The impact of an enhanced recovery programme on length of stay and post-discharge resource usage following hip and knee arthroplasty

Aims The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis. Methods Between May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year. Results Mean LOS for ERAS patients was 1.59 days (95% confidence interval (CI) 1.14 to 2.04), significantly less than that of the matched cohort (3.01 days; 95% CI 2.56 to 3.46). There were no significant differences in readmission rates for ERAS patients at both 30 and 90 days (six vs four readmissions at 30 days, and nine vs four at 90 days). Despite matching, there were significantly more American Society of Anesthesiologists (ASA) grade 3 patients in the ERAS cohort. There was a mean cost saving of £757.26 (95% CI £-1,200.96 to £-313.56) per patient. This is despite small increases in postoperative resource usage in the ERAS patients. Conclusion ERAS represents a safe and effective means of reducing LOS in primary joint arthroplasty patients. Implementation of ERAS principles has potential financial savings and could increase patient throughput without compromising care. In elective care, a preadmission discharge plan is key. Cite this article: Bone Jt Open 2021;2(11):966–973.

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565 POST-OPERATIVE WEIGHT LOSS AND OUTCOMES FOLLOWING ESOPHAGECTOMY

Diseases of the Esophagus ◽

10.1093/dote/doaa087.148 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

R Khaw ◽

S Munro ◽

J Sturrock ◽

H Jaretzke ◽

S Kamarajah ◽

...

Keyword(s):

Weight Loss ◽

Length Of Stay ◽

Hospital Stay ◽

Enhanced Recovery ◽

Length Of Hospital Stay ◽

Failure To Thrive ◽

Post Discharge ◽

Postoperative Weight Loss ◽

Poor Outcomes ◽

The Impact

Abstract Oesophageal cancer is the 11th most common cancer worldwide, with oesophagectomy remaining the mainstay curative treatment, despite significant associated morbidity and mortality. Postoperative weight loss remains a significant problem and is directly correlated to poor prognosis. Measures such as the Enhanced Recovery After Surgery (ERAS) programme and intraoperative jejunostomy feed have looked to tackle this. This study investigates the impact of these on mortality, length of hospital stay and postoperative weight loss. Methods Patients undergoing oesophagectomy between January 1st 2012—December 2014 and 28th October 2015–December 31st 2019 in a national tertiary oesophagogastric unit were included retrospectively. Variables measured included comorbidities, operation, histopathology, weights (pre- and post-operatively), length of hospital stay, postoperative complications and mortality. Pre-operative body weight was measured at elective admission, and further weights were identified from a prospectively maintained database, during further clinic appointments. Other data was collected through patient notes. Results 594 patients were included. Mean age at diagnosis was 65.9 years (13–65). Majority of cases were adenocarcinoma (63.3%), with varying stages of disease (TX-4, NX-3). Benign pathology accounted for 8.75% of cases. Mean weight loss post-oesophagectomy exceeded 10% at 6 months (SD 14.49). Majority (60.1%) of patients were discharged with feeding jejunostomy, and 5.22% of these required this feed to be restarted post-discharge. Length of stay was mean 16.5 days (SD 22.3). Complications occurred in 68.9% of patients, of which 13.8% were infection driven. Mortality occurred in 26.6% of patients, with 1.83% during hospital admission. 30-day mortality rate was 1.39%. Conclusion Failure to thrive and prolonged weight-loss following oesophagectomy can contribute to poor recovery, with associated complications and poor outcomes, including increased length of stay and mortality. Further analysis of data to investigate association between weight loss and poor outcomes for oesophagectomy patients will allow for personalised treatment of high-risk patients, in conjunction with members of the multidisciplinary team, including dieticians.

