Safe elective surgery during the COVID19 pandemic

Patients are asking, "is it safe to have elective surgery while the COVID19 pandemic surrounds us?"

We answer this thoughtful question in the following manner.

(1) Elective surgery is elective. This means that the timing of the procedure is up to the discretion of the patient.

(2) Masking, hand washing and screening are and will remain the primary means of assuring safety for patients and health care providers. 

(3) Preoperative testing for COVID19 is required for all patients having elective surgery.

(4) Persons with respiratory symptoms or fever or other symptoms of a "cold" or "flu" do not have elective surgery and are not involved in patient care. Everyone is screened for these symptoms on the day of surgery with these questions:

Since your last day of work, or since your last visit to a our facility, have you experienced any of the following symptoms?

• A new fever (100.4 F or higher) or a sense of having a fever?
• A new cough that you cannot attribute to another health condition?
• New shortness of breath that you cannot attribute to another health condition?
• A new sore throat that you cannot attribute to another health condition?
• New muscle pain that you cannot attribute to another health condition or that may have been caused by a specific activity, such as physical exercise?
• New gastrointestinal symptoms, such as nausea, vomiting or diarrhea that you cannot attribute to another health condition?
• New respiratory symptoms, such as a runny nose, that you cannot attribute to another health condition?
• New chills that you cannot attribute to another health condition?
• New loss of taste or smell that you cannot attribute to another health condition?
• A new headache that you cannot attribute to another health condition or emotional reason?

If you are sick or have one or more of the above symptoms:

• You must stay home or leave the facility at which you are working.
• Follow your department’s procedure for calling out sick or requesting to work from home.
• Contact your health care provider for medical guidance.

(5) Careful preoperative planning is carried out to assure patient safety and to minimize the duration of hospital stay.

(6) Even with the pursuit of vaccines and treatment for COVID19, these precautions that are in effect now are likely to be necessary for years to come; so surgery at this time is likely to be essentially as safe as it will be for the year(s) to come. 

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Outpatient shoulder arthroplasty - surgeons' concerns about reimbursement.

Surgeons’ experience and perceived barriers with outpatient shoulder arthroplasty

These authors note that outpatient total shoulder arthroplasty (TSA) has been proposed as an alternative to the inpatient setting. They evaluated the expert shoulder surgeon’s experience with and perceived barriers to outpatient TSA.

They used a secure web application to perform an online survey of 484 active American Shoulder and Elbow Surgeons members. The survey assessed surgeon practice demographics, experience with TSA/outpatient TSA, and perceived barriers to successful outpatient TSA.

Of the 179 (37.0%) complete responses received, 20.7% perform outpatient TSA; of those, 78.4% reported an “excellent” experience. Outpatient surgeons were more likely to reside in the southern United States (P = .05) and performed a higher volume of TSAs annually (P = .03). Surgeons not performing outpatient TSA were more concerned with the potential of medical complications (P = .04). Perceived lack of experience (P = .002), low volume (P = .008), insurance contracts (P = .003), and reimbursement (P = .04) were less important barriers compared with outpatient TSA surgeons.

The authors note that as surgeons become more comfortable with outpatient TSA, there is a shift from concerns about medical complications to concerns about reimbursement.

Comment: There are many possible motivations for performing outpatient arthroplasty, including cost savings, patient convenience, marketing (Google "outpatient shoulder replacement"), surgeon ownership of an ambulatory operating facility, and other incentives. As physicians, our primary concern is the safety of the patient and the quality of the patient reported outcomes.  Further study is required to determine what patient characteristics, what surgeon experience, and what infrastructure elements are required to assure that the results of outpatient arthroplasty match those of inpatient arthroplasty. "Value" needs to be measured in terms of the benefit to the patient divided by the total cost of the procedure, including complications and readmissions.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Outpatient total shoulder joint replacement surgery - does it save money, is it safe? A repost

Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: a matched cohort study.

These authors compared 30 patients having outpatient TSA at a freestanding ambulatory surgery center (ASC) with an age- and comorbidities-matched cohort of 30 patients with traditional inpatient TSA by the same surgeon.

