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    Same-day Discharge after Total Joint Arthroplasty: The Future May Be Now

    The authors examine the literature on possible risks of same-day discharge following hip and knee replacement, advances in perioperative protocols, and implications of same-day discharge on healthcare costs, all with the goal of establishing institution-wide criteria for indications and contraindications for same-day discharge.

    Authors

    Jonathan M. Vigdorchik, MD; Vinay Aggarwal, MD; Savyasachi Thakkar, MD; and Kristopher Collins, MD

    Disclosures

    The authors have no disclosures relevant to this article

    Introduction

    Total joint arthroplasty (TJA) is one of the most successful orthopaedic procedures performed. Most patients undergoing TJA in the U.S. are insured through the federal government’s Medicare program, which is challenged by financial constraints. The rising cost of medical care had created tremendous financial pressure that is now critically altering the modes of healthcare delivery and payment.

    In such a financially constrained environment, hospitals are challenged to understand and control costs associated with TJA while maintaining the standard of care for patients. Two strategies that are being used to reduce the cost of TJA are:

    • Shorten the length of the hospital stay (LOS)
    • Minimize perioperative complications

    With the push toward outcomes-based reimbursement, reducing readmissions and perioperative complications is increasingly important.

    TJA has traditionally been performed as an inpatient procedure to mitigate the risks of perioperative complications, limited patient mobility, and pain control issues. Historically, TJA patients would stay in the hospital for 14 days – sometimes even longer – after surgery. [1]

    LOS decreased gradually over the next several decades, with the mean LOS still averaging up to a week in the early 2000s. [2-4] LOS after TJA remains highly variable internationally and even between hospitals within the same country depending on patient and institutional factors. [2,5,6]

    Nonetheless, there is a definite trend toward not only shortening postoperative LOS, but also toward considering a same-day discharge arthroplasty model in appropriately selected patients.

    There are several issues associated with same-day discharges after TJA:

    • Modulating patient expectations
    • Maximizing preoperative patient education
    • Providing care management services in the immediate postoperative period
    • Optimizing modern anesthesia and pain management techniques in concert with rapid rehabilitation protocols for early discharge
    • Cost implications
    • True outcomes and incidence of complication compared with traditional TJA practice protocols

    Safety of Same-Day Discharge

    A major criticism of same-day discharge arthroplasty is the safety of discharging patients less than 24 hours after TJA. Unlike traditional outpatient orthopaedic procedures such as anterior cruciate ligament reconstruction, TJA is associated with a higher incidence of more serious complications, including cardiopulmonary events.

    Parvizi et al [7] examined the timing of fatal and high-morbidity outcomes after TJA and reported a 6% incidence (104/1636 cases) of major life threatening complications in the hospital setting. They had 1 in-patient death, and found that 90% of their major complications occurred within 4 days of the index arthroplasty. The authors said that if these complications occurred outside of the hospital setting, they would have led to the death of 20-25 patients in their cohort.

    While Parvizi et al [7] specifically caution against the early discharge of patients from the hospital after elective TJA, several other authors who have implemented early discharge programs provide reassurance regarding the safety of same-day discharge after arthroplasty. [8-10]

    Same-Day Discharge after TJA Not for Everyone

    Despite reports concerning the safety of same-day discharge after TJA, there are specific patient and surgeon factors that may lead to an unsafe risk for performing same-day TJA.

    Courtney et al [11] evaluated 1012 consecutive patients undergoing primary TJA and found a major complication rate requiring physician intervention of 6.9%. Of these, 84% occurred at more than 24 hours postoperatively.

    They further analyzed risk factors for major complications after a 24-hour period to simulate those that could lead to unsafe discharge in a same-day discharge model. Using a multivariate model, they found patients with a history of CAD, CHF, COPD, or cirrhosis had unacceptably higher risk for complications, which should preclude this patient population from undergoing a TJA. [11]

    No connection was found between patient age, BMI, and presence of kidney disease or diabetes and complications related to same-day discharge after TJA. [11] Parvizi’s group, however, did find a correlation between co-morbidities and major postoperative complications. [7]

    Given the mixed reports in the literature, the presence of co-morbidities cannot adequately predict who will experience severe complications after being discharged from the hospital in a same-day discharge model. In the study by Parvizi et al [7], 58% of patients who experienced a major event after TJA had no predisposing factors to suggest an increased risk of significant postoperative complication.

    Berger et al [12,13] have looked at factors related to the surgical procedure, not factors related to the patient, to evaluate whether patients are appropriate candidates for same-day discharge following TJA. They found no association between age, BMI, or patient co-morbidities and postoperative complications or failure to discharge on the same day as surgery. Instead, they said the factors that could lead to successful same-day discharge were surgery very early in the day and the use of minimally invasive surgical approaches in the hip and the knee. [12,13]

    The contraindications for same-day discharge after TJA at the New York University – Hospital for Joint Diseases are summarized in Tables 1.

