Setting Up an Outpatient or Same-Day Discharge Total Knee Arthroplasty (TKA) Program

Introduction

When the first edition of this book was released, primary total knee arthroplasty (TKA) was a procedure that had a mean length of stay of around 7 days. Dr. Krackow was a pioneer and advanced the issues pertaining to length of stay throughout his career. Advances in operative techniques, anesthesia, and perioperative analgesia have allowed same-day TKA to become a reality. Outpatient total joint arthroplasty has become more popular, with goals to decrease costs while still providing high-value care. To ensure an efficient, effective, and safe outpatient TKA program, it is imperative to establish appropriate protocols. A multidisciplinary team, including the surgeon, anesthesiologist, nurses, operating room (OR) staff, and therapists, is required to set up a successful and safe outpatient total joint program.

Historically, TKA has been performed in the inpatient setting with a 5- to 10-day hospital stay. Patients remained in the hospital to be monitored for postoperative acute blood loss anemia, pain control, and mobilization with physical therapy. Improvements in pharmacological and surgical techniques have markedly reduced the operative blood loss, and fewer patients are requiring postoperative transfusions for anemia. Multimodal pain control has minimized postoperative pain, allowing earlier mobilization and early discharge. The many innovations in total joint arthroplasty and perioperative care have contributed to the successful transition of TKA to the ambulatory setting.

An estimated 680,000 TKAs were performed in the United States in 2014 and this number is expected to increase to 1.26 million by 2030 according to 2000 to 2014 trends. Policies have been instituted that have incentivized patients and physicians to reduce the cost of TKA. The most effective ways to reduce costs are by reducing the lengths of stay, complications, and readmissions. Outpatient total joint arthroplasty procedures, as a whole, have the potential to save up to $7000 per procedure compared with the inpatient setting. Medicare pays for approximately 55% of TKAs in the United States. In 2018 TKA was removed from the Medicare inpatient-only list. Since that time, there has been a marked increase in the number of TKAs done on an outpatient basis. According to Medicare Fee-for-Service Part A claims data, TKA claims went from 0.2% outpatient coding in 2017 to 36.4% in 2019.

It should be noted that there are major differences between performing a TKA in the hospital setting with the intent to discharge the patient on the same day and performing one at a stand-alone ambulatory surgery center (ASC). Even though TKA in a stand-alone ASC may be considered safe for most patients, this type of program requires a team approach from anesthesia, OR support staff, physical therapists, and nurses, with appropriate measures to account for the possible need for a 23-hour overnight stay, which may not be possible at all centers.

Multiple studies have concluded that there are no increased risks of adverse events or complications with a shorter length of stay with outpatient TKA. In a metaanalysis comparing complication rates between inpatient and outpatient total joint arthroplasties there was no increased risk of major complications, readmissions, deep venous thromboses (DVTs), urinary tract infections, pneumoniae, or wound complications with outpatient TKA. These studies suggest that arthroplasty surgeries can be performed safely in an ASC in appropriately selected patients without increased risks of complications. Kelly et al. found that patients who had surgery performed in the ASC had higher patient satisfaction scores in pain management, staff interaction, and preparedness for discharge. Thus reducing discharge delays and improving patient satisfaction scores are paramount considering the financial incentives provided by the Centers for Medicare and Medicaid Services.

Patient Selection

Outpatient TKA may not be feasible or safe for all patients. In the same manner as for traditional TKA patients should be evaluated by their primary care physician preoperatively to note any ongoing medical problems. The first three chapters in this book focus on understanding the comorbidities of patients and how to optimize them. This is important when deciding whether a patient is a good candidate for a same-day discharge or a procedure to be done in an ASC. Patients should be medically optimized for a total joint arthroplasty by correcting modifiable risk factors. An evaluation should be performed by both the surgeon and the anesthesiologist before surgery to determine whether the patient would be a good candidate for TKA at an ASC.

Patients who have specific comorbidities, such as coronary artery disease, diabetes, body mass index (BMI) >40, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), congestive heart failure, cirrhosis, chronic kidney disease, preoperative opioid use, advanced age, higher American Society of Anesthesiologists (ASA) score, and higher Charlson Comorbidity Index, have a higher risk of failure to be discharged or a higher risk of readmission. Patients with these comorbidities may not be good candidates for TKA in an ASC.

Some common criteria used for determining eligibility of patients for outpatient total joint replacement are age <70 years, ASA score I or II, primary total joint arthroplasty, hemoglobin >10 preoperatively, assistance at home, preoperative independent ambulation, and BMI <40. Some exclusion criteria commonly used are coronary artery disease, COPD, congestive heart failure, cirrhosis, chronic kidney disease, HIV positive, preoperative opioid consumption, and chronic pain syndromes (fibromyalgia). These criteria can be used as a guide, but ultimately it should be a joint decision by the patient, surgeon, and anesthesiologist.

When it is determined that TKA in the ASC is appropriate for a patient, it is important to adequately prepare the patient for what will be involved in the preoperative, perioperative, and postoperative settings. It is imperative that appropriate patient education be relayed not just to the patient but also to family members. A video or class that educates the patient on the importance of the preoperative steps and the postoperative risks and physical therapy guidelines can be productive. The literature presents conflicting data on preoperative education with regard to patient satisfaction, but the potential benefits and minimal harm of patient education will likely improve patient expectations. DeCook suggested multiple elements to consider with regard to patient preparation ( Table 6.1 ).

Anesthesia and Preoperative Blocks

Advances in anesthetic techniques and postoperative pain control have allowed earlier mobilization and reduced opioid consumption. Controlling pain in the early postoperative period has a profound effect on postoperative recovery in patients with TKA. Reduced pain allows more aggressive therapy and range of motion exercises in the early postoperative period, which can improve recovery and facilitate an early discharge home. Combining a neuraxial anesthetic approach, an adductor canal block, and periarticular injection can be an effective approach to minimize postoperative pain.