Rapid Recovery Protocols Research Articles

Safe transition home after transcatheter aortic valve implantation feasibility (START-F) study: Very early self-reported function and recovery status after early discharge

Abstract Background Despite significant excellent outcomes and significant improvements in rapid recovery protocols and early discharge, rates of 30-day readmission after transcatheter aortic valve implantation (TAVI) remain stubbornly high. There can be numerous drivers for readmission in older people with valvular heart disease; the time of transition home is the period of greatest risk when patients are most vulnerable to repeat hospitalization. We sought to assess patients’ early recovery (< post-procedure day 3) to inform the evaluation of a nurse-led telephone intervention to mitigate the risks of 30-day readmission after early (1 day) discharge TAVI. Methods We conducted a prospective observational cohort feasibility study in five Canadian TAVI programs to ascertain acceptability, compliance, delivery of the intervention, recruitment and retention. In this preliminary report, we assessed key indicators of patients’ status at the time of discharge and functional status in their early recovery. Results We recruited 188 participants, mean age 81.6 years (SD=7.0), 41.5% women with baseline mean KKCQ 53.4 (SD=20.1). Patients were admitted on the day of the procedure, and underwent TAVI with a balloon-expandable (n=146, 77.6%) or self-expanding (n=30, 16.0%) device, with local anaesthesia +/- light sedation (n=171, 90.1%) or general anaesthesia (n=17, 9.0%). There was 1 in-hospital death (0.5%) and 182 (97.4%) were discharged home. At the time of the 3-day telephone follow-up, 168 (95.5%) reported that an individual had stayed with them during the first 24 hours [spouse: 85 (48.9%); friend: 77 (44.3%)], and 165 (93.3%; missing: 11) were able to complete all activities of daily living, including cooking their own meals (n=80, 45.5%). Self-reported energy was low/very low for 49 participants (26.1%), moderate for 93 (52.8%), and high/very high for 34 (18.1%), with 104 (55.3%) describing feeling somewhat or quite a bit better than before TAVI, and 24 (12.8%) somewhat or quite a bit worse. Bruising was present in 120 participants (68.6%) and 137 (78.8%) had removed their bandage as instructed. 18 participants were readmitted within 30 days, including 14 cardiac-related events. Conclusion This is one of the first reports of TAVI patients’ self-reported function following next-day discharge, providing novel evidence that most patients describe safe self-care and very early improved functional status. Research is needed to identify and support patients who are at higher risk of poorer trajectories of recovery and readmission, and report the feasibility of a nurse-led intervention to mitigate these risks.

Rapid-recovery protocol for minimally invasive mitral valve repair

BackgroundMinimally invasive mitral valve repair (MIMVR), often performed within specialized care pathways, has been shown to reduce hospital length of stay and improve patient recovery. The relative value of rapid-recovery protocols as a component of care pathways, including enhanced recovery programs (ERPs), has not been well described. This study compared clinical outcomes following implementation of a new, comprehensive rapid-recovery protocol within a previously established, mature ERP for patients undergoing MIMVR. MethodsThe rapid-recovery protocol was developed and implemented by a multidisciplinary team to further optimize patient recovery within an existing ERP. The protocol was applied to 75 consecutive patients undergoing MIMVR between September 2022 and December 2023. Outcomes were compared retrospectively to 75 ERP control patients who did not receive the rapid-recovery protocol but experienced the ERP. The primary outcome was a composite of discharge from the intensive care unit (ICU) by postoperative day (POD) 1, discharge to home by POD 4, and no all-cause hospital readmission by 30 days. ResultsBaseline characteristics were similar in the 2 groups. Patients in the rapid-recovery group achieved the primary composite outcome significantly more often compared to the control group (60% vs 40%, respectively). There was no between-group difference in postoperative complications. Multivariable logistic regression showed that age ≤60 years was significantly associated with rapid-recovery protocol success. Clinical barriers to achieving individual components of the primary outcome were described. ConclusionsA rapid-recovery protocol for MIMVR was associated with early ICU and hospital discharge. These benefits were safely achieved without any increase in hospital readmission, morbidity, or mortality up to 30 days postoperatively.

CORR Insights®: Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

CORR Insights®: Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined. When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition? An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming. After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33). Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA. Level III, therapeutic study.

