Is Physical Therapy Clearance Before Arthroplasty Home Discharge Necessary?

Study Overview
=================
Brief Summary
-----------------
Conventionally, physical therapy (PT) clearance is sought before total joint arthroplasty (TJA) discharge. However, PT staffing limitations may preclude same-day discharge in patients having surgery late in the day. Failed same-day discharge in eligible TJA patients results in unnecessary hospital bed occupancy, which increases costs, limits operating room throughput for patients requiring inpatient admission, and introduces risks associated with longer length-of-stay. In collaboration with an institutional PT department, the investigators developed a protocol for discharging same-day TJA patients without postoperative PT clearance. Immediately preoperatively, PT administers gait training. Patients are then discharged home after ambulating with post-anesthesia care unit (PACU) nurses trained by PT on postoperative mobilization. This allows for the maximum number of patients discharged home, including the last patient of the day, PT staffing limitations notwithstanding. Single-institution pilot data demonstrates no increased risk of falls, emergency room (ER) visits, or readmissions with this process. The investigators propose a prospective, controlled, multicenter study to expand on pilot data. The study aim is to assess safety of day-of-surgery preoperative PT and postoperative ambulation with PACU nursing before TJA discharge. The primary endpoint is postoperative falls, while secondary endpoints include 90-day ER visits, 90-day hospital readmissions, patient-reported outcome measures, and patient satisfaction scores.

Official Title
-----------------
Is Postoperative Physical Therapy Clearance Necessary for Safe Home Discharge After Total Joint Arthroplasty?

Conditions
-----------------
Physical Therapy, Total Joint Arthroplasty, Same-day Discharge

Intervention / Treatment
-----------------
* Other: Novel same-day discharge protocol after total joint arthroplasty
* Other: Conventional postoperative physical therapy clearance


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: are 18 years of age or older undergo primary THA or TKA are eligible for same-day home discharge (friends or family available to stay at home with the patient for one week postoperatively and medically stable for discharge from PACU per anesthesia). Exclusion Criteria: 90 years of age or older have sleep apnea (not eligible for same-day discharge) require overnight stay for any reason undergo revision THA or TKA.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 90 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Health Services Research
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Conventional Postoperative Physical Therapy Clearance<br>Patients will be evaluated and cleared by physical therapy after total joint replacement surgery prior to home discharge | Other: Conventional postoperative physical therapy clearance<br>* Physical therapy evaluation and clearance after total joint arthroplasty<br>|
| Experimental: Preoperative Physical Therapy, Postoperative Ambulation with Nursing<br>Patients will receive gait/stair training from physical therapy prior to total joint arthroplasty, then ambulate with nursing postoperatively prior to home discharge | Other: Novel same-day discharge protocol after total joint arthroplasty<br>* Preoperative gait/stair training with physical therapy, then postoperative ambulation with nursing after total joint arthroplasty<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of postoperative falls per patient |  | 6 weeks postoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of emergency room visits per patient |  | 90 days postoperatively | 
| Number of hospital readmissions per patient |  | 90 days postoperatively | 
| Patient satisfaction scores | Surgical Satisfaction Questionnaire-8 (SSQ-8; range 0-100) and numeric satisfaction scale (NSS; range 0-100). Higher scores denote better outcome. | 6 weeks postoperatively | 
| Patient reported outcome measure | Knee Injury and Osteoarthritis Outcome Score (KOOS, JR; range 0-100). Higher scores denote better outcome. | 6 weeks postoperatively | 
| Patient reported outcome measure | Hip Disability and Osteoarthritis Outcome Score (HOOS, JR; range 0-100). Higher scores denote better outcome. | 6 weeks postoperatively | 
| Patient reported outcome measure | Patient-Reported Outcomes Measurement Information System (PROMIS; mean score 50 with standard deviation of 10). Higher scores denote more of measured domain. | 6 weeks postoperatively |