Sunday, April 24, 2011

How Long Should You Be Hospitalized After Joint Replacement Surgery: Not too short….not too long…..just right

Once upon a time, there was a little girl named Goldilocks.  She went for a long walk in the forest.  Soon, she came upon a house and knocked on the door.  When no one answered, she entered.

On the table in the kitchen there sat three bowls of porridge.  Goldilocks was hungry so she set about tasting the porridge from the first bowl.

“This porridge is too hot!” she exclaimed.   So, she moved to the second bowl and tasted.  “This porridge is too cold, “she declared.  So, she tasted the last remaining bowl of porridge.  “Ahhh, this porridge is just right, “she happily proclaimed and ate it all up.

When it comes to how long a patient remains hospitalized after total hip or knee replacement surgery, the scenario is not unlike the situation faced by Goldilocks in the forest.  Length of stay, the “official” terminology used to describe the measurement of the duration of a single episode of hospitalization, is the period between the time that a patient is admitted to the hospital, to the time that the patient is discharged.  As joint replacement surgery advances in terms of procedural technique and care provided to patients, the surgical outcomes have also dramatically improved.  As the result of improved patient outcomes, the length of stay (LOS) for patients after joint replacement surgery has been declining as well.

Much attention has been given to the cost of hospitalization and the impact of these escalating costs on the American healthcare system.  As a result, the length of time in the hospital or (LOS) for patients has come under close scrutiny and is often a marker associated with hospital finances.  In terms of joint replacement surgery, LOS has been a focus of our program’s efforts for reasons outside of the financial realm.

Patients who are able to be discharged to their homes with adequate support systems in place, and with home physical therapy and nursing services, have been found to achieve the best outcomes associated with their joint replacement procedures. Reduced level of pain, optimum mobility, prompt return to previous level of functioning and activity (motion and function), and the avoidance of surgical wound infection are all associated with discharge to the home.

For the reasons just cited, we encourage our patients to return to their homes for convalescence whenever that is possible.  Preparation and discharge planning for this goal is initiated prior to admission to the hospital for the surgical procedure.  For those patients where this is not an option, arrangements are made for a temporary stay at a facility providing short term rehabilitative services.  Nearly 70% of our patients are discharged directly to their homes.

When it comes to exactly how long a patient should remain in the hospital after joint replacement surgery, we subscribe to the “Goldilocks” philosophy: 
·         The post surgical hospitalization should not be so short that the patient leaves prior to being able to accomplish critical tasks such as independent ambulation with an assistive device or adequate control of pain. (The porridge is too hot).
·         Nor should the patient remain in the hospital so long that advancement in their recovery is thwarted by the restrictions of a hospital environment, or that they are exposed to the risk of infection for longer than necessary.  (The porridge is too cold).
·         The ideal joint replacement patient is leaving the hospital at a time that has “optimized” what the hospital environment, staff, and services can do for them, and further recovery advancement will occur at home or a short term rehab center.  The hospital time (like the porridge) is “just right”.  For most hip replacement patients this is between three and four days, and for knee replacement patients between two and three days. 

At St. Joseph’s the length of time that patients do remain in the hospital has progressively shortened over time due to the advancements in surgery and postoperative  care protocols.

Ave Hip Replacement LOS
Ave Knee Replacement LOS
3.71 days
2.85 days
3.64 days
2.73 days
3.64 days
2.64 days
 (Year to Date)
3.57 days
2.64 days
**national ave hip replacement LOS = 3.7 days in 2008
**national ave hip replacement LOS = 9.1 days in 1992

We are committed to ensuring that patients receive the appropriate care in the hospital for the necessary period of time, and then to assist them in a seamless transition to their homes or the next location of care.

A recent study published in The Journal of the American Medical Association  in April of this year reported on a longitudinal study that described the clinical characteristics and associated outcomes of patients undergoing total hip arthroplasty between 1991 and 2008.  Their findings support the fact that the length of stay in the hospital declined during this time period.  The study also cautions that although the length of stay has decreased, there has also been an increase in the rates of discharge to short term rehabilitative facilities and in re-admission to the hospital.

It is because of the delicate balance between too short and too long a period of time in the hospital that we subscribe to the philosophy of an optimized individual time and recognize that one size does not fit all patients.  Most likely, you will find your discharge time to be when the “porridge is just right”, and that time is collaboratively determined by both you and your doctor.

Cram, P., Lu, X., Kaboli, P.J., et. al. Clinical Characteristics and Outcomes of Medicare Patients Undergoing Total Hip Arthroplasty, 1991-2008.  Journal of the American Medical Association. 2011; 305 (15): 1560-1567.

1 comment:

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