---
title: 'Ambulatory Hip and Knee Replacement Outcomes During a COVID Outbreak in Washington State'
type: 'lecture'
url: 'https://doc.social/lectures/ambulatory-hip-and-knee-replacement-outcomes-during-a-covid-outbreak-in-washington-state'
published: '2022-02-22'
author: 'Brett Jones'
topics: 'Pandemic, orthopaedics, Elective Surgery, COVID'
transcript: 'yes'
---

# Ambulatory Hip and Knee Replacement Outcomes During a COVID Outbreak in Washington State

Preliminary study assessing how an online patient engagement platform can help monitor and document the postoperative clinical course.

## Summary

This is a presentation from our 2021 preliminary study assessing how an online patient engagement platform can help monitor and document the postoperative clinical course, PROMs, and COVID-related symptoms during the COVID-19 pandemic in Washington State. Our ongoing goal is to evaluate the safety of performing elective surgeries during an active pandemic.

## Transcript

1,856 words · 12 min · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Hello, my name is Brett Jones. I'm a 2nd-year medical student at the Allison S. Floyd College of Medicine in Washington State. And today, I'm presenting on our work of ambulatory Hip and Knee replacement outcomes during a COVID outbreak in Washington state.
[0:16] I have no disclosures today. Um, to start with an introduction, so the first COVID-19 case was found in the US on January 19, 2020 in Washington state. After that, on March 19th of 2020, our governor suspended all elective joint replacements as well as elective surgeries.
[0:34] And so the suspension of elective surgeries affected patients, providers, family members, as well as the community either directly or indirectly by not being able to have these procedures done, possibly being furloughed from their work or clinics that they worked at. Um, having to, having to continue to care for family member, family members who are dealing with debilitating Osteoarthritis could also be an important factor.
[0:59] So elective surgeries were halted for many important reasons. The Pandemic has challenged healthcare organizations across many fronts such as increased training for medical staff on new Protocols, preserving and reserving scarce PPE and ventilators for COVID-19 patients, as well as creating more intensive care units and COVID-19 recovery beds.
[1:23] And so, for more context on elective joint surgeries, this graphic on the screen is from a report published in 2019 by the Ambulatory Surgery Center Association. And they found that before 2015, less than 1% of total joint replacements were done in an Outpatient setting. And so, what we're looking at here on this graphic below, on the X-axis are years from 2019 to
[1:48] 2029 and on the Y-axis are millions of Operations. And so, what this um report forecasts and so the colored the colored uh graph, so orange is the forecasted Inpatient procedures and green is the forecasted Outpatient procedures. And so, um, as we can see, green sections are increasing in percentages while
[2:13] Orange sections are decreasing in percentages and so what this team has forecasted that come the year 2029, 60% of total Hip and Knee replacement surgeries will be done in an Outpatient setting versus 40% of these surgeries will be done in an Inpatient setting.
[2:29] And so putting this in perspective of COVID-19, ambulatory Surgery centers during the Pandemic have been postulated to be safer for Outpatient procedures, as well as allowing the continuation of these elective joint procedures to take place outside the setting of hospitals. In total, this switch to an Outpatient utilization with these ASCs could provide for a safer environment for patients and potentially
[2:54] Give them a decreased chance and risk of exposure to transmission of COVID um if they were to receive these treatments in a hospital setting.
[3:04] So moving on to our objectives of this study. Our Primary objective was to gain insight into the safety of elective total joint arthroplasties during an active Pandemic. And also we wanted to uh have the study help validate a future study design that will combine patient-reported outcomes as well as clinical-reported outcomes.
[3:24] The methods for this study, so we introduced it, so the study is a retrospective case series um assessing the Patient-reported outcomes from 282 patients. All surgeries were performed in Washington State by Washington state surgeons, 14 of them total from the dates of January 19th to March 19, 2020. Patients, all patients were registered um prior on a cybersecure Outpatient online platform um called the SwiftPath Program.
[3:53] Prior to receiving their Surgery. And what this um platform allowed us to do was to um receive outcomes and questionnaires as well, as well as send questionnaires to these patients during the post-operative period. So this included the Who's Junior and Who's Junior for Hip and Knee arthroplasties, as well as the COVID survey that allowed us to track possible viral infection and transmission during their post-operative recovery time.
[4:20] And so, um,
[4:23] All patients, like I said, all patients were registered for and participated in joint camps on the SWIFT platform prior to receiving their Surgery, and these joint camps focused on patient engagement, Risk Stratification, discharge planning, and home care monitoring. This Patient engagement platform included written materials, online videos, an online portal with videos accessible, as well as interactive tasks. Patients, uh, patient engagement included family involvement.
[4:51] And this had this helped verified uh attestations prior and uh before Surgery.
[4:57] This, uh, the Patient experience also included shared decision making, focusing on knowledge of the procedure and the skills needed for at-home post-operative care.
[5:08] Important important aspect of utilization of ASCs for future elective surgeries is successful Risk Stratification. So in addition for screening of past medical problems and comorbidities, the algorithm used on this platform quantifies patient motivation, beliefs and values, psychological issues, family engagement, physical capabilities, as well as home setup and the environment that patients will actually be experiencing in their homes during their postoperative period.
