Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch

BACKGROUND:Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS:All patients who underwent primary TJA between February 2021 to February 2023, were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS:Overall, SDD was successful in 94.2% (n=2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty (THA), 96.0% with total knee arthroplasty (TKA), and 98.6% with unicompartmental knee arthroplasty (UKA). Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P<0.0001), later surgery start time (P<0.0001), longer surgical time (P=0.0043), higher estimated blood loss (P<0.0001), women (P=0.0102), younger age (P=0.0079), and lower preoperative mental health patient-reported outcomes scores (P=0.0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P=0.6830). CONCLUSION:With a comprehensive multidisciplinary approach dedicated to improving same day discharges at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.