EDITORIAL

 

Is the same calendar day hip arthroplasty for everyone or a select few?

 

 

Hennie Bosch^*

Orthopaedic hip and knee surgeon, Durbanville Mediclinic, South Africa

 

 

 

Same-day hip surgery needs to be clearly defined and clarified. There are two different segments defined as same-day surgery. The one is the same calendar day or 6 to 8 hours post-surgery discharge to home, and the second segment is where people leave the hospital within 24 hours post-surgery.

The introduction of global arthroplasty fees in July 2018 to the South African market has caused a decrease in the average length of hospital stay because of pressure on the surgeon to perform according to a TIER grading. There is a worldwide trend to push for same-day surgery, and this is the same in South Africa. During the 2022 arthroplasty meeting, SURGE (orthopaedic group) presented the results of the first same-calendar-day discharge arthroplasty cases. It caused a stir among fellow arthroplasty colleagues. The question: should you do it, or is it too risky?

I have been an early adopter of new techniques and innovations since I returned from an arthroplasty fellowship in Wales, UK. In 2006, I started with hip arthroscopy, which was very controversial at that stage, and anterior hip arthroplasty in 2010 and fully incorporated it into my practice in 2013. In 2018, I started investigating same-day hip surgery. During the Covid-19 pandemic, I noticed the opportunity to implement elements of this in my practice. During a visit to an Orthopaedic meeting in New York, it was evident that same-day surgery is implemented differently under the same name. For instance, you can operate on the patient in the day hospital, then discharge them to a subacute clinic or retreat, with the surgeon having financial connections to both. These pre-arranged agreements with a funder result in the surgeon and funder benefitting financially. Same-day surgery, in this case, is a marketing tool with no clear differentiation between the same calendar day (6-8 hour hospital stay) or 24-hour hospital stay and discharge to a home or retreat. The problem with this model was that it is and is not same-day surgery. Same-calendar-day hip arthroplasty (6-8 hours) and discharge to the patient's home is difficult to implement and needs a different care model to ensure that it is also beneficial to the patient, not only the surgeon and funder.

The selection criteria and risk stratification tools that consider physical and social factors and clinical comorbidities are available. Advances like minimally invasive surgical techniques, antifibrinolytic agents (tranexamic acid) to control blood loss, and multimodal anaesthesia made same-day hip and knee arthroplasty possible.

Adopting same-day hip arthroplasty (23 hours) into practice is feasible with more efficient standard care. Surgeons who plan to adopt the same calendar day (6-8 hours) must realise that this model will need extra care and significant changes in their care model to do this safely. Looking through the lenses of capability, comfort and calm for the surgeon and patient is of extreme importance for the success of this model.

As surgeons, our primary responsibility lies with the patient, and any major complication could have a detrimental effect on the patient, the surgeon and the hospital, as well as medicolegal implications. Pushing the barrier can thus be counterproductive.

Adopting a care team is pivotal in successfully introducing such a programme. A nurse navigator, social worker and anaesthetic team involved perioperatively and post-discharge is needed. Where most papers quote failure of same-day surgery as readmission within 30 days and major and minor complications, this is seen from the surgeon and hospital's viewpoint and not value-based patient-centred care.

Before discharge, patients should be capable of mobilising well, climbing stairs, and independently doing personal care. Patients should be pain-free without any nausea and experience calm that they have access to the team during the first night post-surgery. Outcomes that matter to our patients must be the aim.

In South Africa, hospital beds are scarce in private and public hospitals. Same-day calendar day arthroplasty frees up more capacity and makes hip arthroplasty more economically viable for the wider population.

Creating a team who can provide same-day discharge hip arthroplasty will take a lot of planning and effort. The care model is then scalable to all arthroplasty patients and improves the outcomes accordingly. I want to motivate all hip arthroplasty surgeons who plan or aspire to do same-day discharge arthroplasty to introduce such a care team. It can lead to value-based patient care for all, not just same-day discharge patients. Value-based care should be our primary aim as surgeons.

 

 

* Corresponding author: hb@hipdoc.co.za