Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care

The length of stay for patients undergoing total joint arthroplasty (TJA) has substantially changed over the past 10 years. Innovations in technology, new surgical and anesthetic techniques, improved management of physiological stress, and better pain control positively influence recovery time after arthroplasty procedures [14,17]. In addition, the preoperative and postoperative phases provide opportunities to optimize patient outcomes and set expectations for their surgical journey. Furthermore, preoperative education allows providers to address any concerns patients have about an ambulatory procedure [7]. The volume of TJA continues to increase, with projections estimating that more than 2 million procedures will be performed annually by 2030 [12].

In 2016, the Advisory Panel on Hospital Outpatient Payment recommended joint replacement be removed from the Centers for Medicare & Medicaid Services list of inpatient-only procedures [4]. This proposal was closely followed by the Comprehensive Care for Joint Replacement program, a reimbursement model where total spending is adjusted against a fixed price for all services provided during an episode of care [1]. These payment reforms to reimbursement strategies have resulted in a growing trend to provide arthroplasty procedures in the ambulatory setting, spurring innovation and transformation of care pathways. Health analysts predict that by 2026, 52% of elective primary knee replacements will be performed in the outpatient setting [2]. Actualizing shorter lengths of stay entails concerted, multidisciplinary, and multifaceted efforts based on Enhanced Recovery After Surgery (ERAS) principles. In this special issue of HSS Journal, authors describe various strategies aimed to safely transition TJA patients to the ambulatory setting.

The ERAS programs are multidisciplinary, best-practice protocols that guide all phases of the surgical patient experience. The ERAS-guided pathways are interdisciplinary and emphasize communication, patient involvement, and continuous evaluation. Orthopedic programs that apply ERAS strategies have reported positive patient outcomes, such as a statistically significant reduction in the incidence of postoperative nausea/vomiting, lowered pain scores, reduced length of hospital stay, better functional outcome, and lower incidence of complications for patients than comparison groups [5,16,19,20]. Opioid-sparing pain control, early ambulation, and follow-up are among other key care features of this evidence-based paradigm [3,8,13,15,18]. The work described in this special issue introduces novel or enhanced care delivery tailored to this specialized orthopedic population.

Proper patient selection for ambulatory joint replacements requires assessment of multiple factors. Several authors discuss the critical nature of identifying appropriate patients both from the medical and the social perspective, as well as factors predictive of length of stay in an ambulatory setting. Three crucial clinical protocols for success are blood, fluid, and pain management [3]. The implementation of standardized, evidence-based protocols for each of these is essential for the success of the transition to ambulatory joint replacement, and in a continuing medical education (CME) offering in this issue, Chalmers and colleagues review the role of tranexamic acid in managing blood loss. The importance of multimodal pain control, such as the addition of acupuncture, and even novel pain management and nausea prevention modalities that can further improve the ability to safely discharge patients on the same day are also discussed. Quinlan and colleagues’ commentary introduces the use of aromatherapy as a standard practice to minimize discomfort and throughput delays related to postoperative nausea. This complementary alternative also enlists patient involvement in their recovery across care transitions. Borsinger et al describe the role of innovative technologies in the operating room that can facilitate more predictable surgery and, therefore, a higher likelihood of anticipated outcomes in any surgical setting.

Informatics and analytics play a logistical role in facilitating appropriate length of stay. Electronic health records have the potential to influence quality of patient care, timeliness of discharge, and provider workloads [3,11]. The ability to evaluate risk and clinical outcomes is accessible through greater support from organizational analytics. Carey et al describes how the investment in electronic data systems and analytics to clinical inquiries provides timely feedback that informs patient selection criteria and reduces risk or gaps in service.

This transition to the ambulatory setting has called for modifications of clinical workflows. Changes in interdisciplinary practice and important considerations when introducing an ambulatory joint replacement pathway are described. Barriers to throughput and creative solutions are detailed, specifically the redesign of a dedicated 23-hour unit for ambulatory patients. Camilleri et al demonstrate how leaders and physical therapists within a hospital system have adapted to the evolution of the episode of care for TJA patients.

