Preoperative High Sleep Quality Predicts Further Decrease in Length of Stay after Total Joint Arthroplasty under Enhanced Recovery Short-stay Program: Experience in 604 Patients from a Single Team

Objective To investigate the safety, efficiency and cost of total joint arthroplasty (TJA) under the enhanced recovery after surgery (ERAS) program and identify predictors facilitating further decrease in length of stay (LOS). Methods We retrospectively collected the information of patients who underwent primary unilateral TJA by a single surgical team between January 2017 and June 2019. A total of 604 patients with LOS <= 3 was enrolled in this study. All patients completed 12-month or longer follow-up. Patients received the same ERAS protocol, mainly including preoperative preparation (patient education, preoperative functional exercises, nutritional support), blood management, pain management, sleep management, prevention of infection, prevention of thrombosis and strict discharge criteria. Preoperative characteristics of patients were collected from the medical record system and were compared between the LOS <= 2 group and the LOS = 3 group. Factors with significant difference were included in multivariate logistic regression analysis to find independent preoperative predictors for LOS. Joint function at the latest follow-up, adverse events rate and hospitalization costs were compared between the LOS <= 2 group and the LOS = 3 group. Results Of the enrolled 604 patients, 271 patients (44.9%) had a LOS of 2 days or less while 333 patients (55.1%) had a LOS of 3 days. Pittsburgh Sleep Quality Index score (odds ratio [OR] = 1.084, 95% confidence interval [CI] = 1.024-1.147, P = 0.005), preoperative albumin level (OR = 0.945, 95% CI = 0.905-0.988, P = 0.012), digestive diseases (OR = 1.084, 95% CI = 1.024-1.147, P = 0.005) and total hip arthroplasty (THA) (OR = 0.273, 95% CI = 0.170-0.439, P < 0.001) were predictors of LOS <= 2 in the multivariate logistic analysis model. The postoperative joint function scores and adverse event rates were comparable between the LOS <= 2 group and the LOS = 3 group. The hospital costs were lower in the LOS <= 2 group than the LOS = 3 group. Conclusion Under the rigorous ERAS program, 2-day discharge in unselected TJA patients can be routinely applied. Patients with high preoperative sleep quality, high preoperative albumin level, free of digestive disease and undergoing THA procedure are more likely to be discharged within 2 days.