Reasons for Unsuccessful Same-Day Discharge Following Outpatient Hip and Knee Arthroplasty: 5½ Years' Experience From a Single Institution

Causes and risk factors for same-day discharge failure after total hip and knee arthroplasty: a meta-analysis

In recent decades, the trend toward early same-day discharge (SDD) after surgery has dramatically increased. Efforts to develop adequate risk stratification tools to guide decision-making regarding SDD versus prolonged hospitalization after total hip arthroplasty (THA) remain largely incomplete. The purpose of this report is to identify the most frequent causes and risk factors associated with SDD failure in patients undergoing THA and total knee arthroplasty (TKA). A systematic search following PRISMA guidelines of four bibliographic databases was conducted for comparative studies between patients who were successfully discharged on the same day and those who failed. Outcomes of interests were causes and risk factors associated with same-day discharge failure. Odds ratios (OR) were calculated for dichotomous variables, whereas mean differences (MD) were calculated for continuous variables. Meta-analysis was performed using RevMan software. Random effects were used if there was evidence of heterogeneity. Eight studies with 3492 patients were included. The most common cause of SDD failure was orthostatic hypotension, followed by inadequate physical condition, nausea/vomiting, pain, and urinary retention. Female sex was a risk factor for failure (OR 0.77, 95% CI 0.63-0.93), especially in the THA subgroup. ASA score IV (OR 0.33, 95% CI 0.14-0.76) and III (OR 0.72, 95% CI 0.52-0.99) were risk factors, as were having > 2 allergies and smoking patients. General anesthesia increased failure risk (OR 0.58, 95% CI 0.42-0.80), while spinal anesthesia was protective (OR 1.62, 95% CI 1.17-2.24). The direct anterior and posterior approaches showed no significant differences. In conclusion, orthostatic hypotension was the primary cause of SDD failure. Risk factors identified for SDD failure in orthopedic surgery include female sex, ASA III and IV classifications, a higher number of allergies, smoking patients and the use of general anesthesia. These factors can be addressed to enhance SDD outcomes.

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.

Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty

BACKGROUND

A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD.

METHODS

A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression.

RESULTS

Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older.

CONCLUSIONS

The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates.

LEVEL OF EVIDENCE

III.

Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty

Background

Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways.

Methods

A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117).

Results

No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001).

Conclusions

Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

Total joint replacement in ambulatory surgery

Total joint arthroplasty is one of the most commonly performed surgical procedures in the United States, and projected numbers are expected to double in the next ten years. From 2018 to 2020, total hip and knee arthroplasty were removed from the United States' Center for Medicare and Medicaid Services "inpatient-only" list, accelerating this migration to the ambulatory setting. Appropriate patient selection, including age, body mass index, comorbidities, and adequate social support, is critical for successful ambulatory total joint arthroplasty. General anesthesia and neuraxial anesthesia are both safe and effective anesthetic choices, and recent studies in this population have found no difference in outcomes. Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, local infiltration analgesia, and peripheral nerve blocks, is the foundation for adequate pain control. Common reasons for "failure to launch" include postoperative urinary retention, postoperative nausea and vomiting, inadequate analgesia, and hypotension.

Are Patients Being Appropriately Selected for Same-Day Discharge Total Knee Arthroplasty?

BACKGROUND

Decreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days.

RESULTS

When comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD.

CONCLUSION

The unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA.

LEVEL OF EVIDENCE

III.

Optimizing Spinal Anesthesia in Same-Day Discharge Knee Arthroplasty Patients: Mepivacaine Versus Ropivacaine

BACKGROUND

Short-acting spinal anesthetics are playing an increasing role in same-day discharge total joint arthroplasty though their direct comparison remains to be studied. Therefore, this study aims to compare two formulations of spinal anesthesia regarding time to discharge following knee arthroplasty surgery.

METHODS

A retrospective study was performed on 207 patients who underwent unicompartmental knee arthroplasty (UKA, n = 172) and total knee arthroplasty (TKA, n = 35) from May 2018 to December 2020 at a single institution and were discharged the same day. Two formulations of the spinal anesthetic were routinely administered in this population: 1) mepivacaine 1.5% 3-4 mL (n = 184) and 2) ropivacaine 0.5% 2.3-2.7 mL (n = 23). Discharge times were subsequently compared between mepivacaine and ropivacaine spinal anesthesia for each surgical procedure and between surgical procedures.