This discussion benefits from articles describing presurgical and postsurgical care offered to TJA patients. Rehabilitation services provide individualized, skilled care throughout a patient’s surgical journey. Authors discuss several ways rehabilitation teams, including physical and occupational therapists, have adapted and transformed TJA care at predetermined time points both before and after surgery [9]. Aligning patient expectations regarding discharge disposition requires early planning. This is accomplished through a comprehensive clinical intake, individualized preoperative education, and discharge planning tools. Preoperative physical therapy education prior to total hip arthroplasty (THA) or total knee arthroplasty (TKA) can favorably affect length of stay and discharge disposition. The effect of preoperative physical therapy education prior to hip or knee arthroplasty on length of stay and discharge disposition is discussed by Bossier and colleagues. Guttenberg et al examine physical function preoperatively, measured by the Timed Up and Go test and its associated effect on length of stay in patients who underwent primary THA. Tuohy et al explore the relationship between 2 commonly used discharge prediction tools, the Risk Assessment and Prediction Tool (RAPT) and the Activity Measure for Post-Acute Care “6-Clicks” Mobility Score (AM-PAC), for patients undergoing THA or TKA. Understanding how discharge planning tools are implemented preoperatively and during hospitalization assists with proper planning postoperatively.

The postoperative period provides important opportunities for physical therapists to assist with a patient’s recovery. One author provides a commentary on a unique home health relationship with an orthopedic specialty hospital and the impact this has on in-person physical therapy care. Fisher et al [6] builds on previous work using a virtual platform to deliver physical therapy after TJA. They investigate whether virtual physical therapy is a viable option for care of TJA patients in the post-acute setting regardless of hospital length of stay. Furthermore, this work highlights how a discharge plan of physical therapy delivered virtually helps meet the needs of select patients and contributes to value-based care. Finally, predictors that may influence the length of care in postoperative outpatient physical therapy are yet to be examined. Wu et al review which factors are associated with higher utilization of postoperative outpatient physical therapy visits for patients who have had primary THA or TKA. This compilation of articles illustrates the immense value physical therapists add to the episode of care and how they have adapted their practice to meet the changing needs of this orthopedic patient population.

It is important to note wide variation exists to describe a shortened length of stay. Phrases including ambulatory, outpatient, same-day discharge, 23-hour stay, short stay, one-night stay, and extended stay are used to indicate a discharge within the same day or within 23 hours of surgery. The articles in this issue do not use consistent terminology to describe this type of encounter. This lack of standardization in terms provides an opportunity for the broader medical community to define shortened length of stay language and use consistent phrasing. Standardization has been shown to improve patient safety, quality of care, decreased errors, and decreased health care costs [10]. This would also offer an opportunity to enhance providers with additional clinical decision-making information.

The topics covered in this special issue provide a substantive picture of multidisciplinary efforts to support shorter length of stay after THA and TKA. The information is timely, sharing impactful changes in orthopedic practice. Continued research to advance care delivery through evidence-based practice could effectuate ambulatory joint replacement as a standard option.

Supplemental Material

sj-docx-1-hss-10.1177_15563316231213367 – Supplemental material for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care

Supplemental material, sj-docx-1-hss-10.1177_15563316231213367 for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care by Sharlynn Tuohy, Michael P. Ast, Patricia Quinlan, Matthew Titmuss and Danielle Edwards in HSS Journal®

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sj-docx-2-hss-10.1177_15563316231213367 – Supplemental material for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care

Supplemental material, sj-docx-2-hss-10.1177_15563316231213367 for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care by Sharlynn Tuohy, Michael P. Ast, Patricia Quinlan, Matthew Titmuss and Danielle Edwards in HSS Journal®

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sj-docx-3-hss-10.1177_15563316231213367 – Supplemental material for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care

Supplemental material, sj-docx-3-hss-10.1177_15563316231213367 for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care by Sharlynn Tuohy, Michael P. Ast, Patricia Quinlan, Matthew Titmuss and Danielle Edwards in HSS Journal®

Supplemental Material

sj-docx-4-hss-10.1177_15563316231213367 – Supplemental material for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care

Supplemental material, sj-docx-4-hss-10.1177_15563316231213367 for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care by Sharlynn Tuohy, Michael P. Ast, Patricia Quinlan, Matthew Titmuss and Danielle Edwards in HSS Journal®

Supplemental Material

sj-docx-5-hss-10.1177_15563316231213367 – Supplemental material for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care

Supplemental material, sj-docx-5-hss-10.1177_15563316231213367 for Innovations in Total Hip and Knee Arthroplasty Episodes of Care: Transitioning from Inpatient to Ambulatory Care by Sharlynn Tuohy, Michael P. Ast, Patricia Quinlan, Matthew Titmuss and Danielle Edwards in HSS Journal®