Abstract
With total hip arthroplasty no longer an inpatient only procedure, this study retrospectively evaluated the percentage of same day, outpatient (<24 h) and inpatient (>24 h) discharges between 543 standard discharge (SDP) and 372 rapid discharge (RDP) patients. Outpatient discharges increased from 31.9% with SDP to 87.4% with RDP (p < 0.001) and 16.4% achieving same day discharge. Patients not achieving outpatient discharge were more commonly older (odds ratio (OR):1.052, p = 0.003), female (OR:2.715, p = 0.003) and a higher comorbidity classification (OR:2.751, p = 0.002). The 12.6% of patients failing to achieve outpatient discharge suggests that careful patient selection may be necessary to obtain 100% success.
Keywords: Inpatient only list, Delayed discharge, Same day discharge, Outpatient
1. Introduction
Against recommendations from the American Association of Hip and Knee Surgeons (AAHKS), total hip arthroplasty (THA) was removed from the Centers for Medicare and Medicaid Services (CMS) Inpatient-Only (IPO) surgical list effective January of 2020.1 It was the position of AAHKS that the performance of outpatient THA requires significant facility expertise, careful patient selection and exceptional post-operative coordination of care, which have not been adequately demonstrated at most institutions.1 The CMS defended their decision by suggesting careful and appropriate patient selection can result in the safe performance of outpatient THA.2
Studies evaluating the efficacy and safety of outpatient THA have reported 75–100% of patients can safely and successfully achieve same day discharge without increased complications.3, 4, 5, 6, 7, 8 However, these patients were highly selected for or represent selected ambulatory surgery center patients and do not represent the majority of patients undergoing THA. These “outpatient” cohorts typically represent 10–28% of all patients referred for THA at the respective institutions.3,8,9 Despite data strongly supporting the feasibility of outpatient THA, eligibility is limited to a small proportion of all THA candidates and removal of THA from the IPO list has placed the burden of justification for inpatient reimbursement on surgeons and hospitals.10,11
In anticipation of this change and in attempting to step towards successful outpatient THA performance, the current study site implemented a rapid discharge protocol (RDP) in March of 2017. The RDP replaced a standard discharge protocol (SDP), characterized by an expected one to two night hospital length stay, which was common to most fast track type arthroplasty services.12, 13, 14 The RDP also focused on the optimization of interdisciplinary coordination of joint arthroplasty patient care to best manage patient expectations and post-surgical patient pathways. This protocol was implemented for all THA patients, regardless of health status, age, gender or body mass index (BMI), in an attempt to evaluate the applicability of outpatient THA pathways. Therefore, the purpose of this study was to (1) evaluate the incidence of outpatient discharge between the newly implemented RDP and the SDP and (2) evaluate RDP patient characteristics between same day, outpatient (<24 h) and inpatient (>24 h) discharge following unilateral THA.
2. Materials and methods
This institutional review board approved, retrospective study evaluated a consecutive series of 915 unselected patients having undergone unilateral direct anterior approach THA between January 2016 and May 2018. All patients met the standard indications for primary THA and patients were not excluded from surgery based on demographic or comorbidity status. Patients were only excluded from data analysis if the primary indication for surgery was femoral neck fracture. A single, high volume (>800 arthroplasties per year) fellowship-trained surgeon in a small, multi-specialty community hospital performed all surgeries. All surgeries were performed with the patients in the supine position on a fracture table (Hana®, Mizuho OSI, Union City, CA, USA) as described by Matta et al.15 All patients received the cementless Ovation® Tribute (Ortho Development Corporation, Draper, UT, USA) short femoral stem and a cementless acetabular component with a neutral faced highly cross-linked polyethylene insert and ceramic femoral head. Intraoperative fluoroscopy was used to ensure proper implant positioning.
Prior to surgery, all patients received appropriate antibiotic prophylaxis dosed by body weight and given 1000 mg of acetaminophen, unless contraindicated. The arthroplasties were performed under general anesthesia and an ultrasound guided paravertebral or quadratus lumborum regional nerve block was given prior to induction at the discretion of performing anesthesiologist, containing bupivacaine 0.5% (20 cc), epinephrine (100mcg) and Clonidine (1mcg/kg). All patients received a pericapsular injection consisting of bupivacaine 0.15% (1 cc/kg) and toradol (30 mg). Finally, each patient received 1 g of intravenous tranexamic acid (TXA) prior to incision and before closure of the arthrotomy. The capsule was closed using interrupted braided suture and the fascia over the tensor fascia lata was closed with a running barbed suture. The subcutaneous layer was closed with either interrupted braided suture or a running barbed suture. Final wound closure was completed using either monocryl and dermabond or a zipper method (ZipLine® Medical, Silicon Valley, CA).14 Dressings consisted of gauze and paper tape over the incision area only. No patient received a Foley catheter, thromboembolic stockings or a wound drain. Upon wound closure, each patient was given dexamethasone (4 mg) intravenously to control postoperative nausea.
