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Total joint arthroplasty (TJA) of the hip (THA) and knee (TKA) are two of the most common surgical procedures performed in the United States. Case volumes for both procedures have steadily increased for decades, and the incidence of the procedures is projected to rise two- to seven-fold in the future. The safety and efficacy of TJA have steadily improved over numerous decades. The longevity and durability of implants also have increased considerably since their invention.
TJA can be a life-altering procedure for patients, greatly reducing or eliminating pain and discomfort and restoring mobility and function.
In August 2019, UPMC Health Plan established a Center of Excellence (COE) program for elective hip and knee joint replacement surgery to improve quality and reduce variation. Developed in collaboration with the University of Pittsburgh Department of Orthopaedic Surgery and affiliated community surgeons, the new program recognizes surgical facilities and orthopaedic surgeons demonstrating high-quality outcomes, low complication rates, and the best patient experience for UPMC Health Plan members in need of joint replacement surgery.
Recent years have seen a growing trend in same-day discharges for TJA procedures for ideal patient candidates.
What should referring physicians know about same-day discharge hip and knee replacement surgery at UPMC? Orthopaedic surgeons Brian Klatt, MD, FAAOS, division chief of Adult Reconstruction and the Adult Reconstruction Fellowship Program Director, and Michael O’Malley, MD, assistant professor and Adult Reconstruction Fellowship Education Director, discuss aspects of same-day TJA at UPMC.
While the novel coronavirus that causes COVID-19 remains prevalent in the United States and around the world, and likely will continue as such for the foreseeable future, referring physicians and patients should know that it is safe to schedule consultations and surgical procedures at UPMC.
UPMC and all of its departments and divisions have robust plans and operating procedures to effectively treat and manage patients while COVID-19 circulates in the population, adhering to the latest, rapidly-changing guidelines from federal, state, and local authorities. Additionally, experts in quality, safety, and infection control continually monitor the situation and revise or evolve protocols at UPMC to keep patients, families, and staff safe and healthy.
"Patients who need hip or knee replacements should feel confident that UPMC has, and continues to implement, the best possible evidence-based procedures to keep them safe during visits to their doctors and stays in the hospital," says Dr. Klatt.
Furthermore, with same-day discharges for some TJA, those patients who may be worried about nocosomial COVID-19 infection (the likelihood of which is low) may be more at ease with scheduling their procedure knowing they likely can go home the same day and avoid an overnight admission.
The population of ideal candidates for same-day discharge TJA is much broader than most referring physicians and patients may realize. The inclusion and exclusion criteria are relatively minimal.
In general, patients who are 75 years of age or less and who are in generally good health are candidates for same-day hip and knee replacement procedures.
Other criteria for a patient to be considered for a same-day discharge include:
At present, only unilateral primary hip or knee replacement patients are candidates for same-day procedures.
Patients who will have bilateral replacements for either their hips or knees are not eligible for same-day discharge as the safety and efficacy of same-day discharge for bilateral TJA has yet to be established. Also excluded from the same-day discharge protocol are revision surgeries and those individuals with an acute fracture of the hip or knee that will be replaced (i.e., no trauma-induced fractures necessitating a TJA).
“Some of the criteria for same-day discharge after hip or knee replacements, for example, the age of the patient, are flexible on a case-by-case basis. I have operated on patients over the age of 75 who went home the same day and did tremendously well,” says Dr. O’Malley.
As with all hip and knee replacement surgeries at UPMC, patients who are same-day discharge surgery candidates receive preoperative education, testing, and consultations with their orthopaedic surgeon. Same-day surgical candidates also must complete standardized prehabilitation protocols before surgery.
UPMC Orthopaedic Care surgeons work with a patient’s primary care physician (PCP) to optimize the patient’s health prior to surgery. If the patient has any underlying chronic conditions, like diabetes, their disease state should be stable and well-managed before surgery. Patients may be counseled on nutrition and weight loss, and they may have specific exercises prescribed to increase their physical strength and endurance prior to surgery.
“There are two questions or worries we frequently hear from patients about same-day surgeries when we begin the consultation process. The first is, are they safe? The other worry that patients have is about pain," says Dr. Klatt. “One of the biggest barriers to patients going home the same day of their surgery is simply a matter of confidence, and not that they are unable or did not meet all the requirements for discharge. Coaching patients through the process and instilling in them the confidence that they can do it is critical both before surgery and during recovery.”
To begin with, same-day discharge TJA patients are scheduled for surgery earlier in the day to give them as much as time as possible to recover from the anesthesia and to navigate all of the postoperative tasks and milestones they need to achieve in order to go home the same day.
To facilitate a more rapid recovery, anesthesia protocols are modified to be slightly less intense than in traditional cases. Adequate pain control is provided, but the effects of the anesthesia wear off faster, thereby allowing patients to achieve mobility sooner and begin the physical therapy process earlier in the day.
For patients who do go home the same day, discharge typically occurs in four to six hours. All patients are scheduled to have two therapy sessions postoperatively, if necessary. Those individuals that pass all of the physical tests in the first session do not need to repeat the battery of tasks.
"We do not bend the discharge rules or rush our same-day discharge patients out of the hospital. Our goals are always the safety and security of our patients. If they can meet all of the metrics for discharge, they can go home. If not, we keep them admitted for another day until they meet our discharge requirements,” says Dr. O’Malley.
While a patient may be an ideal candidate for same-day discharge at the outset, each case must still meet all of the rigorous postoperative discharge metrics to be released. Some of these metrics are variable by the individual. Others are not. Just because a patient is designated a same-day discharge at the beginning of their surgery does not mean they automatically go home that day.
Patients need to ambulate independently or with minimal assistance, and they need a caregiver at home, otherwise they cannot be discharged the same day. If they are required to do stairs at home, they must show they can successfully negotiate stairs before leaving the hospital. A patient must exhibit stable blood pressure and other vital signs. Patients must be able to urinate, and their pain must be controlled with oral pain medications.
"More and more patients can take advantage of a same-day discharge because of the advances the field has made with anesthesia protocols and newer multimodal pain reduction strategies. Early mobility after surgery is essential to the recovery process for virtually all surgeries, and perhaps more so with TJA. Our surgical protocols are all designed to facilitate rapid recovery while maintaining safety and quality,” says Dr. Klatt.
Rehabilitation therapy begins almost immediately after surgery while the patient is in the hospital. Rehabilitation continues at home for as long as prescribed based on the individual patient's needs and goals. Planning for and executing a patient’s postoperative rehabilitation plan is a collaborative effort between the orthopaedic surgeon, physical therapist, and the patient.
“In our program for same-day TJA discharges, physical therapists will visit with the patient the day after discharge, and then two to three times a week for the first few weeks. Some patients do not require outpatient therapy. Our same-day discharges receive the same amount of physical therapy while they are in the hospital and at home as our other cases. There is no difference in quantity or quality,” says Dr. O’Malley.
TJA procedures at UPMC – same-day discharge or otherwise – are comprehensive and collaborative pathways of care from preoperative screening and counseling through postoperative recovery and outpatient rehabilitation. UPMC Orthopaedic Care partners with a PCP to optimize a patient's health prior to surgery to give each individual the best chance of a rapid recovery and positive outcome.
More patients are candidates for same-day discharge after hip or knee replacement than most patients or primary care providers realize. For ideal candidates, same-day discharge TJA is safe and effective, with low readmission and complication rates on par with non-same-day discharge TJA.
For more information or to refer a patient, please call 1-866-884-8579. Additional information for patients can be found at UPMC.com/ortho.