A path for patients returning after joint replacement

The orthopedics service worked with hospital medicine and took more readmitted patients.


Quality control studies at Penn Presbyterian showed that patients who re-presented after total joint arthroplasty weren't receiving consistent treatment for common postoperative problems, such as fever and hypoxia. To help maintain continuity of care and standardize a protocol, “We wanted to devise a program where we could better triage our patients,” said hospitalist Michele Fang, MD, FACP, an associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

The studies showed that 25% of these patients who came back to the hospital required a length of stay of less than 48 hours and did not require an inpatient level of care, she said, and 50% of their readmissions were secondary to medical complications. With these data in mind, the hospital developed the Orthopedic Excess Days in Acute Care program, in which patients were triaged to the appropriate service line (orthopedic vs. medicine) and level of care (observation vs. inpatient).

How it works

Finding these patients was simple, as the electronic health record automatically flagged those who had had a total joint arthroplasty or revision within the past 90 days, said Dr. Fang. If they re-presented to the ED and required admission, the program's algorithm triaged them along the appropriate care pathway, based on common problems after surgery. “Our four options are: Admit to orthopedics observation, admit to medical observation, admit to inpatient medicine, or admit to inpatient orthopedics,” she said.

In the past, a majority of patients who came back to the hospital after surgery went to the medicine service rather than to the orthopedic service, Dr. Fang noted. But now, returning to orthopedics is an option when appropriate. “They stay with the support staff—like the nurses, the physical therapists, the social workers—who know them best from the last stay and not everything has to be reinvented again.”


To assess the effect of the program, a before-after pilot study compared patients' excess hospital days in October 2017 to September 2018 with a preimplementation period of April 2016 to September 2017. Among a total of 2,662 patients, readmissions decreased from 49 (6.1%) to 37 (2.0%), and excess days in acute care decreased from 7.75 days to 4.73 days, according to results published online in July by the Journal of Hospital Medicine. By design, more rehospitalized patients were managed on the orthopedic service, both observation and inpatient, after implementation of the program (70% vs. 35%). Overall, 23 patients were discharged on observation status during the postimplementation period.

Dr. Fang emphasized that the research team didn't “game the system” by shifting readmissions to observations. “That's why we used the outcomes of not just readmissions, but also excess days in acute care. That includes both observation and full readmissions,” she said. “We had a low number of readmissions to start with . . . but when your readmissions are decreased from 49 during preimplementation to 37 during postimplementation, that actually can be an important number, and each readmission is a complication and a cost.”


Because the project worked across service lines, the main challenge was involving staff from different disciplines, particularly orthopedics residents admitting patients in the ED. “We had to make sure they were buying in and then constantly remind them, ‘Hey, we used to send all those patients to the medicine service. Now, orthopedics can take care of them,’” Dr. Fang said. “We also posted our algorithm in the emergency department to make sure the medicine residents were also aware that we don't have to take all these patients anymore.”

She added that the program was well received by the orthopedics service. “[For] the orthopedic surgeons, it makes them feel more vested in their patient rather than trying to drive from behind, telling another service what to do when their patient comes back,” said Dr. Fang.

Lessons learned

The project required no extra dollars or staff, but it did require willingness by orthopedics and medicine to work together to improve patient care, she said. “Even though comanagement typically only usually involves perioperative care, these are our patients and we're invested in them. We also feel that it is important to care for them after discharge too.”

Next steps

The program is still in place, with a new set of residents introduced to it each July. “We were thinking of expanding it to hip fractures and spine surgeries,” said Dr. Fang, “but we haven't expanded yet.” She added that any hospital medicine group that works closely with orthopedics on comanagement should be able to apply a similar strategy to optimally triage orthopedic patients re-presenting to the hospital.