To the Editor:

I read with great interest the article of Causey-Upton, Howell, Kitzman, Custer, and Dressler (2019) in a recent issue of the journal (Causey-Upton et al., 2019). The authors performed a review to evaluate discharge readiness following total knee replacement surgery and discussed factors that are known to impact preparedness for discharge. The authors should be applauded for performing a comprehensive review in an important topic (e.g., discharge readiness) in patients undergoing surgery (Pich, 2018; Sharma, Swisher, Doan, Khatibi, & Gabriel, 2018). The need to minimize healthcare costs is a very relevant topic in perioperative medicine (Finsterwald et al., 2018; Fong, Khoo, & Smith, 2018).

Nonetheless, there are some critical points that need to be clarified by the authors to avoid misinterpretation by the journal readers. First, the authors discussed patient factors related to discharge; however, they appeared not to include health literacy. Health literacy has been found to be a major factor related to hospital readmission (Boyle et al., 2017). It is important to note that health literacy is not perfectly correlated with patient education. Second, the use of nerve blocks can improve postoperative analgesia, but they have not been linked to faster hospital discharge (O'Donnell et al., 2018). Last, surgical duration has been demonstrated to be an independent factor associated to postsurgical morbidity in multiple studies, but it was not discussed by the authors.

I would welcome comments by the authors as this would help to further substantiate the findings to this important review.

-Mark C. Kendall, MD

Anesthesiology Department

Rhode Island Hospital

The Warren Alpert Medical School of

Brown University

Providence, RI

Boyle J., Speroff T., Worley K., Cao A., Goggins K., Dittus R. S., Kripalani S. (2017). Low health literacy is associated with increased transitional care needs in hospitalized patients. Journal of Hospital Medicine, 12, 918-924. [Context Link]

Causey-Upton R., Howell D. M., Kitzman P. H., Custer M. G., Dressler E. V. (2019). Factors influencing discharge readiness after total knee replacement. Orthopaedic Nursing, 38(1), 6-14. [Context Link]

Finsterwald M., Muster M., Farshad M., Saporito A., Brada M., Aguirre J. A. (2018). Spinal versus general anesthesia for lumbar spine surgery in high risk patients: Perioperative hemodynamic stability, complications and costs. Journal of Clinical Anesthesia, 46, 3-7. [Context Link]

Fong J., Khoo E., Smith N. A. (2018). How accurately do anesthetists estimate the cost of their drugs? Journal of Clinical Anesthesia, 46, 45-46. [Context Link]

O'Donnell C. M., McLoughlin L., Patterson C. C., Clarke M., McCourt K. C., McBrien M. E., Shields M. O. (2018). Perioperative outcomes in the context of mode of anaesthesia for patients undergoing hip fracture surgery: systematic review and meta-analysis. British Journal of Anaesthesia, 120(1), 37-50. [Context Link]

Pich J. (2018). Anaesthesia for hip fracture surgery in adults. Orthopaedic Nursing, 37(4), 253-254. [Context Link]

Sharma B. S., Swisher M. W., Doan C. N., Khatibi B., Gabriel R. A. (2018). Predicting patients requiring discharge to post-acute care facilities following primary total hip replacement: Does anesthesia type play a role? Journal of Clinical Anesthesia, 51, 32-36. [Context Link]

Response From the Authors

To the Editor:

We welcome further dialogue regarding the factors that influence preparation to return home following total knee replacement (TKR) surgery. Readiness for discharge after TKR is complex, is multifactorial, and has not been uniformly defined in the literature. Our recent literature review discussed several factors identified in the literature that impact readiness for discharge, such as analgesia, social support, and patient education (Causey-Upton, Howell, Kitzman, Custer, & Dressler, 2019). However, other factors not discussed within the scope and length of this literature review would likely also impact patients' preparation for returning home after TKR surgery (Kendall, 2019).

As discussed by Kendall (2019), poor health literacy has been linked to readmission to hospital (Boyle et al., 2017). Given that only 12% of adults understand healthcare information at the highest literacy proficiency level (Goodman, Finnegan, Mohadjer, Krenzke, & Hogan, 2013), education materials should be tailored to patients' health literacy levels in order to be most effective (Edwards, Mears, & Barnes, 2017) to support discharge readiness. Although not all research has linked analgesia approach to metrics of discharge readiness such as length of stay (O'Donnell et al., 2018), other studies have associated analgesia approach with outcomes such as length of time in hospital, functional performance, and hospital readmission. Local infiltration analgesia may result in shorter length of stay and improved function compared with femoral nerve block as described in our literature review (Kirkness et al., 2016); however, patients at one regional medical center who received periarticular injection for pain control were five times more likely to be readmitted to hospital than those who received a femoral nerve block following total knee arthroplasty (Henson, Thomley, Lowrie, & Walker, 2019). Surgical length for total joint arthroplasty has been associated with increased rates of short-term complications, such as surgical site infections (Duchman et al., 2017), which could influence length of stay and other aspects of discharge readiness. Readiness for discharge after TKR should continue to be explored and defined clearly in the literature to support improved postoperative outcomes through greater knowledge of factors that impact discharge readiness.

-Renee Causey-Upton, PhD, OTD, MS, OTR/L

-Dana M. Howell, PhD, OTD, OTR/L, FAOTA

Department of Occupational Science and

Occupational Therapy

Eastern Kentucky University

Richmond

-Patrick H. Kitzman, PhD, PT

Department of Physical Therapy and Rehabilitation

Sciences

University of Kentucky

Lexington

-Melba G. Custer, PhD, OT/L

Occupational Therapy Department

Spalding University

Louisville, KY

-Emily V. Dressler, PhD

Department of Biostatistical Sciences

Wake Forest University

Winston-Salem, NC

References