Reducing Length of Stay in Total Joint Arthroplasty Care




As health care reforms continue to improve quality of care, significant emphasis will be placed on evaluation of orthopedic patient outcomes. Total joint arthroplasty (TJA) has a proven track record of enhancing patient quality of life and are easily replicable. The outcomes of these procedures serve as a measure of health care initiative success. Specifically, length of stay, will be targeted as a marker of quality of surgical care delivered to TJA patients. Within this review, we will discuss preoperative and postoperative methods by which orthopedic surgeons may enhance TJA outcomes and effectively reduce length of stay.


Key points








  • Preoperative, intraoperative, and postoperative factors should be optimized to decrease hospital length of stay.



  • Risk factors—age over 64 years, operating time, American Society of Anesthesiologists score of 2 or greater, and comorbid conditions—may result in prolonged duration of stay.



  • Many fast track protocols have been adopted to improve postoperative outcomes and decrease length of stay.



  • Patient education and activation remain important measures that optimize overall outcomes.






Introduction


The United States consistently ranks as the leader of developed nations in per capita health care expenditures. Approximately 19.6% of the economy’s spending share will be health care driven, resulting in US$5.4 trillion projected to be spent per year by 2024. Recent policy changes and impending future modifications, such as bundle payments and outcome-based reimbursement, are aimed at reducing costs by improving the efficiency of the provided care. Amid methods to alleviate such spending projections, orthopedic surgeons continue to strive to develop practices that provide evidence-based care that is both individualized, as well as standardized for an aging population.


In 2009, 284,000 primary total hip arthroplasties (THAs) and 619,000 total knee arthroplasties (TKAs) were performed. In only 5 years, these figures are projected to increase to 610,583 THAs and 1,557,975 TKAs. With substantial numbers of procedures being performed annually, optimizing patients’ outcomes while maximizing efficiency remains an overarching goal in total joint arthroplasty (TJA) care. For several decades, literature references that 30% of hospital expenses associated with TJA were allocated toward the patient’s hospital room. Notably, a shorter length of stay (LOS) has been associated with decreased hospital costs. Thus, minimizing the time spent in hospital after TJA has the potential to limit the future financial burden.


There is substantial economic benefit of decreasing LOS in arthroplasty patients. However, few studies directly link reduced LOS with patient satisfaction. An evaluation of 445 TJA patients who underwent “fast track” procedures, aimed toward maximizing efficiency and reducing in-hospital time, reported a 90% patient satisfaction with shorter LOS. Furthermore, the risk of surgical site infection has been shown to be correlated with LOS in TJA patients. Reducing LOS is a realistic target for health care institutions and has the potential to maximize economic efficiency, while simultaneously improving quality and postoperative outcomes. The aim of this review is to explore strategies that have proven effective in reducing LOS, and thereby improving quality of care delivered to TJA patients.




Introduction


The United States consistently ranks as the leader of developed nations in per capita health care expenditures. Approximately 19.6% of the economy’s spending share will be health care driven, resulting in US$5.4 trillion projected to be spent per year by 2024. Recent policy changes and impending future modifications, such as bundle payments and outcome-based reimbursement, are aimed at reducing costs by improving the efficiency of the provided care. Amid methods to alleviate such spending projections, orthopedic surgeons continue to strive to develop practices that provide evidence-based care that is both individualized, as well as standardized for an aging population.


In 2009, 284,000 primary total hip arthroplasties (THAs) and 619,000 total knee arthroplasties (TKAs) were performed. In only 5 years, these figures are projected to increase to 610,583 THAs and 1,557,975 TKAs. With substantial numbers of procedures being performed annually, optimizing patients’ outcomes while maximizing efficiency remains an overarching goal in total joint arthroplasty (TJA) care. For several decades, literature references that 30% of hospital expenses associated with TJA were allocated toward the patient’s hospital room. Notably, a shorter length of stay (LOS) has been associated with decreased hospital costs. Thus, minimizing the time spent in hospital after TJA has the potential to limit the future financial burden.


There is substantial economic benefit of decreasing LOS in arthroplasty patients. However, few studies directly link reduced LOS with patient satisfaction. An evaluation of 445 TJA patients who underwent “fast track” procedures, aimed toward maximizing efficiency and reducing in-hospital time, reported a 90% patient satisfaction with shorter LOS. Furthermore, the risk of surgical site infection has been shown to be correlated with LOS in TJA patients. Reducing LOS is a realistic target for health care institutions and has the potential to maximize economic efficiency, while simultaneously improving quality and postoperative outcomes. The aim of this review is to explore strategies that have proven effective in reducing LOS, and thereby improving quality of care delivered to TJA patients.




