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    PRACTICE PEARLS: Managing Same-Day Discharge Patients

    Same-day discharge of total joint arthroplasty (TJA) patients is a hot topic, with proponents claiming it is the way to improve patient satisfaction while maintaining a successful practice in the era of bundled payment models.

    But not all patients who are thought to be candidates for outpatient procedures end up being discharged the same day as surgery. The 2017 Otto Aufranc Award-winning paper by Goyal et al, [1] for example, found that 24% of outpatients undergoing total hip arthroplasty were unable to be discharged as planned.

    Charles A. DeCook, MD, from Arthritis & Total Joint Specialists in Atlanta, Georgia, has a lot of experience with successfully discharging his TJA patients the same day as surgery. He shared his approach to same-day discharge in a presentation at ICJR’s Pan Pacific Orthopaedic Congress.

    At his institution, 94% of patients go home the same day as surgery. Of those, 70% go home within 6 hours of the procedure, and fewer than 2% stay unexpectedly overnight. Factors that can prevent same-day discharge include:

    • Poor patient selection
    • Patient is not engaged in the same-day discharge process
    • Inadequate medical clearance
    • Low joint class participation
    • Patient is not prepared
    • Poor communication between surgeon and staff
    • Poor surgical technique
    • Anesthesiologist is not engaged

    The key, he said, is being committed to outpatient TJA: The surgeon and support staff have to commit to getting the patients out of the hospital the same day as the surgery, with the surgeon involved in the continuity of care and the development of appropriate protocols, including:

    • Indications and contraindications
    • Medical clearances needed
    • Preoperative medications
    • Intraoperative management
    • Anesthesia
    • Post-anesthesia care unit (PACU)
    • Physical therapy
    • Recovery unit
    • Pain management
    • Physical therapy
    • Discharge
    • Communication

    One of the most important changes Dr. DeCook and his colleagues made at their institution was to do away with NPO before surgery. A 1993 study showed that preoperative drinking does not affect gastric contents [2]. Residual gastric volume and pH remained the same, and there were no problems with aspiration or regurgitation. In contrast, dehydration enhances pain-evoked activation in the human brain compared with rehydration. [3]

    Dr. DeCook said that doing away with NPO has made a big difference in the ability to get patients discharged the same day as the surgery. In fact, he encourages his patients to drink clear liquids until they arrive at the hospital. Then, his patients receive 1 liter of fluids in the hospital preoperatively, 1 liter of fluids in the PACU, and 300 mL of fluids per hour for 4 hours postoperatively or until they leave the hospital.

    One of the reasons patients are not able to be discharged the same day as surgery are the unwanted side effects of anesthesia, [4] including hypotension, nausea and vomiting, urinary retention, and confusion. Without a consistent anesthesia team who all follow the anesthesia protocol, same-day discharge becomes hit-or-miss.

    A well-defined PACU protocol is equally important. Dr. DeCook’s goal is to have his patients out of the PACU within 30 minutes. They should change into their regular clothes, sit up in bed, and take liquids orally as soon as possible. They can receive intravenous acetaminophen and non-steroidal anti-inflammatory drugs, Dr. DeCook said, but opioid administration should be kept to a minimum: Opioids given in the PACU after the surgery may also prevent same-day discharge.

    Determining if a patient is ready to go home is not based on a pain scale number, Dr. DeCook said, but on whether the patient feels comfortable going home. Nausea is acceptable, but there must have been no vomiting for 4 hours. The patient must tolerate food and fluids by mouth and must be able to ambulate independently, climb stairs, and get in and out of bed with limited assistance before discharge.

    Dr. DeCook concluded that same-day discharge for TJA patients is safe and effective and provides improved patient satisfaction, as long as there are established protocols for the entire continuum of care.

    Click the image above to watch Dr. DeCook’s presentation.

    Disclosures

    Dr. DeCook has disclosed that he is a paid consultant and paid presenter or speaker for Corin, Depuy, and Medtronic and that he has stock or stock options in JointPoint, Medical Enterprise, and Radlink.

    References

    1. Goyal N, Chen AF, Padgett SE, et al. Otto Aufranc Award: A Multicenter, Randomized Study of Outpatient versus Inpatient Total Hip Arthroplasty. Clin Orthop Relat Res. 2017 Feb;475(2):364-372.
    2. Phillips S, Hutchinson S, Davidson T. Preoperative drinking does not affect gastric contents. British Journal of Anaesthesia, Volume 70, Issue 1, 1 January 1993, Pages 6–9,
    3. Ogino Y, Kakeda T, Nakamura K, Saito S. Dehydration Enhances Pain-Evoked Activation in the Human Brain Compared with Rehydration. Anesthesia & Analgesia: June 2014 – Volume 118 – Issue 6 – p 1317–1325.
    4. Gan TJ. Risk Factors for Postoperative Nausea and Vomiting. Anesth Analg 2006;102:1884–98.
    5. Edwards PK , Levine M, Cullinan K, Newbern G, Barnes CL. Avoiding readmissions-support systems required after discharge to continue rapid recovery? J Arthroplasty. 2015 Apr;30(4):527-30.