| Abstract / Summary | Background and aims
Fast-track protocols have improved outcomes following hip and knee arthroplasty by reducing length of hospital stay (LOS), postoperative complications, and overall healthcare costs. Discharging patients on day of surgery has emerged as a key objective, reflecting the full potential of enhanced recovery pathways. Although selective use of day-case surgery in individual centres have been shown feasible, the use of day-case surgery on national level is low. The aim of this thesis was therefore to investigate whether discharge on day of surgery following hip and knee arthroplasty could be implemented in a multicentre, public healthcare setting among patients meeting clearly defined eligibility criteria. The thesis sought to assess the influence of procedure type in relation to day-case surgery, factors preventing day-case surgery among eligible patients, patient satisfaction and the safety of discharging patients on day of surgery.
Methods
This thesis is based on a prospective, consecutive multicentre cohort conducted within “Centre for Fast-track Hip and Knee Replacement”, a nationwide collaboration involving 8 publicly funded arthroplasty centres across all 5 regions in Denmark.
Study 1 investigated the implementation of discharge on the day of surgery after primary hip and knee arthroplasty during the first 6-months after clinical adoption of the fast-track protocol. Study 2 investigated the association between surgical procedure type and successful day-case surgery, and further examined causes of not being discharged on day of surgery when eligible and scheduled for day-case THA, TKA and mUKA. Study 3 assessed patients’ willingness to repeat discharge on day of surgery if they were to have a future hip or knee arthroplasty procedure. Study 4 investigated patient safety, defined as inhospital complications, early readmissions, mortality and days alive and at home (DAH) after day-case and non day-case hip and knee arthroplasty.
Results
During the implementation period, we found 37% (CI 35–39) of the patients to be eligible for discharge on day of surgery, of whom 52% were discharged on day of surgery. Overall, 21% (CI 20–23) of all patients (eligible and non-eligible) were discharged on day of surgery, compared to 6% in the control period prior to implementation (2019). Centre-level variation was evident during the implementation period. When stratified by procedure type, eligibility rates were 34% (CI 34-36) for both THA and TKA patients, and 52% (CI 49-55) for mUKA patients. Surgery before 1 p.m. was achieved in 85% of eligible patients with day-case success rates of 59% (CI 55-62) for THA, 61% (57-65) for TKA, and 72% (CI 68-76) for mUKA. Primary causes for day-case failure were mobilisation issues, prolonged spinal anaesthesia and postoperative nausea and vomiting (PONV). 90% (CI 88-91) of patients discharged on day of surgery expressed willingness to repeat day-case surgery if having a future joint arthroplasty. This willingness was consistent across procedure types (THA, TKA, and mUKA). Readmission rates were 0.7% (CI 0.5–1.1) within 48 hours and 1.9% within 30 days (CI 1.5–2.5) for day-case patients, and 0.5% (CI 0.3–0.6) and 5.3% (CI 4.8–5.8) for non-day-case patients within 48 hours and 30 days, respectively. No patients died within 48 hours, and overall 30-day mortality was 0.08% (n=10), with no deaths among day-case patients. The median DAH30 was 30 (range 0-30) for day-case patients and 29 (0-30) for non day-case patients.
Conclusions
This thesis demonstrates, that discharging patients on day of surgery after hip and knee arthroplasty can be safely implemented in a multicentre, publicly funded healthcare system. Overall, 21% of patients were discharged on day of surgery during the implementation period. Eligibility and success rates for daycase surgery were comparable between THA and TKA patients, while higher rates were seen for mUKA patients. Day-case failure among eligible patients was mainly due to mobilisation issues, prolonged spinal anaesthesia, and PONV. 90% of patients reported willingness to repeat discharge on day of surgery, indicating high satisfaction. Safety outcomes were favourable, with low rates of in-hospital complications, early readmissions, and mortality. This thesis further illustrates how research can guide and support the implementation of patient pathways in clinical practice through a data-driven process, enabling continuous evaluation of its clinical soundness, safety, and sustainability.
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| Andre oplysninger | Download afhandlingen
Artikel 1: Implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting.
doi.org/10.2340/17453674.2024.40185
Artikel 2: Day-case success or why still in hospital after total hip, toral knee, and medial unicompartmental knee arthroplasties? A prospective multicenter cohort study on 6,142 patients from a public healthcare system
doi.org/10.1302/2633-1462.511.BJO-2024-0125.R1
Artikel 3: Willingness to repeat discharge on day of surgery after hip and knee arthroplasty
doi.org/10.1302/2633-1462.69.BJO-2025-0109.R1
Artikel 4: Patient safety after day-case and non day-case hip and knee arthroplasty. A multicentre cohort study based on a public healthcare setting.
doi.org/10.1302/0301-620X.108B4.
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