Increasing the Volume of Outpatient Total Joint Arthroplasty Procedures: An Evaluation of a Novel Rapid Recovery Pathway Program Within an Academic Medical Center

Abstract

Background:

There has been a national trend toward shifting joint arthroplasty procedures to the outpatient setting. These cases are often performed in freestanding ambulatory surgery centers (ASCs), which are often not accessible to surgeons within academic practices.

Purposes:

We sought to investigate a novel rapid recovery program used to transition arthroplasty patients to an outpatient-based care system within an academic medical center.

Methods:

All patients undergoing hip or knee arthroplasty between November 2019 and April 2021 were retrospectively evaluated for their eligibility for a rapid recovery pathway through the Extended Stay Unit (ESU) based on clinical and social criteria. Once admitted, patients were evaluated for whether they were discharged from the unit or if hospital admission was necessary.

Results:

Out of the 444 patients deemed candidates for the rapid recovery program, 188 patients were admitted to the ESU (42.3%); 18 (9.6%) required inpatient hospital admission, with the majority of these due to failing physical therapy (16; 88.9%). Of the ESU patients who were successfully discharged home, 55 (32.4%) were discharged on postoperative day (POD) 0 and 115 (67.6%) on POD 1 (<23 hours).

Conclusion:

As total joint arthroplasties shift toward the outpatient setting, surgeons in academic institutions must employ strategies to increase their volume of patient candidates for outpatient procedures. Our retrospective study of prospectively collected data suggests the feasibility of creating a separate rapid recovery unit within the hospital that can be an effective method by which to eventually transition to the ASC setting.

Introduction

There has been a recent national trend toward shifting total joint arthroplasty (TJA) procedures from the hospital to the outpatient setting; a majority are projected to be performed as an outpatient procedure by 2026 [5]. This has been primarily evidenced by the Centers for Medicare and Medicaid Services (CMS) removing all primary TJA procedures from the inpatient only list, which has had significant clinical and financial ramifications nationwide [6,8,14,22,23]. Multiple studies have demonstrated outpatient TJA procedures to have improved cost effectiveness and patient satisfaction over inpatient TJAs, while maintaining patient safety [9,12,21]. In private practice settings, outpatient TJAs are commonly performed in freestanding ambulatory surgery centers (ASCs) [3,4,10,20,21]. These facilities pay particular attention to patient selection and optimization to minimize the risk of complications, which affect cost savings [1,6,17,19,24,25].

Academic centers often serve more medically and surgically complex patients, who may not be considered appropriate candidates for outpatient TJA, even though the common procedural terminology code is the same for each procedure [15]. Although academic centers exhibit lower mortality rates and provide excellent overall quality of care for more complex patients, academic centers are evaluated with the same metrics of performing TJA in the outpatient setting and discharging patients home instead of a non-home destination such as an acute or subacute rehab facility [2,11]. Therefore, academic centers are under pressure to employ strategies to increase the volume of TJAs performed in an outpatient fashion.

Joint replacement surgeons in academic centers often do not have access to freestanding ASCs, and, if they do exist, faculty members typically do not have shared ownership in these facilities [18]. As a result, the same financial incentive for academic faculty does not exist to move outpatient candidates out of the hospital. In addition, academic surgeons are often comfortable operating in inpatient settings due to their familiarity with consistent staff and policies. Our strategy to increase the number of outpatient joint replacement surgeries was to designate a separate area of the hospital (Extended Stay Unit or ESU) focused on rapid recovery, with staff communicating a consistent message to all TJA patients. This unit was created in 2019 to transition from a traditional inpatient approach to an outpatient-based care system within an academic center. Until now, its efficacy has not been assessed.

In this study, the primary outcomes of interest were to determine how often patients were preoperatively identified as appropriate outpatient candidates, followed the rapid recovery pathway, and were discharged home within 23 hours. The secondary outcome was to determine the most common causes of patients requiring hospital admission. We hypothesized that a majority of patients would be discharged home safely within 23 hours and that an inability to clear physical therapy would be the most common reason for subsequent hospitalization.

