Total Joint Arthroplasty: Should Patients Stay or Should They Go?

Doctor shaking hands with patient

Total joint arthroplasties (TJAs) are some of the most commonly performed orthopedic operations in the United States. Historically an inpatient procedure, TJAs were recently removed from the U.S. Centers for Medicare & Medicaid Services’ inpatient-only list.

Today, Brigham and Women’s Hospital is leading the trend toward same-day discharge TJAs thanks to a team approach (as published in JBJS Reviews), consistent patient communication and advances in anesthesia, physical therapy, surgical techniques, and perioperative protocols.

“At first, the idea of transforming TJAs from an inpatient procedure to a same-day discharge procedure was met with a degree of skepticism from clinicians and patients alike,” said Antonia F. Chen, MD, MBA, director of research for the Arthroplasty Service in the Department of Orthopaedic Surgery. “However, as we got everyone on board with the idea, we determined that same-day discharge TJAs could be done safely, without increased complication rates, to satisfy patient needs.”

Team-based Approach Is Vital

According to Dr. Chen, a team-based approach for each phase of TJA care is vital for effective and safe same-day discharge. To that end, Brigham arthroplasty surgeons Vivek M. Shah, MD, and Wolfgang Fitz, MD, collaborated with colleagues across the departments of Surgery, Physical Therapy, Nursing and Anesthesia, as well as operating room (OR) support staff, to create a program that would be amenable to patients and provide them with a valued service.

“Talking to patients was our first step,” Dr. Chen said. “Once we explained that they would do well with this approach, they largely felt comfortable about going home the same day as surgery and recovering in the comfort of their own home and bed. Now, patients are requesting the service more and more.”

As part of the program’s design, the arthroplasty surgeons worked with Physical Therapy to create a plan for postoperative bedside physical therapy. They also collaborated with Anesthesia on an opioid-sparing, short-acting spinal anesthesia and sedation approach that allows patients to mobilize quickly. In addition, they worked with OR staff to schedule TJAs earlier in the day and provided patient greeters with messaging guidance to set patient expectations for their visit.

The Patient Perspective

Not every patient is an ideal candidate for same-day discharge TJA, according to Dr. Chen. The Brigham uses multiple criteria to identify patients who are medically safe enough for same-day discharge, including American Society of Anesthesiologists score, comorbidities (such as severe sleep apnea), and home social support.

If surgeons determine a patient fits the criteria for same-day discharge, they will discuss the general risks, benefits, and preoperative medical optimization required for TJA with the patient before broaching the topic of same-day discharge. They answer patient questions about safety and pain control by pointing to rigorous research studies and clarifying the Brigham’s patient-centered, team-based approach.

After the initial clinic visit, patients attend preoperative appointments or calls with Anesthesia and Physical Therapy. They also attend a mandatory preoperative TJA class in which they learn every step of the patient journey and can ask further questions. The night before the surgical procedure, they receive a call from a surgical team member to go over last-minute instructions that will streamline the operative day.

“These calls provide a wealth of knowledge to the care team about the patient’s readiness and give us an opportunity to mitigate issues that may impact a timely discharge,” Dr. Chen said. “They also help the patient feel more confident and reassured on the day of the surgical procedure.”

For patients to be cleared for discharge after the procedure, they must safely walk short distances with an appropriate device, transfer to the bathroom, climb stairs appropriately, have their pain controlled, tolerate food and have overall safety awareness. They must also maintain stable blood pressure during physical therapy and should be cognitively clear from anesthesia with sensation intact.

The surgical team checks in with the patient by phone the evening following the procedure, and a home nurse visits after discharge. Most of the time, the dressing is removed and the wound is evaluated one week after surgery.

“Patient satisfaction scores for same-day discharge are outstanding,” Dr. Chen said. “What was once considered a ‘crazy’ idea is now a safe, cost-effective way to approach total joint replacement.”

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