For Some Joint Replacement Patients, There’s No Place Like Home

June 1, 2018

Roger Lynn knows a thing or two about pain, having experienced constant agony that required a shoulder replacement in December and a hip replacement in February (and previous joint replacements as well). Now, he’s also knowledgeable about “home recovery,” a new option for eligible patients having total joint replacement surgery at Kaiser Westside Medical Center (KWMC).

The option to leave the hospital five to six hours after surgery is part of ERAS, an acronym for Enhanced Recovery After Surgery. Roger calls it “wonderful” and “much appreciated” because it allowed him to recover in the comfort and safety of his own home, where he received care from his wife and several visits from a physical therapist.

“I went home from the hospital two or three days after my first surgery, and my wife went home a couple days after her hip surgery,” Roger says. “We’re both grateful for the care we received in the hospital, but wish that home recovery had been an option at the time. For my latest surgery, I jumped at the chance for home recovery as soon as it was mentioned. Like they say in the movies, ‘There’s no place like home.’”

Roger’s understanding of ERAS and its home recovery pathway began with a conversation in the clinic with his orthopedic surgeon, Duncan Hodge, MD, and again with a nurse navigator from the total joint program. Each described ERAS as a comprehensive, evidence-based package of guidelines to reduce patient anxiety and improve physical well-being before, during, and after surgery. ERAS is also an important component of our Care Without Delay initiative – the approach to making sure patients get the right care, at the right time, in the right environment for healing.

Integrated Care Leads the Way

According to a study by the Kaiser Permanente Northern California region in the Journal of the American Medical Association (JAMA / July 2017), the benefits of ERAS include:

  • fewer complications
  • less need for opioids
  • ability to return to normal activities sooner

Matt Tam, Orthopedics Hip and Knee program manager, says the new home recovery pathway has been successful. “To date, 75 percent of identified patients have passed medical discharge criteria; no home recovery patients have needed to be re-admitted to the hospital due to earlier discharge; and patient satisfaction is high.”

Matt attributes the success of ERAS and the home recovery pathway to “our well-coordinated team. They provide thoughtful, integrated care through pre-operative and post-operative touchpoints that help our members feel confident they are receiving optimal care.”

Members of the Hip and Knee Replacement Care Delivery Council were integral in the successful launch and implementation of ERAS, with physician leadership from:

  • Roxana Cooley, MD, regional chief of Anesthesia
  • Erik Kroger, MD, KWMC total joint physician lead
  • David Parsons, MD, ERAS executive sponsor and director of operations and regional chief medical officer – Hospital and Surgical Services

KWMC launched ERAS for total joint replacement surgeries in October 2017 and initiated a home recovery pathway trial the following January. In April, the goal was set at two candidates per day, with plans to extend the option to four and eight patients per day in the third and fourth quarters, respectively.

“The care team must agree that a patient is medically eligible for home recovery, and the patient must also want to do this,” says Dr. Kroger, adding, “Nothing is carved in stone – the final decision about home recovery is made while the patient is still in the hospital, recovering from anesthesia. We want everyone to feel good about the decision.”

Providing Optimal Care

Hannah Winchester is a physical therapist with Kaiser Permanente Continuing Care Services. She says, “Our goal is to set patients up for success. We want them to be safe and comfortable.” A large portion of that mental well-being comes from receiving information from their surgeon, nurse navigator, and physical therapist, and attending a required pre-op class for total joint patients.

About a week before surgery, Hannah or another physical therapist visits the patient at home and reinforces information about pain management, exercise, and walking. She also makes sure the patient will be recovering in an environmentally safe place. She checks how he’ll exit his car and enter his home; where he’ll elevate and ice his wound; whether his walker will fit in the bathroom; how he’ll navigate to bed; whether there are tripping hazards such as throw rugs, clutter, and pets; and whether he’ll have 24-hour daily assistance.

When necessary, Hannah “MacGyvers” solutions by designating a guest bedroom as the patient’s temporary quarters, rigging safety gear in the shower, or rearranging furniture.

She visits patients in their home the day after surgery, and several times over the next two weeks, as needed. She guides them through exercises and helps them regain their strength.

Patients are in Good Hands

“Overall, these patients are very healthy – they just have a short recovery period to get through before they can do things they want to do, such as play with their grandkids, travel, or resume their career,” Hannah says.

Roger, the patient who had hip replacement surgery in February, is now fully recovered. Instead of pushing through the pain as he once did just to walk to the mailbox and back, he’s pushing pedals as he puts mile after mile on his bicycle. Recently, he “conquered” the tallest manmade peak in Hillsboro – which also happens to be the eight-story parking structure at KWMC.

KPNW member Roger Lynn

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