Done in a day?
We’re seeing more and more stories of same day knee replacement. Is it safe? And is it something Yorkshire Knee Clinic offers? Prof. Nick London explains.
20 years ago if you needed a knee replacement you could have expected a hospital stay of ten days to two weeks. Even ten years ago, that stay would have been 5-7 days. Today, things have improved so fast that even the NHS website can barely keep up. It still suggests a likely hospital stay of three to five days for a total knee replacement. In reality, most partial and about one third of total knee replacement patients go home the next day. Virtually all total (TKR) and partial knee replacement (PKR) patients are home within two days. The pace of change has been extraordinary – and it hasn’t stopped yet.
Same day service
In the US, day case PKRs have become very popular and we’ve seen lots of day case-only centres springing up. There are several centres in the UK that offer day case PKR too. If you’ve been researching a possible knee replacement, you may well have come across news pieces heralding the latest same day service – and you might reasonably ask why the same level of service isn’t available everywhere.
My Yorkshire Knee Clinic colleagues and I have been at the forefront of dropping discharges down from 4-6 days to 2-3 days to 1 day. In Harrogate, where I perform many knee replacements, virtually all our PKR patients are discharged next day, and within 24 hrs of surgery. The same applies to many of our TKR patients. So why don’t we go the extra yard and commit to same day discharge?
The answer is all about risk.
What we don’t want is infection. Right now, a significant proportion of patients could go home on the day of their operation without any adverse effects. Pain relief, physio and so on – all of that can be managed perfectly well, but the data suggests there may be a slightly increased risk of potential infection in day case patients, because there’s no one immediately on hand to spot worrying wound problems.
Stay in hospital, even just for one night so we can monitor progress and identify any problems early, and that risk is reduced. It’s not that we can’t introduce alternative ways of managing that risk, but a same day discharge system demands a very good support network, spanning surgeons, physios and nursing staff to ensure it is introduced safely. We’re working towards setting up that additional support to give us the confidence that this practice is safe. But it’s not something anyone should rush.
Bearing the weight
There’s also an issue about who carries the burden of risk. In the US, where there’s a very strong cost driver behind day case knee replacement, it’s not the hospital that carries the burden – it’s the surgeon and the patient.
We may well introduce same day knee replacement in the future – particularly for partial knees – and we’re very interested in the experiences and progress of other units offering day case surgery. But for now, we’re holding at one overnight stay as we look carefully at the issue and put the measures in place that ensure risk is reduced to an absolute minimum – and that’s true for every YKC surgeon across their private and NHS practices.