No increase in readmissions or adverse events after implementation of fast-track program in total hip and knee replacement at 8 Swedish hospitals: An observational before-and-after study of 14,148 total joint replacements 2011–2015

Background and purpose — Fast-track care programs in elective total hip and knee replacement (THR/TKR) have been introduced in several countries during the last decade resulting in a significant reduction of hospital stay without any rise in readmissions or early adverse events (AE). We evaluated the risk of readmissions and AE within 30 and 90 days after surgery when a fast-track program was introduced in routine care of joint replacement at 8 Swedish hospitals. Patients and methods — Fast-track care programs were introduced at 8 public hospitals in Västra Götaland region from 2012 to 2014. We obtained data from the Swedish Hip and Knee Arthroplasty Registers for patients operated with THR and TKR in 2011–2015. All readmissions and new contacts with the health care system within 3 months with a possible connection to the surgical intervention were requested from the regional patient register. We compared patients operated before and after the introduction of the fast-track program. Results — Implementation of the fast-track program resulted in a decrease in median hospital length of stay (LOS) from 5 to 3 days in both THR and TKR. The total readmission rate <90 days for THR was 7.2% with fast-track compared with 6.7% in the previous program, and for TKR 8.4% in both groups. Almost half of the readmissions occurred without any AE identified. There was no statistically significant difference concerning readmissions or AE when comparing the programs. Interpretation — Implementation of a fast-track care program in routine care of elective hip and knee replacement is effective in reducing hospital stay without increasing the risk of readmissions or adverse events within 90 days after surgery.


DA. Surgical diagnosis
If the codes occur as the main or a secondary diagnosis during the first admission or as the main diagnosis during a later admission Exact code

G978
Other postprocedural disorders of nervous system G979 Postprocedural disorder of nervous system, unspecifi ed M966G Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate knee/lower leg M968 Other postprocedural musculoskeletal disorders M969 Postprocedural musculoskeletal disorder, unspecifi ed T810 Haemorrhage and haematoma complicating a procedure, not elsewhere classifi ed T812 Accidental puncture and laceration during a procedure, not elsewhere classifi ed T813 Disruption of operation wound, not elsewhere classifi ed T814 Infection following a procedure, not elsewhere classifi ed T815 Foreign body accidentally left in body cavity or operation wound following a procedure T816 Acute reaction to foreign substance accidentally left during a procedure T817 Vascular complications following a procedure, not elsewhere classifi ed T818 Other complications of procedures, not elsewhere classifi ed T818W Other complications of procedures, not elsewhere classifi ed T819 Unspecifi ed complication of procedure T840 Mechanical complication of internal joint prosthesis T840G Mechanical complication of internal joint prosthesis knee/ lower leg T843 Mechanical complication of other bone devices, implants and grafts T843G Mechanical complication of other bone devices, implants and grafts knee/lower leg T844 Mechanical complication of other internal orthopaedic devices, implants and grafts T844G Mechanical complication of other internal orthopaedic devices, implants and grafts, knee/lower leg T845 Infection and infl ammatory reaction due to internal joint prosthesis T845G Infection and infl ammatory reaction due to internal joint prosthesis knee/lower leg T847 Infection and infl ammatory reaction due to other internal orthopaedic prosthetic devices, implants and grafts T847G Infection and infl ammatory reaction due to other internal orthopaedic prosthetic devices, implants and grafts knee/ lower leg T848 Other complications of internal orthopaedic prosthetic devices, implants and grafts T848G Other complications of internal orthopaedic prosthetic devices, implants and grafts knee/lower leg T849 Unspecifi ed complication of internal orthopaedic prosthetic device, implant and graft T888 Other specifi ed complications of surgical and medical care, not elsewhere classifi ed T889 Complication of surgical and medical care, unspecifi ed

DB. Diagnosis for knee-related events
If the codes occur as the main or a secondary diagnosis during the first admission or as a main diagnosis during a later admission

If the codes occur as the main or a secondary diagnosis during the first admission or as the main diagnosis during a later admission
Exact code

I260
Pulmonary embolism with mention of acute cor pulmonale I269 Pulmonary embolism without mention of acute cor pulmonale I460 Cardiac arrest with successful resuscitation I461 Sudden cardiac death, so described I469 Cardiac arrest, unspecifi ed I490 Ventricular fi brillation and fl utter I649 Stroke, not specifi ed as haemorrhage or infarction I770 Arteriovenous fi stula, acquired I771 Stricture of artery I772 Rupture of artery I819 Portal vein thrombosis I978 Other postprocedural disorders of circulatory system, not elsewhere classifi ed I979 Postprocedural disorder of circulatory system, unspecifi ed J809 Adult respiratory distress syndrome J819 Pulmonary oedema T811 Shock during or resulting from a procedure, not elsewhere classifi ed

I21 Acute myocardial infarction I24
Other acute ischaemic heart diseases I60 Subarachnoid haemorrhage I61 Intracerebral haemorrhage I62 Other nontraumatic intracranial haemorrhage I63 Cerebral infarction I65 Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction I66 Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction I72 Other aneurysm and dissection I74 Arterial embolism and thrombosis I82 Other venous embolism and thrombosis

