Implementation of a day-stay joint replacement pathway in an Australian regional public hospital: A descriptive study.

OBJECTIVE: To describe the implementation, feasibility and safety of a day-stay joint replacement pathway in a regional public hospital in Australia. METHOD: Over a 12-month pilot period, a prospective descriptive analysis of consecutive patients undergoing total knee and hip arthroplasty was conducted. The number of eligible day-stay patients, proportion of successful same-day discharges and reasons for same-day failure to discharge were recorded. Outcome measures captured for all joint replacements across this period included length of stay (LoS), patient reported outcomes, complications and patient satisfaction. The implementation pathway as well as patient and staff identified success factors derived from interviews were outlined. RESULTS: Forty-one/246 (17%) patients booked for joint replacement surgery were eligible for day-stay and 21/41 (51%) achieved a successful same-day discharge. Unsuccessful same-day discharges were due to time of surgery too late in the day (7/20), no longer meeting same-day discharge criteria (11/20) and declined discharge same-day (2/20). Over the implementation period 65% (162/246) of all patients were discharged with a LoS of 2 days or less. Patient satisfaction for the day-stay pathway was high. Complication rates and patient-reported outcomes were equivalent across LoS groups. CONCLUSION: The day-stay joint replacement surgery pathway was feasible to implement, safe and acceptable to patients. Day-stay pathways have potential patient and system-level efficiency benefits.

Patient-reported outcomes of a short hospital stay after total knee replacement in a regional public hospital: a prospective cohort treated 2018-2019.

BACKGROUND: Patient-reported outcomes and satisfaction following short length of stay (LoS) after total knee arthroplasty (TKA) in the Australian regional context remain unexplored. This study reports complications, outcomes and satisfaction of patients discharged from an enhanced recovery protocol (ERP), 6 weeks after TKA in a regional hospital. METHODS: Prospective recruitment occurred between 2018 and 2019. Demographics, intraoperative data, complications and emergency department (ED) presentations were retrieved from hospital records. Complications were graded for severity using a published scale. Knee range of motion (ROM), timed up-and-go (TUG), 6-min walk test (6MWT) and Oxford Knee Scores (OKS) were assessed preoperatively and 6 weeks postoperatively. Patient satisfaction was assessed via questionnaire at the postoperative follow-up. RESULTS: One hundred patients/117 primary TKAs were prospectively included. Median LoS was 2 days (interquartile range 1-3 days) with 74.4% and 88.4% of patients satisfied with their knee and LoS, at 6 weeks respectively. Twenty-seven patients presented to the ED a total of 37 times with complication severity of Grade III or less, and 10 patients were readmitted. Significant improvements in objective and subjective outcomes were observed, however only change in median OKS exceeded the minimal clinically important difference (MCID) threshold. CONCLUSION: An enhanced recovery protocol after TKA in a regional hospital can achieve a median LoS of 2 days without compromising patient-reported outcomes and objective functional measures, whilst maintaining a high level of patient satisfaction with both the surgery and LoS. Further work is required to better optimize management of largely low-grade complications in this patient population.

Factors Affecting Hospital Length of Stay following Total Knee Replacement: A Retrospective Analysis in a Regional Hospital.

In an effort to reduce hospital length of stay (LoS) following total knee arthroplasty (TKA), patient management strategies have evolved over time. The aims of this study were threefold: first, to quantify the reduction in LoS for TKA in a regional hospital; second, to identify the patient, surgical and management factors associated with hospital LoS; and lastly, to assess the change in complications incidence and hospital readmission as a function of LoS. A retrospective chart review was conducted on a consecutive series of primary and revision TKAs from January 2012 to March 2018. Factors describing patient demographics, as well as preoperative, intraoperative, surgical, and postoperative management, were extracted from paper and electronic medical records by a team of reviewers. Multivariate linear regression was performed to assess the association between these factors and LoS. In total, 362 procedures were included, which were reduced to 329 admissions once simultaneous bilateral procedures were taken into account. Median LoS reduced significantly (p = 0.001) from 6 to 2 days over the period of review. A stepwise regression analysis identified patient characteristics (age, gender, comorbidities, discharge barriers), perioperative management (anesthesia type), surgical characteristics (approach, alignment method), and postoperative management (mobilization timing, postoperative narcotic use, complication prior to discharge) as factors explaining 58.3% of the variance in LoS. Representation to emergency (6%) and hospital readmission (3%) remained low for the reviewed period. Efforts to reduce hospital LoS following TKA within a regional hospital setting can be achieved over time without significant increases in the rate or severity of complications or representation to acute care and subsequent readmission. The findings establish the role of patient, surgical and management factors in the context of agreed discharge criteria between care providers.

Safely Reducing the Incidence of Contralateral Slipped Capital Femoral Epiphysis: Results of a Prospectively Implemented Prophylactic Fixation Protocol Using the Posterior Sloping Angle.

BACKGROUND: Bilateral slipped capital femoral epiphysis (SCFE) is common. The management of the contralateral hip in unilateral SCFE remains controversial. The aim of this study was to report on the clinical outcomes using a posterior sloping angle (PSA) threshold of 14.5 degrees for prophylactic fixation in preventing contralateral SCFE. METHODS: Having previously established through a retrospective study that PSA was predictive of future slip, the authors put in place a protocol where patients with unilateral SCFE who had a PSA ≥14.5 degrees on the contralateral side were offered prophylactic fixation. Those with unilateral SCFE presenting between January 2008 and December 2018 with a minimum of 12-month follow-up were included. Patients with renal or endocrine disorders were excluded. Primary outcomes were the number of slips prevented, the number needed to treat, and the complication rate. RESULTS: Of the 219 patients who were included, 114 (52.1%) underwent prophylactic fixation.A PSA threshold of 14.5 degrees prevented 77% of subsequent slips with a number needed to treat of 2.4 in our population. There were no cases of chondrolysis, avascular necrosis, or periprosthetic fracture associated with prophylactic pinning. CONCLUSIONS: Prophylactic fixation using a PSA of 14.5 degrees is safe, decreases unnecessary intervention, and reduces 77% of subsequent SCFE. The PSA can increase over time and the authors recommend that the protocol be applied for the duration of follow-up. LEVEL OF EVIDENCE: Level III.

Comparison of open and closed staff-assisted glove donning on the nature of surgical glove cuff contamination.

BACKGROUND: We have observed that surgical glove cuffs commonly fold over during an operation, exposing the inside of the glove cuff to the sterile field and wound, a potential source of contamination if the inside of the glove cuff has been in contact with the fingers during glove donning. We hypothesize that open staff-assisted gloving results in more inside-glove cuff contamination than a closed staff-assisted technique. METHOD: We performed a blinded, randomized study comparing open and closed staff-assisted glove donning. Two surgeons were gloved 20 times after covering their fingers and hands with GlitterBug powder. The gloves were turned inside out and the distance of GlitterBug powder from the free edge of the cuff was measured. RESULTS: Staff-assisted open glove donning was associated with significantly more glove cuff contamination than closed staff-assisted glove donning (P= 0.001). CONCLUSION: Given glove cuff 'turn down' intra-operatively, we strongly recommend closed staff-assisted gloving.