A rapid recovery protocol for head and neck oncology patients undergoing resection, free flap reconstruction, and tracheostomy: a feasibility study

Enhanced recovery after surgery (ERAS) for head and neck oncology patients was first introduced in 2017 and was found to improve patient outcomes, in line with results from other surgical specialties. This article presents a rapid recovery protocol (RRP) to further enhance perioperative care in conjunction with the ERAS protocol, for patients undergoing ablative surgery together with free flap reconstruction and tracheostomy. A prospective multidisciplinary approach was adopted to identify a specific cohort of patients who would benefit from the RRP. Of 26 patients who fulfilled the eligibility criteria, 16 completed the RRP. On average, these patients spent 5 days less with a tracheostomy and were discharged 7 days sooner when compared to a matched control group of nine patients on the standard postoperative care pathway. This resulted in an approximate monetary saving of £ 9955 per patient for the hospital trust. These results demonstrate that the feasibility study should be rolled out further, as the RRP not only decreased the length of stay but also provided substantial monetary savings without compromising patient outcomes.

SAFEGUARDING STABILITY: STRATEGIES FOR ADDRESSING DYNAMIC SYSTEM VARIATIONS IN POWER GRID CYBERSECURITY

The power grid stands as a critical infrastructure supporting modern society, yet it remains susceptible to cyber threatsthat could compromise its stability and functionality. Addressing the dynamic variations and evolving challenges posedby cyber threats requires robust strategies in cybersecurity. This paper investigates methods to safeguard the stability ofthe power grid against cyber intrusions and system variations. This study delves into the multifaceted nature of cyberthreats targeting the power grid and analyzes the dynamic variations within the system that could be exploited bymalicious actors. This paper presents a comprehensive framework encompassing proactive and reactive cybersecuritymeasures. Reactive measures include incident response plans, rapid recovery protocols, and the integration of machinelearning and artificial intelligence for real-time threat detection and mitigation. Moreover, considering the interconnectednature of the power grid, this study explores collaborative approaches among stakeholders, such as utility companies,government bodies, regulatory authorities, and cybersecurity experts, to foster information sharing, best practices, andstandardized protocols. Ultimately, this paper serves as a guide for policymakers, grid operators, and cybersecurityprofessionals to develop robust strategies that safeguard the stability of the power grid in the face of evolving cyberthreats and system dynamics. By implementing a holistic cybersecurity approach, the aim is to ensure resilience,reliability, and continuity in the delivery of electricity to society

Improved perioperative narcotic usage patterns in patients undergoing robotic-assisted compared to manual total hip arthroplasty

BackgroundRobot-assisted total hip arthroplasty (RA-THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA (mTHA), but optimal dosage for peri-RA-THA and mTHA pain relief remains unclear. This study aimed to compare pain control with opioids between patients undergoing direct anterior approach THA with the use of a novel, fluoroscopic-assisted RA-THA system compared to opioid consumption associated with fluoroscopic-assisted, manual technique.MethodsRetrospective cohort analysis was performed on a consecutive series of patients who received mTHA and fluoroscopy-based RA-THA. The average amount of postoperative narcotics in morphine milligram equivalents (MME) given to each cohort was compared, including during the in-hospital and post-discharge periods. Analyses were performed on the overall cohort, as well as stratified by opioid-naïve and opioid-tolerant patients.ResultsThe RA-THA cohort had significantly lower total postoperative narcotic use compared to the mTHA cohort (103.7 vs. 127.8 MME; P < 0.05). This difference was similarly seen amongst opioid-tolerant patients (123.6 vs. 181.3 MME; P < 0.05). The RA-THA cohort had lower total in-hospital narcotics use compared to the mTHA cohort (42.3 vs. 66.4 MME; P < 0.05), consistent across opioid-naïve and opioid-tolerant patients. No differences were seen in post-discharge opioid use between groups.ConclusionsFluoroscopy-based RA-THA is associated with lower postoperative opioid use, including during the immediate perioperative period, when compared to manual techniques. This may have importance in rapid recovery protocols and mitigating episode burden of care.

The Effect of Preoperative, Low-Dose Intrathecal Morphine on Patient Outcomes Following Lumbar Fusion Surgery: Can We Teach an Old Dog New Tricks?

