Safety and feasibility of same-day discharge following uncomplicated transvenous lead extraction.

INTRODUCTION: Transvenous lead extraction (TLE), while mostly a safe procedure, has risk of serious periprocedural complications. As such, overnight hospitalization remains a routine practice. In our center, we routinely discharge patients on the same day following an uncomplicated TLE. METHODS: This is a retrospective study of 265 consecutive patients who underwent uncomplicated TLE in our center between 2019 and 2021. Same-day discharge (SDD) patients are compared with those who stayed at least overnight for observation after the TLE procedure (non-SDD group). To assess the safety of an SDD strategy after uncomplicated TLE, the main study endpoint was to compare the rate of major procedure-related complications at 1-, 7-, and 30-days. To identify the factors influencing the operator's decision to discharge the patient on the same day, the secondary endpoint was to analyze clinical and procedural predictors of SDD. RESULTS: A total of 153 patients were discharged the same day after uncomplicated TLE (SDD), while 112 stayed at least overnight after the procedure (non-SDD). There was no significant difference in major procedure-related complications at 1-day (SDD 0% vs. non-SDD 1.8%, p value = ns), while patients in the SDD group had a lower rate of 7- and 30-day complications when compared with those in the non-SDD group (2.1% vs. 8.2%, p value = .0308; and 3.5% vs. 16%, p value = .0049, respectively). Noninfectious indication for TLE (OR 16.1, 95% confidence interval [CI] 4.29-77.6) and procedure end time before 12:00 (OR 2.82, 95% CI 1.11-7.27) were the only independent predictors of SDD. CONCLUSION: SDD discharge following uncomplicated TLE in selected patients (i.e., those without device infection and when the TLE procedure is completed in the morning) is feasible and safe.

Comprehensive analysis of same day discharge after atrial fibrillation ablation: Clinical, cost, and patient reported outcomes.

BACKGROUND: Same day discharge (SDD) following atrial fibrillation (AF) ablation procedure has emerged as routine practice, and primarily driven by operator discretion. However, the impacts of SDD on clinical outcomes, healthcare system costs, and patient reported outcomes (PROs) have not been systematically studied. METHODS: We retrospectively analyzed patients undergoing routine AF ablation procedures with SDD versus overnight observation (NSDD). After propensity adjustment we compared postprocedure adverse events (AEs), healthcare system costs, and changes in PROs. RESULTS: We identified 310 cases, with 159 undergoing SDD and 151 staying at least one midnight in the hospital (NSDD). Compared with NSDD, SDD patients were similar age (mean 64 vs. 66, p = 0.3), sex (26% female vs. 27%, p = 0.8), and with lower mean CHADS2-VA2Sc scores (2.0 vs. 2.7; p < 0.011). The primary outcome of AEs was noninferior in SDD versus NSDD patients (odds ratio 0.45, 95% confidence interval 0.21-0.99; noninferiority margin of 10%). There were also no differences in overall cost to the healthcare system between SDD and NSDD (p = 0.11). PROs numerically favored SDD (p = NS for all scores). CONCLUSIONS: Physician selection for SDD appears at least as safe as NSDD with respect to clinical outcomes and SDD is not significantly less costly to the health system. There is a trend towards more favorable, general PROs among SDD patients. Routine SDD should be strongly considered for patients undergoing routine AF ablation procedures.

Single-Operator Left atrial appendage Occlusion utilizing Conscious sedation TEE, Lack of Outpatient pre-imaging, and Same-day Expedited discharge (SOLO-CLOSE): A comparison with conventional approach.

