Improving Joint Replacement Surgery: A Patient-First Approach

A recent article in JAMA1 lists questions to ask one’s surgeon before an operation (paraphrasing slightly: “Do I need surgery?” “What are the various options for anesthesia?” “How much pain can I expect and how can it best be managed?”).

Surgeons
Ongoing communication before, during, and after surgery can greatly increase
patients’ sense of control and ultimate satisfaction after a procedure.

I applaud the patient-empowerment stance—the recommended questions are all excellent. But, having read the piece, I felt a bit disheartened. Let me explain.

As a medical director at a medical facility, I’m an insider. I speak the language, know the surgical techniques, understand the larger system. Despite that, a cancer scare earlier this year—thankfully, tests came back negative—reminded me that to be a patient often means to feel a loss of control.

As an orthopedic surgeon, I’m no expert in oncology. Still, I knew which questions to ask, if it came to that. Here’s the thing, though: It didn’t come to that. My patient experience was excellent because there was a patient-focused, integrated system in place—from the primary care physician, to the surgeon, to the imaging team, to all the other invisible support staff. The system anticipated my questions and anxieties and gave me the information I needed, as I needed it. That’s patient-centric care.

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Excellent care puts patients first

It takes a whole system to make such care happen, which is why the JAMA article gave me pause. The article, which was clearly directed to patients, was the last piece in an issue focused on clinicians, as JAMA typically is. To reach it, the reader had to run a gauntlet of articles on transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio, age cutoffs for bioprosthetic vs mechanical aortic valve replacement, and so on.

The presentation, with the patient-focused piece buried at the very end, struck me as a metaphor for the medical system as often perceived by the patient: Mostly foreign terminology and unfamiliar processes aimed at experts, with a brief, tacked-on translation for the patient.

Excellence doesn’t arise from the competence of any one person—not the general practitioner, surgeon, floor nurse, or physical therapist, and certainly not the patient, who has just embarked on a very strange journey. They all need to be placed within a system designed for success—a complex system built on the hard work of many meetings, many hours developing and improving protocols, and mountains of data. And the center of that system must be the patient.

That JAMA patient handout, or something like it, could and should be part of such a system, but it’s only the tip of the iceberg. By itself, it’s a single, lonely hand lifted and waving far out at sea.

Patient-first approach improves pain protocols for joint replacement

I’ve been performing joint replacements for 27 years. In 1988, patients had a 10- to 14-day hospital stay. Today, it’s 2 to 3 days, with better patient outcomes. Still, there’s room for improvement. Three years ago, inspired by organizations such as Mayo Clinic Care Network and the Institute for Healthcare Improvement, a number of people affiliated with my medical facility decided to take a patient-first approach to improve joint replacement surgery.

Our initial focus was to improve pain management for the 2,000 knee and hip and hip replacement patients we serve each year. Such surgeries improve function, alleviate pain, and are often cost-effective2 in the long run. However, in the short run they are resource-intensive and can cause significant discomfort. Elevated pain can increase recovery times. And, of course, pain is painful. So we had two very good reasons for improving our pain management protocols.

Pain Control Survey

Through data collection along with a series of meetings that included surgeons, nurses, physical therapists, pharmacists, anesthesiologists, administrators, and many others, we assessed our current pain management protocols.

We also paid attention to patients and their experiences. After all, the shift from a two-week to a three-day stay for joint replacements came partly from health professionals observing noncompliant patients. Although physicians prescribed bed rest, some patients got up and tried to walk a day or two post-surgery. To many people’s surprise, those patients often did better. We became more aggressive with recovery schedules.

Here’s what our hospital’s self-assessment of pain management uncovered: Extreme variation. Some physicians used pain management regimes that relied more on strong opioids, others on milder medications. Some emphasized scheduled doses of acetaminophen, others advised ‘as needed’ doses. Some used epidurals to block pain, others used peripheral nerve blocks.

Variation is often not optimal in patient care. But when it occurs, you should make it your friend by asking “what seems to work better?” We answered that question, and then we tested our assumptions with our patients. The results were notable. The new pain protocol reduced our patients’ post-operative experience of severe pain by 50%. At the same time, we were able to reduce use of strong opioids, which lowered related risks and side effects. Our patients were going home from the hospital faster. Most were walking a day after surgery.

Post-Op Pain Score Chart

Part of the new protocol involved combinations of pain relievers unfamiliar to most patients: ketorolac, celecoxib, dexamethasone. Part involved a more effective use of acetaminophen. And part was very low tech indeed: We found that ongoing communication before, during, and after surgery greatly increased our patients’ sense of control and ultimate satisfaction with their surgical procedures. As a result, we modified our two-hour pre-operative class (taught jointly by nursing, pharmacy, and discharge planning) to educate our patients on what to expect regarding pain control.

We continue to offer a patient-controlled morphine drip in the operating room. During the past six months, I can only recall two patients pushing that button. So it seems a tested pain protocol plus patient involvement can be more powerful than morphine.

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References:
  1. What to Ask Your Surgeon Before an Operation. Edward H. Livingston, MD JAMA. 2015;313(5):536. doi:10.1001/jama.2015.62
  2. The cost-effectiveness of total joint arthroplasty: a systematic review of published literature. Best Pract Res Clin Rheumatol. 2012 Oct; 26(5): 10.1016/j.berh.2012.07.013.
Post written by James Bried, MD