Scott Webb (Host): Outpatient joint replacements have become very common over the last 10 years or so, and though not everyone is an ideal candidate for outpatient replacement, for those who are, they love being able to get home faster and sleep in their own beds. Joining me today to tell us more is Dr. Ricardo Gonzalez. He's an orthopedic surgeon with SolutionHealth. 

This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Dr. Gonzalez, thanks so much for your time today. We're going to talk about outpatient joint replacement, and I feel like most of us know what's involved in joint replacements, but just set the stage for us here. What does that mean? What is outpatient joint replacement? 

Dr. Ricardo Gonzales: Thank you so much for having me on. That is something that I'm pretty passionate about. Obviously, I've been doing orthopaedics for 23 years. And having said that, you know, I'm old enough to remember when people would get their hip replaced or their knee replaced, and they would be in the hospital for five to seven days. And really, for the first two or three days, they wouldn't even get out of bed. And so, my job as an intern used to be to actually build a traction device for people after hip replacement. They would have to be in traction for a couple of days before we'd get them up and walking. 

So over that time, the whole process has really evolved to the point where we're discharging people at two or three days. And roughly about 10 years ago, I started noticing that there was a pretty good cohort of my patients that were ready to go within a day. So, I personally have been doing outpatient joint replacements, both at the hospital as well as with some of the local surgical centers for about 10 years. So really, it has evolved to the point where now we're doing joint replacements in the morning and my 7:30 a.m. patient is ready to go home by about 12:30 or 1:00. My 9:30 a.m. patient is ready to go home by about 3:30 or 4:00. So, it's an abbreviated encounter in the hospital. And obviously, the key is to make sure that we're doing that safely and we're not doing it just because we want to run people out of the hospital. 

Host: You're not pushing them out the door, right? 

Dr. Ricardo Gonzales: Right, exactly. We want safety and we want value. And so, that was the thing that got me started years ago, because as I would look at my patients who are ready to go home, it's the same surgeon, the same patient, the same device, the same anesthesia group. And we're getting them in and out of the hospital quickly and at much lower cost and, actually, patient satisfaction is much, much higher. And there's also a safety component that's been huge. So, it's basically the definition of value for the right patient to be able to take care of them quickly, efficiently, safely. It's been a big driver of satisfaction for our patients.

Host: Yeah, I'm sure. And as you said, they're the right patient, right? So, I'm sure that there are some patients where outpatient replacement is ideal and perfect and safe and awesome and, for others, maybe not so much. And so, I'm sure you go maybe back and forth, but it does sound like the latest trend and this new thing really is the outpatient replacement. So, just talk about that a little bit. You know, how has that changed things for you, your team, patients and just everybody involved? 

Dr. Ricardo Gonzales: Right. So, at that point in time where we started to transition to the outpatient environment, we really look carefully because, you know, again, we don't want anybody to get hurt. And we spent a lot of time trying to assess which ones of those patients look like they were going to be successful with a discharge to home early. And so, some of that comes with youth. Now, in New England, we have some older patients who are as stout and strong as any 40 or 50-year-old. But, you know, definitely advanced age comes with some medical comorbidities. Patients who have any sort of real serious medical issue that we need hospital services for, so, someone who has any risk for bleeding, something like hemophilia or some other inherited issues with bleeding where we're going to need a blood bank and that could be a risk. Really, really heavy weight. Unfortunately, just as you're trying to get around, if you're carrying a lot of extra weight, that can be something that's going to make it more likely that you need to spend a little bit more time working with a physical therapist in the hospital and then, serious medical problems like COPD, congestive heart failure, really bad heart disease, uncontrolled diabetes, and some of the really serious ones like cirrhosis, which are patients who probably aren't going to be getting joint replacements anyways. So, for those patients, you know, fortunately, and through this whole thing, I'm not saying anything bad about the hospital because they do a great job and they're very needed for those patients. But for patients who don't have those issues, doing an outpatient joint in a safe way is a really good option.

Host: Yeah. And just coincidentally, my mom is having her hip replaced soon. And so, I'm sort of familiar with these conversations about who's a good candidate for outpatient joint replacement and so on. And maybe you could take us through that. Who is a good candidate for outpatient replacements?

 Dr. Ricardo Gonzales: The other piece that I forgot to bring into that last part is that people do have to have a good social structure, so people in their life or in their family who can be around to help them when they get home. We don't want people leaving our facility and just being, you know, completely on their own. And we don't want you to have to worry about things like taking out the trash and all those kinds of things when you're trying to recover from your first couple of days after a hip replacement.

So, the ideal patient for us is, number one, someone who's motivated to do it. And so, if patients have any hesitation about doing it as an outpatient, then we're able to very safely take care of them at the hospital. But our younger patients are more motivated patients, people certainly who want to be a little bit more active. More and more, you know, we are seeing a lot of arthritis in our younger patients who are still intending to not just play golf or just walk, but be a little more aggressive with cycling and hiking and doing those kinds of things. Again, in New England and places like Colorado and California, where you have a lot of older patients who are trying to be more active, that's the ideal patient for an outpatient joint.

Host: Yeah. As I was saying, I've had those conversations with my mom and, you know, she has some stuff. She's 75 years old. And I said, "As long as they're not hurrying you out the door, I’d like you stay as long as you need to." And she assured me that she would, and she has me, of course, to take out her trash. As you say, having a support system, a social system, that's what she has me for. It's been really good stuff today, doctor. As we wrap up here, let's go through again as we're trying to sort of sell people in a way, the benefits of outpatient joint replacement. 

Dr. Ricardo Gonzales: The benefits for outpatient joint placements are, you know, number one, It's not an inferior environment. I want to make sure that that's clear, is that you're getting the exact same surgical techs, the exact same surgeon, the exact same anesthesia, exact same device. So as far as the real nuts and bolts of the mechanics of the joint replacement, we're able to do all that very safely in an ambulatory setting. And even, you know, in the hospitals, we do surgery in the hospital where people go home the same day. So, it's basically a lateral move with respect to the mechanics of the joint replacement. 

Other benefits are it is a big driver of patient satisfaction. If you spend the night in the hospital, it's a lot of bells and whistles and people coming in to check on you and doing things like that. Most patients are much more comfortable in their own environments at home. It's just a lot more comfortable. 

And the other thing I should mention is that we do have a team of visiting nurses and therapists who visit patients one or two times a week after the surgery. And that happens regardless of where you have the surgery done. But we always feel like those are kind of our eyes and ears out in the community who are also helping us to keep track of our patients and make sure that things are safe.

Host: Yeah. And I love hearing just that it's safe and patient satisfaction, seems like it's sort of through the roof and you're still checking on those folks afterwards. And we could do a separate podcast on what's involved in rehabbing and getting back to full speed, of course, with physical therapy and all of that. But for today, this is great. Great to learn more about outpatient joint replacement. Thanks so much. You stay well.

Dr. Ricardo Gonzales: All right. Appreciate it.

Host: And for more information, go to elliothospital.org/website/orthopaedics.php. And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.