BACKGROUND: Left atrial appendage occlusion (LAAO) with WATCHMAN currently requires preprocedural imaging, general anesthesia, and inpatient overnight admission. We sought to facilitate simplification of LAAO. AIMS: We describe and compare SOLO-CLOSE (single-operator LAA occlusion utilizing conscious sedation TEE, lack of outpatient pre-imaging, and same-day expedited discharge) with the conventional approach (CA). METHODS: A single-center retrospective analysis of 163 patients undergoing LAAO between January 2017 and April 2022 was conducted. The SOLO-CLOSE protocol was enacted on December 1, 2020. Before this date, we utilized the CA. The primary efficacy endpoint was defined as successful LAAO with ≤5 mm peri-device leak at time of closure. The primary safety endpoint was the composite incidence of all-cause deaths, any cerebrovascular accident (CVA), device embolization, pericardial effusion, or major postprocedure bleeding within 7 days of the index procedure. Procedure times, 7-day readmission rates, and cost analytics were collected as well. RESULTS: Baseline characteristics were similar in both cohorts. Congestive heart failure (37.5% vs. 11.1%) and malignancy (28.8% vs. 12.5%) were higher in SOLO-CLOSE. Median CHA2D2SVASc score was 5 in both cohorts. The primary efficacy endpoint was met 100% in both cohorts. Primary safety endpoint was similar between cohorts (p = 0.078). Mean procedure time was 30 min shorter in SOLO-CLOSE (p < 0.01). Seven-day readmissions for SOLO-CLOSE was zero. After SOLO-CLOSE implementation, there was a 188% increase in positive contribution margin per case. CONCLUSIONS: The SOLO-CLOSE methodology offers similar efficacy and safety when compared to the CA, while improving clinical efficiency, reducing procedural times, and increasing economic benefit.

Same-day discharge after atrial fibrillation ablation under a nurse-coordinated standardized protocol.

AIMS: Same-day discharge (SDD) after atrial fibrillation (AF) ablation is an effective means to spare healthcare resources. However, safety remains a concern, and besides structural adaptations, SDD requires more efficient logistics and coordination. Therefore, in this study, we implement a streamlined, nurse-coordinated SDD programme following a standardized protocol. METHODS AND RESULTS: As a dedicated SDD coordinator, a nurse specialized in ambulatory cardiac interventions was in charge of the full SDD protocol, including eligibility, patient flow, in-hospital logistics, patient education, and discharge as well as early post-discharge follow-up by smartphone-based virtual visits. Patients planned for AF ablation were considered eligible if they had a left ventricular ejection fraction (LVEF) ≥35%, with basic support at home and accessibility of the hospital within 60 min also forming a part of the eligibility criteria. A total of 420 consecutive patients were screened by the SDD coordinator, of whom 331 were eligible for SDD. The reasons for exclusion were living remotely (29, 6.9%), lack of support at home (19, 4.5%), or LVEF <35% (17, 4.0%). Of the eligible patients, 300 (91%) were successfully discharged the same day. There were no major post-SDD complications. Rates of unplanned medical attention (19, 6.3%) and 30-day readmission (5, 1.6%) were extremely low and driven by femoral access-site complications. These were significantly reduced upon the introduction of compulsory ultrasound-guided punctures after the initial 150 SDD patients (P = 0.0145). Standardized SDD coordination resulted in efficient workflows and reduced the total workload of the medical staff. CONCLUSION: Same-day discharge after AF ablation following a nurse-coordinated standardized protocol is safe and efficient. The concept of ambulatory cardiac intervention nurses functioning as dedicated coordinators may be key in the future transition of hospitals to SDD. Ultrasound-guided femoral puncture virtually eliminated relevant femoral access-site complications in our cohort and should therefore be a prerequisite for SDD.

Same-day discharge after laparoscopic hysterectomy for benign/premalignant disease: A multicentre randomised controlled trial.

OBJECTIVE: To evaluate whether physical function and quality of life was influenced by discharge on the same-day after a total laparoscopic hysterectomy. DESIGN: Multicentre non-inferiority randomised controlled trial. SETTING: Five teaching hospitals and two university hospitals in the Netherlands. POPULATION: Patients undergoing laparoscopic hysterectomy for benign or premalignant disease. METHODS: Following informed consent, participants were allocated 1:1 either to same-day discharge (SDD) or next-day discharge (NDD). MAIN OUTCOME MEASURES: The primary outcome was physical function at 7 days after surgery measured by the Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function short Form 10A. Secondary outcomes were physical function and quality of life at 1 and 3 days and 6 weeks after surgery measured with PROMIS short Form 10A and the EuroQol questionnaire (EQ-5D-5L). RESULTS: Two hundred and five patients were included of whom 105 were allocated to SDD and 100 to NDD. Physical function 7 days after surgery was 35.95 in the SDD group and 35.63 in the control group (mean difference 0.32; 95% CI [0.07-0.57]). As the upper limit of the 95% CI does not exceed the non-inferiority margin of 4 points, non-inferiority of SDD could be demonstrated. No difference in physical function nor quality of life on Days 1 and 3 and 6 weeks could be found. CONCLUSION: This research demonstrates same-day discharge after laparoscopic hysterectomy is non-inferior to next day discharge in physical function 7 days after surgery.

