When Inpatient Becomes Outpatient

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Orthopaedic surgeon Steven Fitzgerald, MD, recent “Dinner with the Doc” honoree, gets patients quickly and safely home and back into life following total joint replacement

UH Clinical Update | July 2022

It wasn’t that long ago that having a total hip or knee replacement involved as many as four days in the hospital, plus a stint at an inpatient rehab facility. Patients put their lives on hold for what was a major, disruptive event.

Those days are gone.

Steven Fitzgerald, MDSteven Fitzgerald, MD

“Things have changed a lot over the past 10 years,” says Steven Fitzgerald, MD, Chief of Adult Reconstruction for the University Hospitals system and Medical Director of Total Joint Replacement at UH Ahuja Medical Center. “We've gone from four days in the hospital to two, to one to less than a day.”

Dr. Fitzgerald has helped implement this sea-change at UH, using evidence-based, high-reliability medicine (HRM) principles to standardize total joint care across the system and achieve ever-lower length of stay, while maintaining patient safety and health care quality. He has worked collaboratively with UH orthopaedic surgeon Matthew Kraay, MD, who began the HRM total joint program several years ago.

“Standardization in joint replacement is really key in order to have good outcomes and reduce complications, Dr. Fitzgerald says. “We share best practices with our colleagues across the system to standardize things.”

The results are impressive. Under Dr. Fitzgerald’s leadership, length of stay for the UH system for total joint replacement fell from 1.8 days in 2017 to its current level of 1.36 days. At UH Ahuja, the results are similar, from 1.6 days down to 1.2 – the third lowest in the UH system. Even same-day discharges for total joint replacement surgeries have gotten shorter, from 12.9 outpatient hours for the UH system in 2020 to 10.5 hours today, and just 9.9 hours at UH Ahuja – again, the third-lowest in the system.

Dr. Fitzgerald was recognized recently for this work with a “Dinner with the Doc” honor from UH CEO Cliff Megerian, MD, FACS. However, he says it’s only through an invested, multidisciplinary team that results like these are possible.

“It’s all about putting together a comprehensive team of everybody who interacts with the patient,” he says. “We have patient coordinators who work with a patient preoperatively and through their hospital stay. We also work with anesthesia, discharge planning, pharmacy and nursing. It’s a comprehensive, multidisciplinary team that works together to fine-tune the care path to make sure that the patient procedure goes as smoothly as possible. We have people who are invested in the program every step of the way to have all those parts work in sequence. Together, we’re able to get the patient out of the hospital.”

And out of the hospital is where the vast majority of these total joint replacement patients belong, Dr. Fitzgerald says.

“The number-one thing we’ve learned is that patients don’t need to stay in the hospital,” he says. “The majority of total joint patients are very healthy, active people and can probably safely go home the same day. It's just putting all the parts together to make it happen.”

Same-day total joint replacement got started at UH at UH Cleveland Medical Center and UH Ahuja and now makes up about 30 to 40 percent of cases there, Dr. Fitzgerald says. It is now becoming more common at UH St. John and UH Elyria as well. He says he’s also working closely with the team at UH Beachwood Medical Center, orienting the Lake Health team joining UH to UH processes and procedures.

“The goal is to take what we've learned from high-reliability medicine and the program at UH Cleveland Medical Center and UH Ahuja and do what we've done with other sites,” he says. “UH Beachwood Medical Center is uniquely situated in terms of their setup. It's a hybrid between a small hospital and an outpatient surgery center, so they're particularly well-positioned to push the outpatient total joint program.”

Next, Dr. Fitzgerald with Dr. Kraay will begin working on the transition of UH’s Center of Excellence in total joint replacement from UH Cleveland Medical Center to UH Ahuja. Through this Center, companies offer their employees the opportunity for a bundled payment arrangement at UH for hip or knee replacement.

“We've proven that we can do these surgeries with an incredibly low complication rate and a low cost, which is a win-win for everybody,” Dr. Fitzgerald says.

And he’ll keep doing the surgeries he loves.

“I love what I do,” he says. “I can't imagine doing anything else. In terms of surgical procedures that you can do, with hip and knee replacement, the impact is so quick and significant.  You take somebody who is extremely frustrated with their quality of life and can't do the daily activities that they would like to do and very quickly give that back to them. It’s incredibly satisfying from the patient's standpoint but from a surgeon standpoint as well, to see these patients come in at six weeks, and you know they have quality of life back, which is awesome.”

Congratulations to Dr. Fitzgerald on his “Dinner with the Doc” honor. To nominate a physician for this honor, please visit the UH Digital Workplace. The next deadline is July 22.

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