Transitioning to outpatient arthroplasty during COVID-19: time to pivot

The CMAJ research article by Wang and colleagues¹ highlights the substantial surgical backlog in Ontario that resulted from the first wave of the coronavirus disease 2019 (COVID-19) pandemic. The impact of Ontario’s second wave on inpatient resources has exacerbated the surgical backlog even further. The total joint arthroplasty (TJA) program at Sinai Health in Toronto recently introduced an enhanced recovery after surgery bundle,² which has enabled us to pivot quickly to an outpatient TJA program in response to restrictions on inpatient surgery.

After careful review of epidemiologic forecasts and resources that were available early during the pandemic,³ our surgical services team anticipated that to continue to be able to perform TJA procedures throughout future waves of the COVID-19 pandemic, we would need to quickly establish a hybrid outpatient/inpatient arthroplasty program.⁴ An internal needs assessment was performed. Results highlighted the need to develop an evidence-based, patient-centred outpatient pathway.⁵ New interventions included well-defined outpatient selection criteria, modification of anesthetic to facilitate early ambulation, outpatient recovery education materials, and virtual postoperative care follow-up. By January 2021, our program evolved into a hybrid TJA program with more than 25% of primary referrals for TJA undergoing surgery as outpatients. This outpatient pathway was well-appreciated by patients and hospital leadership alike.

With an output of more than 125 000 TJA procedures per year, Canadian arthroplasty centres are faced with the challenge of how to continue providing care during the COVID-19 pandemic. To minimize use of inpatient health resources, hospitals need to “pivot” toward outpatient TJA by rapidly implementing pathways, protocols and resources to ensure that patients undergoing TJA continue to receive the surgical care they need.