The impact of patient activation on the effectiveness of digital health remote post-discharge follow-up and same-day-discharge after elective colorectal surgery.

BACKGROUND: Low patient activation (PA) is associated with worse postoperative outcomes, however, its impact on the effectiveness of digital health interventions is unknown. We sought to determine the impact of PA on the effectiveness of digital health application for remote post-discharge follow-up for patients undergoing elective colectomy. METHODS: Data analysis included a control cohort (CC) of patients undergoing elective colorectal surgery from 10/2017 to 04/2018 without the digital health intervention and a digital application cohort (DAC) that received a smart phone application for remote post-discharge follow-up from 03/2021 to 08/2022, including a subset of same-day discharge (SDD) patients. PA was measured using the Patient Activation Measure (PAM; score 0-100) and categorized into low (< 55.1) and high (≥ 55.1). The PAM was administered 4-6 weeks before surgery in the DAC group and on postoperative day (POD) 1 in the CC group. The main outcome measure was 30-day emergency department (ED) visits. RESULTS: A total of 164 patients were included (89DAC with 50 SDD, 75CC), with no differences in patient characteristics other than more stoma closures in the DAC group. Overall, 77% of patients had high PA level, with no difference between CC and DAC (77% vs. 81%, p = 0.25). There was no difference in ED visits between CC and DAC (19% vs. 18%, p = 0.90). Overall, low PA was associated more ED visits (29% vs 14%, p = 0.04). In the SDD subgroup, low PA patients had more ED visits (38% vs. 7%, p = 0.015). PA level did not affect app usage metrics. On multiple regression, only low PA remained independently associated with ED visits (OR 3.42, 95%CI 1.27, 9.24). CONCLUSION: Low PA remains an important predictor of surgical outcomes after elective colorectal surgery regardless of the use of a digital health application for remote post-discharge follow-up. This suggests that improving PA levels may improve postoperative outcomes.

Feasibility of same-day discharge after laparoscopic sleeve gastrectomy in the Netherlands.

BACKGROUND: There is a trend towards laparoscopic sleeve gastrectomy (SG) with same-day discharge (SDD), as an efficient healthcare pathway to alleviate the burden on clinical capacity. This approach seems to be safe, if patients are carefully selected. In our bariatric center, a protocol for Roux-en-Y gastric bypass with SDD has already been successfully implemented. The aim of this study was to evaluate feasibility of applying the same SDD protocol for SG. METHODS: A single-center prospective feasibility study was conducted at a high-volume bariatric center. Low-risk patients who were scheduled for primary SG were included. Strict criteria were used for approval upon SDD. The primary outcome was the rate of successful SDD without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality. RESULTS: Fifty patients were included in the study, of whom 45 were successfully discharged on the same day of the surgery. Nausea and vomiting were the most common reasons for overnight hospitalization (three patients). One patient was readmitted within the first 48 h due to a mild complication related to bleeding, resulting in a success rate of 88% for SDD without readmission within 48 h. No severe complications or mortality were reported in the cohort. CONCLUSION: Our SDD protocol for SG has demonstrated feasibility, with a high success rate of SDD and no severe complications. Strict conditions should be met for the safe implementation of a SDD protocol, including careful patient selection and the establishment of a safety net to detect early complications.

Same-day Discharge Following Vaginal Hysterectomy and Native-tissue Apical Repair for Uterovaginal Prolapse: A Prospective Cohort Study.

INTRODUCTION AND HYPOTHESIS: The safety and feasibility of same-day discharge (SDD) has been consistently reported across the benign and gynecologic oncology literature. However, outcomes of SDD in the urogynecology population are sparse. The objectives of this study were to describe the success of SDD following vaginal hysterectomy and native-tissue colpopexy, and to compare the incidence of postoperative adverse events in patients discharged same-day versus postoperative day 1 (POD1). Further objectives were to compare pain, quality of recovery (QoR), and satisfaction between the groups. METHODS: This was a single-center, prospective cohort study of patients with planned SDD. A standardized ERAS protocol was utilized. The QoR-40 questionnaire was administered at baseline, POD2, and the 6-week postoperative visit. Pain scores were captured similarly, and a satisfaction survey was administered at 6 weeks. The primary outcome was composite adverse events defined as any postoperative adverse event and/or health care utilization, excluding telephone calls, and urinary tract infection. RESULTS: A total of 101 patients were enrolled in the study; the primary outcome was available for 99. SDD was achieved for 76 patients (77.0%); 23 patients stayed overnight (23.2%). The overall incidence of composite adverse events was 20.2% (95% CI, 13.5-29.2), and was not different between the groups (26.1% vs 18.4%, p = 0.42). Additionally, there were no differences in the QoR-40 or pain scores on POD2 and at 6 weeks. Patient satisfaction was high and similar between the groups. CONCLUSIONS: Successful SDD was achieved in 77.0% of the patients. SDD following vaginal hysterectomy and native-tissue colpopexy appears to be safe, feasible, and associated with good QoR and a high degree of patient satisfaction.