Immediate post-operative pain was managed with intravenous hydromorphone (0.2 mg) as deemed necessary by post anesthesia staff. After the patient was fully awake, acetaminophen (1000 mg) was given for primary pain management. Break through pain was treated with tramadol (50 mg) or oxycodone (5 mg) only upon patient request until discharge as needed. Post-operative nausea was symptomatically treated. Intermittent mechanical foot compression was used for all patients until discharge and deep vein thrombosis chemoprophylaxis included aspirin (325 mg) for six week unless contraindicated. Patients who were on preoperative anticoagulation for other medical reasons were allowed to restart the same medication on postoperative day one following surgery. Patients with a history of thrombosis or similar events were preferentially given low molecular weight heparin (40 mg subcutaneously daily for 10 days) or 10 mg of rivaroxaban for 21 days following surgery.
2.1. Standard discharge protocol
Patients having undergone surgery between January 2016 and February 2017 were included in the SDP. The required preoperative educational class informed patients that discharge would be attempted as soon as physically safe to do so and were scheduled for surgery without preference for time of day. Following surgery, patients were transferred from the operating room to the post anesthesia care unit. During this time, each patient was monitored during waking and, if necessary, pain and nausea were treated. Once the patient was fully awake and a hospital room was ready, the patient was transferred to a hospital room to be evaluated by a physical therapist and a hospitalist (internal medicine physician) assigned to the floor to determine if discharge could be safely performed. Importantly, the hospitalist was required to prioritize medical attention across all patents on post-surgical ward, as the hospitalist was not solely responsible for orthopedic postoperative patients. Because of this, patients requiring urgent care were prioritized first and post-operative THA patients were evaluated when appropriate. Discharge criteria include the ability to walk 100 feet with an assistive device, pain and nausea controlled, hemodynamic stability, and, if stairs were present in the home environment, ability to successfully navigate one flight of stairs. If patients could not prove safe, independent function or if evaluation and discharge could not be completed at an appropriate time of day (by approximately 7:00pm), the patient was kept overnight and discharged as soon as possible the following day. Transfer to an acute care rehabilitation facility or skilled nursing facility was arranged if the patient could not demonstrate safe, independent post-operative functional improvement deemed necessary for home discharge.
2.2. Rapid discharge protocol
Implementation of the RDP began in March 2017, highlighting four primary changes to the SDP. First, patients were instructed in the required preoperative class to expect same day discharge or discharge within 24 h. Secondly, unilateral THA patients were preferentially scheduled prior to noon, if possible. Thirdly, an acute care nurse practitioner (ACNP) was assigned to the orthopedic adult arthroplasty service with sole responsibility for post-operative evaluation, medical co-management and efficient, safe discharge planning. The ACNP replaced the role of the hospitalist who had been assigned to all patients being recovered on the hospital ward in question, including higher priority cardiac patients. The addition of a dedicated ACNP to the arthroplasty service allowed for quicker evaluation of arthroplasty patients, as well as, immediate recognition of symptoms that may lead to delayed discharge. Finally, an experienced physical therapist was kept in the hospital until 7:00 p.m., instead of only 5:00pm in the SDP, to allow evaluation and possible discharge in the evening. In the post anesthesia care unit patients were evaluated by the ACNP and disposition planning started. If the patient exhibited any adverse medical issue, such as hypotension, extreme nausea or inability to prove safe, independent function following arrival to the post-surgical ward, disposition planning included plans for re-evaluation and possible discharge the following day. If patients were unable to discharge on the day of surgery, they were reevaluated by physical therapy the following morning for possible discharge. If patients could not achieve safe discharge functional requirements, disposition planning included possible transfer to an acute care rehabilitation hospital or skilled nursing facility prior to discharge to a home environment. Following discharge home, no patients received home care or medical personnel support.
2.3. Statistical analysis
Patient demographics were collected for each patient at the time of surgery, including age, BMI and American Society of Anesthesiologists’ (ASA) classification. Perioperative data reviewed included adverse events during or immediately following surgery, transfusion required, hospital length of stay and discharge disposition. Perioperative complications were defined as any wound or systemic complication arising within six weeks following surgery. Complications were recorded from emergency room visits, readmissions or self-reported at six week follow-up visits.
