This document outlines the surgeon's approach to performing outpatient shoulder arthroplasty through a program called AVATAR. The key aspects of the program are: 1) Focusing on preparing patients through education and optimization before surgery to facilitate recovery. 2) Performing surgeries early in the day and using multimodal pain protocols, regional anesthesia, and periarticular injections to minimize pain and reduce the surgical stress response. 3) Discharging patients home the same day through careful planning, mobilization, and education to ensure a smooth recovery process.

1. Outpatient Shoulder Arthroplasty:
Simple, Stepwise,
Surgeon-directed
Moby Parsons, MD
Portsmouth, NH

2. Background
• Our practice has performed around 1,300
outpatient joint replacements in the past 3
years
• We now send 60% of all patients home true
same-day both at our hospital and ASC
• Developed program called AVATAR
• Has been featured in Becker’s

3. AVATAR
• Once you establish a well-functioning program,
transition to outpatient joints is easy
• Start with the end-goal in mind and work
backwards
• Focus on the finished product and figure out how
to get there
Alignment of Vital Assets To Accelerate Recovery

4. The Historical Paradigm of Joint Replacement

5. The Modern Paradigm of Joint Replacement

6. What Not To Do
Process Map
Algorithm
Value Chain

7. But Wait…..
• The more beholden you are to an institutional process, the less likely you
will succeed in same day joint replacement
• Beward turning this into a complicated administrative process with too
many “Stakeholders”

8. Simplify
1. Determine if patient interested in SDS
2. Apply inclusion criteria
3. Educate patient
4. Manage discharge process in advance
5. Perform surgery
6. Discharge patient home
7. Navigate post-discharge process

9. Surgeon-driven:
• SDS nurses
• Anesthesia
• PACU nurses
• PT/OT
• VNA
These are the people that do the work taking care of the patient

10. Patient Selection
• ASA 1 and 2: almost all qualify
unless they live alone
• ASA 3 can be considered case by
case with medicine and anesthesia
• Note: many patient have chronic
medical problems that they
manage well at home
• Hospital based care can often
disrupt this routine (ie. IDDM)

11. The Psychology of Words
• You can go home the same day.
• It is no longer necessary to spend the
night in the hospital

12. Blockbuster Drugs
• The new blockbuster drug
is not a pharmaceutical!
• Patient Education
• Patient Engagement
• Patient Activation
• Patient Optimization
12

13. Patient Education/Preparation
• Benefits well proven in other
joints and health conditions
• Up to date Patient Guides
• Website

14. Surgical Preparation
• This man ran set the
marathon record in
Berlin in 2018 running
26.2 miles at a 4:37 pace
per mile
• You wouldn’t run a race
like this without training
• You shouldn’t have
surgery without
training
• Preparation is key
14

15. Surgical Optimization
• Different centers have different methods
and protocols
• We encourage better nutrition and
vitamins
• Reduce alcohol intake
• Exercise
• Good hydration leading into surgery

16. Scheduling
• Cases are done early in the day
• Preferably before noon
• Average time from surgery to d/c = 2.5-3.5
hours
• As the system gets more efficient you can do
more and do them later
It is better to plan for patients to go home and have them stay than to
plan for them to stay and then try to send them home

17. Discharge Planning
• Start Preoperatively: set all this stuff
up before the surgery so all the
patient has to do on the day of
surgery is show up.
• Meds
• DME
• VNA
• PT – setup location and first visit in
advance
Don’t make it process based and
complicated like this
Program managers love pathways

18. Controlling
the Surgical
Stress
Response
• A well coordinated care
pathway can reduce the
stress response caused by
surgery
• This can facilitate early
recovery and reduce
complications

19. Protocol to Minimize Surgical Stress and Enhance Recovery After Surgery

20. SDS
• On message about plan for same-day discharge
• Reinforce/empower
• Pre-emptive multimodal analgesia
• No opioids
• Regional anesthetic
• We use a single shot Ultrasound guided interscalene block
• Indwelling catheters not necessary and usually fall out of the nerve sheath
with shoulder dislocation during surgery

21. Intraop Anesthesia
• Nausea/vomiting prophylaxis
• Normothermia
• Calibrated fluid management
• Avoidance of opiates
• Paralysis

22. Intraop Surgical
• Good surgical technique
• Blood management
• We use TXA
• Ligate, cauterize or pack where you know
the bleeders are
• Periarticular Injection
• Cocktail of choice
• Many options – all seem to be helpful

23. Periarticular Injection
• Posterior capsule
• Deltoid
• Pec Major
• Spinoglenoid notch
• Suprascapular notch
• Humeral periosteum

24. Other
• Avoid staples
• Subcuticular absorbable
closure
• Waterproof dressing
• Minimizes postoperative
wound care
• Keeps dirty hands away
from wound

25. Postoperative
• Multimodal protocol
• Minimize opiates
• Nausea/vomiting prophylaxis
• Early nutrition and switch to PO hydration
• PT/OT to see, mobilize and teach

26. Other Thoughts About Postop
• If in hospital: Don’t send patients to floor –
they will get stuck there
• Send them back to SDS from PACU
• Have PT/OT see them there
• Educate SDS nurses about discharge
instructions and criteria
• Have templated instructions in
Logicare/EHG

27. Discharge
• Reinforce multimodal program schedule
• Patient and family education
• Dressing care
• Restrictions
• Potential rebound pain when block wears off
• Home exercise program
• ADLs

28. Navigation
• Call the next day to check in and as often as
necessary to ensure smooth sailing
• Have a person in your office that is easily
accessible
• We have a nurse practitioner who handles
postop issues
• Provide therapists with your cell phone so
they can text you and send you pictures

29. Conclusions
• We have been sending massive cuff
repairs and ACL reconstructions home
for years
• Joints are not special just because there
is a metal implant
• It boils down to changing mindsets of
norms
• Once it becomes well-established it
becomes routine

30. Thank You
•mobyparsons@gmail.com