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We share Bodrogi and colleagues vision that same-day discharge will become common following total hip and knee joint arthroplasty. Three key ingredients for success include physician leadership, system redesign (integration) and adoption of best peri-operative practices.
First, physician support will be critical in leading the design, implementation and evaluation of same-day discharge programs. Some physicians, including primary care will need to evolve traditional patterns of referral, triaging, assessing and caring for same-day arthroplasty patients. Regional central patient intake, nurse practitioner-led assessment clinics, anesthesia-led pre-operative optimization, and virtual care in monitoring patients discharged home are examples of needed care evolution.
Secondly, system redesign in Ontario will be aided by the new Ontario Health Teams (OHTs). OHTs will ultimately be responsible for providing a continuum of care. The integration of primary and specialty orthopedic care with outpatient rehabilitation centres and Home and Community Care will evolve in the context of same-day discharge. The integrated OHT will need to plan for pre-operative optimization, and post-operative home visits including physical therapy. This need could be minimized by patient education including exercise, started well in advance of surgery (prehabilitation) by adoption of best practices.
Third, Enhanced Recovery after Surgery (ERAS) is an “evidence-based multidisciplinary peri-operative care pathway” which includes the use of customized anesthetic techniques and pain management strategies to promote early patient mobilization while reducing complication rates of surgery. It is a leading best practice. It requires the creation of multidisciplinary peri-operative teams in the pre-operative, intra-operative and post-operative phases of care. The benefits are myriad.
For same-day discharge, as many as 55% of current patients hospitalized post-operatively, may be eligible.[1] Patients endorsed same-day discharge 87% of the time.[2] Complication rates were comparable to those admitted. Lastly, system cost saving was estimated at 32.7%.[3]
In summary, three key ingredients for success will be physician leadership, system redesign and integration, and adoption of best practices. As Paul Batalden has said, “Every system is perfectly designed to get the outcomes it gets.” Physician leadership needs to mobilize to redesign our system to ensure success for same-day discharge hip and knee arthroplasty.
Bert Lauwers, MD, FCFP, MPPAL, CCPE
Executive Vice President, Scarborough Health Network
Jon Hummel, MD, FRCPC(ortho)
Chief of Surgery and Orthopedic Consultant,
Scarborough Health Network
Mark Glube MD, FRCPC
Interim Chief of Anesthesiology
Scarborough Health Network
Fred Go, RN, MN, MBA, CHE
Director of Surgery,
Scarborough Health Network
References
[1] Gillis ME, Dobransky J, Dervin GF, Defining growth potential and barriers to same day discharge total knee arthroplasty. Int Orthop; 2019; 43:1386-93.
[2] Dorr LD, Thomas DJ, Zhu J, et al. Outpatient total hip arthroplasty. J Arthroplasty 2010; 25:501-6.
[3] Huang A, Ryu JJ, Dervin G. Cost savings of outpatient versus standard inpatient total knee arthroplasty. Can J Surg 2017; 60:57-62.