Early pain control after lumbar fusion presents a challenge to patients and providers. Intrathecal morphine (ITM) has been used at the end of these procedures with limited benefit, but recent data suggest low-dose ITM at case initiation may be effective. This study aims to evaluate the use of preoperative ITM during lumbar fusion to determine whether there is a benefit for these patients. One hundred and eighty lumbar fusion patients between 1 January 2018 and 31 May 2022 were evaluated. Patients were grouped by whether they received preoperative, low-dose ITM or not. Outcomes of interest included hospital narcotic consumption, pain scores, opioid-related complications, and complications within the first 90 days. Sixty-five study patients received 200 µg ITM at case initiation and 115 did not. No differences in length of stay, discharge disposition, or complications in the first 90 days were noted. ITM patients received fewer milligram morphine equivalents in the postanesthesia care unit (9.7 ± 31.23 vs 21.83 ± 21.07; P = 0.006) and on postoperative day 0 (18.60 ± 35.47 vs 35.47 ± 28.51; P = 0.001). Pain scores were lower in the ITM group both in the postanesthesia care unit and on postoperative day 0, with a decrease in extreme pain scores (>7; 35.4% vs 53.0%; P = 0.034). ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction. ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction.

The Effect of Coffee Consumption after Colorectal Surgery on Bowel Movements and Duration of Hospital Stay

Background: Postoperative ileus after colorectal surgery is a common problem that significantly prolongs hospital stay and increases perioperative costs. The ability of postoperative coffee consumption to produce bowel movement is unclear and needs to be studied. Objective: The objective of this study was to evaluate the effect of coffee consumption on bowel movements and duration of hospital stay after laparoscopic colorectal surgery. Methods: This nonrandomized prospective study examined a population of patients who underwent laparoscopic colorectal surgery between November 2018 and June 2019. The study sample consisted of 51 patients, including the experimental group (25 patients who consumed coffee) and the control group (26 patients). The first bowel sounds, the first flatulence and defecation times, and duration of hospital stay were examined in this study. There was a statistically significant (p < 0.021) difference between the experimental group and the control group when the first flatulence (13.8 times/h) and defecation (14.8 times/h) times were examined. However, the results were not significantly different between the groups despite the earlier start of the first bowel sounds (2.5 times/h) and the shorter duration of hospital stay (mean 1.1/day) in the experimental group (p > 0.05). Conclusion: Postoperative coffee consumption is believed to be an effective, enjoyable, easy, and economical method for increasing bowel movements after surgery and is likely to be added to rapid recovery protocols in the future. Further studies with larger samples will confirm this.

Translated article] Implementation of a rapid recovery protocol in total knee arthroplasty. A randomised controlled trial

BackgroundRapid recovery (RP) in total knee arthroplasty may increase the functionality while reducing costs. The aim of this study is to prove the benefits of a rapid recovery programme compared to our classic protocol. Patients and methodsWe performed a RCT (NCT03823573) in patients undergoing otal knee arthroplasty. Intervention group (RP protocol) received local infiltration of levo-bupivacaine in the periarticular tissue and supervized ambulation 4–6h after surgery. Control (C) group received a femoral nerve block with levo-bupivacaine, while a drain was used. Ambulation after its removal.All the patients completed an Oxford Knee Score prior to surgery and 6 months after discharge. An ecodoppler to assess the presence of deep vein thrombosis was made 1 month after discharge. Minimum follow-up was of 6 months. ResultsA total of 175 patients were included in the trial (92 patients in the control group, 83 patients in the RP group). There were no differences in sex, age, implanted prosthesis, haemoglobin drop, need for transfusion, range of motion on discharge (C: 82.6°, RP: 85°) and at the end of the follow-up (C: 105.1, RP: 106.6), Oxford knee score improvement (C: 17.5 points; RP: 19.3 points), patient satisfaction or re-admissions at the emergency department (C: 7.6%; RP: 10.8%).Significancy was found on time of ischaemia (C: 81.29min; RP: 85.35min; p=.03), need for morphine shots (C: 19.7%; RP: 38.6%; p=.007), hospital stay (C: 3.84 days; RP: 2.54 days, p<.0001) and time until ambulation (C: 2.46 days; RP: 0.23 days; p<.0001). ConclusionRapid recovery protocols can reduce hospital stay without increasing complications or need for re-admission.

