Home with a new hip in 12 hours

By Ana Gajic

Canadian sportscaster Vic Rauter is famous for announcing major sports wins, but earlier this year he participated in a novel hip replacement surgery that has become a win for patients and staff members alike at St. Michael’s Hospital.

Diagnosed with osteoarthritis at age 46, Rauter had his first hip replacement at age 56 – about eight years ago – at St. Michael’s. He stayed in the hospital for three nights to recover. This year, his right hip was deteriorating quickly.

“I was in total agony,” Rauter recalled. “At some announcing events I was using my suitcase handle as a crutch to get up the stairs.”

His first hip surgeon, Dr. Earl Bogoch, introduced Rauter to Dr. Amir Khoshbin, a surgeon in the Division of Orthopaedic Surgery at St. Michael’s, who was touting a novel, same-day discharge option for hip replacements. St. Michael’s had become the first hospital in the city of Toronto to offer same calendar day discharge for hip replacement surgery in January 2018. Right away, Rauter was intrigued.

“I had heard about this rapid discharge option in the United States,” he said. “But now that it was an option at my hospital, where I was born and had my first joint replacement, I knew I had to sign up.”

Changing culture and practice

Dr. Khoshbin joined the St. Michael’s orthopaedics team in September 2017, and started the groundwork to give patients who were suitable the option of a same-day discharge for hip replacement surgery.

“It’s a culture change for patients and the hospital,” Dr. Khoshbin said. “Our pain protocol is now different and the milestones the patient needs to reach before discharge are different. It’s not just a change for the surgical team; it’s also a change for our anesthesia team, the OR/PACU/unit nurses, our advanced care physiotherapists, our case managers, our pharmacists, our clinical leader managers, the physiotherapy team and the occupational therapy team.”

Every department who would cross paths with same-day hip replacement patients worked closely with the orthopaedics team to plan how the procedure would ensure the safest possible experience for patients suitable for rapid discharge.

“The biggest challenge from the anesthesiologist’s perspective for same-day hip surgery is pain control,” said Dr. Nick Lo, anesthesiologist at St. Michael’s. “We developed an approach to help us manage pain efficiently, while minimizing side effects. For a rapid discharge, this means a spinal anesthesia instead of general anesthetic.”

General anesthetic slows recovery time as patients are often groggy and nauseous from the medications after the procedure. With a spinal anesthetic, the pain control is localized to the lower half of their body. During surgery, patients are given additional sedation medication to make them drowsy, but then wake up immediately after the surgery and feel clear-minded.

In addition to the anesthesia team’s plan for same-day hip surgeries, occupational therapy and physiotherapy worked with the orthopaedics team to ensure they could assess patients on the same day as their surgery.

“You really need the right patient, the right team, and the right hospital to perform outpatient total hip replacement,” Dr. Khoshbin said. And as always, the most important objective for our team is patient safety.”

The right patient

Dr. Khoshbin and his team screen patients who might be eligible for same-day hip surgery. Those who have obstructive sleep apnea, diabetes, chronic obstructive pulmonary disease, or who use or require any kind of monitor, atrial fibrillation or strong blood thinners are not candidates for the same-day hip surgery.

For Diane Blackburn, who went through the same-day discharge hip surgery in March 2018, this option was a safe and comfortable way to recover quickly.

“I can’t say there was any distress – I was able to go back to work within three weeks,” Blackburn said. She is a fitness instructor who works with seniors. “I was highly motivated to get back into the swing of everything. Within a few hours of the surgery, I was standing, walking and using the stairs.”

Generally, patients coming in for same-day discharge hip surgery are given the spinal anesthesia before 8 a.m. on the day of their surgery. They’re wheeled into the operating room at 8 a.m. and the procedure lasts about two hours. They are then in recovery for a few hours and closely monitored for pain management. By noon, they’re on the inpatient mobility unit to rest, and then by 2:30 p.m. they are assessed by the physiotherapy and occupational therapy teams. If they meet the right criteria, they are discharged with prescriptions, an emergency phone number to call if needed, and exercises to work on at home.

“I was home within 12 hours of arriving at the hospital,” Blackburn recalled. “I should have used the phone number just to call and say thank you! The whole team was very efficient.”

So far, Dr. Khoshbin and his team have done about 15 to 20 same-day discharge hip replacement procedures. So far, there haven’t been any patients who have had complications or ended up in the emergency department after the same-day discharge. Each procedure saves the hospital about 20 per cent of the costs associated with a longer recovery to hip replacement surgery (that has an average length of stay of two nights), but more importantly offers the patients more comfort.

“Everyone feels much better in their own bed,” Blackburn said. “So if you’re given that option, then why not take it?”

The post-surgery recovery takes about three weeks to get into a normal routine. Patients see their family physicians for a wound check within a week or so. If that goes well, they come back to St. Michael’s for a consultation with an advanced care physiotherapist after six weeks. Then, at the three-month mark, they see Dr. Khoshbin. After that, they have another check-in is at one year.

“This approach shows the evolution of surgery, the forward-thinking at St. Michael’s Hospital and the innovation of the Division of Orthopedic Surgery leaders,” he said.

‘Miracle-like’

Six weeks after his surgery, Rauter is still in awe at how efficient his second hip replacement was.

“To say it was miracle-like is not an overstatement,” he said. Within three weeks, Rauter was gardening without any arthritic pain. “I’m very grateful to the entire team.”

And, as everyone involved in this novel approach is quick to reiterate – it is truly a team effort.

“At St. Michael’s we’re very fortunate to have the infrastructure to support these kinds of procedures,” Dr. Lo said. “We have the knowledge, skills and facilities to be able to handle and lead changes in practice.”

About St. Michael’s Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in more than 29 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.