Prolonged length of stay (PLOS) in a high-volume arthroplasty unit

Introduction The enhanced recovery after surgery (ERAS) concept in arthroplasty surgery has led to a reduction in postoperative length of stay in recent years. Patients with prolonged length of stay (PLOS) add to the burden of a strained NHS. Our aim was to identify the main reasons. Methods A PLOS was arbitrarily defined as an inpatient hospital stay of four days or longer from admission date. A total of 2,000 consecutive arthroplasty patients between September 2017 and July 2018 were reviewed. Of these, 1,878 patients were included after exclusion criteria were applied. Notes for 524 PLOS patients were audited to determine predominant reasons for PLOS. Results The mean total length of stay was 4 days (1 to 42). The top three reasons for PLOS were social services, day-before-surgery admission, and slow to mobilize. Social services accounted for 1,224 excess bed days, almost half (49.2%, 1,224/2,489) of the sum of excess bed days. Conclusion A preadmission discharge plan, plus day of surgery admission and mobilization on the day of surgery, would have the potential to significantly reduce length of stay without compromising patient care. Cite this article: Bone Joint Open 2020;1-8:488–493.

Using Lean Six Sigma to improve rates of day of surgery admission in a national thoracic surgery department

Objective The aim of this study is to improve rates of day of surgery admission (DOSA) for all suitable elective thoracic surgery patients. Design Lean Six Sigma (LSS) methods were used to enable improvements to both the operational process and the organizational working of the department over a period of 19 months. Setting A national thoracic surgery department in a large teaching hospital in Ireland. Participants Thoracic surgery staff, patients and quality improvement staff at the hospital. Intervention(s) LSS methods were employed to identify and remove the non-value-add in the patient’s journey and achieve higher levels of DOSA. A pre-surgery checklist and Thoracic Planning Meeting were introduced to support a multidisciplinary approach to enhanced recovery after surgery (ERAS), reduce rework, improve list efficiency and optimize bed management. Main Outcome Measure(s) To achieve DOSA for all suitable elective thoracic surgery patients in line with the National Key Performance Indicator of 75%. A secondary outcome would be to further decrease overall length of stay by 1 day. Results Over a 19 month period, DOSA has increased from 10 to 75%. Duplication of preoperative tests reduced from 83 to <2%. Staff and patient surveys show increased satisfaction and improved understanding of ERAS. Conclusions Using LSS methods to improve both operational process efficiency and organizational clinical processes led to the successful achievement of increasing rates of DOSA in line with national targets.

Optimisation of perioperative investigations among elective orthopaedic patients in a Dublin-based teaching hospital

Background The current National Institute for Health and Care Excellence guidelines, in accordance with the Association of Anaesthetists of Great Britain and Ireland guidelines, recommend the following haematological investigations for all patients undergoing major elective surgery: full blood count, renal profile and coagulation screen if clinically indicated. However, the guidelines fail to specify a time-interval for which normal blood results remain valid. Currently all patients in Ireland undergoing substantial elective surgery requiring general or regional anaesthetic have a preoperative assessment prior to the surgery. Patients have phlebotomy performed as part of this assessment. Patients admitted for elective surgery often have these bloods repeated on the morning of surgery. Objectives To determine if blood investigations taken over a one-year period prior to surgery can be used as a baseline for clinically stable patients undergoing elective surgery. Study design and methods All consecutive day of surgery admission patients >18 years of age undergoing elective orthopaedic surgery in Tallaght Hospital between 1 December 2014 and 1 December 2015 were identified using hospital records. Their blood results in the one-year period prior to surgery were compared to the blood results on the morning of surgery, using a McNemar’s test. A further clinical analysis was performed. Results There was no statistically significant change between blood results from three months prior to the surgery and the morning of surgery (P < 0.05). Furthermore, the blood results remained largely unchanged in the one year prior to surgery. No patient had the operation deferred due to aberrant blood results, following previously normal results prior to surgery. The potential cost-saving of omitting bloods is enormous. Conclusions There appears to be neither a statistical nor clinical benefit to repeating blood tests on the morning of surgery, following normal bloods <3 months in a clinically stable individual.

Day of Surgery Admission in Total Joint Arthroplasty: Why Are Surgeries Cancelled? An Analysis of 3195 Planned Procedures and 114 Cancellations

Background. Day of surgery admission (DOSA) is becoming standard practice as a means of reducing cost in total joint arthroplasty.Aims. The aim of our study was to audit the use of DOSA in a specialty hospital and identify reasons for cancellation.Methods. A retrospective study of patients presenting for hip or knee arthroplasty between 2008 and 2013 was performed. All patients were assessed at the preoperative assessment clinic (PAC).Results. Of 3195 patients deemed fit for surgery, 114 patients (3.5%) had their surgery cancelled. Ninety-two cancellations (80%) were due to the patient being deemed medically unsuitable for surgery by the anaesthetist. Cardiac disease was the most common reason for cancellation (n=27), followed by pulmonary disease (n=22). 77 patients (67.5%) had their operation rescheduled and successfully performed in our institution at a later date.Conclusion. DOSA is associated with a low rate of cancellations on the day of surgery. Patients with cardiorespiratory comorbidities are at greatest risk of cancellation.