Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty?

BACKGROUND: Total joint arthoplasty (TJA) cost containment has been a key focus for the Centers for Medicare and Medicaid Services spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions before discharge, but the type and quantity of interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA. METHODS: 1725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures, results of interventions, and readmissions. RESULTS: 759 patients were discharged on postoperative day 1. Eighty-four percent (641 of 759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. Ninety-two percent (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. 90-day all-cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention. CONCLUSION: Most patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.

Outpatient Joint Arthroplasty-Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score.

BACKGROUND: The Outpatient Arthroplasty Risk Assessment (OARA) score was designed to identify patients medically appropriate for same- and next-day discharge after surgery. The purpose of this study was to update and confirm the greater predictive utility of the OARA score in relation to American Society of Anesthesiologists Physical Status (ASA-PS) classification for same-day discharge and to identify the optimal preoperative OARA score for safe patient selection for outpatient surgery. METHODS: The perioperative medical records of 2051 primary total joint arthroplasties performed by a single surgeon at an academic tertiary care hospital were retrospectively reviewed. Six statistical measures were calculated to examine OARA score performance in binary classification of successful same-day discharge and preoperative OARA scores equal to 0 to 59 points (yes vs no) vs 0 to 79 points (yes vs no). RESULTS: Mean OARA scores increased more sharply in magnitude with increasing length of stay, providing superior discrimination than the ASA-PS classification with respect to same-day discharge. Preoperative OARA scores up to 79 points approached the desired 100% for positive predictive value (98.8%) and specificity (99.3%) and 0% for false positive rates (0.7%). CONCLUSION: The OARA score was designed to err in the direction of medical safety, and OARA scores between 0 and 79 are conservatively highly effective for identifying patients who can safely elect to undergo outpatient total joint arthroplasty. The ASA-PS classification does not provide sufficient discrimination for safely selecting patients for outpatient arthroplasty.

Preoperative Patient Preparation for Total Knee Arthroplasty.

The perioperative treatment of patients who undergo total knee arthroplasty is commonly discussed and the focus of many researchers. Typically, protocols and pathways are developed by surgeons and hospitals to standardize the care of, improve the outcomes of, and minimize complications in these patients. Intraoperative and postoperative total knee arthroplasty protocols have been well documented in the literature and are the subject of a substantial number of peer-reviewed studies. The preoperative treatment and optimization of these patients is a topic that has been somewhat neglected; however, recent studies have deemed the topic extremely relevant. The preoperative treatment of patients who undergo total knee arthroplasty includes a thorough medical evaluation, an infection prevention plan, and blood and pain management strategies. The perioperative optimization of these patients may lead to improved patient selection, reduced complications, and improved patient satisfaction. Preoperative patient optimization is important given the trend toward pay-for-performance and bundled payment models and has led to a drastic reduction in blood transfusions, improved patient safety, lower postoperative pain scores, and a reduction in the overall rate of infection.

Postoperative Patient Treatment for Total Knee Arthroplasty.

In the current healthcare environment, the postoperative treatment of patients who undergo total knee arthroplasty (TKA) is critical to successful outcomes, patient satisfaction, and controlling costs. Preemptive analgesia and the avoidance of excessive narcotics may help improve the outcomes and satisfaction of patients who undergo TKA because it allows for a more rapid rehabilitation program and reduces overall pain. Various techniques can be used to minimize the postoperative pain routinely observed in these patients. In addition, appropriate postoperative blood management may help minimize the need for transfusion and its associated risks. Such protocols, which involve the use of antifibrinolytic agents, appropriate knee positioning, and adjustment of transfusion triggers, have decreased the transfusion rate to 1% to 3% in patients who undergo routine primary TKA. The enhancement of patient satisfaction and the management of overall costs, which also must be considered in the perioperative medical management of these patients, includes appropriate control of diabetes mellitus, management of hyponatremia, and minimization of unnecessary workup of postoperative fever. The final aspect of postoperative treatment involves wound management, which includes how to best manage early wound drainage. Numerous types of surgical dressings are available for wound coverage, and surgeons should understand the risks, benefits, and costs of each type of surgical dressing. This cumulative knowledge may result in successful outcomes, increased patient satisfaction, and decreased costs for patients who undergo TKA.

Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the "Outpatient Arthroplasty Risk Assessment Score".

BACKGROUND: Current patient selection criteria and medical risk stratification methods for outpatient primary total joint arthroplasty (TJA) surgery are unproven. This study assessed the predictive ability of a medically based risk assessment score in selecting patients for outpatient and short stay surgery. METHODS: A retrospective review of 1120 consecutive primary TJAs in an early discharge program was performed. An Outpatient Arthroplasty Risk Assessment ("OARA") score was developed by a high-volume arthroplasty surgeon and perioperative internal medicine specialist to stratify patients as "low-moderate risk (≤59)" and "not appropriate" (≥60) for early discharge. OARA, American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and Charlson comorbidity index (CCI) scores were analyzed with respect to length of stay. RESULTS: The positive predictive value of the OARA score was 81.6% for the same or the next day discharge, compared with that of 56.4% for ASA-PS (P < .001) and 70.3% for CCI (P = .002) scores. Patients with OARA scores ≤59 were 2.0 (95% confidence interval [CI], 1.4-2.8) times more likely to be discharged early than those with scores ≥60 (P < .001), while a low ASA-PS score was 1.7 (95% CI, 1.2-2.3) times more likely to be discharged early (P = .001). CCI did not predict early discharge (P ≥ .301). With deliberate patient education and expectations for outpatient discharge, the odds of early discharge predicted by the OARA score, but not the ASA-PS score, increased to 2.7 (95% CI, 1.7-4.2). CONCLUSION: The OARA score for primary TJA has more precise predictive ability than the ASA-PS and CCI scores for the same or next day discharge and is enhanced with a robust patient education program to establish appropriate expectations for early discharge. Early results suggest that the OARA score can successfully facilitate appropriate patient selection for outpatient TJA, although consideration of clinical program maturity before adoption of the score is advised.