Outcomes of Patients Undergoing Total Knee Arthroplasty with Spinal Anesthesia: A Comparison of Mepivacaine versus Bupivacaine

Introduction: Previous literature indicates that mepivacaine used for spinal anesthesia may lead to reduced recovery time and urinary retention compared to bupivacaine in patients undergoing total knee arthroplasty (TKA). We sought to compare outcomes between spinal anesthetics in our high-volume joint institution. Materials and Methods: A retrospective review of 553 unilateral primary TKA patients who received spinal anesthesia was conducted. Patients were divided by their receipt of mepivacaine or bupivacaine. Univariate comparisons before and after propensity score matching were used to compare outcomes for TKA patients receiving mepivacaine with those who did not. Results: Of the 553 patients, 102 received mepivacaine, and 451 received bupivacaine. After propensity score matching, patients who received bupivacaine experienced longer lengths of stay, received more oral morphine milligram equivalents (OMMEs), and were less likely to be discharged home. No differences in rates of nausea, urinary retention, or 30-day readmissions were observed between the groups. Discussion: In patients undergoing TKA with a spinal anesthesia, after adjusting for potentially confounding factors using propensity score matching, the use of mepivacaine was associated with shorter length of stay, less overall OMME requirements, and increased likelihood of home discharge, with no increase in complication rates. Based on these results, mepivacaine appears to be a viable alternative to bupivacaine for use in TKA rapid recovery protocols.

A rapid recovery protocol for hip and knee replacement surgery: a report of the outcomes in a referral center.

The number of joint replacements is expected to dramatically increase, and the optimization of the available resources is fundamental to maintain high clinical standards while providing an efficient treatment to an increasing number of patients. The present study describes the outcomes of the application of a rapid recovery (RR) protocol in a referral center for hip and knee replacement surgery. The medical records of every patient undergoing primary hip or knee replacement in 2019 were identified and all the relevant data were retrospectively extracted and compared to those of year 2016 (the last year before the onset of the rapid recovery protocol). The following outcomes were considered: 1) length of stay (LOS); 2) total number of TKR and THR; 3) pre- and post-operative subjective questionnaires; 4) NRS for pain at day 1 following surgery; 5) mean hemoglobin value at discharge; 6) number of blood transfusion performed; 7) complications following surgery. The mean LOS was significantly lower for patients managed through the rapid recovery protocol: 5.1 ± 1.4 days vs. 10.4 ± 2.3 days (p < 0.0001). The earlier discharge of patients promoted an overall increase in the total number of joint replacement procedures performed (2,806 in year 2019 vs. 2,236 in year 2016; p < 0.0001). Higher hemoglobin values at discharge were found in the RR group (10.6 ± 1.4 g/dl vs. 9.6 ± 1.2 g/dl, p = 0.049). No difference was observed in terms of clinical scores and overall complication rate. The application of a multimodal RR protocol for THR and TKR patients was able to reduce the length of stay and optimize the use of blood products, without increasing the risk of complications or jeopardizing the functional recovery.

Hospital-Based Rapid Recovery Protocol in Knee Arthroplasty

This review aims to determine the elements a hospital-based knee arthroplasty program should consider when developing a rapid recovery protocol. It will examine the perioperative pathway and how a program can break down each phase for success. Secondary objectives of this review include how and why the culture surrounding knee arthroplasty has changed and why it is in a hospital's best interest to adopt a rapid recovery pathway in light of this new landscape. An extensive search was performed through databases which included Still OneSearch, EBSCOhost, and PubMed. Sources aligned with the review's objectives. Inclusion criteria involved primary sources, secondary sources, and peer-reviewed articles less than 5 years old. On finding primary and secondary sources, reference sections provided additional materials to ensure high-quality research. Outpatient knee arthroplasty has gained interest in the past 10 years, and rapid recovery protocols have helped promote this likely development. The rapidly changing landscape surrounding knee arthroplasty was triggered by insurance companies and pushed even further because of the COVID-19 pandemic. Developing a rapid recovery protocol in the hospital setting involves a change in overall culture, interprofessional participation, and patient and family cooperation. Although not an easy task, adopting a rapid recovery protocol for knee arthroplasty has been shown to improve overall patient outcomes by decreasing length of stay, decreasing complications, and increasing discharge home rates. Along with improved outcomes, we have improvements in patient satisfaction and overall cost savings.

Outcomes of an Institutional Rapid Recovery Protocol for Total Joint Arthroplasty at a Safety Net Hospital.