These authors endeavored to optimize the safety of ambulatory surgery.  Eligibility was determined after both the surgeon and a staff anesthesiologist reviewed each patient’s health status, medical history, and medications.

They found no significant differences were found between the ASC and hospital cohorts regarding average age, preoperative American Society of Anesthesiologists score, operative indications, or body mass index. No patient required reoperation. There were no hospital admissions from the ASC cohort and no readmissions from the hospital cohort. 

Complications in the ASC cohort were arthrofibrosis in 2 patients and mild asymptomatic anterior subluxation in 1 patient; the only major complication was in an outpatient who fell 11 weeks after surgery and disrupted his subscapularis repair. Three minor complications in the hospital cohort were mild asymptomatic anterior subluxation, blood transfusion, and superficial venous thrombosis. 

Comment: This study suggests that outpatient total shoulder arthroplasty can be safe in carefully selected patients. Such a practice requires not only careful screening and consenting, but also immediate availability of postoperative support in the event of difficulties in pain management, bleeding, and medical issues.

It is of interest that while 30 of the inpatient cases were discharged on post operative day 1, 3 additional patients required an extra day of hospitalization. The reasons for the additional hospital day were pain control in 2 patients and dizziness with subsequent difficulty in mobilization for the third. One might wonder how these issues might have been managed had the occurred among those having outpatient surgery.

Because few of our patients live 'next door', our practice is to plan on a two-day hospital stay after shoulder arthroplasty during which time we initiate early range of motion exercises to minimize the risk of stiffness (as occurred in 2 of the 30 ASC cases) and to optimize pain and medical management.

As emphasized by the authors, outpatient arthroplasty is not appropriate for every patient and requires   a 'safety net' to catch any unexpected medical and surgical problems.

While the drive for outpatient surgery is apparently reduction in cost, the authors did not report the total cost savings of the outpatient cases in comparison to the inpatient cases.

Dr Seth Leopold, editor of CORR, has pointed out that studies of this size cannot fully evaluate the 'safety' of a procedure. Here's an informative editorial that he wrote (see this link). He asks a very important question: "What should it take for us to conclude that something is "safe"? I would assert that most orthopaedic studies are powered to efficacy, not to safety. Most complications that we care about are uncommon -- in the ballpark of 1-3%, perhaps less. With only 30 patients, one is quite likely not even to see them in such a study. So how can one conclude that this intervention is "safe"? It seems one can conclude it is "feasible", and if one likes the effects of it (eg, if patients are happy with it, or if they get somehow achieve better shoulder scores with one approach than another) then perhaps one can conclude it is "effective". But safety would take a good deal more patients to establish."

Thanks, Dr. Leopold.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.

See the countries from which our readers come on this post.

Making elective surgery safer

 We encourage patients to partner with us in optimizing their surgical and postoperative care, starting by asking them to complete a pre-surgery check list as shown below.  

 Here are some steps you can take before your surgery that will increase the quality of the outcome of your procedure. Consider it a ‘pre-flight checklist’. The healthier you are before surgery, the better. Please check off each of these items on this sheet and circle those about which you have questions. Bring the sheet with you to your pre-surgical appointment.

Habits:

__Engage in three hours of aerobic exercise per week if your primary care physician deems it safe.

__Avoid smoking or use of any nicotine-containing products for three months prior to and after surgery.

__Avoid any narcotic medications stronger than hydrocodone for three months prior to surgery. If heavier narcotics have been used, tapering off under physician supervision should be accomplished three months before the surgery.

__For three months before surgery, restrict alcohol consumption to one drink per day for women and two drinks per day for men

Planning:

__ A plan for patient care after discharge needs to be in place well in advance of surgery, recognizing that your shoulder may be less useful for a period after surgery than it was before. Who will be with you and care for you when you are discharged? How will you get home? Some find that they are more comfortable sleeping in a recliner for several weeks after surgery; you may wish to consider having one available.

