key: cord-312199-jy3izkou authors: Kraus, Kent R.; Buller, Leonard T.; Caccavallo, Peter; Ziemba-Davis, Mary; Meneghini, R. Michael title: Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty? date: 2020-07-16 journal: J Arthroplasty DOI: 10.1016/j.arth.2020.07.021 sha: doc_id: 312199 cord_uid: jy3izkou INTRODUCTION: In recent years, cost containment relative to patent safety and quality of care for total joint arthroplasty (TJA) has been a key focus for the Centers for Medicare and Medicaid Services (CMS) spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions prior to discharge, but the type and quantity of medical 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: 1,725 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 performed, results of interventions, and all-cause readmissions. Recorded interventions included any that varied from the preoperative treatment plan, were beyond standard-of-care, and could not be completed at home. RESULTS: 759 patients were discharged on postoperative day one. 84% (641/759) 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. 92% (11/12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in/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: The majority of 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. Conflict of Interest Statement: Each author certifies that he or she has no commercial 31 associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, 32 etc) that might pose a conflict of interest in connection with the submitted article. surgery by a perioperative internal medical specialist whose practice focuses exclusively on hip 94 and knee arthroplasty patients. Each patient's surgery was discussed at a coordinated care 95 conference attended by key members of the multidisciplinary team the week prior to their 96 scheduled surgery. The goal of the meeting is to share information across disciplines and 97 proactively develop patient care plans, shared with everyone who provides direct care or services 98 to the patient. Preoperatively, patients and family members received comprehensive clinic-based 99 joint replacement education and attended a hospital-based joint replacement class. 100 Postoperatively, all patients were encouraged to ambulate by the afternoon on the day of surgery 101 and received the same standardized rehabilitation protocol. Postoperative care was assumed by 102 the operative surgeon, the internal medicine specialist, clinic staff, and a multidisciplinary 103 inpatient care team. The same modern perioperative pain control, clinical, and rehabilitation 104 protocols were used for all patients. 105 Perioperative and Postoperative Pain Control and Anesthesia Protocols: 106 A standardized multimodal preoperative pain protocol was used in all cases. Unless 107 allergic or contraindicated, patients were given acetaminophen (1000 mg PO) 24 hours before 108 surgery and oxycodone (10 to 20 mg PO), celecoxib (200 mg PO), and pregabalin (75 mg PO) 109 immediately before surgery. Intraoperatively, surgeries were performed with standardized light 110 general anesthesia (desflurane or sevoflurane) and a low-dose intrathecal, single-shot spinal 111 injection of either 0.40 mg of morphine with a median of 10.5 mg bupivacaine local anesthetic or 112 25 mcg of fentanyl with a median of 7.5 mg bupivacaine. Beginning January 1, 2015, the spinal 113 anesthesia medication cocktail was changed from morphine to fentanyl. Between September 01, 114 2012 and May 31, 2016, patients were instructed not to consume liquids after 12 AM on the day 115 of surgery. Beginning on June 01, 2016, patients were allowed to drink liquids up to two hours before surgery. Patient-specific, goal-directed fluid therapy involving preoperative, 117 intraoperative, and postoperative administration of approximately 2000 mL total of crystalloid 118 sodium lactate unless patients had significant renal diseases in which case normal saline was 119 used. Postoperatively, patient's ability to void was observed. In and out catheterization was 120 performed in patients that failed to spontaneously urinate after 8 hours from the time of their 121 preoperative void. Additionally, if the patient is able to urinate within those 8 hours but makes 122 less than 300cc of urine on their own, we perform an in and out catheterization and restart the 123 clock. Patients that are unsuccessful in spontaneously voiding after three catheterizations get a 124 consultation with Urology and are taught either self-catheterization or have a Foley docked to be 125 managed by Urology. 126 In knees only, a periarticular injection of 0.2% (200 mg) ropivacaine, 0.5 mg epinephrine, 127 80 mcg clonidine, and 30 mcg ketorolac (removed for patients with renal insufficiency) to equal 128 101.3 mL total volume was used immediately following final implant fixation. Postoperatively, 129 unless allergic or contraindicated, patients received acetaminophen (1000 mg PO tid), 130 OxyContin (10 to 20 mg PO q12 hours), celecoxib (200 mg PO bid), oxycodone (5-10 mg hourly 131 prn for mild pain and 10-20 mg hourly prn for moderate pain), or hydromorphone (0.5 mg IV 132 q20 minutes prn for severe pain). Tests/Treatments/Procedures sections were searched for records dated either the day of or the 159 day after patients' surgeries. Internal medicine staff progress notes were reviewed for additional 160 test results, treatments, and overall status of the patient. The results review section of the EMR was also evaluated for data on additional tests and results. For each intervention, the date, time, 162 results, and cause for the intervention were recorded. The study outcome variables were medical 163 interventions, separated into three categories: diagnostic tests, treatments, and procedures. 