Daniel Hoeffel, MD, is a private practice orthopedic surgeon based in St. Paul, Minn. At the Becker's ASC 25th Annual Meeting: The Business and Operations of ASCs on Oct. 18, 2018 in Chicago, Dr. Hoeffel gave a presentation titled "Optimizing the Orthopedic Patient for ERAS (Enhanced Recovery After Surgery): Importance of Pathway & Partnership" sponsored by Johnson & Johnson Medical Devices Companies.
During the presentation, Dr. Hoeffel, a consultant for DePuy Synthes, discussed how ERAS protocols for orthopedic and total joint replacement patients can improve patient care. He examined the philosophy behind ERAS and how new technology and industry partners such as the Johnson & Johnson Medical Devices Companies can help orthopedic surgeons meet their patient recovery and outcome goals.
Here, Dr. Hoeffel answered six key questions about ERAS protocols and where patient optimization is headed in the future.
Responses have been lightly edited for clarity and length.
Question: How do you approach ERAS for orthopedic and total joint replacement patients to ensure they achieve the best possible outcomes? What are the key pillars to your approach?
Dr. Daniel Hoeffel: The concept of ERAS is not new. It has been coming of age over the last decade. The concept is really based on two elements: one is to address the entirety of the patient, including all organ systems. That goes beyond addressing the heart, lung and renal function to also consider the patient's mind and cognitive function. You have to think about the patient's psychological function and personal state and their cognitive and intellectual capacities.
When we look at all organ systems and the entirety of the patient during the preoperative period, we want to optimize all physiologic systems throughout that time frame and into the postoperative time frame. The concept is that if we optimize the patient at all times, we can potentially enhance the outcomes and avoid complications.
The second concept for us to consider is: What does the patient need in the moment? What should be the focus right now? For example, diabetic patients need their diabetes under control during the preoperative period. It's also important postoperatively, but we will be equally focused on the safety at home, physical therapy and rehab during that time. The patient will change throughout the process and therefore we need to think differently to optimize the patient throughout their care timeframe.
Q: How do you approach ERAS with patients?
DH: When you approach a patient with a checklist, you can show them that their heart is good, lungs are good but the next check might be their endocrine system; do we have to work on their diabetes? Or the patient may have impaired cognitive function if they have early onset Alzheimer's disease. We may want to get the patient's family involved at that point. With an ERAS toolset each patient can be on a standardized pathway and yet have their individual factors considered to receive optimized care.
We've always been aware that the patient is more than just an arthritic joint and we've historically leaned on our medicine counterparts to drive the optimization of the patient and get them ready for surgery. Now we are having conversations with our anesthesia and physical therapy colleagues as well to really, truly bring a multidisciplinary approach and best practice. Now we have a framework (ERAS) for everyone to participate [in] and deliver better care.
Q: How did you develop ERAS protocols? What do you do to ensure you're successful from one patient to the next?
DH: To develop the protocols, you assume perfect state when you first start. In a perfect world, you're able to assemble a multidisciplinary team and get everyone's input [on] the most effective anesthesia and preoperative care for the standard patient. When the rubber meets the road, we want to standardize with the multidisciplinary team. If we can get 80 percent to 90 percent of patients on a solid pathway, that leaves more time and effort for us to think about the 10 percent of outliers who really need a high level of attention to avoid complications.
The multidisciplinary team is the gold standard to address most patients. There is a huge amount of similarities because the protocols are built off best practices, so when everyone uses them to optimize patients for diabetic control and cardiac function, for example, we can get patients to their best state of health. There may be some variability among protocols by geographic location, for example, rural locations may have a lack of therapy services compared to urban locations where there is an abundance of services. Protocols may also vary based on preoperative level of function or other types of impairments patients may have.
Q: From a device and technology perspective, what tools are you using to optimize outcomes for your patients?
DH: You have to find a partner with a big footprint. A company that can partner with you.
Some of the tools are subtle and some are obvious. If we want to automate a care pathway, we need digital care navigation. CareSense by MedTrak© is my partner of choice. We are seeing digital care navigation start to gain momentum in the orthopedic world.
Part of the appeal is that they provide patient information and guidance along the way instead of a single booklet where the patients get all the information at once. We are able to [reach] them electronically with a text, email or phone call or through another application alert to help guide them during the preoperative and postoperative period.
We have also gone through the subtle change of reducing the number of instruments utilized for surgery. We are no longer just consumers of the products from companies, but we are also consumers of the process. To me, it's important to think about the footprint of a partner, which means can the partner help us with data collection, wound management and dressings? For example, I choose to use DERMABOND® PRINEO® Skin Closure System because it offers ease of application and ease of post operative care due to no surgical dressings.
Q: Can you talk about the changes you have seen in the process versus product?
DH: As orthopedists, we are all used to buying a product like new implant technologies with upgraded materials or new engineering, but now we find ourselves wanting implant companies that can provide solutions for surgery and patient care. We need to reduce the number of trays that are being sterilized. We need wound closure that allows the patient to mobilize immediately. Those are the types of things that change the process of patient care and recovery. In my opinion, the device company should be partnered with a company that can track outcomes. Those are the qualities to look for; companies that are digitally or technically connected and connected throughout the continuum of care for the patient.
Q: What role does multimodal pain management play in orthopedic surgery patient recovery? What trends are you seeing to optimize the patient?
DH: The nature of multimodal pain management really has come to the forefront with the current opioid epidemic. The initial drive of multimodal pain management was to reduce pain and decrease patient reported pain scores. That has not necessarily shifted, but the focus has shifted to concerns regarding opioid dependence and addiction, and now the two goals are the best outcomes for a single patient in terms of reducing pain as well as reducing opioid use on a population basis. For the patient we should not forget the enhanced recovery goals of avoiding postoperative nausea and vomiting, constipation and cognitive impairment.
Multimodal pain management also involves patient education and setting expectations preoperatively. [By doing this] it tells [patients] what to expect, gives them some guidance and feedback. When you combine multimodal pain protocols with the ability to digitally navigate a patient, you can also [influence postoperative outcomes]. If the patient is in significant pain, they can contact, via a care navigation platform, the physician and address the situation. The ability of digital care navigation to guide and measure the patient's recovery enhances the physician's ability to tailor care on an individualized basis while reducing opioid use on a population basis.
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