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Melanie Cole (Host): Reid Health Orthopedics and Perioperative care developed a program years ago where surgical patients receive perioperative care to ensure the best outcomes for joint replacement surgery. Because of the success of patient health post-surgery, this partnership has grown into a full, comprehensive care experience for orthopedic patients.

Welcome to Right Beside You, a Reid Health podcast. I'm Melanie Cole, and I hope that you'll join me as we explore the Reid Health Comprehensive Bone and Joint Center, how collaborative care is really paving the way for better patient outcomes. We have a panel with us today, Dr. Annuradha Bhandari, she's the Medical Director of Perioperative Care. And Dr. Joel McClurg, he's the Chairman of Musculoskeletal Services and they're both with Reid Health. Doctors, I'm so glad to have you join us today. What a great topic we're discussing. Dr. Bhandari, I'd like to start with you.

Can you tell us a little bit about the history of the partnership between Musculoskeletal and Periop? How did you develop this program together to impact patient outcomes?

Annuradha Bhandari, MD (Guest): Thanks for having me. I'd be glad to. So this started out back in about 2015. Reid Health embarked on a journey to improve the surgical outcomes of their patients. And we started off actually with our orthopedic service line, looking at elective hip and knee replacements. And the focus was to improve the outcomes in patients and allow for a journey that was easier with less turbulence along the way.

You know, we know now that the majority of issues that happen after surgery really have very little to do with the surgery in itself. It has a lot to do with preparedness of the patient, and also has to do with kind of where their medical status is. So we developed a team of orthopedics, anesthesia and nursing, administration. And somewhere in there, I put my hand up and I said, well, I know why there's so much variation in the outcomes of patients. There's variation in the way that we see those patients and the variation in the way that we evaluate those patients, because my initial training is in internal medicine. And so we did our pre-op valves in our primary care practice.

And so we decided to embark on this journey and we did pre and post implementations. We took a bunch of patients that were gonna come through the Periop Clinic and having the same surgery. And we started to compare those patients and we were excited to see the improvement in the way that the patients recovered. They recovered quicker. They had less complications of their existing medical problems. They felt prepared. They understood what was happening for their surgery. And we developed an exceptional collaborative relationship with our orthopedic group where we work together. If you know that practices are typically in silos, we kind of broke those down and developed a collaborative approach to really making our patients successful. And now we have two clinics and we've joined the orthopedic building here. And we're just so excited to be a part of the team.

Joel McClurg, MD, PhD (Guest): Right. And to add to that, you know, you have to understand where this all started. So before 2015, here and around the country, I was often in charge of trying to figure out if the patient was ready for surgery or not. And so that's probably not the best use of talent is, you know, I'm an orthopedic surgeon and trying to figure out if a patient's heart, lung, liver, kidney, sugar, and everything else is kind of ready and optimized for surgery is not my shtick. And so to be able to work with Dr. Bhandari and you know, and really get these patients ready, to have a program for taking care of them and really kind of stratifying risk. You know, some patients are very low risk and they don't need much to get ready for surgery. Some patients are much higher in risk and they need other kinds of experts to take a look at them. Cardiologists and endocrinologists and all kinds of other ologists to kind of get them ready for surgery.

And when we do that, the patients have better outcomes, better satisfaction and everybody's happier. So it's been a great collaboration so far.

Dr. Bhandari: I'll add that we noted when we first took a look at the patient population that we were caring for. We live in a demographic, in an area with a lot of multiple medical problems. And so we had a huge challenge to try and get a lot of our patients prepared for surgery. And some of it had to deal with their preexisting medical conditions. Not everybody really needs to go to their cardiologist. Not everybody needs to see their pulmonologist and there are other people who should have seen one a long time ago. And so determining that was really helpful in embarking on this journey and really helping patients be successful.