__ Discuss with your surgeon the limitations on your activities after surgery, such as restrictions on driving, as well as the need for someone to be with you for days or weeks after the procedure. If a stay in a skilled nursing facility after surgery will be necessary, this should be discussed with your surgeon well in advance of the procedure.

__Identify a primary care physician who can manage non-surgical concerns and medications after surgery.

__Understand and plan for the rehabilitation program after surgery as well as the plan for follow-up with the surgeon.

Physical and emotional health

__Optimize dental hygiene, including gum care. Dental concerns need to be tended to at least 2 weeks before surgery. Postpone any planned elective dental procedures for at least 3 months after surgery.

__Identify any skin lesions anywhere on the body, especially on the arm of the intended surgery. These need to be completely healed at least two weeks before surgery. Be particularly careful to check the skin in the armpit and under the breasts.

__Assure that any infections are completely resolved and antibiotics discontinued at least 6 weeks prior to surgery.

__Optimize control of sleep apnea, anxiety, depression, diabetes, hypertension, heart conditions, as well as urinary tract function.

Communication with the surgical team

__Discuss the surgeon's personal experience with the problem and the procedure along with possible risks, alternatives and anticipated outcomes

__Notify the team if prior experience suggest that it will be difficult to establish an intravenous (IV) line for surgery, if it has been difficult for an anesthesiologist to establish an airway, if you have had any problems with prior anesthetics, or if it has been difficult to control your pain after surgery.

___Let the team know if you or any family member or blood relative ever had a serious problem with anesthesia, and if so, what was the problem?

__Discuss with the surgeon heart conditions, strokes, kidney disease, liver disease, lung disease, bleeding tendencies, prior surgical complications, reactions to anesthetics, seizures.

__Document and communicate all medical allergies, especially allergies to antibiotics and latex.

__Could you be pregnant? If so, we would recommend that you have a pregnancy test performed before coming for surgery, and if you are pregnant, that you not undergo elective surgery until after delivery.

__Compile and share a complete list of all prescription and over-the-counter medications.

__Anti-inflammatory medications and blood thinners (for example, aspirin, Advil, Coumadin, Warfarin, Plavix, Ibuprofen) will increase the risk of bleeding and their use may need to be modified well in advance of surgery. Let your surgeon know if you are taking drugs to prevent blood clotting. These may need to be stopped or modified before and after your procedure. Be aware that many over-the-counter supplements can also increase the risk of bleeding. Please note any supplements on your list of medications.

__Identify and discuss any legal issues regarding the shoulder problem well in advance of surgery.

__Verify your insurance coverage well in advance of surgery. This is especially important for patients living outside of Washington.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Patient safety in the operating room.

How to Build a Safe and Quality Orthopaedic OR Team in 2014: A Tool Kit to Improve Surgical Outcomes for Your Patients

This was the topic of an instructional course lecture at this year's AAOS meeting. The theme is that surgical safety is essential to provision of optimal orthopaedic care in all orthopaedic settings. 

The authors presented six critical elements of surgical safety based upon analysis of surgical errors: 

1. Surgeon, Surgical Team and Patient Communication, 

2. Surgical Consent, 

3. Surgical Side/Site/Procedure/Level/implant/Patient Confirmation, 

4. Surgical Team Concentration, 

5. Surgical Process Consistency and 

6. Systematic Surgical Data Collection and Analysis.

Comment: we heartily agree.
With respect to #1, we have a beginning of the day huddle with the anesthesiologist, the nurses, and the members of the surgical team to review each case, including all special medical and surgical issues as well as the need for instruments, intraoperative monitoring, recovery and discharge planning.
With respect to #2, we endeavor to provide patients with detailed explanations of the condition being treated, the alternatives in management, and the major risks
With respect to #3, we have multiple 'check points' to assure the patient's identity, side and site, and procedure.
With respect to #4, we do not allow distracting music or conversation about other matters during the course of surgery.
With respect to #5, we have standardized our plans of care for each procedure
With respect to #6, we carefully review any/all deviations from the expected post-operative course.
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Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Getting in shape for surgery - making shoulder surgery safer. A safety check list.

