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Rapid Recovery after Hip and Knee Arthroplasty: A Process and a Destination
The Journal of Arthroplasty 30 (2015) 517
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Rapid Recovery after Hip and Knee Arthroplasty: A Process and a Destination
There are many facets of a successful Rapid Recovery Program after total hip and knee arthroplasty that are detailed in the five manuscripts that follow this editorial. All of them highlight that it is critical to set the expectations of a rapid recovery, not only with the patient and family, but also with the whole interacting health care team prior to surgery, during the hospitalization, and after discharge from the hospital to the home. It is also important to differentiate between early discharge and rapid recovery. Early discharge from the hospital can be accomplished with a coordinated effort [1] and [2], but rapid recovery is a process that begins long before the surgery and continues for quite some time afterwards. A plan for rapid recovery must be established well in advance of the surgery and executed with active participation of the patient as well as the family. Both patient fitness and health need to be optimized prior to surgery. Risk factors, such as co-morbidities, should to be identified before admission and a plan made for anticipating and avoiding pulmonary, cardiac, hematologic, genito-urinary, and other issues that may delay discharge and interfere with the recovery process. Callaghan et al. [4] identified predictors of delayed recovery, including history of myocardial infarction, pulmonary embolism, chronic anticoagulation therapy, high body mass index, smoking, and elevated blood glucose levels. Stambough et al [2] highlight the value of preoperative education including a detailed surgical booklet that emphasizes the expectations for a rapid recovery. Processes need to be standardized to be effective. This is particularly true during the hospital stay and includes proper pain and fluid management [1], coordinated efforts of the nursing and physical therapy teams [2], and staying “on message” about the medical safety of early discharge and rapid recovery [3]. Many patients remember their parents or friends spending 3 weeks in the hospital recovering from elective
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to doi: http://dx.doi.org/10.1016/j.arth.2015.03.001. http://dx.doi.org/10.1016/j.arth.2015.03.001 0883-5403/© 2015 Elsevier Inc. All rights reserved.
joint arthroplasties (common practice in the 1980's) or being discharged to a rehabilitation center rather than to home (common practice as recently as five years ago). It is important to revise these expectations. In this era of performance measurement, financial penalties are in place for early complications and readmissions. Edwards et al [3] highlighted a detailed rapid recovery program that reduced readmissions by 50%. Lavernia and Villa [5] warn that the finances of rapid recovery after total joint arthroplasty are challenging, and that we need to participate actively in ensuring that incentives are in place to promote early discharge, rapid recovery, as well as a safe experience. Rapid recovery after total hip and total knee arthroplasty has always been possible. As outlined in the following manuscripts, rapid recovery is now a predictable and safe reality. William James Hozack, MD Thomas Jefferson University, Philadelphia, Pennsylvania References 1. Sculco PK, Pagnano MW. Perioperative Solutions for Rapid Recovery Joint Arthroplasty: Get Ahead and Stay Ahead. The Journal of Arthroplasty 2015;30(4):518–20. 2. Stambough JB, Nunley RM, Curry MC, Steger-May K, Clohisy JC. Rapid Recovery Protocols for Primary Total Hip Arthroplasty Can Safely Reduce Length of Stay Without Increasing Readmissions. The Journal of Arthroplasty 2015;30(4):521–6. 3. Edwards PK, Levine M, Cullinan K, Newbern G, Barnes CL. Avoiding Readmissions— Support Systems Required After Discharge to Continue Rapid Recovery? The Journal of Arthroplasty 2015;30(4):527–30. 4. Callaghan JJ, Pugely A, Liu S, Noiseux N, Willenborg M, Peck D. Measuring Rapid Recovery Program Outcomes: Are All Patients Candidates for Rapid Recovery. The Journal of Arthroplasty 2015;30(4):531–2. 5. Lavernia CJ, Villa JM. Rapid Recovery Programs in Arthroplasty The Money Side. The Journal of Arthroplasty 2015;30(4):533–4.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Rapid Recovery after Hip and Knee Arthroplasty: A Process and a Destination
