Postdischarge Unscheduled Care Burden After Lower Limb Arthroplasty

Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty

BACKGROUND

Same-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA.

METHODS

We performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student's t-test or Chi-square test. Significant findings were those with P value < .05.

RESULTS

The SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP).

CONCLUSIONS

Patients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.

The impact of an enhanced recovery programme on length of stay and post-discharge resource usage following hip and knee arthroplasty : a service evaluation and cost analysis

Aims

The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis.

Methods

Between May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year.

Results

Mean LOS for ERAS patients was 1.59 days (95% confidence interval (CI) 1.14 to 2.04), significantly less than that of the matched cohort (3.01 days; 95% CI 2.56 to 3.46). There were no significant differences in readmission rates for ERAS patients at both 30 and 90 days (six vs four readmissions at 30 days, and nine vs four at 90 days). Despite matching, there were significantly more American Society of Anesthesiologists (ASA) grade 3 patients in the ERAS cohort. There was a mean cost saving of £757.26 (95% CI £-1,200.96 to £-313.56) per patient. This is despite small increases in postoperative resource usage in the ERAS patients.

Conclusion

ERAS represents a safe and effective means of reducing LOS in primary joint arthroplasty patients. Implementation of ERAS principles has potential financial savings and could increase patient throughput without compromising care. In elective care, a preadmission discharge plan is key.

Cite this article: Bone Jt Open 2021;2(11):966–973.

Same-Day vs One-Day Discharge: Rates and Reasons for Emergency Department Return After Hospital-Based Total Joint Arthroplasty

BACKGROUND

As short stay and outpatient total joint arthroplasties (TJAs) are more widely adopted, it is important to assess whether reducing length of stay leads to increased emergency department (ED) visits or readmissions.

METHODS

This is a retrospective review of 1743 primary TJA patients with same-day discharge (SDD) or 1-day length of stay between January and December 2019. Patients who returned to the ED or were readmitted within 30 days of TJA were identified, and chart review was performed to identify their primary reason for revisit.

RESULTS

Patients discharged on the day of surgery (n = 203, 11.6%) were more likely to be younger (P < .001) and have a lower body mass index (total hip arthroplasty, P = .018; total knee arthroplasty, P < .001) and American Society of Anesthesiologists score (P < .001). The overall rate of return was 6.3%, and 1.3% of patients were readmitted. Controlling for age, gender, body mass index, surgery type, and American Society of Anesthesiologists, patients selected for SDD were not found to be at higher risk of return to the ED compared to 1-day length of stay patients (4.9% vs 6.4%, odds ratio 0.980, 95% confidence interval 0.484-1.984, P = .956).

CONCLUSION

SDD of eligible patients does not increase the risk of 30-day return to the ED. Continued analysis of risk factors for return and readmission will improve prospective identification of patients who can safely be discharged on the day of surgery, and future quality improvement initiatives should target the most common reasons for ED return.

Rapid Discharge and Outpatient Total Joint Arthroplasty Introduce a Burden of Care to the Surgeon

BACKGROUND

Rapid-pathway outpatient (OTJA) and one-night inpatient (ITJA) arthroplasty require close follow-up by the surgeon. We quantify and characterize the total perioperative touches required in the first 7 days, and compare OTJA and ITJA patients.

METHODS

We reviewed 103 consecutive primary total joint arthroplasty (TJA) patients from April 2014 without exclusion; all patients were discharged either within 5 hours or the morning after surgery. All telephone and office visits during the first 7 days following surgery were studied. Specialized outpatient TJA education was included. We measured the frequency, duration, and subject matter of phone calls. Simple Poisson regression analysis and t-tests were used to determine significance.

RESULTS

None of the 103 rapid pathway patients were lost to follow-up. Average age was 61.2 years (range 26.9-83.0), with 49 females (47.6%), 78 total knee arthroplasties, average Charlson Comorbidity Index score of 2.1, and average body mass index of 29.5 kg/m². There were 253 touches required, averaging 2.5/patient. One hundred sixty were outgoing phone calls by the surgical team and 93 were incoming calls from patients. The average duration of each call was 4.74 minutes (SD 3.7). The entire group required 19 hours and 35 minutes of telephone contact. After including specialized education time, this cohort required 83.1 hours of clinical time, or 48.4 minutes per patient.

CONCLUSION

Postoperative care after rapid pathway TJA requires a significant burden of resources, shifted from the hospital to the surgeon. We found that both rapid pathway groups require similar work by the surgeon's team. This additional work should be considered by policymakers.