[5:38] In doing so, this algorithm allows for specific Risk Stratification and will give the surgeon a score that with the score, the surgeon can decide whether ambulatory Surgery is appropriate for each patient's specific scenario.
[5:52] And so this online platform enabled safe and effective Outpatient Operations during um what we saw during the COVID-19, the start of the COVID-19 Pandemic.
[6:05] So our results, um, patients range, patients age range from 30 to 91 with an average age of 67.7 years. Out of the 282 patients who had Surgery, only 254 of the patients registered for this online platform.
[6:23] Of these 254 patients, 166 of them were Total knee arthroplasty patients and 88 of them were Total hip arthroplasty patients.
[6:32] In terms of Outpatient versus Inpatient, 60 patients received their surgeries at an ambulatory surgical center and 187 received their surgeries at a hospital, while 7 did not respond.
[6:45] So this graph is a, a stratification of patients undergoing Hip or Knee Surgery in an ASC or hospital setting.
[6:53] And so, uh, the left bar graph is the uh the amount of patients that had their Surgery, the amount of Total knee arthroplasty patients who had their Surgery in a hospital or ASC. Gray is for hospital and black is for ASC. And so for the total Knee patients, this was split pretty evenly. About half of them had their surgeries in the hospital and half had their surgeries in an ambulatory surgical center. For the total Hip patients,
[7:20] Majority of these patients had their surgeries in the hospital while only a few had their surgeries in ambulatory Surgical center.
[7:27] So continuing on with our results, about 25% of the patients went on to complete both preoperative and postoperative who's Junior and K's Junior questionnaires. And so we had a total of 237 patients complete the preoperative questionnaires while only 72 patients completed postoperative questionnaires, which is um a drawback in this study because we were unable to, with the, each patient that registered for the platform were given the questionnaires, but
[7:57] In this setting, it's hard to keep, it's hard to motivate patients to fill out these questionnaires. And so that's why in a future study, we would like to combine clinical reported outcomes as well as these patient-reported outcomes.
[8:10] And so these figures will start with the top right. And so, um,
[8:17] This figure, this pie chart on the top, or excuse me, the top left labeled A. And so this pie chart is describing the access to the surgical team impacted by clinic closures due to the COVID-19 Pandemic. And so we saw that 10 10% of patients had access to surgical team impacted due to clinic closures. Well, 90% of patients were not impacted by clinic closures from COVID-19. On the top right graph, the pie chart labeled B.
[8:47] This is the percentage of patients who had Physical therapy impacted by COVID-19. And so the majority of patients in the gray area of the pie chart or the um darker gray area of the pie chart did not have any impact to their Physical therapy and had Physical therapy as planned. The light gray signifies that some uh patients had stopped Physical therapy early and the black section of the pie chart represents the amount of patients who had no form of Physical therapy.
[9:15] And in going to the pie chart labeled see in the bottom left-hand corner, this is the percentage of patients um who are satisfied with, with their Physical therapy. And so 20, 20% of patients who responded were satisfied or were not satisfied, whereas 80% of patients who responded to this survey were satisfied. And I'll move out of the way.
[9:36] But this graph at the bottom, this bar graph represents the average satisfaction scored for each patient during the Pandemic. And so, in total out of all the patients who responded, their average satisfaction score was at a 9.5.
[9:53] All right. To summary, so utilization of an Outpatient platform uh can help monitor the Patient-reported outcomes as well as any virus-related illnesses that patients may have come across during the post-operative time. Um, from what we saw and from the responses that we looked at, there was no adverse events postoperatively. Um, this included no COVID-19 transmissions or infections during their post-operative time point.
[10:19] And so as I mentioned earlier, there are challenges uh when we we are reporting Patient-reported outcomes as we are limited in the fact that not every patient will respond and so this was a drawback to the study.
[10:31] But this current study um may provide current insight on the safety of elective surgeries during the COVID-19 Pandemic, utilizing both surgeries performed at, in a hospital setting as well as surgeries performed in an ambulatory surgical setting.
[10:48] So importantly, the future directions, what we plan to do um in the future using the same sort of study design is perform a retrospective case review for total Hip and total Knee patients in Washington state.
[11:00] Um, this current study used about 282 patients, but now we want to expand that to about 1000 patients, and we also want to have two comparison groups. Our first group are patients receiving their surgeries from January 1st to March 19th. So when COVID was still being transmitted or possibly transmitted in the community, but it wasn't as well known to the public at the time.
[11:22] And then our second group are patients receiving their surgeries from March 20th, 2020 all the way to October 1st, 2021. So this group really represents the patients that went on to have their surgeries in the COVID-19 era as we know it as today with um either um different Protocols used by staff as well as many societal um
[11:45] Um, social distancing and mask mandates. And so, in total, we want to evaluate how the COVID-19 impacted major total Hip and Knee elective surgeries before and after the Pandemic shutdown. And also to realize whether um these elective surgeries um had an impact on whether or had patient impact based on their outcomes, whether their Surgery was performed in an Outpatient setting or an Inpatient setting.
[12:11] And so please, if you have any questions, feel free to reach out to me. My email is listed below. And these are the references that we use in our study and I hope you enjoyed. Thank you.