There are many facets of a successful Rapid Recovery Program after total hip and knee arthroplasty that are detailed in the five manuscripts that follow this editorial. All of them highlight that it is critical to set the expectations of a rapid recovery, not only with the patient and family, but also with the whole interacting health care team prior to surgery, during the hospitalization, and after discharge from the hospital to the home. It is also important to differentiate between early discharge and rapid recovery. Early discharge from the hospital can be accomplished with a coordinated effort [1] and [2], but rapid recovery is a process that begins long before the surgery and continues for quite some time afterwards. A plan for rapid recovery must be established well in advance of the surgery and executed with active participation of the patient as well as the family. Both patient fitness and health need to be optimized prior to surgery. Risk factors, such as co-morbidities, should to be identified before admission and a plan made for anticipating and avoiding pulmonary, cardiac, hematologic, genito-urinary, and other issues that may delay discharge and interfere with the recovery process. Callaghan et al. [4] identified predictors of delayed recovery, including history of myocardial infarction, pulmonary embolism, chronic anticoagulation therapy, high body mass index, smoking, and elevated blood glucose levels. Stambough et al [2] highlight the value of preoperative education including a detailed surgical booklet that emphasizes the expectations for a rapid recovery. Processes need to be standardized to be effective. This is particularly true during the hospital stay and includes proper pain and fluid management [1], coordinated efforts of the nursing and physical therapy teams [2], and staying “on message” about the medical safety of early discharge and rapid recovery [3]. Many patients remember their parents or friends spending 3 weeks in the hospital recovering from elective
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to doi: http://dx.doi.org/10.1016/j.arth.2015.03.001. http://dx.doi.org/10.1016/j.arth.2015.03.001 0883-5403/© 2015 Elsevier Inc. All rights reserved.
joint arthroplasties (common practice in the 1980's) or being discharged to a rehabilitation center rather than to home (common practice as recently as five years ago). It is important to revise these expectations. In this era of performance measurement, financial penalties are in place for early complications and readmissions. Edwards et al [3] highlighted a detailed rapid recovery program that reduced readmissions by 50%. Lavernia and Villa [5] warn that the finances of rapid recovery after total joint arthroplasty are challenging, and that we need to participate actively in ensuring that incentives are in place to promote early discharge, rapid recovery, as well as a safe experience. Rapid recovery after total hip and total knee arthroplasty has always been possible. As outlined in the following manuscripts, rapid recovery is now a predictable and safe reality. William James Hozack, MD Thomas Jefferson University, Philadelphia, Pennsylvania References 1. Sculco PK, Pagnano MW. Perioperative Solutions for Rapid Recovery Joint Arthroplasty: Get Ahead and Stay Ahead. The Journal of Arthroplasty 2015;30(4):518–20. 2. Stambough JB, Nunley RM, Curry MC, Steger-May K, Clohisy JC. Rapid Recovery Protocols for Primary Total Hip Arthroplasty Can Safely Reduce Length of Stay Without Increasing Readmissions. The Journal of Arthroplasty 2015;30(4):521–6. 3. Edwards PK, Levine M, Cullinan K, Newbern G, Barnes CL. Avoiding Readmissions— Support Systems Required After Discharge to Continue Rapid Recovery? The Journal of Arthroplasty 2015;30(4):527–30. 4. Callaghan JJ, Pugely A, Liu S, Noiseux N, Willenborg M, Peck D. Measuring Rapid Recovery Program Outcomes: Are All Patients Candidates for Rapid Recovery. The Journal of Arthroplasty 2015;30(4):531–2. 5. Lavernia CJ, Villa JM. Rapid Recovery Programs in Arthroplasty The Money Side. The Journal of Arthroplasty 2015;30(4):533–4.