Dr. McClurg: Right. And you know, and I go back to kind of past experiences, but the community that I came from before I came to Reid had a lot healthier patient database, you know, we keep track of about 40 different conditions, heart, lung, liver, kidney, sugar, depression, anxiety, blood pressure, and 30 more that we kinda keep track of that our patients have. And every single one of those is worse in Southeastern Indiana than it is in upstate New York. And so that means our patients need a lot more intervention beforehand before they're ready to go to surgery. And I was totally blown away by the differences in the general patients' health between here and where I came from.

Dr. Bhandari: I agree. I mean, I think our primary care friends do an exceptional job. Something about surgery is like the carrot, you know, that it promotes a patient to really have their eyes and ears open about what's their health status. When they hear that they're going to undergo anesthesia, they're all ears about, am I safe to do that? And sometimes that creates the impetus to really take an active role in their care. So that really was a foundation of why we needed to start a perioperative program was that some patients really needed the extra push and the extra education to prepare them. And there's a nervousness. You know, you're not sure if you're safe to proceed with surgery and there's an education aspect of it. So I think putting that together, getting the social care together, which, you know, I'm sure we'll talk about today was really, really helpful to make those patients successful.

Dr. McClurg: Yeah. And I agree, and you know, you look at these patients and what we hope to accomplish here is and it's absolutely true that the impetus for them to get healthier is this pending surgery and you know, and orthopedics and it's elective surgery though, so we don't proceed unless the patient's ready, but what we really hope for by making patients aware of their medical condition, by educating them about ways of getting better; whether it's blood pressure or blood sugar or any of the other problems that patients have, is that their health is better after the surgery. Not just because of the surgery, but because their blood pressure is better, they eat better. Their blood sugar is better. So they have better quality of life, not just because of orthopedics. So, you know, we're trying to change hearts and minds for patients and help them find the motivation to lead their kind of best life.

Host: This is absolutely such a great collaboration and initiative and Dr. McClurg, I'd like you to tell the listeners how it works exactly. We've been talking about the importance of this multidisciplinary approach, which certainly is so important for patients undergoing orthopedic procedures, but speak about how that works and how you all work together. Are you having a group in clinics? Are you discussing patients? Speak about how it all works and why it's so beneficial for not only the patients and their outcomes, but for the physicians, the themselves.

Dr. McClurg: Right. So, you know, it normally starts with some, you know, orthopedic problem that the patient has. And in the past we just dealt with the orthopedic problem and we'd start with conservative treatment. And if that doesn't work, you know, you can end up in surgery, but you have to remember, these are elective surgeries. So it's not like we have to rush off to do surgery today or tomorrow, we get these patients ready. That's kind of the beauty of it. And in the past, we would just do our orthopedics until such time as they were surgical candidates. And then we'd say, oh I wonder what we're gonna have to do to get this patient ready for surgery.

And one of the great things about working with Dr. Bhandari is that we start thinking about those things now, before they ever are surgical candidates. So if we're looking at you for your knees and your body mass index, your weight to height kind of ratio is too high, but we think that you may end up being a surgical candidate because you know how severe your disease is in your hips or knees, or you're not responding to conservative treatment; we start thinking about how do we optimize this patient before they're ever really a surgical candidate. Not wait until it's time for surgery and then try to fix everything, but start to intervene much earlier in the process. So that if you have to lose some weight to have surgery, that process starts in the six months or year beforehand.

And that's just not the way we used to think about things. And so having this around and to be able to collaborate and, you know, we're in the same building. So we're able to talk about individual patients. You know, we have all the communication and things and can look at the chart together or send emails and things back and forth to really ask questions and, pass information back and forth to help the individual patients get better.

Dr. Bhandari: And then I'll add, once the patient comes through, then there's a pretty comprehensive evaluation. So the patient will come in. They actually receive a phone call in advance from a RN that does an intake, who asks a lot of questions and kind of tries to figure out where they're getting all of their care from so that we can aggregate all of the medical problems and what the specialists have said or what their thoughts are. And what is the status of their preexisting medical conditions. And really we're essentially determining two things. What's the risk, but also how can we optimize? So there's modifiable things that we can do to make sure that that surgical journey is much more easier for the patient. So, a patient will come in and we ask them to bring their loved one, their, what we say, their home coach and that home coach is the person who's going to help them recover at home.

