of 140, while not terribly high, can be borderline diabetic and brings an ele- vated risk of infection, he says. “I tell my patients that this level means their blood cells are lazy and only working a six-hour work day. A blood sugar of 180 means their white blood cells are in Aruba on vacation.” You need to use terms that patients understand if you want them to follow your instructions, he says. “I explain to my patients that during the six-week preoperative and postoperative peri- ods, they need to follow their diabetic diet and never cheat. That even means skipping cake at their own birthday party. Every little cheat leads to a blood pressure spike that increases their risk for infection.” Wickline also requires patients to stop smoking during those six-week periods. “That decreases their infection risk by about half. I tell my patients that I will not fix their joint unless they agree to my requirements.” To help keep patients on a path for success, the Massachusetts Avenue Sur- gery Center hired a nurse navigator at the end of 2018 to support its joint replacement program, Levitt says. She contacts all its total joint patients sched- uled, verifies they receive physical eval- uations by their primary care physi- cians and completes their blood work and pre-habilitation. She also follows them during their postoperative period to ensure they are receiving rehabilita- tion. “Adding her was an investment, but one that we felt was important to support our growing program,” he says.

Raising the Bar

Great total joint outcomes, Levitt says, are not assured unless patients adhere to their recovery program. This includes immediately starting outpa- tient physical therapy. “If they go home the day of surgery, they must start ther- apy the next day. Any delays can hurt their prospects for a full recovery.” Levitt also requires his patients to have a support system in place. “They

It comes down to patient engagement. You need a platform that educates patients and encourages them to buy into what they must do so their surgery and recovery will be a success.”

—Andrew Wickline, MD, Apex Surgical Center

must identify that they have someone already at home or coming to stay with them who has committed to be there for a week to provide transportation to therapy, get them their meals and help any other way necessary.” For his total knee patients, Wick- line created what he calls “therapy-free total knee.” Performed at home, it com- bines ankle pumps, knee bends, knee straightening exercises and walking with ice, elevation and rest, repeated multiple times a day for the first 10 to 12 days following surgery. “We changed the postoperative pro- tocol to optimize patients’ outcomes,” Wickline says. “Therapy can be help- ful and important, but we have found that for more than 90 percent of our total knee patients, it is unnecessary and greatly decreases episodes of pain.” Less pain means fewer narcotics. This reduces gastroparesis, so there is less nausea, vomiting and constipation. “This approach also eliminates the need for patients to travel to therapy multiple times a week,” he says. The use of outpatient therapy or home

exercises are both valid approaches to rehabilitation, Levitt says. “What mat-

ters is ensuring patients have been edu- cated as to what is expected of them prior to surgery.” At Bedford Ambulatory Surgical

Center, Foti says, the anesthesia team was willing to do whatever was neces- sary to provide patients with the most comfortable operative and postopera- tive experience. “The head anesthesi- ologist took it upon himself to attend seminars featuring leading anesthe- siologists discussing how to provide optimal nerve blocks. We can now achieve a block that delivers pain con- trol for up to about 72 hours.” One of the most critical, but under- appreciated steps to successful out- comes, Levitt says, is what surgeons explain to patients. “My first year in medical school, a leading surgeon came in and said he had only one piece of advice for future surgeons: If you tell your patients what to expect— when the pain will stop, when they are going to start walking, when they are going to start feeling better—they will follow what you say. When you spend just a little more time with patients and set their expectations, I have been amazed to see how well they do.”

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