CommentaryFrom OT Europe

Time for more same day THR discharges in Denmark and Europe

In the past, having patients go home on the same day they underwent total hip replacement was done rarely and only in select cases. As a hip surgeon, I remember these rare cases because the request or demand to go home on the same day that the surgery was performed never came the surgeon. It always came from the patient, who was typically a younger man whose job involved a leadership position and he expected to be “back in business” the next day.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

However, with the dramatic change in the overall set-up for total joint replacement in Denmark in last 2 decades, where length of stay for THR gradually changed from 2 weeks to 1.6 days mean for all primary and revision THR cases, excluding septic revisions, it has been a logical step to now identify more candidates for same-day THR. After an initial study of the selection of qualified candidates to potentially go home on the same day after surgery, I, Kirill Gromov, PhD, and our colleagues found 15% of patients ultimately went home on the day of their THR or total knee replacement surgery. From this study, we learned a lot about logistics, patient information, staff information and our own goals regarding taking the next step in moving toward same-day surgery. One thing we found was we could introduce same-day surgery as a standard practice for case number one and, frequently, also for case number two on a given day in all our OR lines. However, this was still overshadowed by the fact that, at the end of the day, patients can still decide, on a case-by-case basis, whether they wish to stay in the hospital until tomorrow.

Same-day discharge for healthy patients

We still only allow healthy patients or patients with milder comorbidities, such as patients with American Society of Anesthesiologists scores of 1 and 2, to even consider undergoing same-day TJR surgery, and we now have 15% of all THR patients going home on the day of surgery.

I wonder when the frequency of same-day THR surgery will increase in more Danish orthopaedic departments that perform THR, as well as throughout Europe. Fewer than 2% of patients who undergo same-day THR are readmitted in the first 90 postoperative days for reasons related to the surgical approach. Furthermore, our organization and initial selection strategy about same-day surgery and, later on, the high-level information that was communicated about the safety and ease of same-day surgery worked perfectly. These efforts helped convince both patients and staff members that same-day surgery is a standard procedure offered at our institution and we fully support all aspects of it.

Still the exception: Same-day TJR

A few things are for certain. Same-day surgery will never be an approach that is indicated for all patients. There will always be patients who are elderly or with severe comorbidities who, for medical reasons, must be in close proximity to medical staff in the days after they undergo surgery and anesthesia. In addition, I believe the organizational and logistical challenges associated with this type of surgery are the main obstacle to overcome before more orthopaedic departments start performing same-day TJR. In addition, for same-day surgery in TJR to become a reality, different specialties at hospitals and medical centers must be willing to cross-collaborate and have similar goals in this regard.

Every day in our unit we learn from our new patients about what must be considered for a patient to be discharged to home on the day of surgery. Nurses, in particular, are critical to the success of this process because they are the main contacts with the patients during their brief hospital stay. Furthermore, nurses are ideally suited to adapt the important surgical information related to same-day surgery and communicate it to future patients. Because Denmark is a smaller country with a limited number of clinics at which THR is performed, we are all essentially on the same track. Therefore, I foresee that within the next 5 to 10 years same-day surgery will become a standard for most of our patients. However, a unit like ours is “protected” in that it only does TJR and, for that reason, its logistics are never disrupted by acute orthopaedic cases. As a result, this “protection” has had a great, positive impact on our overall, daily flow of patients.

Reimbursement, financial impact

For colleagues elsewhere in Europe, I am unsure of the percentage of their cases that can be turned into same-day TJR cases. Many countries currently have an infrastructure and/or a reimbursement strategy that does not impose a short stay after TJR because such a strategy may impact the overall financial model for TJR. In other countries, their traditions of staying in hospital for a particular length of time after TJR remain an issue because they affect the ability to readily change the length of stay and adopt same-day TJR practices.

If the opinions of patients who undergo same-day surgery were the sole reason for policy changes in this area, more patients would experience same-day hospital discharge. When asked if they would do it again, most patients who undergo same-day surgery for THR say they would. They note it is a quick and safe procedure, they like staying in their own bed postoperatively and they question why they should stay overnight at the hospital only to be sent home the first thing the next morning.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.