We know that patients do better when they recover at home, but the family can sometimes be anxious about being responsible for the care of their loved ones. So they come in at that visit as well. We do a really comprehensive, deep dive into their preexisting medical conditions. And then we look at their fitness. Are they physically fit to have surgery? What is their function day to day? And we also assess their status and preparedness by looking at things like, is their diabetes under control if they have it? And if not then, well in advance, orthopedics will refer that patient to us and we'll work just on optimizing their diabetes.

Putting them on a continuous glucose monitor, getting them on insulin treatment, if that's required, working very quickly. If you think about it, diabetes takes what, three months before you get an A1C and you know, where a patient is. We do that almost instantaneously with that continuous glucose monitor and get that patient controlled.

Dr. McClurg: Right. And we actually, now, when the patient comes in, we're thinking about doing surgery. We get that test called the A1C. It's a blood test that kind of gives us an idea about what your sugars have looked like over the last three months. We do that in the orthopedic clinic now, so that Dr. Bhandari has that information as soon as possible. So we can start working on that particular problem, which hangs up a lot of patients in this area with blood sugars that are just too high and unsafe for having surgery, it increases infection risk. It increases the length of stay in the hospital. So we hop on that right away. And so that's another example of us collaborating and trade data back and.

Dr. Bhandari: So once we get those patients prepared and we get them on the appropriate treatment, we get them in with the nutrition that they need. They may actually be given nutritional drinks and nutritional therapy. We also look at pre-rehabbing them. We know there's a lot of data that supports if a patient is active before surgery, their recovery time is cut from months to weeks. So, there are some patients that we do what we call Surgery Fit, which is a new program that we've started at Reid. We'll look at patients that are candidates to get optimized in terms of their ability to function.

And they get prepared through our physical therapy folks. If we have patients that are anemic, we know that there is a mortality risk with patients postoperatively that are anemic which is low blood counts and blood loss. And so I think our colleagues with orthopedics have done an exceptional job with other modalities to reduce blood loss perioperatively but we wanna prepare those patients for surgery. And we give them IV iron and that allows us to fill the stores and reduce blood utilization. So we don't do blood transfusions, cuz that requires observing the patient. It's very expensive, takes a lot of time and we want our patients to be up and moving and ready to go home.

So, there are so many breathing exercises that we give the patient. We do a lot of counseling. We discuss with the family, what are their needs? And so one of the things that we've been working on now is something called the social determinants of health. And I'm sure you may have heard of this phrase. It's a big buzzword in the United States, and it is that we can do all of these things for a patient, all of these medical treatments, but if there are social issues, it's really hard to get them completed. So, what does that mean? That means if they've got transportation issues, if they can't get access to medications, if they have financial problems, if they have no family support, if they don't understand, they have poor healthcare literacy, these are all barriers. We take all the time during this visit to determine what those are. And they meet with a nurse navigator who is a coach, who's going to stand beside them step by step and help them focus through all of these things and get measures in place, do things to get all of those things taken care of before a surgery.

Dr. McClurg: Yeah. And it blows me away that this happens in like a little over an hour or so the amount of information about those social determinants of health and their conditions and their medications. I mean, it's a pretty intense afternoon to get people ready for surgery, but it is so gratifying when we go over the data. And so we go over all this data, we collect all this data about outcomes and transfusion and how long you were in the hospital and what your pain level was and how much pain medicine we gave you. And whether you came back to the hospital in 30 or 60 or 90 days, it is so gratifying to go over this data with Dr. Bhandari's group, and a lot of other people in our institution that are interested in this and see how good the numbers are and how they get better every single quarter.