Factors that affect hospital stay


At the most basic level, to decrease LOS, the time required for patients to meet discharge criteria must be minimized. The final decision to discharge a patient is multifactorial and takes into consideration the patient’s level of independence, pain control, mental status, control of other medical conditions, gastrointestinal and genitourinary function, and dietary intake, among others. Husted and colleagues reported that “age, sex, marital status, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA [American Society of Anesthesiologists] score, and time between surgery and mobilization, were all found to influence postoperative outcome in general, and LOS and patient satisfaction in particular.” A retrospective study assessing 10,000 TJAs examined primary reasons for delayed discharge from the hospital. In almost 6000 THA patients, the leading causes of prolonged LOS were wound drainage (41.5%), slow physical therapy (22%), discharge issues (17%), and previous health conditions. In the TKA cohort, hospital-acquired conditions (22.5%) was also frequently noted. In a recent study, Inneh concluded that age over 64 years, operating room time, American Society of Anesthesiologists score greater than or equal to 2, and comorbid conditions were risk factors for prolonged LOS after primary TJA, and general anesthesia increased LOS in THA patients specifically.




Fast track pathways


In recognition of the interplay affecting the in-hospital stay duration, “fast track” protocols have been developed. The underlying premise is to devise a multimodal, evidence-based treatment plan that aims to improve efficiency and clinical outcomes. Areas of focus for these pathways include preoperative education and assessment, anesthesia, fluid therapy, pain therapy, and early postoperative mobilization. Pour and colleagues reported that patients in the fast track had shorter hospital stays, increased walking distance at discharge, and an higher probability of discharge to home versus an extended care facility. Similarly, a recent study noted a significant reduction in LOS from 8.1 days to 3.1 days after implementing a fast track treatment plan for TJA patients.


Owing to its multidisciplinary nature, it is unlikely that a single intervention will decrease LOS in TJA patients across institutions. A further reaching protocol that incorporates and addresses preoperative, intraoperative, and postoperative variables to maximize efficiency at each stage of the patient’s experience will likely produce more preemptive improvements. However, this requires the collaboration of the orthopedic surgeon with various providers in other specialties as well as ancillary staff to develop a well-rounded care-plan. The implementation of a multidisciplinary horizontal hierarchal structure of multidisciplinary teams that approaches patient care through the learning cycle of diagnosis, design, action, and reflection, has been proposed as an effective way to promote the necessary cooperative environment. This system of repeated reevaluation and reflection has demonstrated improved quality of care and patient outcomes in preliminary implementation.




Preoperative education


The process of maximizing efficiency of care to reduce LOS for TJA patients begins in the preoperative period. Preparing the patient both mentally and physically for the upcoming surgical experience has been shown to have positive effects on clinical outcomes. A randomized controlled trial conducted by Giraudet-Le Quintrec and colleagues, reported a decrease in preoperative anxiety and pain in THA patients who received preoperative education. Conversely, a systematic review by Panteli and colleagues did not report reduction in LOS in TJA patients who received preoperative education when compared with those who did not. Importantly, one of the limitations of this review was the lack of consistency in the type of preoperative education provided or the delivery method chosen among the included studies.


In contrast, Yoon and colleagues reported a decrease in LOS and increased probability of home discharge among their TJA patients who received preoperative education. Furthermore, joint classes, during which TJA candidates receive education specific to the procedure, achieved shorter hospital stays among participating patients. Many fast track protocols have adopted a preoperative patient education component. These programs range from telephone question-and-answer sessions to multiple physical therapy and informative classes. The most cost-effective form of preoperative education has yet to be determined. Nevertheless, it is an important component of any arthroplasty care plan aimed at optimizing outcomes and efficiency.




Assessing nutritional status


The effect of a patient’s nutritional status also aids in determining the length of hospital stay. Malnutrition is defined by a total lymphocyte count of less than 1500 cells/mm 3 and/or serum albumin concentration of less than 3.5 g/dL. Multiple studies reported an association between malnutrition and impaired wound healing in TJA patients. A prospective evaluation of preoperative nutritional status in 213 TKA patients found a significant increase in both superficial and deep wound infections in malnourished patients by anthropometric means. In particular, obese patients with a body mass index of greater than 39 kg/m 2 were noted to have a 9-fold increase in periprosthetic knee infection. Among THA patients, obesity was reported to be a significant risk factor for hospital stay greater than 3 days. Furthermore, malnourished patients often display impaired wound healing with prolonged drainage, which has been shown to be a source for prolonged hospital stay after TJA. Therefore, patients must be optimized before undergoing TJA procedures to decrease the risk of such postoperative complications.