164 Interventions utilized to look for pathology in a patient were defined as diagnostic tests, 165 including cardiac enzymes, EKGs, ultrasounds, urinalysis, and x-rays. Treatments were all 166 interventions administered orally or intravenously to improve a patients' condition. Procedures 167 were defined as invasive interventions, such as cardiac or urinary catheterization. We recorded 168 all medical interventions that varied from the preoperative treatment plan, were beyond standard-169 of-care or routine interventions, and that patients could not complete at home. Therefore, routine 170 basic metabolic panels, hemoglobin and iron levels, blood sugar control, over-the-counter 171 treatments, and patient comfort measures were not recorded. If an intervention was performed 172 prior to 4 PM on the day of surgery, we did not include it in our counts because the same 173 Thirteen patients (13/759; 1.7%) underwent 13 diagnostic tests (Table 3 ), all of one of 197 which were negative with none of these patients readmitted to the hospital within 90-days. Table 198 1 presents the proportion of patients who received and did not receive diagnostic tests 199 based on sex, age, BMI, ASA-PS classification, and procedure type. 200 The majority (66/100; 66%) of 100 treatments in 90 patients were IV fluids for oliguria 201 or hypotension (Table 4 ). Two patients who underwent a treatment (both IV fluids for oliguria) 202 were readmitted to the hospital within 90-days, one for a gastrointestinal bleed and one for acute 203 kidney injury and acute hypercapnic respiratory failure. Twenty-nine of the procedures were in-out catheterizations for urinary retention. As shown in Table 1 We observed that only 1.6% of patients discharged on POD 1 following primary TJA 243 underwent a diagnostic test beyond routine standard-of-care. This is a novel finding, as the 244 number of patients receiving a postoperative test after primary TJA has not been described. All 245 but two of the diagnostic tests was negative, suggesting that a further reduction in testing may be 246 possible without compromising patient safety. Similarly, these results may be interpreted to 247 mean that not every early discharge patient requires diagnostic testing following TJA, as has Additionally, as previously suggested, research may be conducted to evaluate the necessity of 267 receiving these treatments as an inpatient and to explore the feasibility of doing them at home 268 under the direct or indirect supervision of a healthcare provider. 269 Perhaps the most notable finding of this study was that 84% of patient discharged on 270 POD 1 did not require any intervention prior to discharge, suggesting these patients did not 271 receive any benefit from an overnight stay and endured an unnecessary hospital stay. Our all-272 cause readmission rates were low and are similar to those previously reported in the literature 273 [17]. Our finding that there was no significant difference in the readmission rates between 274 patients requiring an intervention and those not requiring an intervention suggests that same day 275 discharge may be safe and unlikely to result in increased complications for many patients. This descriptive study is not without limitations, including its retrospective cohort design. 280 Despite inherent bias of this study design, all of the data were prospectively collected on 281 consecutive cases performed by a single surgeon with identical protocols, which may reduce 282 selection and interpretation biases. It should be noted that this study was not designed to evaluate 283 interventions received by unhealthy patients requiring prolonged inpatient care, but instead 284 relatively healthier patients discharged on POD 1. Some patients in the cohort were eligible for 285 but declined same day discharge. Thus, findings may add to the utility of the OARA score in 286 safely identifying and educating patients eligible for outpatient TJA [26] . Future studies may 287 seek to determine whether a predictive model, or even the OARA score, is capable of 288 determining which same day discharge eligible patients require an intervention overnight. 289 Additionally, it has been suggested that pain, muscle weakness, and dizziness are the main 290 reasons why patients stay in the hospital longer than expected [33] . It is unknown if patients in 291 this study felt they required an inpatient stay due to pain, weakness ,or dizziness. Therefore, it is 292 possible that some of the patients receiving no medical interventions might not have been ready 293 to leave the hospital the day of surgery. Additionally, it is possible patients requiring readmission 294 did so at another institution, in which case the readmission rates may be underreported. 295 In conclusion, the results of this study demonstrate that the majority of patients 296 discharged on POD 1 following primary TJA did not require any medical interventions. 297 Additionally, there was no difference in readmission rates between the patients that required an 298 intervention and those that did not. These data suggest that overnight hospitalization following TJA may be unnecessary for more patients than are currently identified. Adequate hydration and 300 avoidance of POUR seem to be the greatest targets of perioperative optimization and should be 301 Arthroplasty of the Hip: A New Operation Is it safe? 346 Outpatient total joint arthroplasty with discharge to home at a freestanding ambulatory 347 surgical center Outcomes of the First 1,000 Total Hip Total Knee Arthroplasties at a Same-day Surgery Center Using a Rapid-recovery Protocol Arthroplasty Has Minimal Short-Term Complications With the Use of Institutional Effects of the Length of Stay on the 355 Cost of Total Knee and Total Hip Arthroplasty from 2002 to 2013 Outpatient Surgery as a Means of Cost 358 Reduction in Total Hip Arthroplasty: A Case-Control Study Hospital Discharge 361 within 2 Days Following Total Hip or Knee Arthroplasty Does Not Increase Major Complication and Readmission Rates Rapid Recovery of stay increase readmissions after total joint replacements? Between Hospital Length of Stay and 90-Day Readmission Risk Within a Total Joint 372 Arthroplasty Bundled Payment Initiative An Analysis of a National Database Choosing 383 Wisely': a growing international campaign How to save costs by reducing unnecessary testing: Lean thinking in clinical practice Outpatient Joint Arthroplasty-Patient 395 Selection: Update on the Outpatient Arthroplasty Risk Assessment Score Eliminating Waste in US Health Care Projections of primary and revision hip and 400 knee arthroplasty in the United States from 2005 to 2030 A population-403 based nested case-control study of the costs of hip and knee replacement surgery The Unintended Impact 406 of the Removal of Total Knee Arthroplasty From the Center for Medicare Recovery Total Joint Arthroplasty Why still in 417 hospital after fast-track hip and knee arthroplasty?