Descriptive statistics, including mean, standard deviations and range, were performed for patient demographics. Normality of continuous variables was evaluated through the Kolmogorov-Smirnov test. No continuous variables were normally distributed, therefore, the Mann-Whitney U test was performed to determine group differences. Categorical variables were evaluated by Chi-squared test or Fisher's exact test. Data were first compared between SDP and RDP groups. Only the RDP patients were evaluated next, comparing patients achieving outpatient discharge and those requiring inpatient status. With the RDP patients only, a univariate logistic regression was performed to determine the influence of patient characteristics on successfully achieving outpatient discharge. For significant variables, a multivariate analysis was performed. Results were presented as odds rations (OR), 95% confidence intervals (CI) and p-values. All statistical analyses were performed using SPSS v25 and a significance level of p < 0.05.
3. Results
Overall, 543 SDP and 372 RDP patients were evaluated, having no significant difference in patient demographics (Table 1). The percentage of patients successfully achieving outpatient status (<24 h hospitalization) increased significantly from 31.9% in the SDP group to 87.4% in the RDP group, with 16.4% of RDP patients having achieved same day discharge. There was also a significant decrease in the number of transfusions required from 5.3% in the SDP group to 1.3% in the RDP group. Approximately 90% of patients in both groups were discharged directly home. There were no differences in wound and systemic complications, as well as similar 90-day emergency room visits (p = 0.051).
Table 1.
Comparison of standard and rapid discharge protocols - mean (SD)/Freq (%).
| Standard Discharge (N = 543) | Rapid Discharge (N = 372) | p-value | |
|---|---|---|---|
| Age (years) | 66.03 (10.8) | 66.82 (10.1) | 0.304 |
| Body Mass Index (kg/m^2) | 26.96 (5.2) | 27.13 (5.1) | 0.431 |
| Gender (Male) | 259 (47.7%) | 197 (53.0%) | 0.067 |
| ASA >2 | 232 (42.7%) | 157 (42.2%) | 0.465 |
| Length of Stay | <0.001 | ||
| Same Day | 0 (0.0%) | 61 (16.4%) | |
| <24 Hours | 173 (31.9%) | 264 (71.0%) | |
| ≥2 Days | 370 (68.1%) | 47 (12.6%) | |
| Disposition (Home) | 487 (89.7%) | 339 (91.1%) | 0.272 |
| Transfusion | 29 (5.3%) | 5 (1.3%) | 0.001 |
| Complications | |||
| Deep Infection | 3 (0.6%) | 4 (1.1%) | 0.302 |
| Superficial Infection | 0 (0.0%) | 0 (0.0%) | 1.000 |
| Pulmonary Embolism | 0 (0.0%) | 2 (0.5%) | 0.165 |
| Deep Vein Thrombosis | 1 (0.2%) | 1 (0.3%) | 0.648 |
| 90-Day ED | 14 (2.6%) | 18 (4.8%) | 0.051 |
SD = standard deviation; Freq = frequency; N = number of patients; ASA = American Society of Anesthesiologists; ED = emergency department.
When evaluating just the RDP group, patients achieving outpatient discharge were significantly younger (p = 0.002), were more commonly male (p = 0.002) and had a lower ASA category (p = 0.011) (Table 2). Additionally, those successfully achieving outpatient status were more commonly discharged to their home environment (p < 0.001) and less likely to require a transfusion (p = 0.016). There were no significant difference in outpatient and inpatient groups for wound or systemic complications. Those requiring inpatient status had significantly more 90-day emergency room visits than those achieving outpatient discharge (p = 0.017). The results of the univariate logistic regression for outpatient and inpatient status with only RDP patients are presented in Table 3. Of the significant variables, only female (OR: 3.155, CI: 1.615–6.163; p = 0.001) and ASA over two (OR: 3.186, CI: 1.658–6.125; p = 0.001) were significant contributors to inpatient status.
Table 2.
Comparison of outpatient and inpatient for rapid discharge protocol - mean (SD)/Freq (%).
| Outpatient (N = 325) | Inpatient (N = 47) | p-value | |
|---|---|---|---|
| Age (years) | 66.22 (9.6) | 70.96 (12.2) | 0.002 |
| Body Mass Index (kg/m^2) | 27.32 (4.9) | 25.70 (6.0) | 0.030 |
| Gender (Male) | 182 (56.0%) | 15 (31.9%) | 0.002 |
| ASA >2 | 127 (39.1%) | 30 (63.8%) | 0.001 |
| Disposition (Home) | 310 (95.4%) | 29 (61.7%) | <0.001 |
| Transfusion | 2 (0.6%) | 3 (6.4%) | 0.016 |
| Complication | |||
| Deep Infection | 3 (0.9%) | 1 (2.1%) | 0.419 |
| Superficial Infection | 0 (0.0%) | 0 (0.0%) | 1.000 |
| Pulmonary Embolism | 2 (0.6%) | 0 (0.0%) | 0.763 |
| Deep Vein Thrombosis | 1 (0.3%) | 0 (0.0%) | 0.874 |
| 90-Day ED Visit | 12 (3.7%) | 6 (12.8%) | 0.017 |
SD = standard deviation; Freq = frequency; N = number of patients; ASA = American Society of Anesthesiologists; ED = emergency department.
