Risk-Stratifying Same-Day Joint Replacement

While same-day discharge for joint replacement is increasingly being employed by hospitals and clinics as a way to get patients back on their feet sooner and reduce costs, the research regarding benefits and risks remains largely inconclusive.

Some research has shown that careful patient selection based on specific criteria can result in low rates of complications and need for readmission among same-day joint replacement patients while other studies suggest that sending patients home so quickly can elevate certain risks.

A recent study from Hospital for Special Surgery (HSS), “Same day discharge total joint arthroplasty is associated with increased risk of perioperative complications: a population-based study,” found that same-day discharge following total knee arthroplasty (TKA) or total hip arthroplasty (THA) was associated with a higher risk for cardiac and pulmonary complication.

The HSS researchers presented their findings at the 2019 American Society of Regional Anesthesia and Pain Medicine Annual Meeting.

Overall, there are still very few specific guidelines for these same-day joint replacements.

What’s in a Definition?

Paul K. Edwards, M.D., a hip and knee surgeon at the University of Arkansas for Medical Sciences shared some of his experiences with same-day discharge hip and knee replacement at last year’s International Congress for Joint Reconstruction (ICJR) South Hip & Knee Course at Ocean Reef.

He told attendees at the meeting that the first thing to understand about same-day discharge is that the definition can vary depending on the institution. Discharge (DC) Same Calendar Day is different from DC within 24 hours and Same Day Discharge in Hospital is different from Same Day Discharge in an ASC (ambulatory surgery center) setting. At his institution, he and his colleagues mostly perform DC within 24 hours in a hospital setting.

“Sometimes we will do DC Same Calendar Day on our unicondylars and total hips but most stay overnight and are discharged by 11 a.m. post op day 1,” he said.

He added that understanding definitional differences is important because it can get mixed up in the literature and influence how postoperative risks are assigned referring to a study, “Definitional Differences of ‘Outpatient’ versus ‘Inpatient’ THA & TKA Can Affect Study Outcomes” published in the Clinical Orthopaedics And Related Research in December 2017.

In this study, there were 72,651 total hip arthroplasties (THAs) performed and of 529 “outpatients,” only 63 (12%) had a length of stay of zero. There were also 117,454 total knee arthroplasties (TKAs) performed and of 890 “outpatients,” only 63 (11%) had a length of stay of zero.

Here “inpatient” THA was associated with increased risk of any adverse event, serious adverse event and readmission compared with “outpatient” THA. And a similar trend was also found in the TKA cohort.

Lots of Moving Parts Required

According to Edwards, there are a lot of factors that go into successfully participating in same-day discharge including teamwork, nutrition counseling, education, communication, collaboration, early mobilization and fluid management.

He said though that it really hinges on enhanced recovery through all the phases: preoperative, intraoperative and postoperative.

He explained that a team-work approach is essential, that it takes a lot of moving parts, a lot of people to participate and make it happen, including a hospitalist consultant, mid-level providers, social workers, RN coordinators and physical therapists.

“The key here is education to the patient and to the family and a strong social support system so they can understand what is happening and agree to the plan,” he said.

“Discharge planning begins in the office. Expectation is always set as DC postoperative day 1 (POD#1). The first time I meet with them in my office for hip or knee replacement we talk about when they can expect to go home and the expectation is always set as DC POD#1.”

“If there is a medical reason to keep them, we can talk about it and keep those patients longer, but we initially start out those conversations with DC POD#1 prior to 11 a.m.”

Patients are also expected to take a hip and knee class before their surgery. Attendance is mandatory and their “coach” is also expected to attend. The class usually lasts one or two hours and covers dressing care, disposition (home), physical therapy and any durable medical equipment (DME) that might be needed.

At his institution there are two pathways to preoperative medical clearance:

• Healthy, controlled hypertension, stable cardiac with routine cardiology follow-up and cardiac clearance, diabetes (DM) with minimal health complication—cleared through the Musculoskeletal Service Line by a non-operative ortho M.D.
• Aggressive anticoagulant, renal disease, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), rheumatoid arthritis (RA), uncontrolled diabetes mellitus (DM), history of deep vein thrombosis/pulmonary embolism (DVT/PE)—cleared by an internal medicine M.D.

Their exclusion criteria includes:

• BMI > 40
• Hgb A1c > 8.0
• Active smoker
• Active use of narcotics
• Skip hip and knee Education Class

Edwards said that they also write up an agreement for the patient to sign for accountability. They want the patient to read and understand what the purpose of the surgery is and what they can expect to happen. That way if patients come back and say they were never told that they were getting discharged on POD #1, the surgeon has the paperwork to show that they did talk about it.

Pain management is also important during all three stages of surgery. Preoperatively at his institution, Edwards said they administer:

• Celebrex 400 mg PO
• Oxycontin CR 10 mg PO
• Toradol 15 mg

During the operation, pain management includes a general anesthetic and peri-articular local anesthetics. Patients also receive 1g tranexamic acid given IV or topically. No folly catheters are used.

