The Creation and Implementation of a Hospital-Based Same-Day Discharge Program for Total Joint Arthroplasty

Background: Over the past several years, there has been a focus on decreasing hospital length of stay after primary total joint arthroplasty (TJA). With the removal of total knee and total hip arthroplasties from the Centers for Medicare and Medicaid Services inpatient-only list in 2018 and 2020, respectively, the number of arthroplasties performed on an outpatient basis has dramatically increased. Methods: A gap in quality was identified, as only 19% of primary TJA patients were discharging postoperative day 0 (POD 0) at our institution. Using the DMAIC quality improvement format (define, measure, analyze, improve, and control), we aimed to increase the number of TJA patients that discharge on POD 0 by 51% from 19% to 70% without adversely impacting 30-day hospital readmissions. Results: Interventions were tested and refined based on learning curves and continuous process improvement. After 90 days, the improvement measure was remeasured. At this point, the rate of POD 0 discharge for TJA patients increased to 41%. At the second remeasurement (1-year post intervention), this increased to 71%. The balancing measure of 30-day hospital readmissions was unchanged. Conclusion: Many factors must be considered when selecting patients for same-day discharge (SDD) after TJA. Regardless of SDD or overnight stay, patient safety should always be the number one priority. Our institution demonstrated that a post-anesthesia care unit-based TJA SDD program could be safely implemented without negatively impacting 30-day hospital readmissions. Defining clear objectives, having a multidisciplinary team structure, and engaging stakeholders regularly are all necessary to ensure project success.