If the codes occur as the main or a secondary diagnosis during the first admission or as a secondary diagnosis during a later admission
Exact code J952 Acute pulmonary insuffi ciency following nonthoracic surgery J953 Chronic pulmonary insuffi ciency following surgery J955 Postprocedural subglottic stenosis J958 Other postprocedural respiratory disorders J959 Postprocedural respiratory disorder, unspecifi ed J981 Pulmonary collapse N990 Postprocedural renal failure N998 Other postprocedural disorders of genitourinary system N999 Postprocedural disorder of genitourinary system, unspecifi ed R339 Retention of urine

DA. Surgical diagnosis
If the codes occur as the main or a secondary diagnosis during the first admission or as the main diagnosis during a later admission Exact code

G978
Other postprocedural disorders of nervous system G979 Postprocedural disorder of nervous system, unspecifi ed M966F Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate hip/femur M968 Other postprocedural musculoskeletal disorders M969 Postprocedural musculoskeletal disorder, unspecifi ed T810 Haemorrhage and haematoma complicating a procedure, not elsewhere classifi ed T812 Accidental puncture and laceration during a procedure, not elsewhere classifi ed T813 Disruption of operation wound, not elsewhere classifi ed T814 Infection following a procedure, not elsewhere classifi ed T815 Foreign body accidentally left in body cavity or operation wound following a procedure T816 Acute reaction to foreign substance accidentally left during a procedure T817 Vascular complications following a procedure, not elsewhere classifi ed T818 Other complications of procedures, not elsewhere classifi ed T818W Other complications of procedures, not elsewhere classifi ed T819 Unspecifi ed complication of procedure T840 Mechanical complication of internal joint prosthesis T840F Mechanical complication of internal joint prosthesis hip/ femur T843 Mechanical complication of other bone devices, implants and grafts T843F Mechanical complication of other bone devices, implants and grafts hip/femur T844 Mechanical complication of other internal orthopaedic devices, implants and grafts T844F Mechanical complication of other internal orthopaedic devices, implants and grafts, hip/femur T845 Infection and infl ammatory reaction due to internal joint prosthesis T845F Infection and infl ammatory reaction due to internal joint prosthesis hip/femur T847 Infection and infl ammatory reaction due to other internal orthopaedic prosthetic devices, implants and grafts T847F Infection and infl ammatory reaction due to other internal orthopaedic prosthetic devices, implants and grafts hip/ femur T848 Other complications of internal orthopaedic prosthetic devices, implants and grafts T848F Other complications of internal orthopaedic prosthetic devices, implants and grafts hip/femur T849 Unspecifi ed complication of internal orthopaedic prosthetic device, implant and graft T888 Other specifi ed complications of surgical and medical care, not elsewhere classifi ed T889 Complication of surgical and medical care, unspecifi ed

DB. Diagnosis for hip-related events
If the codes occur as the main or a secondary diagnosis during the first admission or as a main diagnosis during a later admission

If the codes occur as the main or a secondary diagnosis during the first admission or as the main diagnosis during a later admission
Exact code

I260
Pulmonary embolism with mention of acute cor pulmonale I269 Pulmonary embolism without mention of acute cor pulmonale I460 Cardiac arrest with successful resuscitation I461 Sudden cardiac death, so described I469 Cardiac arrest, unspecifi ed I490 Ventricular fi brillation and fl utter I649 Stroke, not specifi ed as haemorrhage or infarction I770 Arteriovenous fi stula, acquired I771 Stricture of artery I772 Rupture of artery I819 Portal vein thrombosis I978 Other postprocedural disorders of circulatory system, not elsewhere classifi ed I979 Postprocedural disorder of circulatory system, unspecifi ed J809 Adult respiratory distress syndrome J819 Pulmonary oedema T811 Shock during or resulting from a procedure, not elsewhere classifi ed

I21
Acute myocardial infarction I24 Other acute ischaemic heart diseases I60 Subarachnoid haemorrhage I61 Intracerebral haemorrhage I62 Other nontraumatic intracranial haemorrhage I63 Cerebral infarction I65 Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction I66 Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction I72 Other aneurysm and dissection I74 Arterial embolism and thrombosis I82 Other venous embolism and thrombosis

DM. Diagnoses for other medical events
If the codes occur as the main or a secondary diagnosis during the first admission or as a secondary diagnosis during a later admission Exact code J952 Acute pulmonary insuffi ciency following nonthoracic surgery J953 Chronic pulmonary insuffi ciency following surgery J955 Postprocedural subglottic stenosis J958 Other postprocedural respiratory disorders J959 Postprocedural respiratory disorder, unspecifi ed J981 Pulmonary collapse N990 Postprocedural renal failure N998 Other postprocedural disorders of genitourinary system N999 Postprocedural disorder of genitourinary system, unspecifi ed R339 Retention of urine