Is it safe? Outpatient total joint arthroplasty with discharge to home at a freestanding ambulatory surgical center

Abstract

BackgroundTotal joint arthroplasty (TJA) is trending toward shorter hospitalizations; as a result, there are many ambulatory surgical centers (ASCs) starting to perform outpatient TJA. However, there are limited studies examining the safety of outpatient TJA in the freestanding ASC setting. This study aims to evaluate 30-day and 90-day complication rates in patients who underwent outpatient TJA at a freestanding, independent ASC with direct discharge to home.MethodsA retrospective cohort review using health records was performed on the first 115 TJAs performed between August 2015 and March 2017 by one of the 4 orthopedic surgeons. Before the first TJA, the ASC had developed a multidisciplinary TJA pathway.ResultsOf the 115 TJAs, 37 (32%) were total hip arthroplasties (THAs), 53 (46%) total knee arthroplasties (TKAs), and 25 (22%) unicompartmental knee arthroplasties, with a mean age of 57 ± 7 years and body mass index of 30 ± 5 kg/m2. There were no intraoperative or direct ASC-related complications. There was 1 instance (0.9%) of a postoperative minimally displaced intertrochanteric femur fracture after THA due to a fall treated nonoperatively complication within 30 days of surgery. Of the 90-day complication events, there were 2 patients (2%) with postoperative arthrofibrosis of the knee after TKA requiring manipulation under anesthesia, 1 postoperative patellar tendon rupture during therapy after TKA requiring surgical repair and 1 delayed hematogenous infection after international travel after THA requiring 2-staged exchange.ConclusionsOutpatient TJA with discharge to home at a freestanding, independent ASC is a safe option after development of a multidisciplinary TJA pathway.

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

“…However, there is disagreement regarding the optimal inpatient length of stay. Some surgeons cite early discharge TJA as safe [ [5] , [6] , [7] , [8] , [9] , [10] , [11] ] and without increased readmission rates [ [15] , [16] , [17] ], whereas others criticize early discharge TJA as risky, claiming inpatient stays allow for the recognition of life-threatening complications and those complications that prompt readmission [ [19] , [20] , [21] ]. With the removal of TKA from the inpatient-only list, hospitals and payers must now consider all Medicare TKA patients as potential outpatients [ 30 ].…”

“…These developments have become part of Centers for Medicare and Medicaid Services efforts to contain costs while maintaining the safety and quality of TJA. Evidence has demonstrated early discharge TJA to be safe [ [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] ] and cost saving [ 13 , 14 ], without increasing readmission rates [ [15] , [16] , [17] ]. In fact, the paradigm has shifted, and in the modern context, prolonged inpatient lengths of stay have been associated with higher unplanned 90-day readmission rates [ 18 ].…”

Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols

“…However, innovations in perioperative care, including surgical technique, pain management, blood conservation, and physical therapy, have enabled rapid recovery and early discharge [ [2] , [3] , [4] ]. Evidence demonstrates early discharge primary TJA (<24-hour stay) to be safe [ [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] ] and cost saving [ 13 , 14 ], without increasing readmission rates [ [15] , [16] , [17] ].…”

Total Knee Arthroplasty in Ambulatory Surgery Centers: The New Reality!

“…ASCs may not have the personnel or resources to immediately handle such complications. In addition, ASCs may not be equipped to handle unanticipated overnight stays in the event that discharge to home is not possible [11]. There are currently no minimum ASC requirements to guide written agreements for hospital transfers [12].…”