Table 3.
Rapid discharge patients only: Univariate logistic regression for outpatient and inpatient status.
| OR | CI | p-value | |
|---|---|---|---|
| Age | 1.052 | 1.018–1.088 | 0.003 |
| BMI | 0.937 | 0.877–1.001 | 0.055 |
| Gender | |||
| Male | Reference | ||
| Female | 2.715 | 1.416–5.207 | 0.003 |
| ASA | |||
| ≤2 | Reference | ||
| >2 | 2.751 | 1.457–5.194 | 0.002 |
OR = odds ratio; CI = confidence interval; BMI = body mass index; ASA = American Society of Anesthesiologists.
When comparing RDP outpatients, achieving same day or next day discharge, patients discharged same day were significantly younger (p = 0.006) and more commonly male (p < 0.001) (Table 4). Age (p = 0.001) and female (p < 0.001) were significant contributors to requiring one overnight hospital stay (Table 5). In the multivariate analysis, age (OR: 1.043, CI: 1.012–1.074; p = 0.006) and female (OR: 2.869, CI: 1.493–5.513; p = 0.002) were significant contributors to requiring an overnight hospital stay.
Table 4.
Comparison of same day and next day discharge for rapid discharge protocol - mean (SD)/Freq (%).
| Same Day (N = 61) | Next Day (N = 264) | p-value | |
|---|---|---|---|
| Age (years) | 62.51 (10.2) | 67.08 (9.3) | 0.006 |
| Body Mass Index (kg/m^2) | 27.62 (4.2) | 27.25 (5.1) | 0.450 |
| Gender (Male) | 47 (77.0%) | 135 (51.1%) | <0.001 |
| ASA >2 | 19 (31.1%) | 108 (40.9%) | 0.102 |
| Disposition (Home) | 61 (100%) | 249 (94.3%) | 0.041 |
| Transfusion | 0 (0.0%) | 2 (0.8%) | 0.659 |
| Complications | |||
| Deep Infection | 0 (0.0%) | 3 (1.1%) | 0.535 |
| Pulmonary Embolism | 0 (0.0%) | 2 (0.8%) | 0.659 |
| Deep Vein Thrombosis | 0 (0.0%) | 1 (0.4%) | 0.812 |
| 90-Day ED Visit | 1 (1.6%) | 11 (4.2%) | 0.306 |
SD = standard deviation; Freq = frequency; N = number of patients; ASA = American Society of Anesthesiologists; ED = emergency department.
Table 5.
Rapid discharge patients only: Univariate logistic regression for same day and next day discharge.
| OR | CI | p-value | |
|---|---|---|---|
| Age | 1.05 | 1.020–1.081 | 0.001 |
| BMI | 0.985 | 0.931–1.042 | 0.599 |
| Gender | |||
| Male | Reference | ||
| Female | 3.208 | 1.685–6.106 | <0.001 |
| ASA | |||
| ≤2 | Reference | ||
| >2 | 1.53 | 0.844–2.774 | 0.161 |
OR = odds ratio; CI = confidence interval; BMI = body mass index; ASA = American Society of Anesthesiologists.
4. Discussion
Removing THA from the IPO list has added a significant burden and financial stress to hospitals, particularly for those with fast track arthroplasty protocols where typical patients typically require one to three days for discharge. As of 2020, literature suggests that most U.S. hospitals do not possess highly efficient outpatient THA protocols to address these changes. In two previous studies examining large, national databases of over 70,000 THA cases, only 0.73%–2.9% of cases were performed as “outpatient” THA, defined as less than a 24 h hospitalization.10,16,17 In the current study, 32% of SDP patients successfully achieved outpatient status, which was well above the percentage previously reported. In line with the position of AAHKS,2 the success of the SDP in the current study was likely due to the experience and well-coordinated post-operative care provided. However, the percentage of patients having successfully achieved outpatient discharge significantly increased to 87.4% with the implementation of the RDP.