In the past, having patients go home on the same day they underwent total hip replacement was done rarely and only in select cases. As a hip surgeon, I remember these rare cases because the request or demand to go home on the same day that the surgery was performed never came the surgeon. It always came from the patient, who was typically a younger man whose job involved a leadership position and he expected to be “back in business” the next day.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

However, with the dramatic change in the overall set-up for total joint replacement in Denmark in last 2 decades, where length of stay for THR gradually changed from 2 weeks to 1.6 days mean for all primary and revision THR cases, excluding septic revisions, it has been a logical step to now identify more candidates for same-day THR. After an initial study of the selection of qualified candidates to potentially go home on the same day after surgery, I, Kirill Gromov, PhD, and our colleagues found 15% of patients ultimately went home on the day of their THR or total knee replacement surgery. From this study, we learned a lot about logistics, patient information, staff information and our own goals regarding taking the next step in moving toward same-day surgery. One thing we found was we could introduce same-day surgery as a standard practice for case number one and, frequently, also for case number two on a given day in all our OR lines. However, this was still overshadowed by the fact that, at the end of the day, patients can still decide, on a case-by-case basis, whether they wish to stay in the hospital until tomorrow.

Same-day discharge for healthy patients

We still only allow healthy patients or patients with milder comorbidities, such as patients with American Society of Anesthesiologists scores of 1 and 2, to even consider undergoing same-day TJR surgery, and we now have 15% of all THR patients going home on the day of surgery.

I wonder when the frequency of same-day THR surgery will increase in more Danish orthopaedic departments that perform THR, as well as throughout Europe. Fewer than 2% of patients who undergo same-day THR are readmitted in the first 90 postoperative days for reasons related to the surgical approach. Furthermore, our organization and initial selection strategy about same-day surgery and, later on, the high-level information that was communicated about the safety and ease of same-day surgery worked perfectly. These efforts helped convince both patients and staff members that same-day surgery is a standard procedure offered at our institution and we fully support all aspects of it.

Still the exception: Same-day TJR

A few things are for certain. Same-day surgery will never be an approach that is indicated for all patients. There will always be patients who are elderly or with severe comorbidities who, for medical reasons, must be in close proximity to medical staff in the days after they undergo surgery and anesthesia. In addition, I believe the organizational and logistical challenges associated with this type of surgery are the main obstacle to overcome before more orthopaedic departments start performing same-day TJR. In addition, for same-day surgery in TJR to become a reality, different specialties at hospitals and medical centers must be willing to cross-collaborate and have similar goals in this regard.

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Every day in our unit we learn from our new patients about what must be considered for a patient to be discharged to home on the day of surgery. Nurses, in particular, are critical to the success of this process because they are the main contacts with the patients during their brief hospital stay. Furthermore, nurses are ideally suited to adapt the important surgical information related to same-day surgery and communicate it to future patients. Because Denmark is a smaller country with a limited number of clinics at which THR is performed, we are all essentially on the same track. Therefore, I foresee that within the next 5 to 10 years same-day surgery will become a standard for most of our patients. However, a unit like ours is “protected” in that it only does TJR and, for that reason, its logistics are never disrupted by acute orthopaedic cases. As a result, this “protection” has had a great, positive impact on our overall, daily flow of patients.

Reimbursement, financial impact

For colleagues elsewhere in Europe, I am unsure of the percentage of their cases that can be turned into same-day TJR cases. Many countries currently have an infrastructure and/or a reimbursement strategy that does not impose a short stay after TJR because such a strategy may impact the overall financial model for TJR. In other countries, their traditions of staying in hospital for a particular length of time after TJR remain an issue because they affect the ability to readily change the length of stay and adopt same-day TJR practices.

If the opinions of patients who undergo same-day surgery were the sole reason for policy changes in this area, more patients would experience same-day hospital discharge. When asked if they would do it again, most patients who undergo same-day surgery for THR say they would. They note it is a quick and safe procedure, they like staying in their own bed postoperatively and they question why they should stay overnight at the hospital only to be sent home the first thing the next morning.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.