Introduction: The increasing numbers and costs of lower limb arthroplasty procedures has lead to medical and administrative pressures to reduce lengths of stay (LOS) and the hospital costs associated with these procedures. We compared a prospective application of an arthroplasty care pathway in a tertiary referral unit in the United States (US) to a retrospective review of standard practice in an Irish unit to assess reasons for delayed discharge.
Methods: We performed the study in 2 orthopaedic units, one in the US and one in Ireland. In the US an arthroplasty perioperative care pathway was implemented, which among other elements involved a coordinated undertaking by therapists, surgeons and social workers to achieve discharge on the 3rd postoperative day. A consecutive series of primary total knee and hip arthroplasty patients were entered into that limb of the study and had demographic, clinical and LOS data collected. We then collected the same data from a randomly selected consecutive series of primary total knee and hip arthroplasty patients in the Irish unit.
Results: In the US orthopaedic unit 43 patients were included, 24 women and 19 men, of average age 60.5 years (range, 36–82). The average LOS was 3.6 days (range, 2–10), with 27 patients going to a rehabilitation facility and 16 directly home.
In the Irish orthopaedic unit 42 consecutive hip and knee arthroplasty patients from a single consultant were included. There were 26 women and 16 men with average age of 63.9 years (range 36 to 88 years). The average LOS was 6.5 days (range, 3 to 10 days), with 24 patients going to a rehabilitation facility and 18 directly home.
There was no correlation found between LOS and either comorbidities, social factors or complications, in both groups although one patient had a delayed discharge due to haematoma and wound drainage in the US. Prolonged LOS in both groups was correlated with delays in rehabilitation bed and transportation availability, reported short staffing in hospital and weekend stays.
Both groups were well matched for comparison. The average shorter LOS noted in the US unit appears to be almost entirely attributable to an implemented perioperative care pathway and a more proactive coordinated approach to discharge planning.
Discussion and Conclusion: This study demonstrates the effectiveness of multidisciplinary clinical pathways in achieving desired LOS objectives but that substantial impediments still exist from an administrative and logistical viewpoint. Such information is important for clinicians in negotiating and establishing appropriate management of their arthroplasty patients in the current care provision climate.
