As a team we can then prioritize them. We can also make sure whoever sees the patient has a good amount of time to spend with them. This is fairly simple but has been extremely helpful! Drop in the comments section, simple or complex, what your team is doing that’s optimized the way you handle day-of discharge for total joints!
Elective surgeries have a large value in hospitals and surgical centers and we bring a massive value to the implementation and success of them. If you work somewhere now that’s currently not doing same day discharge, I’d say change is probably coming.
This change brings an opportunity for us to remind the systems we work in of our value. Becoming part of the conversation can prevent us from simply tolerating the conditions determined for us. Hopefully some of these ideas are helpful for you and your team!
Any other ideas? Share in the comments section and make sure to watch on Instagram @the_pt_page over the next couple weeks. I plan on putting out a few polls to get the conversation going there as well. Between everyone’s sharing and ideas we can help make total joint same day discharge more successful both for our patients and ourselves!
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