Methods

Institutional Board Review approval was obtained for this retrospective study of prospectively collected data. All patients undergoing lower extremity arthroplasty (total hip, total knee, or partial knee) by a single surgeon (senior author) between November 2019 and April 2021 were included in the study. Revision or conversion TJA patients were excluded. All study patients were evaluated for their eligibility for rapid recovery through the ESU as determined by the surgical team’s preoperative outpatient clinic assessment. This assessment was performed at the time the informed decision was made with the patient to proceed with surgery. Patients were deemed appropriate surgical candidates for a primary lower extremity arthroplasty with discharge from the ESU if they presented with significant joint pain, decreased ambulatory capacity, and failed nonoperative management with no significant medical comorbidities. We also use the risk assessment and prediction tool (RAPT) to ensure patients have the necessary social support for rapid discharge. A score of higher than 8 out of 12 was deemed a sufficient score for ESU admission. Patients were excluded from extended stay admission if they presented with at least one of the following: complicated intraoperative course or post-anesthesia care unit (PACU) stay, significant medical comorbidities (unstable cardiac disease, end stage liver or kidney disease, pulmonary disease), body mass index (BMI) >45, severe frailty or physical incapacitation, or post-op destination to a skilled nursing facility or rehabilitation center. In addition, patients must have preoperative clearance for an outpatient procedure. Space and adequate staff must be available in the ESU for admission. All patients were further screened by the perioperative and social work teams in addition to the attending physician and physician assistant. In addition, all patients also had to receive insurance precertification in order to avoid disqualification from the rapid recovery pathway. Once admitted to the ESU, patients were evaluated for whether they were discharged from the ESU within 23 hours or required subsequent inpatient hospital admission. For all patients who required admission, the reason for admission was documented based on thorough review of the electronic medical record during their hospital encounter.

During the study time period, a total of 571 consecutive patients underwent lower extremity arthroplasty procedures (269 total hip, 142 total knee, and 160 partial knee arthroplasties). This cohort included 343 women (60.1%), with a mean BMI and age of 30.2 and 64 years, respectively (Table 1).

Table 1.

A review of the patients’ demographics in terms of arthroplasty performed, gender, age, and body mass index (BMI).

Type of arthroplasty	Gender	Patient mean age	Patient mean BMI
269 total hip (47.1%)	Male: 228, 39.9%	64 (range, 15–88)	30.2 (range, 15.1–55.5)
142 total knee (24.9%)	Female: 343, 60.1%
160 partial knee (28.0%)

BMI body mass index.

All patients admitted to the ESU postoperatively were subject to the same clinical protocol. They were administered mepivacaine spinal anesthesia and were treated with the same perioperative multimodal pain regimen. Specifically, patients were prescribed aspirin or another blood thinner, a stool softener, a long-acting or short-acting opioid, anti-inflammatory medication, and gabapentin or pregabalin. Patients underwent standard wound closure with a running subcuticular monofilament suture and surgical glue for the skin with a waterproof, silver-impregnated dressing placed over the incision. All patients were transferred to the post-anesthesia care unit following the procedure. Once the spinal anesthetic effect had resolved, patients were transported to the ESU.

In the ESU, the patient was then evaluated and treated by a physical therapist and occupational therapist, typically within 4 to 6 hours of arrival. The therapy team made the recommendation regarding clearance and discharge on postoperative day 0 (POD 0) or on postoperative day 1 (POD 1) if an additional physical therapy session was necessary. Patients were required to pass physical therapy examination by 2 therapists for approval for home discharge: climbing one flight of stairs, walking a safe distance with minimal support, no nausea or vomiting, completing basic daily activities (rising from bed, showering, dressing, etc.), manageable pain, tolerating diet, and adequate social support. The attending surgeon resolved all decision conflicts on a patient’s readiness for discharge and approved all launches from the ESU. In addition, the patient’s medical status was assessed by a team of advanced practice providers, and failure to clear physical therapy or evidence of any deterioration of the patient’s medical condition resulted in hospital admission.

Statistical analyses were carried out using Microsoft Excel software, including the calculations of percentages and averages and other descriptive statistics. Continuous variables were reported as means and standard deviations, while categorical variables were reported as percentages.

Results

A total of 444 patients (77.8%) were deemed eligible for the ESU based on the surgical team’s preoperative evaluation (Table 2). Of this eligible cohort, 188 (42.3%) were admitted to the ESU after surgery (Fig. 1); 18 (9.6%) of these patients required subsequent inpatient hospital admission. A majority of these (16; 88.9%) required admission secondary to failing physical therapy, orthostasis, functional limitation, or continued weakness after spinal anesthesia. Other reasons for admission were pain control and social issues (2; 11.1%) (Fig. 2).

Table 2.

An overall representation of the selected patient cohort with the Extended Stay Unit.

Total patients	Gender	Patient mean age
ESU eligible	Male: 228, 39.9%	64 (range, 15–88)
Went to ESU	Female: 343, 60.1%
Failed to leave ESU within 24 hours and were admitted

ESU Extended Stay Unit.

Fig. 1.

A comparison of the number of patients eligible to go to the Extended Stay Unit (ESU) who received precertification from their insurance to do so with the number of patients eligible to go to the ESU that did not receive precertification from their insurance.

Fig. 2.

(a) A comparison of the number of patients from the cohort who were able to be successfully launched from the Extended Stay Unit (ESU) within 24 hours to the number of patients who failed to launch from the ESU within 24 hours and were admitted to inpatient. (b) The incidence rates of the different reasons for failure to leave the ESU within 24 hours.

