Hi Dr. Amanatullah!
Hi thanks for having me!
Of course. For your run of the mill joint replacement, what would you say is the usual discharge time?
I would tell you every patient is really different, but in general, I basically use four criteria to determine when it’s time to go home from the hospital.I would like my patients to have their pain controlled with pills alone, so not taking anything else to manage their pain. Could be different pills, hopefully not very much narcotics, but at least controlled by pills.
Next, we want to make sure there’s no medical problems. They have someone to help them at home at least for the first week or two or ten days when the patients recovering from the most amount of pain and might have some difficulty getting around or might need a little bit of help.
And lastly, the patient can walk a hundred feet on their own, and maybe negotiate three to five stairs. The reason that’s important is because we want the patient functional enough to be independent. Basically the person at home is just there to help if they get themselves into trouble.
How soon that happens? I would say in about sixty to eighty percent of the patients, that happens within twenty four hour. Some patients even go on the same day of surgery. There’s about twenty percent of patients that need another day, and they go home on the second day.
There’s another cohort of patients who tend to be older, maybe a little bit more deconditioned, or have a really severe and don’t have a common problem like the one you’re discussing, and it may take them three days, or they never get to the point where they meet those criteria meaning it’s really hard for them to walk a hundred feet on their own unassisted.
For those people, we like to see them go to a skilled nursing facility to get more conditioning and a little stronger, or to home with a home health aide or a nurse specifically designed to check up on them. That’s particularly useful in people who don’t have the family circumstances to have someone around.
So I would say in general most people go home the day after surgery or the same day. Some people need a little more or a little less help. And then, other people need a lot of help and they need to go to some other place or have additional help outside of the hospital at around three days.
Got it. So you mentioned that age often plays a factor in how soon someone goes home. What are some other things that someone can do either before or during or immediately after the surgery that would lengthen or shorten their discharge time?
Dr. Derek Amanatullah:
So this is actually a really hard question.
People talk about using all kinds of devices. There’s one that gets used often called a continuous passive motion machine. People talk really about using physical therapy aggressively, patients really want to get in the physical therapy as quick as possible. And then people even talk about prehabilitation or rehabbing yourself ahead of time.
I would say in general for joint replacements, physical therapy is actually not that important anymore.The reason for that is is the patient is the best therapist.
If the patient hurts, is not having a good day, it’s better for them to take a break then have the therapist push on their knee and pull on their knees hard as possible to get some range of motion. But if the patients having a great day they should move as tolerated .And that’s gonna get them most of their motion. The good part about joint replacement is we use most of our motion our daily routine — sitting, standing, getting out of a car, laying down, getting up, and that motion will come back.
The reason the joints are stiff is because we had surgery and they’re going to swell, but the motion the patient had at the time of surgery will come back no matter what device we use. In fact the continuous passive motion machine is really been renamed the continuous pain maker. By making people move when they don’t want to move just creates pain actually maybe generates the feeling of stiffness or feeling behind and creates anxiety. So we don’t use those really anymore. Prehabilitation — lots of data showing prehabilitation actually doesn’t work the reason it doesn’t work is because when we make the incision, and some muscle or tendon or ligament or whatever ends up getting cut, that has to have time to heal regardless and is injured. So you can’t really have a way that injury and that’s driving everything.
Lastly, people want to do aggressive physical therapy. The motion will return. I used to have a mentor that said, “if you put the joint replacement in right, it’ll work fine, and if it doesn’t work right, blame physical therapy.” So therapy is not depriving the recovery of these things — it’s their installation, how much muscle or things need to be dissected or damaged really in order to see, and patients recover because the joint is better. They’re actually better right after surgery. It’s a matter of managing their pain.
So things that I think people can do is have appropriate expectations about their pain. Create the appropriate family or living environment to make things easy on you within the first two weeks. Take your medications ahead of time. Being ahead of the pain is more important than being behind the pain, trying to be a hero.
And last, listen to your joint, o your knee or to your hip, and do what you feel comfortable doing. If it’s painful and difficult, is probably needs more time to heal. So lots patients recover in different trajectories. Just because it’s taking a little longer, that’s okay.
Our goals for surgery, say for a knee replacement, are that within about two to six weeks, the patient has zero (meaning straight) to ninety degrees of motion. That would be a good success. If you have that date two, that’s amazing. If you have it at day twenty-two, that’s amazing. It’s all the same you don’t need to run the race as fast as possible to win — we just need to get you to the finish line.
For sure. So when it comes to the discharge location and where the patient is undergoing this, what should a patient look for in the best discharge location for them?
Dr. Derek Amanatullah:
Yeah so this is a really great question.
The best discharge very clear. The most safe place for a patient to go is actually home. And it’s really interesting because people don’t feel — I don’t think instinctual adults feel that way. They feel like the hospitals the safest place. And in reality the hospital is the least safe place
The reason for that is people are comfortable at home. They know where things are, and how far things are, they have the food that they like, the people that they like. They have the circumstances and surroundings they’re comfortable them. And that’s worth a lot. That assumes that it’s safe to be at home — you don’t have a medical problem, unmanageable pain, all the things that we covered previously.
If you need those things have to be in the hospital, but the hospital’s dangerous. There other people in the hospital or sick. Lots of people come in to check your wound and touch things and manage things and things beep and you can’t sleep in the up maybe have someone else in the bed next to you. So things are awkward and uncomfortable although there’s a lot of supervision.
So if you need it, we want that supervision, but if you don’t need it and you’re safe at home, no doubt that’s the safest place to be.
In the middle, between home in the hospital, we have the skilled nursing facility and the home health aide to visit you at home or help you with therapy or other things that you might need after the joint replacement.
They’re really the bridge in between, and it could be in certain scenarios just as safe as home or just as safe as the hospital. So we use those as a bridge when insurance wise or patient stability dictate that those things might be required, meaning a little bit more time but you don’t have any medical problems — you need to get little stronger condition because the patient’s been de conditioned on a walker or in a wheelchair, and as they need to recover it’s gonna take more than a standard amount of time but it’s not safe to be at home, you might need to go to a skilled nursing facility.
So discharge time, and I think discharge location are really dependent upon the patient, their circumstances and their overall ability to get from this kind of unsafe monitored scenario in the hospital to the safest place outside of the hospital.
And that is really determine that a patient to patient basis.
It turned out about eighty percent or more of the patients can go home because they’ll meet the basic criteria necessary to do that. But if they don’t, there’s all the safety net and practice in place to make sure that they stay safe because the last thing we want to someone going home and having a fall or having unmitigated pain or having an issue that brings them back to the hospital. That’s completely unnecessary. We should manage those things ahead of time and do our best to anticipate that to get you to the safest place possible.
For sure. Thank you so much for your time today!
Dr. Derek Amanatullah:
Absolutely thanks for having me.