Dr. Bhandari: And you know, when we, you look at the data, it's true, we look at 30, 60, and 90 day. And when we measured that it became very clear to us that we were not just preparing the patient for surgery, but we were preparing the patient for health success because those patients were not just not getting readmitted 30 or 60 days, but 90 days later, they still, for any reason, if you were to come into the hospital for any reason and get readmitted, that would go against us. And we would look at that data and we saw that patients were not coming back. So it wasn't just preparing them for the surgery. It was preparing them and optimizing their general overall health because even 90 days out, they were still not coming back to the hospital, which means that maybe their blood pressure was better controlled or their COPD or their asthma or their diabetes. And those things had a lasting effect on their health. So we really were just not just preparing the patient for surgery, but preparing them for success.

Dr. McClurg: Right. And we kinda came up with this idea of this prescription for wellness. Yes. The surgery may be the impetus for them to finally take control of their health literacy and their health in general. But we want to see these patients do better, not 30, 60, or 90 days, but for the rest of their life to have better information and better control over their blood sugar or blood pressure or depression or anxiety. And so we kind of make this wellness prescription for them that we hope that they can follow in the future so that their entire life is better. Not just their knee or their hip.

Host: Dr. Bhandari, as you're telling us how perioperative care impacts the outcomes of orthopedic patients, how can work done in perioperative care, carry them through that surgery into rehab and ultimately recovery. As you were mentioning, complex social determinants of health. Where does ERAS fit into this picture and how will this care model improve the way that patients receive their care?

Dr. Bhandari: I'm so glad you asked me about enhanced recovery. So ERAS stands for enhanced recovery after surgery and much of what we do are concepts that we have borrowed from enhanced recovery after surgery. So enhanced recovery really started with, I think, colorectal and urologic surgery. And they looked at what we understood with what recovery looks like decades ago is really not where we are now. And I think it comes from many different things. The technology that we have now is very different than what we had before. I think the modalities of treatment are very different. And so all of those processes made an impact in terms of how patients recover. So as this was studied it, they really looked at multimodal approaches, very different things. And if you look at a patient's surgical journey, oftentimes the surgery is really the shortest part of that entire journey.

And the presurgical aspect in terms of enhanced recovery looks at things like how is the patient's nutritional status and optimizing it. So we've embarked on that aspect of enhanced recovery with nutrition by giving patients preoperative carbohydrate loading in the appropriate patient. That reduces their postop anxiety that helps reduce postop nausea, and vomiting. It's gonna help patients feel like if you think about it, surgery is a energy consuming situation. And then we say nothing after midnight, we cut you off from that.

And so this kind of fills that gap and we really are doing away with the nothing by mouth after surgery concept anyways because enhanced recovery has taught us that's not beneficial to patients either. In fact, feeding patients before surgery was shown to reduce aspiration.

Dr. McClurg: Right. And that's been going on for a hundred years that, you know, the idea of not giving anybody anything after midnight is a hundred year old concept.

Dr. Bhandari: So we worked on that. We work on setting up expectations for pain medications, and utilization of pain medications. What are the side effects and preparing patients for things like post op constipation. We look at respiratory status. We look at prehabilitation and that is getting the patient's body ready for surgery and all of these aspects. And then we also offer recommendations and thoughts to anesthesia and anesthesia then will alter their approach based on what the patients determined preoperative risks are and that then leads to better outcomes for the patient postoperatively. So this enhanced recovery programs were shown to decrease length of stay by over 50%. Reduced readmissions.

And to be honest, we did not think that we were gonna be able to have the same outcomes as larger academic centers for a community hospital. So when we did this, we were so excited and it makes sense. I guess the science doesn't change. Right? So although we were concerned, we weren't gonna see the same outcomes. We saw the exact same thing. We saw a reduction, a dramatic reduction in length of stay, a dramatic reduction in readmissions and our postoperative complications and all of that from these concepts of enhancing a patient's journey with recovery. And when we put these mechanisms in place, the duration of recovery was shorter too. I mean, they were recovering and moving a lot sooner than patients were, who didn't have these multimodal measures put into place.

