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Study: Two-day Discharge After Arthroplasty Feasible

Clinical Pain Medicine ISSUE: OCTOBER 2011 | VOLUME: 9:10

Toronto—A multidisciplinary program implemented two years ago in an Ontario hospital allows patients to be discharged from an ambulatory hospital two days after primary hip- or knee-replacement surgery.

Physicians at the Kingston General Hospital associated with Queen’s University implemented the fast-track arthroplasty program in 2009 at Hotel Dieu Hospital, the local ambulatory care center. They recently compared patients’ discharge times and outcomes before and after implementation of the program and found that patients’ average length of stay was reduced from 116 to 47 hours.

Key components of the program include early patient education and discharge planning, intraoperative local infiltrative analgesia and physiotherapy starting four to six hours after surgery. The clinicians select patients for the fast-track program based on criteria that have been shown in the literature to be associated with improved outcomes following lower-limb total joint arthroplasty.

“Our fast-track model is easily adoptable, requiring little investment in additional resources or the mastery of new technical skills,” said lead investigator Michael Raphael, fourth-year medical student at Queen’s University, during a poster presentation of the results at the Canadian Anesthesiologists’ Society’s 2011 annual meeting. “This will allow our program to be implemented outside of tertiary care specialty centers in almost any hospital setting.”

“I will talk to my colleagues about this—I’m most interested because it reduces the length of stay and therefore can increase efficiency and the number of surgeries that are done,” said Michael Gallagher, MD, staff anesthesiologist with the Greater Niagara Hospital in Niagara Falls, Ontario, and former director of anesthesia for the Greater Niagara Health Authority, after viewing the research. “However, while it seems simple, there is a lot of work involved, including using people from many different health disciplines.”

The eligibility criteria for the fast-track program include age up to 85 years; an American Society of Anesthesiologists score no greater than 3 with no functional limitation due to cardiac or respiratory disease; a body mass index of 45 kg/m2 or less; independent mobility, a normal hematocrit; no history of rheumatoid arthritis; no history of pulmonary embolism or deep vein thrombosis within the previous six months, an absence of warfarin therapy unless atrial fibrillation is present; and having functional strength in the upper extremities. Patients also need to have stairs-free access to their home bedroom and bathroom, and have adult assistance available on return from the hospital.

Eligible patients are provided with information about the program, including the details of the analgesia regimen, the rapid start of postoperative physiotherapy and the possibility of postoperative nausea and vomiting. Upon arrival at the hospital they are given 975 mg oral acetaminophen and, if they do not have any contraindications, 200 mg oral celecoxib (Celebrex, Pfizer) and 25 mg oral pregabalin (Lyrica, Pfizer).

The intraoperative analgesia is spinal anesthetic (9-13 mg bupivacaine and 100 mcg intrathecal morphine) and a periarticular injection mixed in 120 mL saline (300 mg ropivacaine [Naropin, APP] for most patients or 200 mg for those over age 80 or under 60 kg), 300 mcg epinephrine, 5 to 10 mg morphine in the absence of an allergy or sensitivity to it and 15 to 30 mg ketorolac in the absence of renal dysfunction. Incisions are infiltrated with a dilute solution of local anesthetic at the end of the operation.

The first postoperative night patients receive IV patient-controlled anesthesia and then are transitioned to oral medications. They are started on physiotherapy within four to six hours of surgery.

Patients also receive 650 mg oral acetaminophen every four hours for 24 hours, 200 mg oral celecoxib every 12 hours for 24 hours and 25 mg oral pregabalin every eight hours for 24 hours if opioids were used preoperatively, as well as 5,000 units of subcutaneous low-molecular-weight heparin for 14 to 28 days. One week postsurgery, the patients are contacted by phone; six weeks postsurgery, they have a follow-up visit at the orthopedic clinic.

Raphael and two physicians compared data from 100 patients treated at Hotel Dieu Hospital before program implementation with 100 patients treated with the fast-track program. The fast-track patients experienced significantly lower median rest and active pain scores and used significantly lower amounts of opioids. The fast-track patients also had a significantly shorter average length of stay, at 47 hours versus 116 hours, after adjustment for age, sex, body mass index, smoking, comorbidities and surgical procedure (P<0.05).

The groups also had a similar number of postoperative emergency department visits (14 and 13, respectively). In the fast-track group, there was one readmission for postoperative hematoma and another for infection; in the standard-discharge group, there was one readmission for inadequate pain control.

Seventy-nine of 82 patients (96%) contacted one week postoperatively said they had good overall surgical and hospital experiences Three reported moderate to severe pain; two of these patients were using low-dose oral opioids and the other was taking only nonsteroidal anti-inflammatory drugs.

—Rosemary Frei, MSc