"FAST Pathway is a beautiful and powerful example of what's possible when cross-disciplinary collaboration works. It improves patient care, increases systems efficiencies, and saves costs at the same time." - Dr Tim Kostamo, orthopedic lead

"The FAST project is an effective and engaging collaboration of health care providers that enhances patient experience and recovery after major orthopedic surgery. It allows utilization of resources such as hospital beds for other patients in the community." - Dr Reza Faraji, anesthesiologist

"Developing a robust, sustainable, patient-centered pathway increased patient participation in the SDD program. This pathway was made possible through the team's enthusiasm and dedication to achieving positive patient outcomes, improving workflow efficiency, and addressing fiscal responsibility in a strained health care system." - Jennifer Watters and Brittany Spence, nurse practitioners

When the orthopedic team at Burnaby Hospital determined that only 8% of patients being admitted for elective total hip or knee arthroplasty were going home the same day, they saw an opportunity.

Same-day discharges, which increase access to surgery and improve patient experience without reducing safety, were only being offered ad hoc, owing to the absence of a clear pathway, effective communication systems, and multidisciplinary buy-in.

The solution

The team—an orthopedic surgeon, anesthesiologist, nurse practitioners, a CIOC nurse, and a Quality Improvement project manager—set out to build a same-day discharge pathway that would not only transform their own program but could be replicated elsewhere.

They engaged with affected staff and secured endorsement from hospital and regional leaders. With funding and support from Facility Engagement, the Physician Quality Improvement (PQI) initiative, the Department of Nurse Practitioner, and Burnaby Hospital site leadership (Leanne Appleton and Dr. Ish Ahmed), they developed a collaborative project charter to define the problem, scope, aim, measures, data collection plan, potential barriers, and milestones, ensuring alignment across all interest holders.

The working group developed an evidence-based screening tool, automated flagging of candidates, and streamlined communication. Drs Kostamo and Faraji led their respective groups in developing standardized surgical and anesthesia approaches. The team also created customizable resources to educate patients on pain management, wound care, and mobilization. They named the results of their work the Focused Arthroplasty Same-Day Track (FAST) pathway.

Impacts

The aim was to increase the mean rate of same-day discharges from 8% to 15% for elective total joint arthroplasty patients within 12 months. Their project exceeded expectations, resulting in an increase to 33% that has proved sustainable since 2023, when the FAST pathway was introduced. Additional results include:

• Patient safety: No increase in 30-day ER visits or 30-day readmission rates as compared to the standard inpatient cases
• Improved experience: Both staff and patients reported high levels of satisfaction one year post-pathway implementation

The FAST pathway has been permanently integrated at Burnaby Hospital and approved by the SSC Fraser Health Quality Improvement Steering Committee to spread to other regional arthroplasty programmes within the health authority. At Abbotsford Regional Hospital, the pathway was first introduced for hip replacements and has now expanded to include same-day discharge for knee replacements. 

"Burnaby gave us an evidence-based framework that we could adapt to our centre," says Dr Chris Day, an Abbotsford-based orthopedic surgeon. "Expanding our RADD program from hips to knees has helped increase access to same-day discharge joint replacement surgery while maintaining the same high standards of quality and safety here at Abbotsford Hospital."

The pathway achieved several of the IHI quintuple aims, including reducing costs to the health system by decreasing inpatient length of stay. According to 2024 Canadian Institute of Health Information data, the estimated daily cost per surgical patient is $2,000. Therefore, over a 36-month period, with 570 same-day discharges, the team achieved soft green-dollar savings of approximately $1.14 million, averaging $31,666.67 per month.

Read the full report on BMJ Open Quality. 

Key takeaways and lessons learned

• Collaboration between the orthopedic and anesthesia departments, coupled with an engaged working group and committed leadership, was critical.
• Long surgical wait times delayed the pathway’s initial utilization. They retroactively screened all scheduled patients and booked those eligible as same-day discharge, allowing for a timely transition to the pathway.
• Failures were viewed as opportunities for improvement.
• By continuously collecting data, the team were able to demonstrate a significant and sustained system change.

Patient testimonials

• "This is my second joint replacement, and this experience has been amazing. The team is wonderful every step of the way. I'm so impressed."
• "This is my second knee [surgery] in the past year. I had no issues after my last surgery. It went smoothly. I found the discharge materials so helpful that I kept them to review before this surgery."