With no significant difference in patient demographics between the SDP and RDP groups, the increased percentage of patients successfully achieving outpatient discharge was likely due to the perioperative management following the RDP implementation. Compared to the SDP, RDP protocol changes primarily focused on preoperative patient expectation management and efficient postoperative patient evaluation and mobilization protocols. Despite the positive outcomes for outpatient discharge, protocol modifications brought about new or persistent barriers to rapid discharge. Due to the high volume of joint arthroplasties performed, patients undergoing unilateral THA were not always able to be preferentially scheduled early in the day. Secondly, despite having a dedicated orthopedic ACNP and extended physical therapy hours to evaluate, manage and discharge patients, these evaluations occurred on the floor after the patient had been recovered in the PACU. Although not specifically collected, frequent delays in patient navigation or room availability likely influenced the success of prompt discharge. Future efforts will be focused on assessing discharge ability while in recovery to limit dependence on post-operative patient navigation.
As with any protocol, ensuring patient safety and controlling readmissions is critical to not only the patient but to control the financial burden to both the hospital and patient.18 Implemented changes associated with the RDP did not increase the frequency of wound or systemic complications compared to the SDP. Additionally, there were no significant differences in complications between RDP patients successfully achieving same day discharge compared to those required to stay one night. Similar to previous studies,17,19,20 the rate of transfusions decreased significantly between the SDP (5.3%) and RDP (1.3%), with three of the five RDP transfusions occurring in patients unable to achieve outpatient discharge. Although not significant, the number of 90-day emergency department visits was slightly higher in the RDP group compared to the SDP group. However, similar to previous research,21 length of stay may have been the primary influence of emergency department visits, as 12.8% of RDP patients requiring inpatient status sought treatment within the emergency department compared to only 3.7% of patients achieving outpatient discharge. Based on these results, achieving outpatient discharge did not increase the percentage of post-operative complications, for both same day and next day discharged RDP patients.
Although the primary purpose of this study was to evaluate the success of outpatient discharge following implementation of the RDP, 16.4% of patients were able to achieve same day discharge. Consistent with previous literature, younger males were more likely to achieve same day discharge.5,9 However, the percentage of patients having successfully achieved same day discharge in the current study was far less than the 75%–100% of patients achieving same day discharge in previous literature.3, 4, 5, 6, 7, 8 As previously mentioned, those studies included highly selected patients with extensive exclusion criteria, including age >75 years, BMI >40 kg/m2, ASA ≥3, and the presence of comorbidities.3, 4, 5, 6, 7, 8 These exclusion criteria likely misrepresent the THA population, as RDP patient demographics in the current study included 42.2% of patients with an ASA category three or four, a max BMI of 43.4 and max age of 90 years old. These results suggest that achieving same day discharge or even outpatient status (<24 h stay) in 100% of THA patients is unlikely, even when well-coordinated RDPs are followed.
There are many limitations of this study. First, the RDP in the current study was implemented in an established setting, with an experienced surgeon and pre-existing coordination of care between multiple departments, including anesthesiology, pharmacology, physical therapy, hospitalists and nursing staff. Therefore, the protocol and subsequent results are likely not generalizable to low volume settings, which further emphasizes the unlikelihood of achieving 100% outpatient status following THA. Secondly, ASA category was used as a general indicator of health status instead of individual comorbidities. With only age and gender significantly contributing to discharge status, future studies should evaluate individual comorbidities to better identify patients unlikely to be good candidates for rapid discharge. Thirdly, while an attempt was made to prioritize scheduling of unilateral THA patients earlier in the day, this was not possible due to the daily surgical case load of a high volume surgeon. However, since operative start time was not collected, the relationship between operative time and successful discharge within 24 h cannot be determined. Finally, the patient social support network and preoperative functional status were not evaluated, both of which likely influence the ability to successfully undergo rapid discharge. Future prospective studies should evaluate pre and post-operative outcomes to determine the influence on discharge status.
5. Conclusions
The implementation of a collaborative, multi-departmental RDP, focused on patient expectation management, scheduling, and staffing, resulted in a significant increase in the percentage of patients successfully and safely achieving discharge within 24 h following unilateral THA. Although the improvement in outpatient and same day discharge status was significant (87.4% and 16.4%, respectively), the percentages remain well below previous research evaluating carefully selected patients chosen for outpatient THA. These results represent an unselected, representative sample of the general population undergoing THA and provide insight into feasibility of outpatient THA if attempted for all patients. Future research should evaluate other patient characteristics, in addition to age and gender identified as contributing factors in the current study, to better prioritize patients and optimize success for rapid discharge.
Declaration of competing interest
Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jor.2021.09.012.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
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