What determines length of stay after total hip and knee arthroplasty? A nationwide study in Denmark

The goal of this study was (1) to identify logistical and clinical areas of importance for length of stay (LOS) by identifying departments with short and long LOS and to evaluate their set-up; and (2) to evaluate patient satisfaction in relation to LOS. Based on the National Register on Patients in 2004 on LOS following total hip and knee arthroplasty (THA and TKA), departments with short and long LOS were identified. The three departments with the shortest and the three departments with the longest postoperative hospital stay were chosen for evaluation. The logistic setup and the clinical treatment/pathway were examined with on-location focus interviews to identify logistic and clinical factors acting as improvement or barriers for early rehabilitation and subsequent discharge. Also, the patients from these departments answered a questionnaire regarding satisfaction with components of their stay, co-morbidity, sex and age. Mean LOS was 7.4 and 8.0 days after THA and TKA, respectively staying from 4.5 to 12 days. Departments with short hospital stay were characterised by both logistical (homogenous entities, regular staff, high continuity, using more time on and up to date information including expectations on a short stay, functional discharge criteria) and clinical features (multimodal opioid-sparing analgesia, early mobilisation and discharge when criteria were met) facilitating quick rehabilitation and discharge. Patient demographics from departments with the shortest stay were similar co-morbidities than patients from departments with longer stays, but were either as satisfied-or more satisfied-with all parts of their stay. There was no difference in staffing (nurses/physiotherapists) between the two types of departments. Nationwide implementation of fast-track THA and TKA would result in a significant decrease in the needed number of hospital beds with similar or better outcome for the patients. Implementation of updated logistical and clinical features is expected to increase rehabilitation and reduce LOS with similar or improved patient satisfaction. These results support the implementation of fast-track total hip- and knee arthroplasty.