“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.
Other HSS authors involved in the study are Douglas Padgett, M.D., Thomas Sculco, M.D., Michael Urban, M.D., Ph.D., and Stephen Lyman, Ph.D. No author received financial support related to the study.
About Hospital for Special Surgery Affililiated Physicians Office in Greenwich
The Hospital for Special Surgery Affiliated Physicians Office is located at 143 Sound Beach Avenue, Old Greenwich, Conn. Telephone: 203-409-3000. Specialties include foot and ankle, hand/upper extremity, hip and knee, spine, pediatric and adolescent sports medicine, pediatric orthopedics and scoliosis, physiatry-focused spine and sports medicine, sports medicine and shoulder surgery, trauma and joint replacement.
About Hospital for Special Surgery
Founded in 1863, Hospital for Special Surgery (HSS) is a world leader in orthopedics, rheumatology and rehabilitation. HSS is nationally ranked No. 1 in orthopedics, No. 2 in rheumatology, No. 19 in neurology and No. 16 in geriatrics by U.S. News & World Report (2011-12), has received Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center, and has one of the lowest infection rates in the country. From 2007 to 2011, HSS has been a recipient of the HealthGrades Joint Replacement Excellence Award. HSS is a member of the NewYork-Presbyterian Healthcare System and an affiliate of Weill Cornell Medical College, and as such all Hospital for Special Surgery medical staff are on the faculty of Weill Cornell. The hospital's research division is internationally recognized as a leader in the investigation of musculoskeletal and autoimmune diseases. Hospital for Special Surgery is located in New York City and online at www.hss.edu.
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