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Tourniquet use in routine primary total knee arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a real-world study

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03623-5 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Hong Xu ◽

Jingli Yang ◽

Jinwei Xie ◽

Zeyu Huang ◽

Qiang Huang ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Length Of Stay ◽

Knee Arthroplasty ◽

Enhanced Recovery ◽

Primary Total Knee Arthroplasty ◽

Transfusion Rate ◽

Partial Regression Coefficient ◽

Postoperative Length ◽

Total Knee ◽

The Impact

Abstract Background In an enhanced recovery after surgery program, a growing number of orthopedists are reconsidering the necessity of tourniquet use in total knee arthroplasty (TKA). However, the impact of tourniquet use on transfusion rate and postoperative length of stay (PLOS) in TKA remains controversial. Therefore, we carried out a study to investigate the effect of tourniquet application in routine primary TKA on transfusion rate and PLOS. Methods We analyzed data from 6325 patients who underwent primary unilateral TKA and divided them into two groups according to whether a tourniquet was applied during the procedure, and a tourniquet was used in 4902 and not used in 1423. The information for transfusion and PLOS was extracted from patients’ electronic health records, and the data were analyzed with logistic and linear regression analyses. Results Following TKA, the transfusion rate and PLOS were 14.52% and 7.72 ± 3.54 days, respectively, in the tourniquet group, and 6.47% and 6.44 ± 3.48 days, respectively, in the no-tourniquet group. After adjusting for the different related variables, tourniquet use was significantly correlated with a higher transfusion rate (risk ratio = 1.888, 95% confidence interval (CI) 1.449–2.461, P < 0.001) and a longer PLOS (partial regression coefficient (B) = 0.923, 95%CI 0.690–1.156, P < 0.001). Conclusions Our findings suggested that tourniquet use in routine primary TKA was related to a higher transfusion rate and a longer PLOS. The impact of tourniquet use on transfusion rate and PLOS should be taken into account in clinical practice.

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Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program

Australian Health Review ◽

10.1071/ah17099 ◽

2018 ◽

Vol 42 (5) ◽

pp. 542 ◽

Cited By ~ 5

Author(s):

Sharon Lawn ◽

Sara Zabeen ◽

David Smith ◽

Ellen Wilson ◽

Cathie Miller ◽

...

Keyword(s):

Emergency Department ◽

Heart Disease ◽

Length Of Stay ◽

Chronic Conditions ◽

Chronic Condition ◽

Hospital Admissions ◽

Self Management ◽

Psychosocial Needs ◽

Post Discharge ◽

The Impact

Objective The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health’s Hospital Admission Risk Program (HARP). Methods A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model. Results The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P = 0.037) and complex needs (P < 0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P < 0.001), heart disease (P = 0.015) and complex needs (P = 0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs. Conclusion The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0–65, had received more targeted care. What is known about the topic? Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation. What does this paper add? This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia’s health system. What are the implications for practitioners? Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.

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Enhanced Recovery Protocol Reduces Transfusion Requirements and Hospital Stay in Patients Undergoing an Elective Arthroplasty Procedure

Advances in Orthopedic Surgery ◽

10.1155/2016/9846910 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Kirsten Juliette de Burlet ◽

James Widnall ◽

Cefin Barton ◽

Veera Gudimetla ◽

Stephen Duckett

Keyword(s):

Length Of Stay ◽

Enhanced Recovery ◽

Transfusion Rate ◽

Transfusion Requirements ◽

Total Knee ◽

Enhanced Recovery Protocol ◽

Knee Arthroplasty Surgery ◽

The Impact ◽

Arthroplasty Surgery ◽

Arthroplasty Procedure

Background. Enhanced recovery (ER) for elective total hip or total knee replacement has become common practice. The aim of this study is to evaluate the impact of ER on transfusion rates and incidence of venous thromboembolism (VTE). Methods. A comprehensive review was undertaken of all patients who underwent primary hip or knee arthroplasty surgery electively between January 2011 and December 2013 at our institution. ER was implemented in August 2012, thus creating two cohorts: the traditional protocol (TP) group and the ER group. Outcome measurements of length of stay, postoperative transfusion, thromboembolic complications, and number of readmissions were assessed. Main Findings. 1262 patients were included. The TP group contained a total of 632 patients and the ER group contained 630 patients. Postoperative transfusion rate in the ER group was reduced with 45% (P≤0.05). There was no statistical difference in postoperative VTE complications. The length of stay was reduced from 5.5 days to 4.8 days (P<0.05). Conclusions. There was no difference in the number of readmissions. ER has contributed to a significant decrease in transfusions after elective arthroplasty surgery, with no increase in the incidence of thromboembolic events. Furthermore, it has significantly reduced inpatient length of stay.