Dr. McClurg: Right. Yeah. And so we kind of bounce back and forth of getting better. So you know, our surgeries now, and it is true, they're, it's the shortest part of the whole process. So we're doing robotic total hip and knee replacements in 35 to 55 minutes, but that's the big stressor. That's what gets us wanting to get these patients ready for surgery, but everything that happens before and everything that happens after is just as important to the patient's perception of how they did after surgery. And so as we get better and Dr. Bhandari's group gets better and we use data to make changes to our program. We are relentlessly working on making every single aspect of patient care from the time they come in to see us for conservative treatment, to when they come to see us again for their next hip or knee replacement and everything in between trying to make it better.

Host: I'm so glad you both have joined us today. What an interesting discussion this has been, and I'd like to give you each a chance for a final thought to discuss the Reid Health Comprehensive Bone and Joint Center and how this collaborative care paves the way for better patient outcomes. So Dr. Bhandari and starting with you, what's your vision for this program you mentioned ERAS and perioperative care and how this can carry them through surgery, into rehab and ultimately recovery. Tell us what you see happening and your vision for the program.

Dr. Bhandari: So the vision initially, I mean, when we first started this program, we've started off as a preoperative risk stratification. It was just, is the patient ready to go for surgery? Over time, that's evolved with enhanced recovery now to not just allow the patient to be prepared, but also optimized for surgery. The next vision we have is really looking at a robust postoperative program as well in terms of helping patients with the recovery aspect of it. And I think a lot of the success has been the ability to collaborate. Before people were practicing in silos, everyone kind of dropped their note in the medical record and you had to try to figure out what was happening.

Collaborative care, we know now there is so much data in this country that shows improved patient outcomes, improved safety, patient has less anxiety, patient is more prepared and more successful. And I think it also helps with the healthcare system too. I think between physicians and providers who are caring for the patient, there's a, the collaboration allows us all to be successful in the process.

Moving over here means allowing the patient to have that continuum of streamless care and access to all of the care that they require for their surgery well in advance. So we're really excited to be a part of the bone and joint program here at Reid Orthopedics and to grow this relationship where we can work together in a really strong collaborative friendship towards the success of the patient.

Dr. McClurg: Right. And you know, and for us, our big next step is, you know, to have the patients right now, when I, when we started this program, it was about a length this day of two and a half days. Now it's about a day, very few patients, only about 2% of patients end up in acute care rehab, which means they don't go home to their home. And we're doing a million total joints a year in the United States. And so, you know, you're always looking to give better care in a shorter time span. And so right now the patients stay about 23 hours after their surgery. And the not too distant future a lot of our patients will only be in the hospital about four hours.

And so that means they even have to be better prepared for surgery, better risk stratified, better optimized for them to be able to safely do that. And, you know, and there's a push from society because, you know, total joint replacement is a pretty expensive operation, but it also offers a great outcome for patients.

And so if we can spend less money on it versus from society standpoint and do it in a shorter time, just as safe, then that's sort of the next step. So we are always looking at the next advancement in orthopedics, but we need our partners on the perioperative side to help make sure that we're doing what's in the patient's best interest and getting better outcomes for the patient.

Dr. Bhandari: You know, I'll add that value is really important. When you think about what is valuable to your patient, or if I put myself as a patient what's value to me. Value to me is that I have an ailment or an issue, I need to have this surgery and that I have this in the most efficient way possible so that I can go back into the world and enjoy my life. And I didn't have a lot of complications and it wasn't a really arduous journey. To make it as easily and as simple for me. And so that's what we're focusing on is to ensure that we're providing excellence and value to our patient in terms of their surgical process.

Host: Thank you both so much for joining us today and telling us about the Reid Health Comprehensive Bone and Joint Center, and really how this collaborative care paves the way for better patient outcomes, how you all work together. Thank you so much again. To request an appointment, please visit reidhealth.org/ortho. That wraps up this episode of Right Beside You, a Reid Health podcast. For updates on the latest medical advancements and breakthroughs please follow us on your social channels. I'm Melanie Cole. Thank you so much for joining us today.