DISCHARGE

Same day discharge following shoulder arthroplasty, either from the PACU of an inpatient facility or from an ambulatory surgical center, is a viable option for select patients following surgery.  There is no convincing evidence to suggest that same day discharge following shoulder arthroplasty is not a safe option.  Engagement of the surgeon and each individual patient is required to determine if the patient is a suitable candidate for same day discharge without an undue increase in peri-operative risks.

There have been several studies (Leroux et al. 2016, Brolin et al. 2017, Fournier et al. 2019, Leroux et al. 2018, Charles et al. 2019) which have examined the safety, efficacy, complication rate, and incidence of readmission following outpatient shoulder arthroplasty

Fournier et al. developed a validated patient selection algorithm for proper patient selection as to who would be appropriate candidates for outpatient shoulder arthroplasty. Stratification was based on age and cardiopulmonary comorbidities with an endpoint of complications, adverse events, and hospital admission. Using this selection algorithm there were no hospital readmissions for cardiopulmonary events within 90 days, and the authors noted a 5% acute complication rate.

Charles et al., Leroux et al. 2018, Brolin et al., Leroux et al 2016. all reported results of outpatient shoulder arthroplasty demonstrating no significant difference with regards to major or minor complication rates and readmission rates when compared to the inpatient setting. This data provides supporting evidence that in the appropriate patient population this is a safe and cost-effective practice. Patient selection is key to success and the patients most at risk for dissatisfaction with pain control postoperatively are those who have been taking chronic narcotic pain medication preoperatively.

Strength of Evidence (evidence quality): No reliable evidence

Benefits & Harms: 

It is possible that same day discharge in patients who are not good candidates could result in increased risk of uncontrolled postoperative pain or medical complications.  Most important considerations would be concern for cardiopulmonary or thromboembolic events which would require intervention and or readmission, postoperative wound problems, or increased need for reoperation.  Patients may also have increased rates of return to the emergency department or hospital re-admission. 

Outcome Importance: 

Given the increasing utilization of shoulder arthroplasty shown by several recent studies, demonstrating the efficacy of same day discharge will better help surgeons meet this future demand. 

Cost Effectiveness/Resource Utilization: 

This will likely prove to be a cost-effective endeavor when compared to current post-operative protocols with patients staying 1-2 days following surgery.  It may be that utilization of a Surgical Care Program Manager, while an initial added expense, is required to ensure that safe and effective patient centered care can be provided across the continuum.

Feasibility: 

The impact upon physician and hospital reimbursement will need to be explored to see if wider adoption of same day discharge is feasible.
 

Future Research: 

Further research is needed to determine those patients who are the best candidates for same day discharge following shoulder arthroplasty, as well as to better understand which patients are most at risk for emergency room visit or readmission/hospitalization following outpatient shoulder arthroplasty. 
 

Additional References:

Fournier, M.N., Brolin, T.J., Azar, F.M, Stephens, R., Throckmorton, T.W., Identifying appropriate candidates for ambulatory outpatient shoulder arthroplasty: validation of a patient selection algorithm. J Shoulder Elbow Surg. 2019 Jan;28(1):65-70.

Leroux, T.S., Zuke, W.A., Saltzman, B.M., Safety and patient satisfaction of outpatient shoulder arthroplasty. JSES Open Access. 2018 Feb 15;2(1):13-17.

Brolin, T.J., Mulligan, R.P., Azar, F.M., Throckmorton, T.W., Neer Award 2016: Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: a matched cohort study. J Shoulder Elbow Surg. 2017 Feb;26(2):204-208.

Leroux, T.S., Basques, B.A., Frank, R.M., Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty. J Shoulder Elbow Surg. 2016 Nov;25(11):1780-1786.

Charles, M.D., Cvetanovich, G., Sumner-Parilla, S., Nicholson, G.P., Verma, N., Romeo, A.A., Outpatient shoulder arthroplasty: outcomes, complications, and readmissions in 2 outpatient settings. J Shoulder Elbow Surg. 2019 Jun;28(6S):S118-S123.

Nwankwo, C.D., Dutton, P., Merriman, J.A., Gajudo, G., Gill, K., Hatch, J., Outpatient total shoulder arthroplasty does not increase the 90-day risk of complications compared with inpatient surgery in prescreened patients. Orthopedics. 2018 Jul 1;41(4):e563-e568.

Bean, B.A., Connor, P.M., Schiffern, S.C., Hamid N., Outpatient shoulder arthroplasty at an ambulatory surgery center using a multimodal pain management approach. J Am Acad Orthop Surg Glob Res Rev. 2018 Oct 23;2(10):e064.