Defining Same-Day Criteria: Knowing When to Change Course

Logan Cooper

Tyler D. Goldberg

Introduction

Projections suggest total joint arthroplasty procedures performed in the United States will continue to rise significantly over the next decade.¹ Given the current economic strains on the health care industry, providing high-quality, cost-efficient solutions to meet demand must be a priority. Clinical care pathways encompassing medical optimization of the patient, preoperative evaluation, less invasive surgical techniques, and postoperative pain control and rehabilitation have facilitated rapid discharge programs along with minimizing potential complications, thus saving prolonged and expensive hospitalizations. Direct anterior approach (DAA) total hip arthroplasty (THA) is an ideal procedure to facilitate rapid, same-day discharge. Several authors have reported the safety and efficacy of rapid discharge in DAA THA, specifically in a patient cohort deemed low risk as defined by having few premorbid health conditions and low risk for postoperative complications.²^,³^,⁴^,⁵

This chapter discusses in depth the reasons why same-day discharge programs are needed and helps to define the ideal patient candidate to undergo this procedure. Furthermore, we discuss patients who may not be suited for rapid discharge.

Why Same-Day Discharge?

THA has been traditionally considered an inpatient surgical procedure with hospital stays ranging from 2 to 5 days. However, length of stays after THA have seen a gradual decrease as patient care pathways are formalized and optimized surrounding this procedure. “Outpatient” arthroplasty has grown in popularity but continues to be an ambiguous term in the literature. Outpatient may indicate an inpatient stay of up to 23 hours with an overnight stay or may mean a true discharge from the facility the same day. Same-day discharge is currently the final hurdle in care pathway optimization for THA.

There are essentially four reasons to move toward same-day discharge recovery programs in THA. First, safety for the patient should be considered. Hospital-acquired conditions (HACs) are avoided with same-day discharge. In 2010, the Department of Health and Human Services reported the incidence of HACs was 27%, or 5.9 million complications, in the United States. These complications resulted in prolonged hospitalizations, permanent harm, life-sustaining interventions, and even death. Unfortunately, 50% of these HACs were deemed entirely preventable.⁶

Furthermore, Keswani et al⁷ reviewed 106,360 patients in a national database analyzing discharge location and safety. In their bi- and multivariate analyses, patients discharged home had decreased readmissions and adverse events. In contrast, patients discharged to rehabilitation facilities had increased readmission and adverse event rates.⁷

Multiple reports have shown safety with same-day discharge (Table 41.1). Arshi et al² compared 2184 outpatient THA procedures with 73,596 inpatient THA procedures using PearlDiver Insurance records. Multivariate logistic regression analysis found that, after adjusting for confounding variables, the rates of surgical complications were comparable within the two groups, demonstrating efficacy.²

TABLE 41.1 Published Literature Addressing the Safety of Outpatient Total Hip Arthroplasty (THA)

