Nobody wants to be hospitalized. Hospitals are expensive, risky, and noisy environments, providing probably the worst set-up for restorative sleep. Add to that the issue of health care costs, and it becomes imperative to investigate ways to identify patients and procedures that can be safely moved to the outpatient environment.
Addressing that imperative was the aim of a time-series study in the January 15, 2020 issue of The Journal by Wolfstadt et al. The authors report on the success of a streamlined pathway for safely shifting less-urgent fracture cases to an outpatient environment.
Using the interventions described in the study, a large, urban academic hospital in Canada increased the percentage of fracture patients managed as outpatients from 1.6% pre-intervention to 89.1% post-intervention. None of the >300 patients had a readmission during the intervention period, and there were no complications while patients waited for surgery at home. Although the average time-to-surgery increased to 48 hours after the pathway was implemented, the extra time waiting at home did not negatively affect patient-satisfaction scores.
On the cost/resource side, the hospital estimated that conversions to outpatient care in these patients led to an annual reduction in operating costs of nearly $240,000 CAD. The hospital used the bed capacity freed up by the outpatient fracture pathway to increase its volume of elective hip and knee replacements.
It has been suggested that 90% of orthopaedic procedures can be safely performed in non-hospital environments. Wolfstadt et al. emphasize that successfully doing so requires extra patient education, a team-based and patient-centered culture, and support from hospital administrators.
Marc Swiontkowski, MD
One thought on “Strong Case for Outpatient Fracture Surgery”
In Australian hospitals 2 decades ago,… many orthopaedic/plastic surgical patients, including those with hip fractures and open fractures, had significant delays in surgery (sometimes 7 days) and associated complications.
A seachange in Australia towards 2010 was aided by allowing hip fracture patient urgent access to theatre time during daytime working hours. In addition to that, suitable patients who did not require interim inpatient care could be discharged home to return at an allocated time for surgery, in contrast to the uncertainty of being on a big pool of emergency lists.
Unfortunately, trauma lists are now becoming the very victims of their own success in tertiary hospitals… There is no ability physically or staffing-wise to increase trauma list theatres during weekday-time; the only potential slots to use are during the weekend, which many hospital administrators are reluctant to use since it involves significantly higher costs than the weekday lists… In some cases, the wait for trauma surgery in an outpatient setting can be as long as 3 weeks from the date of booking, instead of the usual 7 days.
It will take another visionary who has the political and clinical support to improve the pathway by redefining patient journeys for trauma care via surgical outpatient theatre. But she/he will have to face significant incumbent resistance and mental silo complexes, a challenge which is perennial in medical culture…