Discharge Program for Joint Arthroplasty Allows for Same-Day Release Following Surgery

The healthcare system is moving in the direction of value-based care, and this extends to joint arthroplasty. Researchers from New York University (NYU) Langone Orthopedic Hospital developed a same-day discharge (SDD) program in 2015, and during a poster presentation at the AAOS 2018 Annual Meeting, they highlighted the program, detailed necessary steps for success, and reported challenges associated with the initiative.

Arthroplasty candidates at NYU who are scheduled for lower extremity joint surgery (total hip/knee, unicompartmental arthroplasty, or hip resurfacing) can opt into the facility’s SDD program. The booking orthopaedic surgeon screens all eligible candidates for the following criteria:

• Inclusion criteria:
  • Patient-expressed commitment to rapid recovery
  • Attend an educational session with a coach who is present on day of the surgery
  • American Society of Anesthesiologists score of less than 3
  • Undergoing unilateral total joint arthroplasty
  • No history of narcotic dependence
  • Ambulatory prior to surgery
• Exclusion criteria:
  • Body mass index great than 40 kg/m²
  • Fasting blood glucose greater than 180 mg/dL
  • Active cardiovascular disease
  • History of venous thromboembolism
  • Chronic anticoagulation
  • Active pulmonary disease
  • Active liver disease
  • Neurocognitive/psychologic deficits
  • Physical deconditioning
  • Lack of social support

Upon enrollment, the SDD risk coordinator who oversees the SDD integrated care pathway is notified. Two weeks prior to surgery, the patient and their designated coach are required to attend preadmission testing and an educational session with a clinical care coordinator and physical and occupational therapists. Immediately following surgery, the patient begins rigorous rehabilitation with physical and occupational therapists and nursing staff. Once functional and medical milestones are met, the patient is discharged home.

Since the program began, 506 arthroplasty recipients have participated, with an average length of stay of 14 hours; 91% of patients were discharged home on the same day as surgery. Forty-one surgical candidates were not discharged on the day of surgery and were considered “failures to launch.”

Patients released on the same day had a 0.6% risk of readmission at 30 and 90 days. Those who underwent the procedure under conventional inpatient terms had a readmission rate of 1.61% at 30 days and 3.60% at 90 days.

Although many areas of overlap exist, patients in the SDD program require more acute therapy to be discharged on the same day.

The authors noted that this type of program does require a robust support staff with invested stakeholders needed for success.

“As SDD arthroplasty becomes more common, we believe a standardized arthroplasty service line is required if value-based care initiatives are to be successfully implemented,” the authors concluded. “By implementing a robust evidence-based SDD service line, we predict that up to 40% of elective lower extremity arthroplasties may be eligible for same-day [release].”