Introduction:Rapid recovery protocols (RRPs) for total joint arthroplasty (TJA) can reduce hospital length of stay (LOS) and improve patient care in select cohorts; however, there is limited literature regarding their utility in marginalized patient populations. This report aimed to evaluate the outcomes of an institutional RRP for TJA at a safety net hospital.Methods:A retrospective review of 573 primary TJA patients was done, comparing the standard recovery protocol (n = 294) and RRP cohorts (n = 279). Measured outcomes included LOS, 90-day complications, revision surgeries, readmissions, and emergency department visits.Results:The mean LOS reduced from 3.0 ± 3.1 days in the standard recovery protocol cohort to 1.6 ± 0.9 days in the RRP cohort (P < 0.001). The RRP cohort had significantly fewer 90-day complications (11.1% versus 21.4%, P = 0.005), readmissions (1.4% versus 5.8%, P = 0.007), and revision surgeries (1.4% versus 4.4%, P = 0.047).Conclusion:A RRP for primary TJA can be successfully implemented at a safety net hospital with a shorter LOS and fewer acute adverse events. Such protocols require a coordinated, multidisciplinary effort with strict adherence to evidence-based practices to provide high-quality, value-based surgical health care to an underserved cohort.

Adductor Canal Block Combined with Interspace between the Popliteal Artery and Capsule of the Knee (iPACK) versus Periarticular Injection for Total Knee Arthroplasty.

The combination of the adductor canal block (ACB) and the infiltration of anesthetic solution into the interspace between the popliteal artery and capsule of the knee (iPACK) has become increasingly used to augment rapid recovery protocols in total knee arthroplasty (TKA). However, its efficacy in comparison with periarticular anesthetic injection (PAI) alone has yet to be evaluated. Hence, we conducted a retrospective study to compare PAI and ACB + iPACK for controlling pain after TKA. Propensity scores, incorporating American Society of Anesthesiologists scores, body mass index, age, and sex, were used to match the ACB + iPACK group with the PAI group. All patients received the identical surgical technique and postoperative care. Outcome measures were visual analog scale (VAS) for pain, morphine consumption, knee flexion angle, straight leg raising (SLR), postoperative nausea vomiting (PONV), and length of stay (LOS) after the surgery. After matching by propensity score, there were 49 patients with comparable demographic data in each group. The VAS and morphine requirements of the PAI and ACB + iPACK groups were not different during the first 48 hours after TKA. At 72 hours postoperatively, the VAS of the ACB + iPACK was 0.97 higher than that of the PAI group (p = 0.020). Knee flexion angle, SLR, PONV, and LOS were not significantly different between groups. No procedure-related complications were identified in either group. The anesthesiologist-administered ACB + iPACK was as effective as surgeon-administered PAI in controlling pain in the first 48 hours after TKA. However, the ACB + iPACK group had higher intensity of pain than did the PAI group at 72 hours after TKA.

No Effect of Surgical Approach on Discharge Outcomes in Outpatient Total Hip Arthroplasty.

Background: The interest in ambulatory total hip arthroplasty (THA) has increased recently due to a national focus on value-based care and improved rapid recovery protocols. Purpose: We sought to determine if surgical approach had an effect on discharge outcomes in outpatient THA. Methods: We performed a retrospective cohort study examining patients who underwent unilateral THA at a single institution using a standardized perioperative care pathway who were discharged home within 24 hours. In total, we compared 106 patients who underwent THA using the direct anterior approach (ATHA) and 90 patients who underwent THA using the posterior approach (PTHA). Univariate and multivariable analyses were used to compare time to ambulation, length of surgery, readmissions, and 90-day complications. Results:Time to ambulation in the ATHA and PTHA groups was 3.9 hours and 4.1 hours, respectively, and time to discharge was 5.9 hours and 6.0 hours, respectively. Length of surgery was shorter in the ATHA group than in the PTHA group (78 minutes vs 86 minutes, respectively). Complications occurred in 3 patients (3%) in the ATHA group vs 4 patients (4%) in PTHA group. In both groups, early ambulation (within 5 hours) predicted earlier time to discharge. Surgical approach was not associated with time to ambulation or time to discharge on multivariable analysis. Conclusion: In this retrospective study, outpatient THA was feasible in a well-selected population of patients undergoing anterior or posterior approaches. Further study is warranted.

Outpatient Total Hip and Knee Arthroplasty Performed in a Safety Net Hospital System.

