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Implementation of a Total Joint Replacement-Focused Perioperative Surgical Home: A Management Case Report

Garson, Leslie MD*; Schwarzkopf, Ran MD, MSc; Vakharia, Shermeen MD, MBA*; Alexander, Brenton MSc*; Stead, Stan MD, MBA*; Cannesson, Maxime MD, PhD*; Kain, Zeev MD, MBA*

doi: 10.1213/ANE.0000000000000191
General: Research Report

BACKGROUND: The perioperative setting in the United States is noted for variable and fragmented care that increases the chance for errors and adverse outcomes as well as the overall cost of perioperative care. Recently, the American Society of Anesthesiologists put forward the Perioperative Surgical Home (PSH) concept as a potential solution to this problem. Although the PSH concept has been described previously, “real-life” implementation of this new model has not been reported.

METHODS: Members of the Departments of Anesthesiology and Perioperative Care and Orthopedic Surgery, in addition to perioperative hospital services, developed and implemented a series of clinical care pathways defining and standardizing preoperative, intraoperative, postoperative, and postdischarge management for patients undergoing elective primary hip (n = 51) and knee (n = 95) arthroplasty. We report on the impact of the Total Joint Replacement PSH on length of hospital stay (LOS), incidence of perioperative blood transfusions, postoperative complications, 30-day readmission rates, emergency department visits, mortality, and patient satisfaction.

RESULTS: The incidence of major complication was 0.0 (0.0–7.0)% and of perioperative blood transfusion was 6.2 (2.9–11.4)%. In-hospital mortality was 0.0 (0.0–7.0)% and 30-day readmission was 0.7 (0.0–3.8)%. All Surgical Care Improvements Project measures were at 100.0 (93.0–100.0)%. The median LOS for total knee arthroplasty and total hip arthroplasty, respectively, was (median (95% confidence interval [interquartile range]) 3 (2–3) [2–3] and 3 (2–3) [2–3] days. Approximately half of the patients were discharged to a location other than their customary residence (70 to skilled nursing facility, 1 to rehabilitation, 39 to home with organization health services, and 36 to home).

CONCLUSIONS: We believe that our experience with the Total Joint Replacement PSH program provides solid evidence of the feasibility of this practice model to improve patient outcomes and achieve high patient satisfaction. In the future, the impact of LOS on cost will have to be better quantified. Specifically, future studies comparing PSH to traditional care will have to include consideration of postdischarge care, which are drivers of the perioperative costs.

From the Departments of *Anesthesiology and Perioperative Care; and Orthopedic Surgery, University of California Irvine, Irvine, California.

Funding: Departmental funding.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Zeev Kain, MD, MBA, Department of Anesthesiology & Perioperative Care, UC Irvine, 333 City Blvd., Orange, CA 92868. Address e-mail to

© 2014 International Anesthesia Research Society