Generally healthy patients who have a total hip replacement (THR) can be “fast-tracked” to be discharged from the hospital in two days, compared with the standard three to six days, according to a new study by Dr. Bryan Nestor, an orthopedic surgeon who practices in the Greenwich Affiliated Physicians Office of Hospital for Special Surgery (HSS). The quicker discharge could help cut down on hospital-acquired infections, reduce hospital costs and improve patient satisfaction, according to the research. Dr. Nestor, a specialist in joint replacement who resides in Darien, was principal investigator of the study.
“Before this study, we were uncertain how safe it would be to discharge patients within two days after a total hip replacement, but based on this study, we now know it is safe. This is evidenced by the fact that the patients who were discharged within two days did not have an increase in complications, readmissions or reoperations,” said Dr. Lawrence Gulotta, an orthopedic surgeon at Hospital for Special Surgery in Manhattan and first author of the study. “This is something that can help improve health care costs and provide better care for our patients.”The study, reported in Springer’s HSS Journal, compared outcomes of patients undergoing THR at Hospital for Special Surgery between 2004 and 2008. One group of 149 patients underwent THR with a fast track protocol. The other group of 134 patients underwent THR followed by the hospital’s traditional clinical pathway, which aimed to discharge patients at four days at that time.
Patients in the two groups were matched for age, sex, body mass index and other health conditions. Patients were excluded if they had inflammatory arthritis, complex THR, and medical problems such as a history of a myocardial infarction, pulmonary embolism or deep vein thrombosis. Blood clots can be a complication of THR, and patients with a history of any of these medical problems cannot be treated with aspirin. All patients in the study were discharged with aspirin.
Patients on the fast track protocol had a physical therapy session on the day of their surgery. The main difference was that a patient’s pain medication was discontinued in the fast track group on postoperative day one (as long as pain was deemed to be under control), whereas in the traditional group, pain medication is usually discontinued on day two.
Patients in both groups were sent home with aspirin, an arrangement for work with a physical therapist, a patient management plan including a list of daily goals, and nausea and pain control plans. A study coordinator screened for complications one day and one week after discharge.
The investigators found that 58 percent of the fast track group was discharged within two days of a THR and 73 percent were discharged within three days. The average discharge time was 2.6 days in the fast track group and 4.1 in the traditional group. Patients were less likely to be discharged rapidly in the fast track cohort if they had significant post-operative pain, nausea, or dizziness. At one year, there were no differences in complications, readmissions or reoperation in the two groups.
“For a select group of patients, we have shown that a two day discharge is safe and feasible for patients undergoing a total hip replacement,” Dr. Nestor said. He pointed out that the two day fast track is not for higher risk patients, the ones who were excluded from the study. While the authors did not measure if the fast track protocol saves money, since it involves shortened hospital stays, the researchers expect it will be more cost-effective.
Roughly half a million THRs are performed every year in the United States, and this number is expected to grow. Many in the baby boomer generation are not willing to be sedentary and as their joints age, they are seeking joint replacement surgeries to keep active.
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