We have posted often on the "4 Ps" that contribute to the outcome of a shoulder surgery: the problem being treated, the characteristics of the patient having the procedure, the procedure itself and the physician performing the procedure.

Most shoulder surgery is elective; this means surgery should not be undertaken until everything is optimized. In this post we present the concept of "prehabilitation", that is, steps the patient can undertake before  surgery to make it safer and more effective.

Here is a 'risk calculator' which estimates the surgical risk related to some important characteristics of the patient. What is important to note is that the risk factors outlined here and elsewhere are, in many cases modifiable by the patient.

Here are some steps for the patient considering surgery that can reduce the risk of surgery. Consider it a 'pre flight check list'.

Habits:
__Engage in three hours of aerobic exercise per week if your primary care physician deems it safe.

__Avoid smoking or use of any nicotine-containing products for three months prior to surgery.

__Avoid any narcotic medications stronger than hydrocodone for three months prior to surgery. If heavier narcotics have been used, tapering off under physician supervision should be accomplished three months before the surgery.

__For three months before surgery, restrict alcohol consumption to one drink per day for women and two drinks per day for men

Planning:
__ A plan for patient care after discharge needs to be in place well in advance of surgery, recognizing that the shoulder may be less useful for a period after surgery than it was before. Understand the limitations on their activities after surgery, such as restrictions on driving, as well as the need for someone to be with you for days or weeks after the procedure. The need for a skilled nursing facility should be identified and discussed with your surgeon well in advance of the procedure. Some patients find that they are more comfortable sleeping in a recliner for several weeks after surgery; you may wish to consider having one available.

__Identify a primary care physician who can manage non-surgical concerns and medications after surgery.

__Understand and plan for the rehabilitation program after surgery as well as the plan for followup with the surgeon.

Physical and emotional health
__Optimize dental hygiene, including gum care. Dental concerns need to be tended to at least 2 weeks before surgery.

__Identify any skin lesions anywhere on the body, especially on the arm of the intended surgery. These need to be completely healed at least two weeks before surgery. Be particularly careful to check the skin in the arm pit and under the breasts.

__Assure that any infections are completely resolved and antibiotics discontinued at least 6 weeks prior to surgery.

__Optimize control of sleep apnea, anxiety, depression, diabetes, hypertension, heart conditions, as well as urinary tract function.

Communication with the surgical team
__Discuss the surgeon's personal experience with the problem and the procedure along with possible risks, alternatives and anticipated outcomes

__Notify the team if prior experience suggest that it will be difficult to establish an intravenous (IV) line for surgery or has been difficult for an anesthesiologist to establish an airway or if you have had any problems with prior anesthetics, or if it has been difficult to control your pain after surgery.

___Let the team know if you or any family member or blood relative ever had a serious problem with anesthesia, and if so, what was the problem?

__Discuss with the surgeon heart conditions, strokes, kidney disease, liver disease, lung disease, bleeding tendencies, prior surgical complications, reactions to anesthetics, seizures.

__Document and communicate all medical allergies, especially allergies to antibiotics and latex.

__Could you be pregnant? If so, we would recommend that you have a pregnancy test performed before coming for surgery, and if you are pregnant, that you not undergo elective surgery until after delivery.

__Compile and share complete list of all prescription and over-the-counter medications.

__Anti inflammatory medications and blood thinners ( for example, aspirin, Advil, Coumadin, Warfarin, Plavix, Ibuprofen) will increase the risk of bleeding and their use may need to be modified well in advance of surgery. If you are taking drugs to prevent blood clotting, you should consult with the pre-anesthesia clinic at least 10 days in advance to obtain instructions regarding when these medications need to be stopped, or modified.

__Identify and discuss any legal issues regarding the shoulder problem well in advance of surgery.

__Verify insurance coverage needs to be verified well in advance of surgery. This is especially important for patients living outside of Washington.
You may also be interested in the Strong for Surgery concept explained here.

===
Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.