Patients discharged on postoperative day zero had higher unadjusted rates of 30-day complications to total hip/knee and unis.
So even though we say that we have good selection criteria, obviously from looking at the AJRR database study, it’s not followed. And they concluded that a hospital admission is probably the best plan for a patient not optimized for outpatient joint arthroplasty and I think Keith would agree.
Careful screening is needed, but in real-life practice this needs to be improved.
Goyal et al., published a randomized trial at two centers looking at outpatient versus inpatient surgery.
They looked at postoperative pain, perioperative complications, as well as the surgeon’s staff work effort. Inclusion criteria: age less than less than 75, BMI [body mass index] less than 40; no chronic opioids. Patients received the primary total hip via an anterior approach. They found no difference in pain on the day of surgery between the two groups. But on postoperative day one, there was a significantly higher increase in pain for the postoperative day zero group.
So, one day after surgery, higher pain in the patients who were discharged on the same day. No difference in complications. No difference in work for the surgeon’s office, but they lacked sufficient power to really analyze this. And 24% of the patients were unable to be discharged.
There are difficulties with same day discharge, which has been pointed out in the literature—nausea and hypotension are problems. Dorr’s study noted that only 36% of patients wanted to leave on the day of discharge. And only 77% could be discharged. In Berger’s study everyone was able to be discharged but 25% required additional treatment that delayed discharge and it was usually nausea and hypotension.
Social factors can clearly influence the process. How far is the patient living from the hospital? How long is that drive going to be? Do they have the appropriate support at home if they go home the same day?
I think there are some other issues that need to be resolved. What kind of system do you have in place to make sure the patient selection is done in a meticulous fashion?
Another issue is if the doctor owns the outpatient surgery center, is it a conflict of interest to push patients to have a same day discharge? Should the surgeon tell the patient that he or she has a financial incentive to have a same day discharge?
I think that same day total hip replacement may be done in a safe, effective manner. We need to clearly define the indications and contraindications for same day discharge. One needs to develop a screening system and well-defined protocols in your institution related to pain management, anesthesia, and physical therapy. As seen in the literature, this is not being followed now.
What happens to patients that cannot be discharged? Where are they going to go? So, if you’re in an ambulatory surgery center, you need to have some observation capability or an arrangement with a hospital. And remember we need to do what is best for each individual patient or we’ll lose the trust of the public.
Moderator Thornhill: So Keith, Jay’s asked you a whole bunch of questions. Did you write any of them down?
Dr. Berend: I did. We must disclose to the patient that we own the surgery center and that we have a financial influence and will benefit performing their procedure at the surgery center. That’s every single patient that walks in whether they go to the hospital or not or whether they go the surgery center.
That’s the law. You can’t NOT do that.