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center.

BACKGROUND: Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described. METHODS: A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes. RESULTS: Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization. CONCLUSIONS: Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges.

BACKGROUND: As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly. METHODS: This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P < .05 was considered statistically significant. RESULTS: There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P = .12, Elixhauser Comorbidity Index P = .067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P < .001), and the SDD group higher rate of intraoperative tranexamic acid use (P = .015) and lower estimated blood loss (P = .009). There were no differences in 90-day overall minor (P = .20) and major complications (P = 1.00), ED utilization (P = .63), readmission (P = .25), or reoperation (P = .51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P = .80) and minor (P = .36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS = 8.4 hours in ≥65 to <75-year cohort vs. LOS = 25.9 hours in ≥80-year cohort; P < .001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P = .82). CONCLUSION: SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

The Effect of Surgical Approach on the Outcomes of Same-Day Discharge Outpatient Total Hip Arthroplasty at a Single Ambulatory Surgery Center.

BACKGROUND: Primary total hip arthroplasty (THA) is increasingly being performed in the outpatient setting. However, there is little known regarding the differences in same-day discharge (SDD) rates and complications of operative approach in same-day total hip arthroplasty in the ambulatory surgery center (ASC) setting. METHODS: A retrospective chart review was performed between July 2019 and October 2021 for all patients who underwent primary THA in a single freestanding ASC. Successful SDDs, surgical approaches, lengths of surgery, estimated blood losses (EBL), complications, and readmission events were recorded for each patient. Complications were compared using Pearson Chi-Squares, while EBL and surgery lengths were compared with 1-way analysis of variances (ANOVA) (alpha = 0.5). There were 17 total complications in 326 total hip arthroplasties (5.2%), including direct admissions to the emergency department, 30-day and 90-day readmissions, wound complications, instability, infection, and revision surgery. Among all complications, there were 5 direct admissions, making the successful SDD rate 98.5%. RESULTS: Complications and direct admissions were not associated with approach. The 30-day readmission rates were associated with approach, with no readmissions in the direct anterior approach (DAA) or the antero-lateral approach (AL) cohorts and 3 (4.3%) in the posterior approach (PA) cohort. CONCLUSIONS: In the ASC setting, patients undergoing THA regardless of approach showed no difference in successful SDDs or complications aside from 30-day readmissions. Same-day THA can be safely performed in the DAA, AL, and PA to the hip.

Inconsistent Classification of "Outpatient" Surgeries Leads to Different Outcomes Following Total Hip Arthroplasty in Medicare Beneficiaries: A Critical Analysis.

BACKGROUND: With rising utilization of outpatient total hip arthroplasty (THA) in older patients including Medicare beneficiaries, the objective was to compare differences in definition including (1) patient demographics; (2) lengths of stay (LOS); and (3) outcomes of "outpatient" (stated status) versus "same-day discharge" (SDD) (actual LOS = 0 days) utilizing a nationwide database. METHODS: A national database from 2015 to 2019 was queried for Medicare-aged patients undergoing outpatient THA. Total outpatient THAs (N = 6,072) were defined in one of 2 ways: either "outpatient" by the hospital (N = 2,003) or LOS = 0 days (N = 4,069). Demographics, LOS, discharge destinations, and complications were compared between groups. Logistic regression models computed odds ratios (ORs) for factors leading to complications, readmissions, and nonhome discharges. P values < .008 were significant. RESULTS: Women (OR: 1.19, P = .002), diabetes mellitus (OR: 1.31, P = .003), general anesthesia (OR: 1.24, P = .001), and longer operative times (≥95 minutes) (OR: 1.82, P < .001) were associated with 'outpatient' designation versus SDD. Within the hospital-defined 'outpatient' cohort, 49.1% (983 of 2,003) were discharged the same day (LOS = 0 days), and 21.8% had LOS 2 or more days. The hospital-defined 'outpatient' cohort had greater odds of nonhome discharges (6.3 versus 2.8%; OR: 1.88, P < .001) compared to SDD surgeries. The incidence was higher for any complication among hospital-defined 'outpatient' designated patients compared to SDD (5.5 versus 3.9%, P = .007). CONCLUSIONS: Outpatient surgeries may be misleading and often do not correlate with SDD, as over 20% remain in the hospital 2 or more days. Investigators should quantitatively define the "outpatient" status by actual LOS to allow standardization and results comparison. LEVEL OF EVIDENCE: III.

Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty.

BACKGROUND: Same-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA. METHODS: We performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student's t-test or Chi-square test. Significant findings were those with P value < .05. RESULTS: The SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP). CONCLUSIONS: Patients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.

The Effect of the COVID Pandemic on the Rate of Same-Day Discharge in Primary Hip and Knee Arthroplasty.

BACKGROUND: Same-day discharge (SDD) following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) started increasing prior to 2020. The purpose of this study was to evaluate the change in the rate of SDD after the pandemic and determine whether those changes became permanent. METHODS: The annual rate of SDD for 15,208 primary THA and TKA cases performed between January 1, 2015, and September 9, 2022, at a single institution was determined. We also examined changes in SDD patient demographics as well as differences in the 90-day complication rates of SDD and overnight patients. RESULTS: In 2015, the rate of SDD for primary arthroplasty was 24%, which grew annually to 29% in 2019. Postpandemic, the rate of SDD jumped above 50% and continued up to 64% by 2022. The biggest increase was in TKA, which went from under 10% SDD prepandemic to 50% by 2022. The average age and body mass index of SDD cases prepandemic increased significantly to 62 ± 9 years and 29.4 ± 5.3 (P < .01). Overnight patients had higher rates of 90-day postoperative complications (8.4 versus 4.2%, P < .00001). CONCLUSIONS: The pandemic caused major changes in the rate of SDD for primary THA and TKA, increasing in subsequent years. The SDD patients became older and heavier due to the expanded criteria for SDD cases. The 90-day postoperative complication rate was lower for SDD patients since higher risk patients were kept overnight. At the prepandemic rate, 29% of patients currently being sent home would have stayed overnight.

Ten Year Experience With Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, but Safe Outcomes Were Maintained.

BACKGROUND: This study aimed to characterize changes in patient demographics and outcomes for same-day discharge total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital. METHODS: A consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index, and American Society of Anesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into 3 groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022). RESULTS: The mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery. CONCLUSIONS: Our study has 3 important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and age-adjusted Charlson Comorbidity Index. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that same-day discharge-THA continues to be safe in properly selected patients.

Same-Day Discharge Does Not Increase Resource Utilization Within One Year of Total Joint Arthroplasty.

BACKGROUND: While the safety of rapid recovery total joint arthroplasty is well established, less is known about its impact on postoperative care utilization patterns. We wished to examine whether same-day discharge-and its associated presumed reduction in hospital-based postoperative care and education-translates to the need for more postoperative support during the 1-year recovery period. METHODS: A retrospective review of 1,237 total hip arthroplasty (THA) and 1,710 total knee arthroplasty (TKA) patients who had 0- or 1-day length of stay (LOS) from January 2020 to October 2023 was conducted. The primary outcome was the number of follow-up visits with total joint arthroplasty providers at our institution during the 1-year postoperative period. Secondary outcomes included 30-day emergency department returns, readmissions, 1-year physical therapy utilization, and improvement in Patient-Reported Outcomes Measurement Information System Physical Function scores at 6 to 12 months postoperatively. Bivariate and multivariable analyses were performed to compare outcomes between 0-day and 1-day LOS THA and TKA patients. RESULTS: In both the THA and TKA populations, 0-day LOS patients were younger, had a lower average body mass index, were more likely to be White, men, and had an American Society of Anesthesiologists score < 3 than 1-day LOS patients. After controlling for differences between groups, no significant differences in the number of one-year follow-up visits, physical therapy visits, emergency department returns, or readmissions were seen between 0 and 1-day THA or TKA patients. In TKA patients, 1-day LOS was associated with lower improvements in Patient-Reported Outcomes Measurement Information System Physical Function scores. CONCLUSIONS: After risk adjustment, same-day discharge of THA and TKA patients did not result in increased resource utilization during the one-year postoperative period. In the setting of a coordinated joint arthroplasty program with nurse navigator support, same-day discharge can be safely performed without increasing the need for postoperative care in appropriately selected patients undergoing both THA and TKA.