After the surgery, patients receive only oral pain medication either Hydrocodone 5 mg (for the narcotic naïve) or Oxycodone 7.5 mg (for patients who have taken narcotics preoperatively).

Physical therapy starts within approximately three hours after the patient arrives on the floor POD#0 and beginning early around 7:30 a.m. on POD#1 with all patients discharged by 11 a.m. on POD#1 and 94% of their patients discharge to home.

Their discharge criteria includes:

• Ability to walk 80 feet on level ground
• Ability to walk up and downstairs
• Ability to transfer in and out of car
• Ability to stand from bed
• Ability to transfer back and forth from the bathroom
• Ability to dress self
• Pain, nausea/vomiting under control
• Ability to void
• Vital signs stable
• Have a ride home and support set up at home during recovery

Edwards said they also provide a hotline number in patients’ pre-op packets for when they have an emergency during the middle of the night and on weekends. They also have it set up so a third party, in their case TAVHealth, follow ups with patients at a minimum at 48 hours postop, 10 days postop, 4 weeks postop and 3 months postop.

Edwards and colleagues have conducted several studies to measure the effectiveness of their clinical pathway. In “Avoiding Readmissions – Support Systems Required After Discharge to Continue Rapid Recovery?” published in the April 2015 issue of the Journal of Arthroplasty, they retrospectively reviewed 1,874 total joint arthroplasties, finding that the use of a patient management support system like TAVHealth in their clinical pathway helped reduce the readmission rate.

However in “A Perioperative Patient Support System Was Unable to Mitigate the risk of Hospital Readmission for Total Hip Arthroplasty Patients With High American Society of Anesthesiologist Grades” published in the April 2017 issue of the Journal of Arthroplasty, Edwards and colleagues found that high ASA (American Society of Anesthesiologist) grade predicted increased readmission for THA regardless of the clinical pathway.

What Do Other Studies Say?

In another study from the Journal of Arthroplasty, “Effect of Total Joint Arthroplasty Surgical Day of the Week on Length of Stay & Readmissions: A Clinical Pathway Approach,” they found no significant difference in mean length of stay (LOS) for each day of the week with the use of their clinical pathway. Readmission was also not significantly affected by surgical day of week. This study was published in December 2016.

“This is in a little bit of contrast from other studies, but our goal was to utilize 5 operating days,” he said.

He added, “Our model is unique, and I acknowledge that. We are not an ASC, so patients can easily be admitted when needed. All our surgeries are performed in hospital. We do perform unilateral knee replacements as DC same calendar day, but approximately 96% of our primary total joint arthroplasties go home within 24 hours (before 11 a.m. POD#1) and approximately 90% of our revision total joint arthroplasties go home within 24 hours as well.”

Edwards emphasized the need for accommodations to keep patients overnight, pointing to “A Multicenter Randomized Study of Outpatient versus Inpatient Total Hip Arthroplasty” published in Clinical Orthopaedics and Related Research in February 2107. In that study, 24% (27 of 122) of patients planning to have outpatient surgery were not able to be discharged the same day.

“They found that outpatient THA may be implemented without requiring additional work; however facilities to accommodate overnight stay should be available.”

Another study “Same-Day Discharge Compared with Inpatient Hospitalization Following Hip & Knee Arthroplasty” in The Journal of Bone & Joint Surgery found that while there was no difference in adverse events or readmission, inpatients had increased thromboembolic events while same-day patients had increased rate of return to the OR. In addition, patients with a body mass index of ≥35 kg/m, diabetes, and an age of ≥85 years had an increased risk of 30-day readmission following same-day procedures. It is usually due to infection, which is a common trend in the literature.

In “Who Should Not Undergo Short Stay Hip & Knee Arthroplasty? Risk Factors Associated with Major Medical Complications Following Primary Total Joint Arthroplasty”, out of 1,012 elective primary THA and TKA patients, there were 70 complications (6.9%) with 59 (84%) happening past 24 hours postop. The authors said that patients with history of COPD, CHF, CAD and cirrhosis should not be scheduled for outpatient total joint arthroplasty, another common theme in the literature.

“I think it is important that we are risk-stratifying patients, especially in an ASC where it may be more difficult to keep them in a hospital,” Edwards said pointing to another study, “Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: The Outpatient Arthroplasty Risk Assessment Score” published in the August 2017 Journal of Arthroplasty. This study showed that the OARA score for primary TJA has more precise predictive ability than the ASA and CCI scores for the same- or next-day discharge (81.6% vs. 56.4% and 70.3%, respectively).

Learn More about Same-Day Discharge at the Upcoming ICJR South Hip and Knee Course

Thomas L. Bradbury, M.D will discuss issues surrounding same-day discharge during the session Economics of Healthcare at the 7th Annual International Congress for Joint Reconstruction South Hip & Knee Course which will be held June 27-29, at the Ocean Reef Club in Key Largo, Florida.

The conference is designed for orthopedic surgeons and allied health professionals looking to learn the latest in orthopedic technology, surgical technique and optimum patient care. The course will include current controversies in TKA and THA, enhanced recovery and outpatient arthroplasty, and perioperative patient management.

To register, click here.