Of the patients admitted to the ESU who were successfully discharged home (170; 90.4%), 55 (32.4%) were discharged on POD 0 and 115 (67.6%) on POD 1 (within 23 hours). Of the patients who were admitted to the ESU but failed to successfully launch and required inpatient admission, 4 (22.2%) were discharged on POD 1, 11 (61.1%) were discharged on POD 2, and 3 (16.7%) were discharged on POD 3 or 4 (Fig. 3).

Fig. 3.

(a) The length of stay of patients that were successfully launched from the Extended Stay Unit (ESU) within 24 hours. (b) The length of stay of patients that were unable to be successfully launched from the ESU.

Of the 256 patients who were deemed ESU candidates but were never admitted to the unit, 16 (6.3%) were discharged on POD 0, 134 (52.3%) were discharged on POD 1, and 106 (41.4) were discharged on POD 2 or greater (Fig. 4).

Fig. 4.

The length of stay of patients that were not successfully launched from the Extended Stay Unit (ESU) within 24 hours.

Discussion

We found that we could identify patients in an academic center who were appropriate for a rapid recovery pathway and that more than 90% of patients admitted to the ESU were safely discharged within 23 hours of admission. Nearly one-third of the patients were discharged on the day of surgery. Although this rate is not as high as what has been published for many freestanding ASCs, it is consistent with data from other academic institutions [7,16]. It is important to note that, as this was a pilot program with a safety net of inpatient admission, we did not expect to have same-day discharge rates in line with ASCs (many of which do not offer overnight stays or 23-hour observation).

Our study has several limitations. First, we did not have clearly delineated inclusion or exclusion criteria when identifying ESU candidates in the outpatient clinic. This determination was made using clinical experience and relied on a review of the patients’ comorbidities, social support, and body habitus during the initial evaluation. Similarly, elucidating why patients were deemed candidates but subsequently denied ESU admission was challenging. Although we believe patient exclusion was related to the factors discussed above, we cannot be certain. Finally, a majority of our patients from the ESU were discharged on POD 1, which makes comparison to ASCs difficult; these facilities usually are defined as same day, discharging patients on POD 0.

As we hypothesized, the primary barrier for successful discharge from the ESU was failure to clear physical therapy. As our therapists are accustomed to working in an inpatient setting, we believe this rate can be improved upon as our rapid recovery program continues to mature. This may require more staff, allowing patients to have multiple sessions and opportunities for clearance and potentially avoiding inpatient admission. Our perioperative multimodal pain regimen appears to be effective, as only one patient required hospital admission for pain control. Urinary retention, often cited as a concern with same-day or outpatient TJA, was not found to be an issue in our cohort, and we did not routinely prescribe a prophylactic regimen [25].

Out of the 571 overall patients, we considered 444 patients (77.8%) to be candidates for the ESU. However, only 188 (42.3%) were admitted to the unit. We believe this is due to several factors. First, patients often did not receive the required insurance pre-authorization for an outpatient designation, likely due to several insurance providers being slow to adopt CMS’s outpatient TJA guidelines. Second, other patients were excluded from outpatient or rapid recovery TJA due to identification of hidden/disqualifying comorbidities (eg, obstructive sleep apnea) during the preoperative clearance process. Third, patients with inadequate home or family support were further uncovered by our social work team. Finally, a minority of patients did not make it to the ESU due to an unforeseen lack of bed availability or staffing on the day of surgery (Table 3). However, as we evaluated the data on the patients deemed eligible but did not qualify for the ESU, 150 out of the 256 (58.6%) were still discharged on POD 0 or 1. This shows that from a clinical perspective, the surgical team was able to identify approximately 75% of rapid recovery patients accurately. Our data is consistent with other published studies performed at high-volume academic medical centers, where an overall 70% of TJA patients were found to be eligible for surgery at an ASC [13]. This data highlights the importance of addressing structural barriers, often financial and insurance in nature, to increase the number of patients who could benefit from a rapid recovery program.

Table 3.

Barriers to ESU admission.

Insurance precertification
Disqualification from ESU by another member of the clinical team (eg, social worker, perioperative nursing team)
Lack of resources (beds or nursing staff)

ESU Extended Stay Unit.

In conclusion, our retrospective analysis suggests that a novel rapid recovery pathway within an academic hospital, aimed at functioning similarly to an ASC, may be an effective method of transitioning patients to the ASC setting. Our findings suggest that through a multidisciplinary approach, eligible candidates may be identified and discharged within one day of surgery in a safe manner. We found that financial barriers and social support need to be addressed, particularly constraints placed by insurance companies. Furthermore, identifying ways to optimize patient care from a physical and occupational therapy standpoint will have a large effect on increasing the success rate of a rapid recovery pathway. Future studies should be focused on delineating inclusion and exclusion criteria, optimizing staffing in this setting, and negotiating with insurance companies to ensure all appropriate patients have access to a rapid recovery pathway.