    Table 1: Contraindications for Same-Day Discharge after TJA

    Age > 65 years ASA 3 or 4
    Ischemic heart disease (positive stress test) On aggressive anticoagulation or clopidogrel
    Poor ventricular function (LVEF < 50%) Oxygen-dependent pulmonary disease
    Renal insufficiency or end-stage renal disease, Cr > 1.6 Steroid-dependent asthma or chronic obstructive pulmonary disease
    Pulmonary hypertension (PAP >45) Morbidly obese, BMI 40 or greater
    Chronic liver disease (Childs class B or worse) Cerebral vascular disease
    Proven obstructive sleep apnea without treatment, or STOP/BANG >5 Insulin-dependent diabetes mellitus, blood glucose >180
    History of DVT or PE History of congestive heart failure
    Hemoglobin < 11 or Jehovah’s Witness  

     

    Cost Effectiveness: Is Shorter Really Cheaper?

    One of the main drivers of reducing LOS after TJA is the potential for cost reductions for hospitals and healthcare insurers.

    Aynardi et al [14] examined costs associated with same-day versus traditional discharge in total hip arthroplasty procedures performed at their institution and found a significant difference in the costs: $23,529 for same-day discharge versus $31,327 for traditional discharge (P=0.0001) based on a non-itemized bill. [14] There were 4 conversions of patients from the same-day discharge to the traditional group for various reasons, including workup for pulmonary embolus or myocardial infarction. This study did not include post-discharge costs in the analysis.

    Lovald et al [15] followed their patients for 2 years postoperatively and examined costs associated with all aspects of the TJA episode of care, including potential costs for postoperative complications, readmissions, and revision surgeries. They included patients in 3 groups:

    • Same-day discharge
    • 1- to 2-day LOS
    • Traditional 3- to 4-day LOS (control cohort)

    They found cost savings of $8527 for the same-day discharge group and $1967 for the 1- to 2-day LOS groups when compared with the control group.

    Although Berger has one of the most prolific same-day discharge TJA centers in the United States, he cautions that in the end, transitioning to a same-day discharge model may not be cost-effective for practicing orthopaedic surgeons [12,13] In his model, he found that the same-day, rapid discharge pathway required significant preoperative, intraoperative, and postoperative coordination and planning from a multidisciplinary team.

    This team was a part of the operating surgeon’s infrastructure, which is not reflected in the reimbursement mechanism to the surgeon, although hospital costs will decrease regardless of the change in overall cost of the arthroplasty.

    Outcomes and Complications

    How LOS affects patient outcomes and postoperative complications is worth examining as we move toward a same-day discharge model.

    The theoretical risk of higher readmission rates after outpatient TJA has been refuted by several authors in their short-term analyses of same-day discharge patients. [12,16-18] The major issues that arise after same-day discharge are not related to major medical or surgical complications requiring readmission, such as pulmonary emboli, problems related to anticoagulation, or infections.

    Rather, uncontrolled postoperative nausea, orthostasis, and pain control are the most common reasons for delayed discharge from the fast-track pathway and for emergency department visits in the first few weeks after same day TJA surgery.

    Further, TJA patients seem to have higher patient satisfaction and functional outcomes after same-day discharge. Berger found that out of 150 same-day total hip arthroplasties performed, 144 were highly satisfied with their experience and would choose the same pathway again; only 6 patients believed they might have benefited from a night in the hospital due to issues related to nausea and pain. [12]

    Other centers have reported similar levels of satisfaction via questionnaires answered by their same-day discharge patients at 6- and 12-week intervals following TJA surgery. [16,17]

    The caveat to these data is that patients in same-day pathways are often carefully screened and are only included if they meet specific criteria to minimize the chance of postoperative complications or poor outcomes.

    Most studies of same-day discharge included patients with BMI less than 40 (averages were often less than 30); younger patients; and patients with minimal medical co-morbidities and no history of pulmonary emboli, myocardial infarction, or chronic anticoagulation therapy. In addition, the surgeon generally used a minimally invasive surgical approach with these patients.

    Perioperative Pain Management and Advanced Anesthesia

    Many high-volume centers have developed clinical pathways coupled with multimodal pain management protocols to accelerate the early recovery of patients and reduce LOS. [19-26] The purpose of these protocols is to minimize the risks and drug side effects in the perioperative period by combining minimally invasive surgical technique with an effective anesthetic program.

    This approach reduces pain, nausea, and sedation; minimizes narcotic use; enables patients to mobilize more quickly; and allows surgeons to safely discharge patients to home the same day as or the day after surgery.

