Geisinger surgeons have performed countless joint replacement surgeries over the years. Jeffrey Steele, 61, of Danville, was added to that number when he received a total knee replacement on Feb. 9. But his case stands out from the rest, as he was the very first patient to undergo the procedure as an outpatient at the Geisinger Woodbine Ambulatory Surgery Center — a freestanding facility with no inpatient beds, and thus no overnight stays for patients.
According to Dr. Daniel Feldmann, chief of the Division of Sport Medicine for Geisinger, all of the pieces for an outpatient procedure for joint replacements have existed for some time. Now, they have been able to put those pieces together.
After 20 years in the field, Feldmann can look back and remember when patients undergoing joint replacement surgeries were kept in the hospital for four to five days. Over the years, advancements have caused those stays to progressively shorten for the majority of patients.
Steele wasn’t the first at Geisinger to return home the same day after the procedure, but those same-day cases have been rare in the hospital setting. However, now that’s changing as Geisinger is initiating a program several years in the making that puts them in line with national trends. According to Sg2, a health care analytics consultancy, approximately 51 percent of primary hip and knee joint replacement surgeries will be performed in an outpatient setting by 2026, which is up from just 15 percent in 2016.
As they strive for those numbers, however, Feldmann said they select candidates carefully.
“The biggest issue is having a healthy patient that doesn’t have a significant list of health conditions that could potentially become amplified due to the stress of a joint replacement surgery,” he said. So the process begins with identifying those patients that are healthy enough to go home shortly after the procedure.
Steele was that ideal patient to kick off their new initiative.
“It was getting to the point where I could barely walk,” Steele said of the difficulty he was having with his knee. “It was awful painful to just go about a daily routine.”
Feldmann advised him to have the replacement. And to do so as an outpatient – the first at Geisinger.
Steele said he “had no worries whatsoever” and was glad for the team that was caring for him.
“They were very reassuring…I knew how things were going to go. Everything went smoothly.”
Steele said he was at the ambulatory surgery center for about eight hours, start to finish, before being cleared to return home with detailed instructions and a schedule for follow-up therapy appointments.
“They made sure that I could get up and walk – I was using a walker,” he said. “According to them, I did pretty good.”
He is now well into his estimated six- to-eight-week recovery process.
“I’m pretty much almost back to normal,” he said. “I’m walking very well. I don’t use a walker anymore, or a cane. I’m able to drive. Things have progressed very well.”
“As we anticipated it would be, I think we had a great first patient for it,” Feldmann said. “The team at the surgery center really studied up on everything, from the actual surgical team to our anesthesia team – how to administer anesthesia and control post-operative pain. Everybody involved with the whole process did a fantastic job.”
Feldman said the right candidate is also one who is mentally prepared for the outpatient process. “If you are of the mindset that you want to go home and be in your own environment, and understand there may be some pain involved,” he said, “– those patients are going to be able to manage or cope with whatever they feel like the next day after surgery.”
Feldmann explains that anesthetic procedures, including injections into the deep tissues of the knee during the implant, provide for extended periods of pain relief following the procedure. In addition, patients are giving a medication that limits how much blood loss they have and “this jumpstarts the body into making more blood to replace,” he said.
Methods such as these, he said, “are all things we’ve been working with in the now standard joint replacement world,” which is also helping with the transition to outpatient procedures.
The process is further streamlined by having physical therapy professionals on the floor to teach patients how to sit down, get up, walk around, and use their walker.
These advancements are also helping to limit the amount of time many patients are spending in the hospital at other regional facilities.
At UPMC, hip replacements and unilateral knee replacements made up the majority of the procedures at UPMC Williamsport in 2020. Dr. John Bailey, orthopedic surgeon, said a more technological streamlined and less-invasive direct anterior approach for hip replacement procedures, which they began eight years ago, helped to cut down the length of a hospital stay from two to three days, to two days, and then one day. Because muscles are not touched in this new method, that means a quicker recovery time as well.
“Now we are doing about 10 percent as outpatient procedures,” he said.
For knee replacements, he said, “the biggest change for us is using more regional anesthesia.” Four years ago, they began implementing a nerve block following the procedure to numb up the knee, which has gradually led to a decrease in the length of hospital stays. In addition, they are spending a little less time in the operating room and more time in pre-operative discussions with the patients, coming up with a plan for them to return home as quickly as possible following the procedure.
Bailey said his average patient’s stay last year was about 1 ½ days, with half of his patients going home the next day. Within one to two months, UPMC plans to progress to an outpatient total knee replacement pathway for qualified patients. He anticipates around 25 percent of these patients will be able to take this pathway in the next year or two.
Advancements continue to also be made at Evangelical Community Hospital in Lewisburg. In 2020, 85 percent of all patients undergoing a joint replacement surgery were able to return home in 24 hours or less.
Thomas Dominick, MD, is a surgeon at SUN Orthopaedics of Evangelical. Most of his procedures are total hip and total knee replacements. In the field for approximately 20 years, he said very little has changed in regard to the actual components are methods that are used in the surgery.
“In essence, what is getting people home earlier is the post-operative pain management,” he said. He calls their method a “multi-modal approach.” Patients are treated pre-operatively, perioperatively, intraoperatively, and postoperatively. Regional blocks, he said, will numb the area for 18 to 20 hours after the procedure – the time normally when the most pain is experienced. This means less necessity for the patient to take narcotics, which can cause nausea and constipation – “all the things that make the recovery process not much fun,” Dominick said.
