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minutes, to just under 2 hours.
By reducing time in the PACU as well as length of stay and readmissions,
we're already saving money, and we expect to save much more in the long run.
We have a 23-hour protocol for total joint replacements, but plan to start per-
forming same-day total joints in 2019. We're working toward putting in place all
the elements that will set us up for success once we decide to make that move,
and we know that pain control is a primary consideration.
Currently for total knees, we use a combination of local infiltration and multi-
modal analgesia, as well as regional anesthesia and continuous catheters. Most
patients receive adductor canal blocks, because they target the saphenous nerve
and help preserve quadriceps strength, along with ultrasound-guided injection
of local anesthetic behind the knee (the interspace between the popliteal artery
and the capsule of the knee, or "IPACK" block). But for patients with chronic
pain issues, we typically use femoral nerve blocks, which sacrifice some muscle
function but which have been shown to reduce opioid requirements.
We also usually give patients with continuous catheters elastomeric pain
pumps, but we'll consider providing "smart" pumps if we feel patients would
benefit from having a bolus option. The downside of smart pumps is the alarm
functions that may lead to unnecessary phone calls. Patients have also com-
plained that they're noisy and may disturb sleep.
Our protocols for hip arthroscopy and ACL repairs use similar elements to
those we use in the multimodal protocols for other procedures.
Making it work
As our multimodal protocols have evolved, we've learned several valuable les-
sons:
• Flexibility is key. Minimizing variability in health care is an important goal,
but we found that one-size-fits-all approaches don't work. Multimodal protocols
need to be more like large umbrellas under which you can accommodate the
