Achieving effective and timely quality of care in same-day discharge total hip arthroplasty without compromising patient safety.

Abstract

Using quality improvement (QI) processes, we sought to safely achieve >80% efficiency in same-day discharge (SDD) of eligible primary total hip arthroplasty (THA) patients. A "Plan-Do-Study-Act" approach was used. QI elements included: research of prior relevant publications, clinical audit for data-driven evaluation, service evaluation assessments and clinical transformation on a small scale for piloting change. Care interventions were introduced within an already established highly iterative and enhanced recovery after surgery-based programme. Intervention 1 established patient eligibility. Those eligible could be SDD once discharge criteria were met (the "Standard" cohort). Intervention 2 implemented "Enhanced Recovery Canada" (ERC) recommendations for pre-emptive nausea and pain management, and lidocaine-based regional surgical anaesthesia (the "ERC" cohort). Intervention 3 changed from epidural to spinal lidocaine for surgical anaesthesia. This cohort was evaluated as part of the ERC cohort, as well as a stand-alone Lidocaine Spinal cohort. Clinical audits were the main comparative benchmarks. Improved rates of SDD were the primary measure of success. Safety was based on rates of unscheduled hospital encounters within 30-days of surgery. Data was collected prospectively and analysed using logistic regression, adjusting for age and gender. Patient satisfaction was also surveyed. The ERC cohort had significantly greater odds of successful SDD compared to the standard group (74.4% vs 54.3%, OR 2.51, p=0.0015). Odds were even higher for Lidocaine Spinal (80.6% vs 54.3%, OR 3.4, 95% CI (1.34 to 8.66), p=0.0102). There was no significant difference in the rates of unscheduled 30-day hospital encounters. The ERC group experienced fewer complications that prevented SDD (25.6% vs 45.7%, OR 0.41, p=0.0015). Patient satisfaction scores were high in the Spinal Lidocaine group. Implementing ERC recommendations significantly improved SDD rates for THA without increasing postoperative complication rates. This suggests that targeted interventions can enhance the efficiency of SDD THA programmes without compromising patient safety.