Enhanced Recovery for Orthopedic Surgery By Arman Dagal MD, FRCA; Chad M. Craig, MD, FACP & Ruchir Gupta, MD T otal hip and knee replacements amount to nearly 1,000,000 surgical procedures annually in the United States and are expected to triple in volume by 2030. It is estimated that 7 million people are currently leaving with total hip or knee replacement in the United States alone. In addition to the joint replacement, spine surgery is amongst the costliest procedures in U.S. Between 1998 to 2008 the number of spinal fusion procedures increased by 137%. The spine care (direct and indirect) cost around $100 billion annually in the U.S. alone. 1 remain variable across institutions.2 Bundled Care and Health Care Delivery. The Center for Medicare and Medicaid Innovation (CMMI) was created by the Affordable Care Act to tests innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for the beneficiaries. The Bundled Payments for Care Improvement (BPCI) initiative is the product of the CMMI. Under this initiative hospital and physician services combined into a single payment, using episode based rather than the fee for service payment method. Bundled payments provide an incentive for the hospitals and its medical staff to improve coordination of care to improve value and eliminate unnecessary cost. Hospitals and its providers share the associated risk and financial penalties if they cannot control the cost and quality of care. In this new definition of the surgical episode also includes the post-acute care expenses up to 90 days from the surgery. Along with the mission of value-based care, this year, Joint Commission launched a new Advanced Certification program for Total Hip and Total Knee Replacement. The Advanced Total Hip and Total Knee Replacement certification program is designed to assist healthcare organizations to provide high-quality healthcare with an emphasis on patient safety. The certification program will focus on the transitions of care for patients undergoing a total joint replacement. The uniqueness of this certification begins with reviewing the procedures associated with the orthopedic consultation, pre-operative, intraoperative and post-surgical orthopedic surgeon follow up care. The Joint Commission identified standardized performance measures for this program. Currently, the joint commission is collaborating with the pilot sites to develop standards for the electronic performance measure set 1-4 in relations to Pre-admitting, Operating Rooms, PACU, and Orthopedic Units areas. https://www. jointcommission.org/total_hip__total_ knee_replacement_/ 1. Usage of Neuraxial Anesthesia 2. Postoperative Mobilization on Day of Surgery 3. Discharged to Home 4. Preoperative Functional/Health Status Assessment ERAS orthopedic care bundles. Enhanced recovery after surgery ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org (ERAS) concept emerged following the work of Henrik Kehlet, M.D., Ph.D 1992 on colorectal surgeries. ERAS is a model of coordinated care delivery of evidence-based care bundles, aimed at achieving perioperative optimization and reducing the adverse effects of the surgical stress response. A number of studies have examined the ERAS pathway care bundles for primary hip and knee replacement surgeries, with a recent review highlighting that such pathways can be applied to a wide variety of patients. Aasvang et al.3 concluded in their study that ERAS can in fact be applied routinely to all hip and knee replacement patients in order to 11 Despite the apparent success of these surgeries, quality and cost
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