Success of Same-Day Discharge Total Hip and Knee Arthroplasty: Does Location Matter?

BACKGROUND: Same calendar day discharge (SCDD) following total joint arthroplasty is desirable for patients and surgeons alike. The aim of this study was to compare the success rate of SCDD in an ambulatory surgical center (ASC) versus hospital setting. METHODS: A retrospective analysis was performed on 510 patients who underwent primary hip and knee total joint arthroplasty over a 2-year period. The final cohort was divided into 2 groups based on location of surgery: ASC (N = 255) or hospital (N = 255). Groups were matched for age, sex, body mass index, American Society of Anesthesiologists score, and Charleston Comorbidity Index. Successes of SCDD, reasons for failure of SCDD, length of stay (LOS), and 90-day readmission and complication rates were recorded. RESULTS: All SCDD failures were from the hospital setting (36 [65.6%] total knee arthroplasty [TKA] and 19 [34.5%] total hip arthroplasty [THA]). There were no failures from the ASC. The main causes of failed SCDD in both THA and TKA included failed physical therapy and urinary retention. Regarding THA, the ASC group had a significantly shorter total LOS (6.8 [4.4 to 11.6] versus 12.8 [4.7 to 58.0] hours, P < .001). Similarly, TKA patients had a shorter LOS in the ASC (6.9 [4.6 to 12.9] versus 16.9 [6.1 to 57.0], P < .001). Total 90-day readmission rates were higher in the ASC group (2.75% versus 0%), where all but 1 patient underwent TKA. Similarly, complication rates were higher in the ASC group (8.2% versus 2.75%), where all but 1 patient underwent TKA. CONCLUSION: TJA performed in the ASC, compared to the hospital setting, allowed for reduced LOS and improved success of SCDD.

Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study.

BACKGROUND: Spinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). METHODS: We took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). RESULTS: All spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). CONCLUSIONS: Both spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. LEVEL OF EVIDENCE: Level 3, Retrospective Cohort Comparison.

A Remote Physical Therapy Program Demonstrates Similar Outcomes Compared to In-Person, Supervised Physical Therapy After Same-Day Discharge Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: A growing number of total knee arthroplasty (TKA) patients are candidates for same-day discharge (SDD). Previous research has shown that internet-based remote physical therapy (RPT) can produce equivalent outcomes to supervised outpatient physical therapy (OPT) after TKA. We sought to compare outcomes between RPT and OPT in patients undergoing SDD TKA using an electronic remote perioperative management (ERPM) program. METHODS: Patients undergoing SDD TKA were enrolled in an ERPM program and randomized to ERPM + RPT or ERPM + OPT. Preoperative and 6-week functional assessments included knee range of motion, timed up and go, and 4-meter gait speed. Numerical Rating Scale pain scores were evaluated preoperatively, at 6 and 12 weeks, and satisfaction was assessed at 6, 12, and 52 weeks postoperatively. Participants completed the Veterans Rand 12 Item Health Survey and Knee Injury and Osteoarthritis Outcome Score preoperatively and at 6, 12, and 52 weeks postoperatively. OPT utilization was collected 90 days postoperatively. RESULTS: Of 197 initially randomized patients, 76 remained in the ERPM + RPT group and 95 in the ERPM + OPT group after withdrawals and crossovers. Baseline characteristics showed no differences between the 2 groups. No clinically relevant differences were observed in knee range of motion, Numerical Rating Scale pain, patient-reported outcomes, functional assessments, or satisfaction at any follow-up time. Participants in the ERPM + OPT group attended an average of 11.57 physical therapy sessions, incurring a total cost of $462.8 and 133 minutes of travel. Conversely, the ERPM + RPT group experienced no expenses or travel time. CONCLUSIONS: Patients in the ERPM + RPT group had similar outcomes, lower costs, and saved time compared to patients in the ERPM + OPT group after SDD TKA. Further analysis is needed to determine predictive indicators for crossovers.

Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch.

BACKGROUND: Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS: All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS: Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830). CONCLUSIONS: With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.