RESULTS

There was no significant difference in discharge times between patients receiving mepivacaine versus ropivacaine for UKA (202 minutes [range = 54-449] versus 218 minutes [range = 175-385], P = .45) or TKA (193 minutes [range = 68-384] versus 196 minutes [range = 68-412], P = .93). Similarly, no difference was found in discharge times between UKA and TKA patients receiving mepivacaine (P = .68) or ropivacaine (P = .51).

CONCLUSION

There was no significant difference in discharge times between anesthetic agents among knee surgery patients. Therefore, either agent may be recommended for same-day discharge.

Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors

Aims

The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD.

Methods

This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m². Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression.

Results

In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m² (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD.

Conclusion

SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology.

Cite this article: Bone Jt Open 2022;3(9):684–691.

Same Day Joint Replacement Surgery: Patient Selection and Perioperative Management

Joint replacements are increasingly performed as outpatient surgeries. The push toward ambulatory joint arthroplasty is driven in part by the changing current health care economics and reimbursement models. Patients' selection and well-designed perioperative care pathways are critical for the success of these procedures. The rate of complications after outpatient joint arthroplasty is comparable to the rate of complications in the ambulatory setting. Patient education, adequate social support, multimodal analgesia, regional anesthesia are key ingredients to the ambulatory care pathway after joint arthroplasty. Motor sparing nerve blocks are often used in these settings. Implementation of the elements of fast protocols can result in overall improvement of outcome metrics for all patients undergoing joint arthroplasty, including reduced length of stay and increased rate of home discharge.

A Formal Same-Day Discharge Total Joint Arthroplasty Program May Not Be Necessary: A Propensity-Matched Cohort Study

BACKGROUND

Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged on the day of surgery. This study compares the outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD.

METHODS

We retrospectively reviewed all patients who were SDD following TJA from 2015 to 2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups.

RESULTS

Of the 1778 patients included, 1384 (78%) completed the SDD TJA program and 394 (22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. The surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39 vs 87.29 minutes; P < .001). Discharge disposition (P = .999), 90-day emergency department visits (P = .476), 90-day all-cause readmissions (P = .999), 90-day all-cause revisions (P = .563), and Hip disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS, JR) and Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement at all time points did not significantly differ.

CONCLUSION

Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients who are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and an experience with value-based care.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Orthopaedic surgeons' perspective on the implementation of outpatient hip and knee arthroplasty - Results of a nationwide survey

Background

Outpatient joint arthroplasty (OJA) for the hip and knee is gaining popularity among orthopaedic surgeons worldwide. The purposes of this study were to (1) assess the proportion of Dutch orthopaedic surgeons who perform OJA; (2) identify surgeons' willingness to implement OJA in the future; (3) identify reasons and barriers to implement OJA; and (4) gather surgeon's perspective on the implementation of OJA.

Methods

A 20-item survey was developed and administered by email to orthopaedic surgeons who are a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 40% (N = 123).

Results

Twenty-two respondents (18%) already implemented OJA, and 46% of respondents (who don't perform OJA) were interested to implement OJA in the future. Reasons to perform OJA included own positive experiences (82%), available evidence (77%) and patients' request (77%). Proponents' and opponents' view on safety and added value conflicted with each other. Other barriers included patient selection and organizational related (e.g., multidisciplinary support). Surgeons' view on evolution and relevance of OJA significantly differed by respondents who perform OJA versus respondents who don't perform OJA. Most respondents agreed with one another that the healthcare institution benefits most from OJA, and that optimization of the arthroplasty pathway could be reached through better patient education and -participation (e.g., eHealth, wearables).

Conclusion

One in five respondents currently implement OJA pathways, and about half of the remaining respondents are interested to implement OJA in the future. OJA-opponents aren't convinced of the value and safety of OJA, despite accumulating evidence supporting OJA. Future research should inform patient-selection and -acceptance and organizational implementation.

Failure to Meet Same-Day Discharge is Not a Predictor of Adverse Outcomes

INTRODUCTION

As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay.

MATERIALS AND METHODS

We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences.

RESULTS

A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts.

CONCLUSION

Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.

Recent Increases in Outpatient Total Hip Arthroplasty Have Not Increased Early Complications

BACKGROUND

Outpatient total hip arthroplasty (THA) has increased in recent years. Recent regulatory changes may allow and incentivize outpatient THA in more patients; however, there are concerns regarding safety. The purpose of this study is to assess early complications in outpatient THA compared to longer hospitalization.

METHODS

We identified patients undergoing primary THA in the National Surgical Quality Improvement Program database between 2015 and 2018. Patients were stratified by length of stay (LOS): 0 days (LOS 0), 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Multivariate analysis was performed.

