Incidence of 30 Day Return to Hospital Following Same Day Discharge Total Hip Arthroplasty
Condition: Osteoarthritis, Hip; Arthroplasty Complications; Complication of Surgical Procedure; Perioperative Complication
MeSH terms: Osteoarthritis, Hip
Study type: Observational

Summary: 
      Amongst patients who are discharged home from hospital on the same day as their elective
      Primary Total Hip Arthroplasty, the Investigators seek to quantify the incidence of return to
      hospital within 30 days of surgery for assessment &/or treatment of surgical related problems
      or complications. This incidence rate will be compared to a cohort of patients who are not
      discharged on the same day as their Primary Total Hip Arthroplasty. The Investigators wish to
      know if the incidence of 30 day return to hospital is significantly different between these
      two groups of patients.
    

Detailed description: 
      At UBC Hospital, a program to facilitate same day discharge of elective Primary Total Hip
      Arthroplasty patients was developed in 2017/18. The program is called the "Short Term
      Accelerated Recovery" (STAR) program, and patients within the program are called "STAR
      Patients." The first patient in the program had their surgery on Oct 15, 2018, and the
      program has been running ever since.

      The STAR process begins by the attending surgeon (there are 5 Arthroplasty Surgeons at UBC
      involved in this program) earmarking a patient as a potential same day discharge candidate
      based on their assessment of the patient. Following this, the patient is assessed by both
      Physiotherapy and Anesthesia to either confirm or reject their STAR eligibility.

      STAR eligibility criteria can be divided into both Social and Clinical requirements. The
      Social requirements are for the patient to live within an hour's drive of the Vancouver
      General Hospital (VGH) Emergency Room, and that they have a support person (either family or
      friend) that will stay with them in their home for at least the first 24 hours following
      surgery and can be called upon at any time subsequent to help in caring for the patient or
      facilitating their return to hospital if needed.

      Strict Clinical Requirements to be STAR Eligible were established by the Dept of Anesthesia
      based on best evidence and expert opinion. These criteria were used to establish a
      "Check-List" of items to ensure all eligibility criteria are met. Items on this Checklist
      included the correct Surgical Procedure, patient age ≤ 75, Pre-Anestheic Risk Assessment, and
      Lab Result Reviews.

      Patients initially enrolled in the STAR Program by their Orthopedic Surgeon at the time of
      surgical booking [presently a total of 87 patients] could end up in one of three possible
      cohorts following their surgery:

        1. The patient was deemed STAR eligible preoperatively, had their hip replacement surgery
           and went home the same day as their surgery [presently 24 patients].

        2. The patient was deemed STAR eligible preoperatively, had their hip replacement surgery
           but were NOT sent home same day as their surgery for failing to meet criteria for safe
           discharge and thus staying a minimum of one overnight in hospital [presently 24
           patients].

        3. The patient was deemed NOT eligible for STAR prior to their surgery, and therefore
           stayed at least one night in hospital following their surgery [presently 39 patients].

      Thus far, the STAR program has failed to adequately assess the incidence of 30 day
      post-surgical complications. Despite an infrastructure to attain this quality assessment
      being in place by way of a postoperative survey sent to patients via Email, return of these
      surveys has been minimal thus far. As a result, the Investigators are seeking a more robust
      and comprehensive search of postoperative hospital encounters for surgically related problems
      amongst these patients by way of chart review.

      This project is a retrospective cohort quality assurance chart review study. Given that the
      criteria for enrollment in STAR is site specific and has not been established before, this
      project is designed to be both a preliminary safety assessment and also able to inform future
      prospective studies on the program's safety for potential sample sizes needed for such
      assessments. As well, the study would also expose the potential for a higher than expected
      return to hospital for same day discharge patients which may not otherwise have been known.

      A log of all patients initially enrolled as potentially "STAR Eligible" by their surgeon has
      been maintained by the PI. Using this list of patients, the following sequence of events will
      occur to assess each for hospital encounters for surgical related problems, inquiries or
      complications during the 30 days immediately following surgery:

        1. All patient's charts, both paper records at VGH and UBC Hospital, as well as electronic
           charts within the BC Care Connect network that can show encounters at hospitals
           throughout the province of British Columbia, will be retained by Research Personnel.

        2. Charts will be perused for any hospital encounters during the 30 days immediately post
           the date of surgery.

        3. If encounters are found, the specific nature of the encounter will be ascertained.

        4. Study personnel will decide, based on the clinical presentation and documentation
           available on the patient's chart, whether the encounter may be considered a "surgically
           related problem, inquiry or complication".

           Examples of surgically related problems include (but are not limited to) wound or
           surgical site infection, deep vein thrombosis, pneumonia, urinary tract infection, pain
           issues as a result of having surgery, failure or concerns for the function of the new
           prosthesis, trauma or falls as a result of reduced mobility following surgery.

        5. Some encounters may be obvious as surgically related problems - eg. concerns for a
           possible wound infection at the surgical site. Others may be less obviously surgically
           related depending on the presentation - eg. sepsis or organ failure. It will be left to
           the PI to invigilate and decide whether the reasons for hospital encounter are or are
           not obviously surgical in nature. For those deemed not obviously surgical, opinion will
           be sought from 2 independent specialists in Perioperative Internal Medicine on whether
           they feel the encounters to be related to the patient's hip arthroplasty. Reviewers will
           be blinded to each other's opinions. If both Reviewers agree that the encounter was for
           a surgically related problem then it will be tallied as such. If there is disagreement
           or both believe the problem to not be surgically related then it will not be considered
           a surgically related hospital encounter.

        6. If a hospital encounter is found amongst the patient's records, but no documentation
           about the nature of the encounter is available, then the Patient's Orthopedic Surgeon
           will be contacted to see if they retain any record of postoperative up to 30 day
           encounters and what the nature of the encounter was. Patients will NOT be contacted for
           the purpose of this QA study.

      Approval for this study has been attained from the following:

        1. University of British Columbia Research Ethics Board.

        2. Vancouver Coastal Health Research Institute.

      Study Personnel who will be retaining and invigilating patient charts will be the PI - a
      staff Anesthesiologist, a Resident in the UBC Anesthesiology Post-Graduate Program, and a UBC
      Medical Student.

      It is anticipated that between 100 and 150 patients will have been through the STAR process
      at the time retrospective chart review begins.
    

Intervention name(s): Eligible for Same Day Discharge; Primary Single Joint Total Hip Arthroplasty; Discharge Same Day
Intervention type(s): Other; Procedure; Other
Intervention description(s): Preoperative Physiotherapy and Anesthesia Criteria met.; Total Hip Replacement Surgery; Postoperative criteria for Same Day Discharge met.
Observational model: Case-Control
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Patients with hip joint pathology being booked for elective joint replacement by
        Orthopedics and earmarked by the surgeon as potentially Same Day Discharge eligible at the
        time of surgical booking.
      
Keywords: complication; surgery