Delayed hospital discharge after total shoulder arthroplasty: why, and who is at risk?

Abstract

BackgroundThere is growing policy interest in reducing the length of stay (LOS) after discretionary orthopedic surgery but few data to guide improvement efforts. We characterized the primary reasons and predisposing factors associated with extended LOS after elective total shoulder arthroplasty.MethodsWe retrospectively identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017. Extended LOS was defined as a stay greater than the 75th percentile. Medical records were manually reviewed to ascertain the primary reason for extended LOS. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with prolonged hospitalization.ResultsThe most common reason for extended LOS was pain (41%), followed by medical problems (39%), limited social support (18%), and blood transfusions (2%). Only 41% of patients with delayed discharges had documented adverse events (any medical or surgical problem), all of which were minor. The top 4 medical issues were transient hypoxemia (42%), nausea and/or vomiting (13%), electrolyte abnormalities (12%), and altered mental status (10%). In decreasing order of magnitude, the predictors of prolonged LOS were greater number of self-reported allergies, female sex, unmarried patient, diabetes, lower American Shoulder and Elbow Surgeons score, depression, reverse shoulder arthroplasty, and American Society of Anesthesiologists score of 3 or greater. Operative time did not correlate with LOS.ConclusionsProlonged hospitalizations after shoulder arthroplasty are commonly related to pain and limited social support. Sociodemographic and psychological factors seem to have more influence than patient infirmity and technical issues. These findings support a comprehensive approach to care with attention to the physical, mental, and social determinants of health.

A comparison of patient same-day discharge selection after shoulder arthroplasty before and after the COVID-19 pandemic

“…Additionally, data on possible readmissions or emergency department visits at other hospitals were not available and may have not been recorded in the patient record. However, the low readmission rates reported in this study are similar to rates reported in past studies 6 , 10 , 20 , 212 , 23 . The rate of anatomic (TSA) and reverse shoulder arthroplasty (RSA) procedures differed between the two groups, with more RSA patients in the post-COVID group.…”

The safety of outpatient total shoulder arthroplasty: a systematic review and meta-analysis

“…The disproportionate number of younger patients in the outpatient group can be explained by the fact that younger patients have less comorbidities and are thus safer for the outpatient pathway. However, the under representation of females in the outpatient groups could be related to surgeon selection bias, as female sex has been reported to be a significant predictor for longer hospitalization [ 30 , 31 ]. Another finding in this review was that the outpatient group was generally healthier than their inpatient counterparts.…”

COVID-19 as a Catalyst for Same-Day Discharge Total Shoulder Arthroplasty

“…The finding that baseline preoperative patient characteristics remained unchanged compared to before the outbreak suggests that the observed changes in discharge patterns may indeed be a direct consequence of COVID. There is recent evidence that sociodemographic and psychological factors may have more influence than patient infirmity and technical issues in the variation in LOS and discharge disposition after shoulder arthro-plasty [11]. Although this requires formal investigation, it is possible that patients may be more motivated to go home after surgery during the pandemic to minimize risk of contagion [8].…”