Easily adoptable total joint arthroplasty program allows discharge home in two days

• Published in: Canadian journal of anesthesia 2011-10, Vol.58 (10), p.902-910
• Main Authors: Raphael, Michael, Jaeger, Melanie, van Vlymen, Janet
• Format: Article
• Language: English
• Subjects: Aged; Analgesics, Opioid - administration & dosage; Analgesics, Opioid - therapeutic use; Anesthesia; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthesiology; Arthroplasty, Replacement, Hip - methods; Arthroplasty, Replacement, Hip - rehabilitation; Arthroplasty, Replacement, Knee - methods; Arthroplasty, Replacement, Knee - rehabilitation; Biological and medical sciences; Canada; Cardiology; Cohort Studies; Critical Care Medicine; Female; Hospitalization - statistics & numerical data; Humans; Intensive; Joint replacement surgery; Length of Stay; Male; Medical personnel; Medical sciences; Medicine; Medicine & Public Health; Middle Aged; Morphine; Pain Medicine; Pain, Postoperative - drug therapy; Patient education; Patient Education as Topic; Patient Readmission - statistics & numerical data; Patient safety; Patient Satisfaction; Pediatrics; Physical therapy; Pneumology/Respiratory System; Reports of Original Investigations; Retrospective Studies
• ISSN: 0832-610X; 1496-8975
• DOI: 10.1007/s12630-011-9565-8

Purpose A safe efficient care pathway is needed to address the increasing need for arthroplasty surgery in Canada. Our primary objective was to determine whether a fast-track model of care can reduce length of hospital stay following total hip and knee arthroplasty while maintaining patient safety and satisfaction. Methods In this historical cohort study, 100 patients treated in a newly implemented fast-track program for total joint arthroplasty were compared with 100 patients treated before the introduction of the program. The fast-track program emphasizes preoperative patient education, postoperative multimodal analgesia with periarticular injections, early physiotherapy and rehabilitation, and discharge home with an outpatient rehabilitation program. The primary outcome was hospital length of stay. Secondary outcomes were concerned with patient safety and involved evaluating postoperative side effects, transfers to the tertiary care hospital, and emergency department (ED) visits and readmissions to hospital within 30 days of discharge. Results Length of hospital stay adjusted for age, sex, smoking, comorbidities, American Society of Anesthesiologists’ physical status classification, body mass index, and surgical procedure was reduced significantly for patients in the fast-track program compared with the standard program (mean 47 hr; 95% confidence interval [CI] 41 to 53 vs mean 116 hr; 95% CI 110 to 122, respectively). Patients in the fast-track program were discharged from hospital 69 hr earlier than patients in the standard program (95% CI −60 to −78). Despite significantly less morphine utilization, pain scores trended lower in the fast-track patients, both at rest and with activity, than in patients in the standard group (median 7.5 vs 35 mg, respectively). There were no significant differences between the two groups in the rate of ED visits or readmissions in the first 30 days. Conclusion Our multimodal multidisciplinary fast-track protocol reduced hospital stay and opioid consumption while maintaining a high level of patient safety. Program implementation is feasible both in tertiary care and in community hospitals.