More Evidence FOR TJA in the ASC Setting

Besides the chance to have another hospital meal, what else do total joint arthroplasty (TJA) patients get by staying overnight in the hospital? Several researchers in Indiana wanted to find out. Their work, “Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty?” was published in the January 1, 2021 edition of the Journal of Arthroplasty.

R. Michael Meneghini, M.D. director of the Indiana University Health Hip and Knee Center, and co-author explained the genesis of this study to OTW, “We were anecdotally observing patients who stayed overnight after primary hip and knee replacement and were not really having any issues and we were getting the feeling that the overnight stay was merely for patients’ comfort or out of fear from going home same day. So we wanted to quantify this observation and see what the data revealed in terms of the true need for early discharge patients to stay overnight in the hospital.”

Dr. Meneghini and the team reviewed data from 1,725 consecutive primary unilateral TJAs performed between 2012 and 2017 by one surgeon in a rapid-discharge program, all of whom were managed by a perioperative internal medicine specialist.

When OTW asked why little is written or, perhaps, even known about the type and quantity of interventions provided for TJA patients who stay overnight, Dr. Meneghini replied, “Probably because we have not been required to consider these issues. However, now that primary hip and knee arthroplasty are off the inpatient only list we must critically look at justifying if and why patients need to spend the night in the hospital after surgery.”

These researchers found that 759 patients were discharged on postoperative day 1; the vast majority of individuals (84%; 641 of 759) received no medical interventions while in the hospital overnight. Twelve (1.6%) underwent diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. Of the diagnosic tests, 92% (11 of 12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in and out catheterizations for urinary retention. In addition, the 90-day all-cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention.

Wasted beds?

According to Dr. Meneghini, who is also professor of Clinical Orthopaedic Surgery at the Indiana University School of Medicine, “The take home message is that if a patient is deemed an ‘early discharge’ by the surgeon and medical team and the patient is screened for and/or prevented to have urinary retention, there is no evidence to suggest that the majority of patients should stay in the hospital overnight.”

“This has dramatic implications in 2021, as hospitals in the U.S. and worldwide are burdened with COVID and other medically burdened patients and need to preserve beds for these patients. The ability to perform outpatient same day surgery safely provides increased access for patients suffering from debilitating hip and knee arthritis. It also provides evidence that a significant number of patients undergoing primary hip and knee arthroplasty can undergo their surgery in an ambulatory surgery center, rather than have surgery performed in a hospital setting.”