Day surgery for total knee replacement by Dr Sam Martin
Dr Sam Martin, orthopaedic surgeon There have always been demands for efficiency in health care and this only seems to increase. Year after year, the Australian health budget grows by a greater percentage than GDP and this is not sustainable. The COVID-19 pandemic has further increased the need for efficient delivery of medical services. Local disasters like the steriliser breakdown in Grafton or the terrible floods in Lismore and surrounds further blow our surgical waiting lists out. I have been in Northern NSW for a bit over 10 years but it wouldn’t be a surprise if waiting lists for elective surgery in the public system are as bad now as they have ever been. That also has flow on effects for the provision of care in the private system, where especially in Victoria, significant private capacity has been used for the provision of public elective surgery. There is clear impetus for change here. As clinicians though, improvements to our models of care ideally arise in a patient focused manner with the motivation being to do the best we can for the patient in front of us. In many cases that will also result in more efficient health care. Day-only total joint replacement is an exciting example where patient centered concerns align with a benefit at the health resource level. This is not ground-breaking stuff. It is self-evident that, all other things being equal, it is both a better patient experience and more cost effective if a patient recovers from (say) pneumonia more rapidly rather than more slowly. So why, aside from a few isolated pockets of ERAS (enhanced recovery after surgery) programs, aren’t we seeing more of a concerted effort to have 20 | NorDocs
Grafton’s first two patients to complete same day joint replacement
people recover more rapidly after surgery? This may be down to a misunderstanding. Many clinicians are under the mistaken impression that ERAS and day surgery total joint replacement programs are tricks to cut costs or otherwise under-service patients and then somehow still salvage an acceptable outcome. Clinicians suspect that day surgery programs or short stay programs are health resource focused rather than patient centered. Others may believe that we are discharging patients who really require inpatient care, but somehow recreate the hospital environment at home with super resources. Neither of these is the case. A unit that is trying to discharge patients who aren’t discharge-ready and then make up for it is probably going about day surgery the wrong way. I recently had the pleasure of presenting
a NorDocs webinar on the day surgery total knee replacement (TKR) pilot program that commenced in August 2020 at Grafton Base Hospital. We combined the results with a number of self-funded, day surgery TKR patients from the private system and compared these to the overnight patients from the same time period. It is worth pointing out that other than the day of surgery discharge and one extra visit to the office for pain and catheter removal, the day surgery and overnight patients had equivalent and standard care with standard resources. There are multiple small interdependent and cumulative factors that all contribute to a successful day surgery model of care. That in itself is a very interesting area. There is certainly no one key thing. In TKR surgery, a less invasive approach, minimal tourniquet use, thoughtful local anaesthetic infiltration, intra-articular
