In the urgency of the pandemic, elective surgeries were canceled or delayed across the board. From a public health perspective, this made sense: these measures preserved hospital resources including medical and administrative staff, ventilators and ICU beds. However, many patients were left in a painful limbo waiting for their elective procedures to take place.
The word “elective”, as many people understand it, is probably not an accurate description. “Elective” means both the patient and physician choose when you do the surgery – not necessarily if the patient should have the surgery. Consider a patient in extreme pain due to their arthritis. They cannot ambulate easily, placing them at risk for falls, blood clots, pneumonia, and various other problems associated with limited mobility. Yet, their surgery is still called elective. This classification worked when patients and their physicians could schedule these procedures promptly with little logistical concern. During the recent delay caused by COVID-19, though, patients were left to stay at home with very few options for managing their discomfort and limitations on their activities of daily living.
Even as the initial restrictions of the pandemic were relaxed later in 2020, limitations on surgeries requiring any hospital bed (even for only 23 hours) remained. This heavily impacted how physicians conducted joint replacement surgeries and some spine surgeries – that’s when a potential challenge soon became a silver lining. Orthopedic surgeons have long been aware of the benefits of performing surgeries as truly outpatient (ambulatory procedures in which the patient arrives and leaves the care facility in the same day). For reasons ranging from lags in policy and proof to a general hesitancy from a system built around inpatient procedures, it was not standard to do these as outpatient surgeries. COVID has become the ultimate impetus to speed up this transition.
The patient benefits from outpatient surgery are many: outpatient procedures for joint replacement means patients are discharged home from recovery within a few hours of their procedure. Oftentimes, recovering from their home’s comfort with family members is less stressful, less of a financial burden, and makes for potentially better outcomes with fewer complications. It is estimated that outpatient joint replacements cost about 75% less than the same procedure done as an inpatient, this is a considerable cost savings for the insurers as well as the patient. Studies also note the favorable impact of early mobilization for these patients and less of a chance of complications such as DVTs, UTIs, and pneumonia. In the COVID world, these patients do not come into the hospital, which reduces their chance of being exposed to the virus among many other infectious diseases.
At my practice, we carefully planned and took more steps to educate everyone involved to optimize care journeys for these procedures to be performed outpatient. We selected healthy patients with criteria such as few or no comorbidities (heart disease, diabetes, etc.), BMI under 40, and family help at home who understood what was required, allowing for early success. Extra time was spent on preoperative planning to establish the correct patient expectations. We also reliably predicted what extra items they would need at home: walkers, canes, elevated toilet seats. These were prescribed and given to the patients before surgery. Postoperatively, the patients were contacted by midlevel providers on a more consistent basis to answer questions and alleviate any concerns. Physical therapy was initiated in the recovery room and was already scheduled for continuation outpatient. Outpatient joint replacement requires detailed planning prior to surgery to ensure that the operative care plans are in place and approved. All of these extra steps and thoughtful selection criteria have resulted in very favorable results with high patient satisfaction (consistent with previously observed reactions from orthopedic outpatients at a broader level).
As hospitals and practices follow the trending rise in the number of outpatient procedures, flexibility is a must for all stakeholders involved. Policies and providers need to absorb the holistic benefits of outpatient care we’re observing and reflect them in their guidelines. Meanwhile, as practitioners, we must understand what the transition may feel like for a patient who is not used to undergoing such a good portion of recovery in the home setting. Digital health platforms are in a unique position to assist with this transition by interacting with every player, keying patients into their care journeys and encouraging the outpatient route from physicians to the point of normalization.
What does the return to elective surgeries look like post-COVID? While the data is not available yet, I predict one of the positive results of COVID will be a notable shift to truly outpatient orthopedic surgery for joint replacements since it is better for the appropriately selected patient medically, financially, and emotionally. As we are permitted to do more procedures in the hospital, those who did not meet outpatient criteria will be able to proceed with their surgery. We will likely see more facilities for outpatient procedures that allow for a 23 hour overnight stay, keeping healthy patients away from hospitals with COVID patients. But this requires changes in behavior and changes in practice, both for patients and physicians. There is an opportunity for educating physicians and supporting staff to embrace performing procedures outpatient, and make sure patients are comfortable being treated in an ambulatory surgery center on an outpatient basis. I see a role for novel technology and tools to better support physicians and patients navigate this change.
With all of this in mind, I do not predict that we will be inundated with long waits for elective procedures in the coming months. The pandemic will eventually pass, but tactics that sustained us now and will allow for efficiency later are here to stay.
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About the Author: Traci Granston M.D.