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The impact of COVID-19 on an inpatient mother and baby unit: a service evaluation

BJPsych Open ◽

10.1192/bjo.2021.833 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S316-S316

Author(s):

Joanna Cranshaw ◽

Gertrude Seneviratne ◽

Ranga Rao ◽

Julia Ogunmuyiwa ◽

Rebecca McMillin ◽

...

Keyword(s):

Mental Health ◽

Length Of Stay ◽

Social Services ◽

Unit Length ◽

Perinatal Period ◽

Service Evaluation ◽

Psychotic Illness ◽

Mental Health Act ◽

Mother And Baby Unit ◽

The Impact

AimsUnique challenges have been faced by women in the perinatal period during the COVID-19 pandemic and the impact of this is compounded for women suffering from mental illness. This service evaluation looked at different aspects of the treatment pathway on a specialist inpatient psychiatric Mother and Baby Unit during the pandemic to identify what changes occurred.MethodData were collected for all admissions to the unit between January 2019 and October 2020, with the beginning of the pandemic being defined as on or after 1st March 2020. Information was collected retrospectively from electronic clinical notes on ethnicity, length of stay, diagnosis, mental health act use and restrictive practice, medication, psychology, occupational therapy and social services involvement.ResultThere were 114 admissions to the MBU during the study period. 4 were parenting assessments rather than acute psychiatric admissions and were excluded from the analysis, giving a sample of 110 women. 58% (62/110) were classed as “pre-pandemic” and 43.6% (48/110) were “during pandemic”. 95.45% (105/110) of women were postpartum 4.55% (5/110) were pregnant. Mean length of stay was shorter during the pandemic at 44 days, compared to 61 pre-pandemic. There was greater use of the mental health act during the pandemic: only 43.75% of patients were informal throughout admission, compared to 70.97% pre-pandemic. Mean duration of detention was shorter at 25 days (32 pre-pandemic). Psychotic illness made up a greater proportion of diagnoses during the pandemic: 56% (27/48) compared to 44% (27/62) pre-pandemic. The next most common diagnostic group was mood and anxiety disorders, which made up 29% (14/48) of diagnoses during the pandemic, but 43% (27/62) pre-pandemic. Outcomes as measured using the Health of the Nation Outcome Scale showed a mean improvement between admission and discharge of 6.65, compared to 5.15 pre-pandemic. HONOS scores were higher on admission during the pandemic (12.83, vs 10.88), suggesting a higher level of acuity.ConclusionDuring the COVID-19 pandemic on this Mother and Baby Unit, length of stay was shorter, a greater proportion of patients were detained under the mental health act (although length of detention was shorter) and psychotic illness was more prevalent. This study demonstrates that there were differences in this perinatal inpatient population during the pandemic and this may be a reflection on the wider impact of COVID-19 on perinatal mental health.

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Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

American Journal of Perinatology ◽

10.1055/s-0041-1732450 ◽

2021 ◽

Author(s):

Jared L. Tepper ◽

Olivia M. Harris ◽

Jourdan E. Triebwasser ◽

Stephanie H. Ewing ◽

Aasta D. Mehta ◽

...