    Perioperative multimodal pain management involves preemptive analgesia that minimizes the inflammatory and neurogenic pain from the surgical trauma, ultimately reducing the perception of pain from reaching the central nervous system.

    Safe and effective postoperative pain control can be achieved with a combination of pre- and postoperative anti-inflammatory medication, antiemetics, regional anesthetics, and intraarticular injections. The goal is to minimize narcotic use, which will reduce postoperative sedation and hypoventilation and ultimately allow the patient to be discharged home on the day of surgery.

    Epidural and spinal anesthesia are effective methods to block the pain signal pathway from reaching the brain. The use of regional anesthesia is effective in decreasing postoperative narcotic use. [27] In addition, a randomized prospective study demonstrated that regional anesthesia allowed more-rapid achievement of in hospital postoperative rehabilitation goals compared with general anesthesia. [28]

    Intraarticular local anesthetic injections stop immediate transmission of pain signals as well as provide prolonged postoperative pain control after epidural removal. The addition of an intra-articular injection of 0.25% bupivacaine with epinephrine and a long-acting opioid has been shown to significantly reduce the need for a break-through opioids on the day of surgery, reduce postoperative confusion, and allow patients to achieve greater knee range of motion after total knee arthroplasty. [29]

    Liposomal bupivacaine is a newer long-acting local anesthetic that has been shown to be safe and reduce postoperative pain; it can provide up to 72 hours of local anesthetic effect.

    Barrington et al [30] studied the effect of local injection of liposomal bupivacaine in hip and knee arthroplasty patients. They evaluated more than 2000 joint replacement patients, half of whom were treated with periarticular injection of bupivacaine, ketorolac, and morphine and half of whom had liposomal bupivacaine added to the periarticular injection. Patients in the liposomal bupivacaine group were found to have significantly lower Visual Analog Scales (VAS) pain scale scores. [30]

    Rapid Rehabilitation Protocols

    The goal of rapid rehabilitation protocols is for patients to be alert and able to participate in therapy soon after surgery.

    The use of short-acting perioperative analgesia, including short-acting epidural and spinal anesthetics, facilitates elimination of pain catheters, indwelling urinary catheters, and long-acting motor blockade. Typically, the epidural catheter, if used, is pulled 1 to 4 hours postoperatively, and the urinary catheter, if used, is removed 2 hours postoperatively. Oral opioids, acetaminophen, and anti-inflammatories are used to manage pain as needed.

    Physical therapy is initiated 5 to 6 hours after surgery. To be discharged home, patients must demonstrate the ability to independently move from a supine to a standing position and return from a standing position to a supine position. They must also be able to independently transfer to and from a chair and to a standing position. After these initial criteria are met, patients must then be able to ambulate at least 100 feet and ascend and descend a full flight of stairs.

    Other standard discharge criteria used include stable vital signs and the ability to tolerate a regular diet. Prior to discharge the staff again ensures that the patient has adequate pain control on oral medications to minimize readmission for pain control issues.

    Prior to surgery, arrangements must be made to ensure that the patient has support at home, along with a plan for postoperative therapy and monitoring of any early complications. Typically, in-home physical therapy is used initially to reduce the need for patient travel. This can then be transitioned to outpatient therapy 1 to 2 weeks after surgery.

    Conclusions

    The future of adult reconstructive surgery is moving toward a greater use of same-discharge following TJA. Although the trend toward decreasing LOS is real, data are still lacking concerning the safety of same-day discharge.

    Surgeons must, therefore, use caution with regard to patient selection for same-day discharge and should transition to a same-day discharge model with a gradual decrease in LOS. Although the costs associated with same-day discharge surgery appear to be less compared with traditional TJA surgery, it is unclear what will occur with reimbursement for surgeons.

    Overall, as with most surgical procedures in orthopaedics, same-day discharge provides a safe, cost-effective alternative to a traditional inpatient model for hip and knee replacement – provided patients are carefully selected and the surgeon and team are appropriately trained and prepared for much greater involvement in the postoperative patient experience.

    Communication during the early discharge period and coordinated care management are crucial to ensure the safety of the patient during the high-risk period after surgery.

    Author Information

    Jonathan M. Vigdorchik, MD, is an Assistant Professor of Orthopaedic Surgery and Associate Fellowship Director in Adult Reconstruction at NYU Langone Medical Center’s Hospital for Joint Diseases, New York, New York. Vinay Aggarwal, MD, is a Resident in Orthopaedic Surgery at NYU Langone Medical Center, New York, New York. Savyasachi Thakkar, MD, and Kristopher Collins, MD, are Fellows in the NYU Langone Medical Center-Insall Scott Kelly Adult Reconstruction Fellowship Program, New York, New York.

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