Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty?

Abstract

Introduction: In recent years, cost containment relative to patent safety and quality of care for total joint arthroplasty (TJA) has been a key focus for the Centers for Medicare and Medicaid Services (CMS) spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions prior to discharge, but the type and quantity of medical interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA. Methods: 1,725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures performed, results of interventions, and all-cause readmissions. Recorded interventions included any that varied from the preoperative treatment plan, were beyond standard-of-care, and could not be completed at home. Results: 759 patients were discharged on postoperative day one. 84% (641/759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. 92% (11/12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in/out catheterizations for urinary retention. 90-day all cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention. Conclusion: The majority of patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.