Predictors of Failure to Achieve Planned Same-Day Discharge after Primary Total Joint Arthroplasty: a Multivariable Analysis of Perioperative Risk Factors

Abstract

Introduction: Failure to achieve planned same-day discharge (SDD) primary total joint arthroplasty (TJA) occurs in as many as 7% to 49% of patients in the United States. This study evaluated the association between 43 perioperative risk factors and SDD failure rates. Methods: A retrospective analysis of prospectively collected data from 466 primary TJAs with planned SDD to home was performed. Surgeries were performed at an academic tertiary care center comprising a hospital facility and a stand-alone ambulatory surgery center (ASC) on the same campus. Factors associated with failed SDD were identified using a multivariable analysis. Results: Only one of 316 (0.3%) patients who underwent surgery in the ASC failed planned SDD (P < 0.001) compared with 33.3% of 150 patients who underwent surgery in the hospital. The ASC failure was because of pain that interfered with physical therapy. Sixty-two percent (n = 31) of hospital failures were attributed to medical complications, 24% (n = 12) to physical therapy clearance, 8% (n = 4) to not being seen by internal medicine or therapy on the day of surgery, and 6% (n = 3) to unknown causes. Failure was increased in patients with preoperative anemia (P = 0.003), nonwhite patients (P = 0.002), patients taking depression/anxiety medication (P = 0.015), and for every 10-morphine milligram equivalent increase in opioids consumed per hour in the postacute care unit (P = 0.030). Discussion: Risk stratification methods used to allocate patients to ASC versus hospital outpatient TJA surgery predicted SDD success. Most failures were secondary to medical causes. The findings of this study may be used to improve perioperative protocols enabling the safe planning and selection of patients for SDD pathways.