Safety of quickly performing TJR with fast-track methods raises questions
During the last decade, accelerated patient programs have been introduced worldwide for more orthopaedic procedures. Total hip and knee replacement are good examples of how changes in pain treatment strategies, concepts on how and when to mobilize patients after surgery and the impact of detailed preoperative information given to patients and their relatives have dramatically decreased the length of in-hospital stays to an average of 1 day to 2 days in most Scandinavian orthopaedic departments. This has significantly reduced or even removed waiting times for surgery after the visit to the outpatient clinic, increased productivity for most clinics and, therefore, reduced the overall costs to society.
However, an open question for some time has been how fast should fast-track surgery should be or should aim to be. Can we expect to offer total hip and knee replacement as same-day surgery within a few years for all patients or only selected cases? Will patients be sent home from the hospital or transferred to a rehabilitation center as the next step in recovery from such surgery?
During the last 2 years to 3 years, we heard about some clinics doing joint replacement on a same-day basis. So, if some surgeons can do it, can we all do it? Is it because the cases presented in the literature are represent highly selected patients? Is it that the specific program setup in a given department that makes it possible or are there other myths hidden behind the published facts that allow those patients to go home on the day of surgery?
Be better, safer
My comments are that first, we need to do it better and safer; then, we can do it faster. However, as a local pioneer in terms of driving total joint replacement (TJR) to have a short length of stay, I never thought that one day (today) patients would show up to my outpatient clinic demanding a total hip replacement (THR) done as a same-day surgery. Therefore, I wonder what got us to this point.
First, when our average length of stay was about 3 days, we decided to provide only the basic information to our staff that we expected, from that time forward, all patients would leave the hospital 1 day earlier. Three months later, the average length of stay at our hospital for THR was reduced to 2 days. Without any further initiatives or changes, more cases started leaving the clinic the morning after surgery — staying only 24 hours and 1 night in our department, if the required discharge criteria were met.
Length of stay studied
We therefore decided to begin a prospective study with another clinic that had the same length of stay and discharge criteria that we did. Surgeons were told to screen all new patients recommended for TJR who were American Society of Anesthesiologists grade 1 or 2. These patients were informed if they had surgery before noon, we would then look at strict criteria like pain, mobilization, wound and their radiographic outcomes to determine their discharge status. If everything was okay, then we would request they go home on the day of surgery, if a relative could stay with them the first night. However, the patient still was the person who made the final decision. As of now, approximately 20% of screened patients in the study were discharged to home on the day of surgery. This percentage has increased as the study continued.
We have not yet completed the study, but since many other initiatives in our department during the last 15 years have focused on shortening hospital stay, this has quickly changed the behavior of the patients, who now ask for day surgery, as well as of staff, who focus on details to increase the possibility of same-day discharge.
Same-day discharge more popular
Despite progress, facts and myths remain. It is a fact that the data that emerge at the conclusion of our study will show yet another change has taken place among our surgical team. The myth, however, is that what triggered the team to make these changes may remain unknown. It possibly was team spirit had an effect or it could perhaps be that in 2017 the knowledge and mentality of patients related to TJR has changed significantly compared to a few years ago.
In our department, we are convinced that within 2 years’ time most patients will leave the clinic on the day of surgery after primary TJR. However, it is my personal feeling we will never see more than 70% to 80 % of our cases discharged on the day of surgery. But, then again, I may be pleasantly surprised.
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- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Rd., Thorofare, NJ 08086, USA; email: firstname.lastname@example.org.
Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.