RESULTS

In total, 4813 (4%) patients underwent outpatient THA, 84,627 (64%) had LOS of 1-2 days, and 42,293 (32%) had LOS ≥3 days. LOS 0 patients were younger, had lower body mass index, and less medical comorbidities compared to those with postsurgical hospitalization. Any complication was experienced in 3.2% of the LOS 0 group, 5.3% of the LOS 1-2 group, and 15.6% for the LOS ≥3 group (P < .0001). Readmission rates were 1.6%, 2.6%, and 4.7% for the 3 groups, respectively (P < .0001). After controlling for confounding variables, patients with LOS 1-2 days had higher odds for any complication (odds ratio 1.56 [1.32-1.83) and readmission (odds ratio 1.41 [1.12-1.78]) compared to LOS 0 days. Patients with LOS ≥3 days had higher odds for complications compared to LOS 0 or 1-2 days.

CONCLUSION

Outpatient THA had lower odds for readmission or complications compared to LOS 1-2 days. Despite increased outpatient surgery, many patients had postsurgical hospitalization and, due to patient factors, this remains an integral patient of post-THA care.

Outcomes of a Total Joint Arthroplasty Enhanced Recovery Program in a Community Hospital Setting

BACKGROUND

Same-day discharge (SDD) total joint arthroplasty (TJA) is increasingly popular, yet there remain concerns regarding patient safety, complication rates, and unforeseen overnight admission (failure to launch; FTL). The aim of this study is to retrospectively examine the outcomes of a large consecutive SDD-TJA series in the community hospital setting.

METHODS

We retrospectively reviewed 1200 consecutive SDD-TJA candidates between March 2017 and December 2019 by 5 surgeons at a community hospital. Patient demographics, perioperative data including anesthesia type, and 30-day complications were evaluated, including FTL, infection, intraoperative fracture, postoperative periprosthetic fracture or dislocation, return to operating room, and unplanned postoperative care.

RESULTS

We included 1200 SDD patients (582/618 total hip arthroplasty/total knee arthroplasty, mean age 62.1 years, 595 females, 605 males). Spinal anesthesia was more common than general anesthesia (1087 vs 113 patients). There were 85 FTLs (7.1%), of this cohort 58.8% were female, with a mean age of 62.4 years. General anesthesia increased the risk of FTL (odds ratio 2.93). Complications resulting in FTL included block-induced neuropraxia (32.1%), orthostatic hypotension (26.1%), urinary retention (19.0%), and nausea (13.1%). Sixteen patients were readmitted within 30 days (1.3%). Six patients returned to the operating room for periprosthetic fracture (4), wound dehiscence (1), and superficial surgical site infection (1).

CONCLUSION

SDD-TJA can be safely performed at community hospitals, but general anesthesia should be avoided to decrease risk of FTL. Inpatient programs may allow young surgeons to gain experience with SDD-TJA while retaining overnight admission as a safety net for their patients.

LEVEL OF EVIDENCE

Level III (Prognostic).

The introduction of day-case total knee arthroplasty in a national healthcare system: A review of the literature and development of a hospital pathway

INTRODUCTION

As we now drive to reinitiate our full capacity elective services in an attempt to tackle an ever-growing demand for lower limb arthroplasty, this pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency.

AIMS

We present the development of an evidence-based multidisciplinary perioperative care pathway for day-case total knee arthroplasty (TKA) in a United Kingdom National Health Service (NHS) institution, in conjunction with a review of the literature upon which the protocol is founded.

METHODOLOGY

We performed a review of the literature reporting complication or readmission rates at ≥30 day postoperative following day-case TKA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed.

RESULTS

13 manuscripts with a total of 3370 day-case TKAs, defined as discharged on the same-calendar-day of surgery, were included in analysis. Mean 90-day complication rates (8.31% [range, 0-16.3%] vs 9.49% [range, 0-13.1%], respectively) and readmission rates (2.71% [range, 0-10.0%] vs 3.41% [range, 0-9.9%], respectively) were equivocal between day-case and inpatient TKA. The overall rate of successful same-calendar-day discharge was 95.8%. Our evaluation and critique of the evidence-based literature identifies day-case TKA to be safe, effective and economical, benefitting both patients and healthcare systems alike.

CONCLUSION

We further validate the introduction of our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) based on the evidence presented. Careful patient selection paralleled with well-defined care pathways are essential for successful introduction of day-case TKA into the NHS.