Reduced Length of Stay Following Patient Pathway Optimization for Primary Hip and Knee Arthroplasty at a Swiss Hospital

Abstract

Total knee and hip arthroplasties (TKA and THA) are common surgical procedures in Switzerland and worldwide. Alongside increasing demand for these procedures, many providers have adopted enhanced recovery programs (ERPs) that aim to optimize recovery after these surgeries. We evaluated the impact of implementing a Patient Pathway Optimization (PPO) program designed around ERP principles for patients undergoing TKA or THA in a Swiss Cantonal hospital. The primary objective was to determine whether PPO implementation for patients undergoing TKA or THA reduced length of stay (LOS) during index hospitalization. Additional study outcomes were hospital inpatient costs, rate of complications and readmissions, and patient discharge destination. Methods: This was a retrospective, observational study comparing outcomes before and after PPO implementation for patients who underwent primary TKA or THA from 2014 to 2019. The PPO program modified the care pathway and implemented five ERP principles (preoperative patient education, pre-operative physiotherapy, local infiltration analgesia, early mobilization, and oral analgesia). Hospital electronic medical record and billing data were used for the analysis. Results: After implementation of PPO, LOS was shorter compared with the pre-PPO period (reduction of 2.5 and 2.4 days in TKA and THA cohorts, respectively, both p < 0.001). Mean inpatient costs per patient were also reduced following PPO (decrease of USD2016 [p = 0.015] and USD340 [p = 0.54] for TKA and THA cohorts, respectively). There were no observed increases in readmissions or complications after PPO implementation in either the TKA or THA cohort. More patients in the post-PPO groups were discharged to home vs an alternative health-care setting than in the pre-PPO groups (TKA, 83.8% vs 68.4% [p = 0.07]; THA, 80.4% vs 73.9%, [p = 0.31]). Conclusion: Patient pathway optimization and implementation of additional enhanced recovery principles for TKA and THA may benefit both health systems and patients, by reducing LOS and costs without increases in complications or readmissions.

A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection

“…(3) preoperative carbohydrate and/or protein loading to reduce the metabolic stress of starvation [27, 46-48, 60, 69, 72], (4) preoperative staff education on short-stay joint replacement programmes [28,31,34,49,58,60,69], (5) hypnotics to promote patient compliance with early mobilisation [45], (6) wearing patients' own clothes during admission to promote patient comfort and satisfaction [43,60], (7) not using negative vacuum suction drains [69,71], [8] low tidal volume ventilation strategy to prevent ventilator-associated lung injury [38,62], (9) higher dose of steroids [45], and (11) preoperative physiotherapy [73].…”

“…Data from the other observational studies were available for eight of the 14 pre-specified safety outcomes: readmissions [72], blood loss (including requiring a blood transfusion) [36,48,52], infection [47,72], mortality [46,51,72], other complications [36,47,52,72,73], venous thromboembolism [47,72] and wound complications [72]. The certainty of the evidence was low and not downgraded or upgraded.…”