Best Practices for Same-Day Total Joint Arthroplasties

With advances in perioperative care, including improvements in minimally invasive surgeries and anesthesia, same-day discharge total joint arthroplasties (TJAs) are becoming increasingly common. As Bodrogi et al. (2020) highlight, the optimal candidate or patient for this surgery is, “younger than 80 years without preoperative bleeding disorders, cirrhosis, clinically important cardiac disease or end-stage renal disease.” Avant-garde Health recently hosted a roundtable among our cohort members to discuss best practices on performing successful same-day TJAs. The discussion included,

Selection Criteria

• Patient Selection: It is important to determine which patient populations are most likely to have successful outcomes from same-day TJAs. Beyond measuring baseline functional status, providers should interview patients to understand their reasons for receiving a same-day TJA, as well as the support they will have at home for recovery.
• Surgeon Discretion: Surgeons in the organization should be allowed flexibility in determining who should and should not receive same-day TJAs.
• Use of Digital Tools: Digital tools, such as DJO Global’s OaraScore, can be used to assist with patient selection criteria.

Pre-Op Planning & Patient Education

• Pre-op PT: By preemptively introducing pre-operative physical therapy (including a home assessment) 30 days prior to the operation, patients are given the chance to prepare to use a walker, stairs, and durable medical equipment (DME).
• Pre-op Education: Mandatory pre-operative classes are instrumental to inform patients of the process, align expectations, review potential complications and address any questions.

Operating Room

• Anesthesia: Anesthesia is an important factor in the success of same-day TJA programs; spinals are the most common anesthesia approach.

Post-op Care

• Physical Therapy: Eligible same-day TJA patients should be tasked with outpatient PT sessions in order to avoid the need for a home health aide (HHA).
• Home Health Agencies & Aides: “Homebound” patients on the other hand should be tasked with HHA, which is commonly billable for such patients.
• Complications: If a patient is experiences complications, effective use of outpatient consults will aid in treatment and helps avoid costly emergency departments visits.

Discharge

• Post-op Movement: Patients should be tasked with ambulating in the hospital within two-three hours after operation.
• Post-op Same Day PT: Patients should engage in PT in hospital; to ensure that patients do not have to stay overnight, organizations should stagger PT hours to ensure patients are discharged the same day.
• Equipment: In certain situations, patients can be sent home with a catheter or pain pump to facilitate early discharge.
• Post-op Contact: Organizations should get ahead of potential readmissions by calling patients post-op, focusing on pain management, urinary retention, and constipation.

When the appropriate patient is selected and the right organizational structures are in place, same-day TJAs introduce opportunities for organizations to provide top-quality care in minimally disruptive ways to the patient. Additionally, as payors, such as the Centers for Medicaid and Medicare Services (CMS), continue to assess the efficacy and expand their reimbursement for same-day joint replacements, organizations will benefit from being early adopters of this effective set of procedures.