Study	n	Mean follow-up	Outcomes
Goyal et al⁴	Inpatient: 108 Outpatient: 112	4 wk	No difference in the number of reoperations, hospital readmissions, ED visits, acute office visits, or number of phone calls and emails to the surgeon’s office
Nelson et al⁸	Inpatient: 63,424 Outpatient: 420	30 d	After adjusting for potential confounders, patients undergoing outpatient THA were not at greater risk of 30-d adverse events or readmissions
Lovecchio et al⁹	Inpatient: 1476 Outpatient: 492	30 d	Outpatients had higher medical complication rates (10.0% outpatient vs 6.7% inpatient). Most complications were bleeding requiring transfusion. No difference in readmission rates. (This study includes THA and TKA.)
Arshi et al²	Inpatient: 73,596 Outpatient: 2184	1 y	Patients undergoing outpatient THA had comparable rates of complications, including component revision, irrigation and debridement, and hip dislocations.
Gromov et al¹⁰	Inpatient: Outpatient:	NA	A total of 557 consecutive unselected patients were screened for eligibility for outpatient THA or TKA. Authors determined 54% were potentially eligible for outpatient surgery. Actual same-day discharge occurred in 13% to 15%. Female sex and surgery late in the day were risk factors for delayed discharge.
Otero et al¹¹	Inpatient: 107,922 Outpatient: 762	30 d	THA patients discharged on POD 0 had a higher complication rate than those discharged on PODs 1 through 4 (5.6% vs 2.0%). Risk factors include age > 70 y, BMI > 30, smoking, CAD, steroid use, bleeding disorder, operative time > 120 min, and ASA PS ≥ 3. (This study included THA, TKA, and UKA.)
Hoffmann et al¹²	1009	NA	Of the 1009 selected for outpatient TJA, 955 (94.7%) were discharged on the same day. Failure to discharge occurred secondary to pain, hypotension, and nausea. Twenty (1.98%) readmissions or ED visits occurred, and 20 (1.98%) patients required reoperation. One major complication occurred (myocardial ischemia) in a patient with preexisting CAD. (This study included THA and TKA.)
Klein et al¹³	549	630 d	Of 549 outpatient THA procedures, four visited the hospital within 2 days of surgery. One was admitted for pain control, one for acetabular component migration, and one for hypotension/bradycardia. The fourth patient was seen in the ED for pain control and later discharged home.
Richards et al¹⁴	Inpatient: 136 Outpatient: 136	90 d	8.8% of the outpatient cohort and 10.3% of the inpatient cohort experienced an adverse event. There was no significant differences between the rate or severity of adverse events. There were no serious adverse events in either group. In the outpatient group, there was a correlation between the dosage of spinal anesthetic and the time required in the PACU.
Gromov et al¹⁵	Inpatient: 339 Outpatient: 138	90 d	6% of outpatients and 4% of inpatients were readmitted within 90 d. No readmissions occurred in the first 48 h. No readmissions were related to DOS discharge. Of the 138 outpatients, 116 were successfully discharged on DOS. (This study included THA and TKA.)
Toy et al¹⁶	145	90 d	One of the 145 procedures required transfer from the ASC to the hospital for blood transfusion. Three patients required surgical intervention. Persistent drainage occurred in one leading to I&D with head/liner exchange. One sustained a periprosthetic fracture after a fall. The last patient required a superficial I&D. An additional patient required a visit to the ED for a dislocation, which was reduced in the ED, and the patient was discharged home.
Weiser et al¹⁷	Inpatient: 1315 Outpatient: 164	90 d	There was no statistically significant difference in 30-d readmission rates between groups (outpatient 0.6% vs inpatient 1.6%). The outpatient group had a significantly lower rate of 90-d readmissions (0.6% vs 3.6%).
ASA PS, American Society of Anesthesiologists physical status; ASC, ambulatory surgery center; BMI, body mass index; CAD, coronary artery disease; DOS, day of surgery; ED, emergency department; I&D, incision and drainage; NA, not applicable; PACU, postanesthesia care unit; POD, postoperative day; TJA, total joint arthroplasty; TKA, total knee arthroplasty; UKA, unicompartmental knee arthroplasty.

Second, patient satisfaction is excellent with patients undergoing same-day discharge. Kelly et al¹⁸ evaluated satisfaction surveys on 64 patients undergoing outpatient THA versus 102 patients undergoing inpatient THA. The overall satisfaction was high in both cohorts; however, differences favored the outpatient group. Specifically, patients were more satisfied with medication explanations, pain management, and nurse treatment. Facility and overall experiences were similar between the two groups. However, patients in the inpatient facility did not feel prepared to discharge to home.¹⁸

Third, the financial implications of same-day discharge cannot be overlooked given the current state of our health care economy. New ways to deliver value-based care are critical to creating a healthy and sustainable health care system. Multiple authors have reported significant cost savings while maintaining safety by performing outpatient THA procedures. For example, Aynardi et al¹⁹ evaluated complications, length of stay, and the overall costs associated with outpatient versus inpatient DAA THA. With no increase in complications, they demonstrated over $7000 in savings per case by those performed in the outpatient setting.

The fourth and final reason to perform same-day discharge is to maximize physician control over the episode of care surrounding the procedure. Although not easy to report, it is well known that physician control over the patient experience is decreased as more stakeholders are involved in a particular episode. Even the most well-designed care pathways can be sabotaged by a well-meaning but uninformed care provider associated with a hospital. The pursuit of a rapid, same-day discharge program will minimize unwanted interactions and consequently allow the physician’s message to be paramount in the patient’s experience.

Outpatient arthroplasty should be performed only in carefully selected patient populations. However, debate exists over the selection criteria. Gromov et al¹⁰ found that only 15% of unselected patients referred for THA were eligible for same-day discharge. Consequently, the physician must be meticulous in indicating a patient for same-day discharge.

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