Optimization of medical conditions and comorbidities is imperative for proceeding with surgery. Preoperative evaluation by an internist is recommended as an important step toward maximizing rate of postoperative recovery. Comorbidities pertaining to the circulatory, respiratory, and genitourinary systems are especially associated with prolonged hospitalization. Specifically, poorly controlled diabetes mellitus has been associated with increased local and systemic complications, mortality, and LOS in arthroplasty patients. Diabetes diagnosed at time of surgery has been shown to increase the likelihood of postoperative prosthetic joint infection, and as such, glycemic control in the perioperative period remains crucial.




Minimizing risk of postoperative infection


Multiple studies have examined ways to decrease the rate of infections after TJA. Decolonization protocols are supported; however, the wide variation in protocols makes it difficult to recommend any one regimen over the other. These include intranasal mupirocin, clorhexidine baths, and clorhexidine mouth wash in combination or alone for up to 5 days preoperatively. Perioperative antibiotics are used as a prophylactic measure to eliminate microorganisms that might gain access to the surgical site during the procedure. Antibiotic dosages and timing of administration should exceed the minimum inhibitory concentration of organisms likely to be encountered for the duration of the operation. The use of antibiotics has been well-documented to decrease the risk of infection, and thereby decrease the likelihood of delayed discharge.




Anesthesia modality and blood management


In addition to prophylactic antibiotics, modality of anesthesia administration has been assessed as a factor that contributes to postoperative LOS. A systematic review identified a large body of randomized, controlled trials that reported lower pain scores and morphine consumption postoperatively with the use of regional anesthesia in comparison with general anesthesia in TKA patients. Another randomized control trial evaluated the use of peripheral femoral nerve block in TJA, and the authors reported improved pain control and a 24-hour shorter LOS among this cohort. Regional anesthesia may lead to shorter operative times in THA candidates correlating with reduced LOS. Helwani and colleagues recently examined 13,000 THAs and noted a decrease in deep surgical site infection and LOS in patients who had received regional anesthesia—spinal or epidural—versus those who received general anesthesia. General anesthesia has also been shown to increase risk of cerebrovascular events and cardiac arrest in comparison with spinal anesthesia, despite its tendency to be used in younger patients with lower Charlson Comorbidity Indexes.


Furthermore, anesthesia modality has an impact on blood loss, further affecting the hospital LOS. A recent study reported an overall blood transfusion rate of approximately 17% after THA. Intuitively, LOS and hospital cost are both increased in patients that receive an allogenic transfusion in comparison to those who do not. This same patient population also experiences increased infection rate, pulmonary compromise, thromboembolic events, and mortality rate. Reported risk factors for allogenic transfusion are age, race, payer status, and medical comorbidities. Protocols that can decrease the rate of blood transfusion among arthroplasty patients have significant potential to improve postoperative outcomes and reduce hospital stay. Limiting allogenic transfusions to patients whose hemoglobin is less than 8 g/dL or exhibiting symptoms of anemia, and transfusing 1 unit at a time has displayed a 10% reduction in rate of transfusion. Furthermore, orthopedic surgeons must be cognizant that patients who receive transfusion remain in the hospital on average 1 day longer. Nonetheless, the initial step in achieving this goal is to educate staff and other providers, including anesthesiologists, on transfusion guidelines for the patient.


In efforts to minimize the amount of blood loss, surgeons have turned to hypotensive epidural anesthesia (HEA). HEA is achieved by using a continuous infusion epidural catheter to achieve total sympathetic blockade with a target mean arterial pressure of 45 to 50. A randomized, controlled trial of 30 TKAs demonstrated that HEA reduced transfusion rate compared with spinal anesthesia. Interestingly, it does not seem that the hypotension alone is the driving force in this difference. Hypotensive total intravenous anesthesia has not been shown to be as effective in decreasing intraoperative blood loss or total number of units transfused when compared with HEA, despite having no difference in mean arterial pressure, heart rate, or partial pressure of oxygen.




Urinary catheterization


Postoperative urinary retention, a potential factor that contributes to longer LOS, is not uncommon, and the incidence has been reported to be as high as 84% after arthroplasty procedures. It was historically reported that short-term catheterization after arthroplasty decreases the incidence of urinary retention without increasing the rate of urinary tract infections. Conversely, recent studies have demonstrated that postoperative patients who are not catheterized experience better outcomes. In a retrospective study that evaluated 6154 TKA patients, patients who were not managed with postoperative catheterization were noted to have shorter hospital stay, lower cost, decreased complications, and lower rates of 30-day readmission. Routine catheter use should be avoided, but intermittent catheterization may be required for a select group of patients.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Oct 6, 2017 | Posted by in ORTHOPEDIC | Comments Off on Reducing Length of Stay in Total Joint Arthroplasty Care

Full access? Get Clinical Tree

Get Clinical Tree app for offline access