At Evangelical, preoperative education of patients has also helped with quicker and better outcomes following the surgery.
“When they’re prepared, there’s less anxiety, less questioning, and they’re ready to do what they need to do to get better,” Dominick said.
That’s where Candi R. Taylor and her team come in. Taylor is director of nursing for acute rehab at the Center for Orthopaedics and Lift Team at Evangelical.
“The preoperative preparation is huge,” Taylor said. Nurse navigators, office and in-patient staff members walk alongside the patients, who are also given a guidebook that takes them through the whole process, also addressing medications, home setup, adaptive equipment, medication and therapy requirements.
Following surgery, members of Taylor’s team monitor vital signs, manage pain, and get them moving as soon as possible, all the while reinforcing the teaching that the patients were given before the operation so they know what to do and watch out for once they return home.
“Since we have modified the program and started saying that from the time you’re scheduled for surgery, you’re going home the next day, people have really come expecting to go home the next day,” she said. “A lot of times that’s half the battle.”
There are several benefits that come with the continued push for shorter turnaround times for joint replacement procedures.
Feldmann said “patient satisfaction” is at the top of the list, since most people would much prefer recuperating at home versus a hospital – especially in the pandemic environment we find ourselves in. Estimated arrival to departure time for outpatient total joint replacement surgery at Geisinger’s Woodbine facility is between five and six hours.
While Geisinger does currently have a waiting list for joint replacement surgeries due to a backup caused by COVID restrictions, Feldmann said those patients who qualify for an outpatient procedure may be able to get scheduled sooner.
In addition, more outpatient procedures mean more hospital beds are freed up for those patients with medical conditions requiring hospitalization, he said.
Dominick said most people recover better mentally and physically in their home environment. “If their pain is well-managed and they’re eating and doing the things they need to do,” he said, “there’s no reason to stay in a hospital.”
In fact, a big part of the recovery process, he said, is “getting back into the swing of your own daily activities – being able to do things for yourself in your own environment.”
Not to mention patients should probably see lower healthcare bills.
As Bailey explains, “The outpatient procedures are less expensive, because there is no hospital stay."
As hospitals continue to make advancements, patients qualifying for same-day or outpatient procedures have been pleasantly surprised.
Walt and Doreen Eisenhauer, of Jersey Shore, both had joint replacement procedures done within the last couple of years at UPMC by Dr. Bailey. They were both close to retirement, Doreen said, and “We had a lot of plans and a lot of things we wanted to do.” The couple hikes, skis, bikes, and travels quite a bit, so they were looking for a way to get the surgeries they needed without it hindering their activities any more than necessary.
“We put it off for as long as we possibly could,” Walt said. But they realized that they were going to have to have the surgeries if they were going to maintain their active lifestyle in the future.
Doreen had a knee replacement surgery two years ago, and was pleased with how quickly she was able to return home and recover, compared to her other knee replacement five years before that.
“I had surgery in the morning, and physical therapy in the afternoon,” she said. “The recovery was so much quicker than the first one.” She spent only one night in the hospital, and she credits different anesthetic and pain management procedures for making it so much more manageable than her first experience was.
Walt also had a good experience when he had to undergo a total hip replacement in December 2019.
“It was actually nothing short of amazing as far as the experience went,” he said. “Everybody was very kind and very helpful and polite. The pre-operative instructions were very thorough.”
When the procedure was done, he said, “I remember waking up in the room and basically feeling just about as good as when I went down. There was no discomfort.”
He was able to meet his physical therapy goals quickly, and return home. He was able to navigate steps the first day, and progress to crutches after only a couple of days. Two months later, he was hiking to the top of a mountain.
Within two months after Doreen’s knee replacement surgery, they were spending a month in South Africa on an African safari.
They have also been cross-country skiing about four to seven miles a day, and are doing a lot of traveling. They spent a month in Hawaii with their son, golfing, hiking, swimming, “and doing anything we wanted to do,” Walt said. “We really have returned to a total normal active lifestyle for a young 60 years old – and we couldn’t be more pleased.”
Looking to the future
Since Steele’s operation, the ambulatory surgery center at Geisinger has completed three other outpatient joint replacement procedures and are of course looking to do more.
Currently, their focus is on knee replacements, which are most common and according to Feldmann is “a fairly straightforward operation,” and one that the staff at the surgery center was able to immediately begin.
While some of his colleagues at the hospital have been able to perform hip replacement surgeries on patients who have been able to go home the same day, Feldmann said they are moving slowly toward incorporating hip replacement procedures at the outpatient center.
“I think we have to open the door a little bit and prove that we can do it safely in this environment,” he said. “I think all the other joint replacement surgeries can follow.”
But “there’s no reason” he said, why they wouldn’t be able to add hip, shoulder, and ankle replacements to their schedule in the future.
That's great news for those needing such an increasingly common procedure. Bailey said he anticipates the number of joint replacement surgeries to double over the next 10 years as the population ages.
At Evangelical, the staff is back this week to a full schedule of performing joint replacement procedures, following a pause in elective surgeries due to COVID restrictions. They continue to make efforts to streamline the process for patients who qualify. Dominick estimates that approximately 20 percent of their patients would be able to take advantage of an outpatient pathway, and he sees “great advantages” to such a future. It’s one that they are considering as well.
“I think that will be the next step,” he said.