Introduction:High-percentage outpatient total joint arthroplasty (TJA) performed in a safety net hospital system has not been described. A rapid recovery protocol (RRP) was instituted at our safety net hospital that allowed eventual transition to outpatient TJA.Methods:Retrospective review of all primary total knee and hip arthroplasty performed by a single surgeon (RR) using an RRP was performed. The initial cohort of patients was monitored overnight with the goal of next-day discharge (n = 57), and as the RRP evolved, the subsequent cohort of patients had the possibility of same-day discharge (PSDD, n = 61). Outcome measures included the rate of same-day discharge in the PSDD cohort and short-term adverse event rates.Results:In the PSDD cohort, 86.9% (n = 53) of patients were successfully discharged on the day of surgery, and hospital length of stay was decreased by 17.7 hours (13.5 versus 31.2 hours, P < 0.0001). Comparing the next-day discharge and PSDD groups, no significant differences were found in 30-day emergency department visits (5.3% versus 3.3%, P = 0.67), 90-day complications (15.8% versus 13.1%, P = 0.79), 90-day readmissions (0% versus 3.3%, P = 0.50), or 90-day revision surgeries (0% versus 3.3%, P = 0.50).Conclusions:This study demonstrates that the transition to outpatient TJA can be successfully performed in a safety net hospital system without increasing short-term adverse events.

Improving Arthroplasty Efficiency and Quality Through Concentrating Service Volume by Complexity: Surviving the Medicare Policy Changes

We have an academic medical center (AMC), an associated community-based hospital (CBH) and several ambulatory care centers which are being prepared to provide same day discharge (SDD) total joint arthroplasty (TJA) and unicompartmental knee arthroplasty (UKA). The near-capacity AMC cared for medically and technically complicated TJA patients. The CBH wanted to increase volume, improve margins, and become a center of excellence with an efficient hospital outpatient department and SDD TJA experience. MethodsWe transitioned primary, uncomplicated TJA, UKA, and minimally invasive TJA to the CBH. Revision surgeries, patients with extensive comorbidities, and complex primaries were performed at the AMC. Protocols were developed to facilitate SDD UKA and total hip arthroplasty (THA) as well as rapid recovery protocols for total knee arthroplasty (TKA) at both hospitals. A protocol-based system was put in place to make both hospitals ready for the removal of TKA from the Inpatient-Only list to avoid Quality Improvement Organization and possible resultant Recovery Audit Contractor audits if referred after implementation. ResultsThe CBH volume increased 36.7% (+239). AMC volume slightly decreased (−0.46%, −5) resulting in an increase in margin contribution for the system. CBH quality metrics (surgical site infections, length of stay, readmissions, and mortality) were improved. Surgeon satisfaction improved as their volume, efficiency, quality metrics, and finances were enhanced.Although CBH per case revenue was 80.3% and 74.4% of the AMC for THA and TKA, net margins were 3.6% and 18.8% higher for THA and TKA, respectively. Increased efficiency, lower hospital cost, and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case. ConclusionThis strategy will help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient which will be subjected to further decreases in net revenue per patient.

Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients.

Retrospective review. The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA). Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication. AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared. There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly >11.6% of PCA patients (P < 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P < 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P < 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation. This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Impact of Intrathecal Fentanyl on Hospital Outcomes for Patients Undergoing Primary Total Hip Arthroplasty With Neuraxial Anesthesia.

BackgroundIntrathecal opioids have been used to reduce pain after total joint arthroplasty; however, the utility of these drugs is disputed. We examined the impact of eliminating intrathecal fentanyl on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA).MethodsRetrospective review of 376 THA patients from a single institution was conducted. Univariate analysis was used to compare intraoperative medication usage and postoperative outcomes for THA patients receiving intrathecal fentanyl compared with those who did not receive intrathecal fentanyl.ResultsRecovery room pain scores were significantly lower for patients who received intrathecal fentanyl (intrathecal fentanyl 1.4 vs no 2.2, P = .001), but no difference in opioid consumption was observed (intrathecal fentanyl 9.3 milligram morphine equivalent vs no 10.5 milligram morphine equivalent, P = .200). Intraoperative use and dose of intravenous morphine, hydromorphone, and dexamethasone did not differ significantly between groups. There were no significant differences in length of stay between the groups (intrathecal fentanyl 1.1 days vs 1.1 days, P = .973), 90-day readmission, or recatherization rates between groups (readmission, intrathecal fentanyl 4.8% vs no 5.8%, P = .709; recatherization, intrathecal fentanyl 0% vs no 0.7%, P = 1.00).ConclusionThe administration of intrathecal fentanyl does not have a significant effect on early postoperative narcotic consumption, length of stay, 90-day readmissions, or recatheterization after THA with neuraxial anesthesia. Intrathecal fentanyl does not appear to improve outcomes and should not be included as a standard element of THA rapid recovery protocols.