Drs McAllister, Fuchs, and Stickney are continuing to study the impact of the SwiftPath Method
for outpatient joint replacement. The early results of this work has been accepted for
presentation at the Annual Meeting of the American Association of Hip and Knee
Surgeons in November and at the American Academy of Orthopedic Surgeons in
March of 2016.
Clinical Outcomes and Cost Implications of Rapid Discharge Versus Traditional Pathways
after Joint Replacement
Craig McAllister, Ira Kirschenbaum, Jeff Stepanian, Geoff Burk
Traditional total joint replacement typically involves a 2 to 3 day length of stay, considerable
postoperative pain, and difficult and long rehabilitation. Rapid discharge after joint replacement
is gaining interest as a way to improve outcomes, enhance the patient experience, and reduce
costs. Focused patient education, advanced methods in non-narcotic pain management,
minimally invasive surgical methods and newer home care protocols are allowing patients to go
home on the day of their hip or knee replacement.
This study compares the outcomes of a traditional care pathway versus a rapid discharge
pathway for patients undergoing knee replacement for osteoarthritis.
METHODS
A single surgeon performed 169 primary total joint arthroplasties in patients with osteoarthritis.
In the traditional group, 89 joints were done using a traditional care pathway. In the traditional
pathway, patients attended a hospital-based joint camp that presented a standardized clinical
pathway with a 3 day hospitalization. A standard surgical approach was used. No periarticular
injections, pre-emptive analgesics, or postoperative multimodal pain regimen were utilized.
In the rapid discharge group , 80 primary joint replacements were done using a comprehensive
approach designed specifically to allow a shortened length of stay, decrease pain, and improve
the early rehabilitation. This protocol included multimodal pain management, an MIS-computer
navigated method, periarticular injections, and a novel approach to preoperative patient
education program. Each patient and a designated family member were enrolled prospectively
and participated in a “swiftpath” jointcamp.
At the joint camp, patients calculated their own selection scores, and those scores were used to
assign them to a standard hospital stay, 23 hour stay or same-day discharge. Patients were
encouraged to go home after surgery and avoid transfers to extended care facilities. Homecare
was monitored by family members without visiting nursing services, labs, or home PT. All
patients were followed prospectively with daily VAS pain scores, clinical parameters and long
axis and standard radiographs. Additionally, patients participated in an 6 month online, cybersecure patient reported outcome system where they reported their daily pain experience, weekly
rehabilitation, return to activities and overall patient satisfaction.
Results
The the patients in both groups were similar demographically. There was no statistically
significant difference between groups with regard to age, diagnosis, sex, weight, preoperative
ROM, or medical co-morbidities. There was no statistically significant difference between groups
with regard to age, diagnosis, sex, weight, or preoperative ROM.
Patients in the rapid discharge group had shorter incision length, shorter length of stay, and less
pain than in the traditional group. Moreover, those patients in the rapid discharge group had
better flexion 6 weeks. By 12 weeks, there was no difference in the flexion between the two
groups. However, manipulation was necessary in 14% of the traditional group compared with
2% in the rapid discharge group.
All 80 patients in the rapid discharge group completed the joint camp and the 6 month protocol.
Based on the selection score, 42 patients were assigned to the same-day discharge and 21
patients were assigned to 23 hour stays. Seventeen (17) were admitted to the hospital. The
average LOS for the entire group was 0.43 (range 0 - 3 days). No patients were transferred to
extended care facilities.
In the outpatient protocol, all of the patients assigned to the sameday discharge pathway met
their discharge criteria and were successfully discharged to home. Likewise, all of the 23 hour
went home the morning after surgery. No labs, physical therapy, or other formal home care was
instituted in these patients. There was no difference in the readmission rate between the
traditional and the outpatient groups. There were five readmissions: 2 in the rapid discharge
group and 3 in the traditional group. None of the patients in the rapid discharge cohort utilized
and extended care facility. This was in contrast to 27 patients (37%) in the traditional group who
used the transitional care unit or other rehabilitation facility. The acute care LOS was 3.8 days
for the traditional group and 0.46 for the rapid discharge group.
In terms of pain, the traditional group required significantly more narcotics and reported a higher
VAS by three days. There was a significantly more pain reported in the traditional hospital
group. During the first four days after surgery, oral narcotics were used for breakthrough pain
14% of the time. The overall patient satisfaction for pain control was 8.0 on a ten point scale
with 90% reporting that they were satisfied with their pain control. On a 10 point scale, patients
reported a 9.8 for being likely to refer a family member, and 93% of patients felt that their joint
replacement met their expectations in terms of function by 12 weeks.
Conclusions
Traditional joint replacement offers an excellent solution for the severely arthritic joint. A
significant proportion of these patients can avoid admission to the hospital. Our results show
that patients can be safely and predictably assigned to sameday and 23hr discharge pathways.
Patients who are discharged early after joint replacement are as likely to be happy with their
pain control and functional result as patients who are admitted for traditional hospitalization.