Keyword(s):

Length Of Stay ◽

Cesarean Delivery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Opioid Consumption ◽

Quality Improvement Initiative ◽

Adjusted Relative Risk ◽

Opioid Use ◽

Opioid Prescription ◽

The Impact

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02). Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. Key Points

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Enhanced recovery programmes in knee arthroplasty: current concepts

Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine ◽

10.1136/jisakos-2018-000218 ◽

2018 ◽

Vol 3 (5) ◽

pp. 282-286

Author(s):

Robert M Middleton ◽

Alexander G Marfin ◽

Abtin Alvand ◽

Andrew J Price

Keyword(s):

Knee Arthroplasty ◽

Enhanced Recovery ◽

Surgical Techniques ◽

Surgical Patients ◽

Surgical Patient ◽

Multimodal Approach ◽

Postoperative Rehabilitation ◽

Enhanced Recovery Programme ◽

Recovery Approach ◽

The Impact

The concept of a multimodal approach to improve the care of surgical patients was first proposed by Kehlet in the 1990s. Measures to optimise the surgical patient, and minimise perioperative stresses, aimed to improve postoperative outcomes. Although originally introduced in colorectal surgery, these ‘enhanced recovery programmes’ have now seen widespread uptake in multiple surgical specialities, including orthopaedics. Patients undergoing knee arthroplasty are well suited to an enhanced recovery approach. These programmes optimise the patient at each stage of the surgical journey, including preoperative optimisation of fitness, perioperative anaesthetic and surgical techniques and finally postoperative rehabilitation and discharge plans. The available evidence supports a number of improvements after programme introduction, including shorter length of stay, morbidity and economics. However, the impact on other outcomes is less clear. One of the issues in the field is a lack of consensus on what interventions an enhanced recovery programme should contain and the specifics of these interventions. As a result, individual units develop their own programmes, making the interpretation and comparison of their impact difficult. This article discusses interventions that could be considered for inclusion in an enhanced recovery programme for knee arthroplasty.

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Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients

Anesthesiology ◽

10.1097/aln.0b013e318286061d ◽

2013 ◽

Vol 118 (5) ◽

pp. 1046-1058 ◽

Cited By ~ 246

Author(s):

Stavros G. Memtsoudis ◽

Xuming Sun ◽

Ya-Lin Chiu ◽

Ottokar Stundner ◽

Spencer S. Liu ◽

...

Keyword(s):

Length Of Stay ◽

General Anesthesia ◽

Knee Arthroplasty ◽

Joint Arthroplasty ◽

Neuraxial Anesthesia ◽

Perioperative Outcomes ◽

Anesthetic Technique ◽

Complication Risk ◽

Comorbidity Burden ◽

The Impact

Abstract Background The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes. Methods Data from approximately 400 hospitals between 2006 and 2010 were accessed. Patients who underwent primary hip or knee arthroplasty were identified and subgrouped by anesthesia technique: general, neuraxial, and combined neuraxial–general. Demographics, postoperative complications, 30-day mortality, length of stay, and patient cost were analyzed and compared. Multivariable analyses were conducted to identify the independent impact of choice of anesthetic on outcomes. Results Of 528,495 entries of patients undergoing primary hip or knee arthroplasty, information on anesthesia type was available for 382,236 (71.4%) records. Eleven percent were performed under neuraxial, 14.2% under combined neuraxial–general, and 74.8% under general anesthesia. Average age and comorbidity burden differed modestly between groups. When neuraxial anesthesia was used, 30-day mortality was significantly lower (0.10, 0.10, and 0.18%; P < 0.001), as was the incidence of prolonged (>75th percentile) length of stay, increased cost, and in-hospital complications. In the multivariable regression, neuraxial anesthesia was associated with the most favorable complication risk profile. Thirty-day mortality remained significantly higher in the general compared with the neuraxial or neuraxial–general group for total knee arthroplasty (adjusted odds ratio [OR] of 1.83, 95% CI 1.08–3.1, P = 0.02; OR of 1.70, 95% CI 1.06–2.74, P = 0.02, respectively). Conclusions The utilization of neuraxial versus general anesthesia for primary joint arthroplasty is associated with superior perioperative outcomes. More research is needed to study potential mechanisms for these findings.

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