Implementation of a total joint replacement-focused perioperative surgical home: a management case report.
BACKGROUND
The perioperative setting in the United States is noted for variable and fragmented care that increases the chance for errors and adverse outcomes as well as the overall cost of perioperative care. Recently, the American Society of Anesthesiologists put forward the Perioperative Surgical Home (PSH) concept as a potential solution to this problem. Although the PSH concept has been described previously, "real-life" implementation of this new model has not been reported.


METHODS
Members of the Departments of Anesthesiology and Perioperative Care and Orthopedic Surgery, in addition to perioperative hospital services, developed and implemented a series of clinical care pathways defining and standardizing preoperative, intraoperative, postoperative, and postdischarge management for patients undergoing elective primary hip (n = 51) and knee (n = 95) arthroplasty. We report on the impact of the Total Joint Replacement PSH on length of hospital stay (LOS), incidence of perioperative blood transfusions, postoperative complications, 30-day readmission rates, emergency department visits, mortality, and patient satisfaction.


RESULTS
The incidence of major complication was 0.0 (0.0-7.0)% and of perioperative blood transfusion was 6.2 (2.9-11.4)%. In-hospital mortality was 0.0 (0.0-7.0)% and 30-day readmission was 0.7 (0.0-3.8)%. All Surgical Care Improvements Project measures were at 100.0 (93.0-100.0)%. The median LOS for total knee arthroplasty and total hip arthroplasty, respectively, was (median (95% confidence interval [interquartile range]) 3 (2-3) [2-3] and 3 (2-3) [2-3] days. Approximately half of the patients were discharged to a location other than their customary residence (70 to skilled nursing facility, 1 to rehabilitation, 39 to home with organization health services, and 36 to home).


CONCLUSIONS
We believe that our experience with the Total Joint Replacement PSH program provides solid evidence of the feasibility of this practice model to improve patient outcomes and achieve high patient satisfaction. In the future, the impact of LOS on cost will have to be better quantified. Specifically, future studies comparing PSH to traditional care will have to include consideration of postdischarge care, which are drivers of the perioperative costs.
From the Departments of *Anesthesiology and Perioperative Care; and †Orthopedic Surgery, University of California Irvine, Irvine, California.
Leslie
L
Garson
Ran
R
Schwarzkopf
Shermeen
S
Vakharia
Brenton
B
Alexander
Stan
S
Stead
Maxime
M
Cannesson
Zeev
Z
Kain
D000368:Aged; D000758:Anesthesia; D019643:Arthroplasty, Replacement / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D019090:Case Management; D003363:Cost Control; D005240:Feasibility Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007430:Intraoperative Care; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D061214:Patient Safety; D018802:Patient-Centered Care; D019990:Perioperative Care / Q000379:methods*; D011182:Postoperative Care; D011300:Preoperative Care; D058996:Quality Improvement; D016896:Treatment Outcome