Fast track protocol reduces hospital costs and infections in total hip replacement surgery

Generally healthy patients who undergo total hip replacement (THR) can be fast tracked to be discharged in two days compared with the standard three to six days, according to a new study by researchers at Hospital for Special Surgery (HSS) in New York City. The study could help cut down on hospital-acquired infections, reduce hospital costs and improve patient satisfaction.

"Before this study, we were uncertain how safe it would be to discharge patients within two days after a total hip replacement, but based on this study, we now know that it is safe. This is evidenced by the fact that the patients who were discharged within two days did not have an increase in complications, readmissions or reoperations," said Lawrence Gulotta, M.D., an orthopedic surgeon at HSS and first author of the study. "This is something that can help improve health care costs and provide better care for our patients by keeping them out of the hospital." Bryan Nestor, M.D., an orthopedic surgeon in Adult Reconstruction and Joint Replacement Service at HSS, was principal investigator of the study.

The prospective study that will be reported in an upcoming issue of Springer's HSS Journal compared outcomes of patients undergoing THR at HSS between 2004 and 2008. One cohort of 149 patients underwent THR with a fast track protocol. The other cohort of 134 patients underwent THR followed by the hospital's traditional clinical pathway, which aimed to discharge patients at four days at that time.

Patients in the two cohorts were matched for age, sex, body mass index, and comorbidities. Patients were excluded if they had inflammatory arthritis, complex THR, and medical comorbidities such as a history of a myocardial infarction, pulmonary embolism or deep vein thrombosis. Blood clots can be a complication of THR, and patients with a history of these comorbidities cannot be treated with simple aspirin consumption. All patients in the study were discharged with aspirin.

Patients on the fast track protocol had a physical therapy session on the day of their surgery. The main difference was that a patient's pain medication was discontinued in the fast track cohort postoperative day one (as long as pain was deemed to be under control), whereas in the traditional cohort, pain medication is usually discontinued on day two.

Patients in both cohorts were sent home with aspirin, an arrangement for work with a physical therapist, a patient management plan including a list of daily goals, and nausea and pain control plans. A study coordinator screened for complications one day and one week after discharge.

The investigators found that 58 percent of the fast track cohort was discharged within two days of a THR and 73 percent were discharged within three days. The average discharge time was 2.6 days in the fast track cohort and 4.1 in the traditional cohort. Patients were less likely to be discharged rapidly in the fast track cohort, if they had significant post-operative pain, nausea, or dizziness. At one year, there were no differences in complications, readmissions or reoperation in the two cohorts.

"For a select group of patients, we have shown that a two day discharge is safe and feasible for patients undergoing a total hip replacement," Dr. Nestor said. He pointed out that the two day fast track is not for higher risk patients, the ones who were excluded from the study. While the authors did not measure if the fast track protocol saves money, since it involves shortened hospital stays, the researchers expect it to.

Roughly half a million THRs are conducted every year in the United States, and this number is expected to grow. Many in the baby boomer generation are not willing to be sedentary and as their joints age, they are demanding joint replacement surgeries to keep active.