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.

Background. Predicting length of stay (LOS) is key to providing a cost effective and efficient arthroplasty service in an era of increasing financial constraint. Previous studies predicting LOS have not considered enhanced recovery protocols in elective hip and knee arthroplasty. Our study aims to identify patient variables in the pre and peri-operative period to predict increased LOS on patients enrolled into the standardised Chichester and Worthing Enhanced Recovery Programme (CWERP). Methods. All patients undergoing elective hip and knee arthroplasty were enrolled into CWERP using standardised anaesthetic, surgical and analgesic protocols. A data analyst prospectively collated data over 6months from anaesthetic charts and daily ward review from 663 patients between Dec 2012 and June 2013. An independent statistician undertook statistical analysis (program R, version 3.1.1). 80% of the 6months consecutive data (530 patients) were analysed, and predictive variables identified. These variables were tested against the remaining 20% of data (133 patients) predicting a LOS greater or less than our median of 4 days. Results. 663 patients were enrolled into CWERP over this period, 54% in hip arthroplasty. Statistical analysis was performed using Chi-squared test for association between actual and predicted (dichotomised) LOS being significant (p<0.0000000017). In the initial 80% (530 patients), this identified the following statistically significant variables in predicting LOS > 4 days: Age > 80 yrs, ASA 4, failure to mobilise on day of surgery, urinary catheterisation and need for blood transfusion. The statistical model when applied to the remaining 20% (133 patients) correctly categorised LOS in 101 (76%) of the patients. Conclusions. Identifying patients who fulfil our variables in the preoperative period affords better planning, maximising resources, bed efficiency and discharge planning. This also provides opportunities for financial remuneration for higher risk patients. Level of Evidence. 4

Aims

This non-blinded randomised controlled trial compared the effect of patient-controlled epidural analgesia (PCEA) versus local infiltration analgesia (LIA) within an established enhanced recovery programme on the attainment of discharge criteria and recovery one year after total knee arthroplasty (TKA). The hypothesis was that LIA would increase the proportion of patients discharged from rehabilitation by the fourth post-operative day but would not affect outcomes at one year.

Aims

The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality.

The December 2013 Hip & Pelvis Roundup³⁶⁰ looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting

Enhanced recovery programmes have improved outcomes following elective arthroplasty surgery. Most studies assess whole advanced recovery programmes. There are few studies assessing the role of patient education. We therefore assessed our outcomes. As part of our enhanced recovery programme at Wrexham Maelor Hospital, all patients are offered the chance to attend ‘joint school’, a preoperative education class. Not all patients attend these sessions allowing comparison of outcomes in these two groups using our prospectively collected database of outcome measures. Between April 2009 and March 2013, 915 patients underwent elective hip or knee arthroplasty. Revision cases were excluded, leaving 567 knee replacements, 315 hip replacements and 27 unicompartmental knee replacements. In patients undergoing knee replacement, those attending joint school had shorter length of stay (4.38 vs 4.85 days, p=0.145) and better Oxford Knee Score at 6 months (p=0.026) and two years (p=0.035). Patients undergoing total hip arthroplasty had a statistically significantly shorter length of stay (3.64 vs 4.54 days, p=0.011); increased frequency of mobilising on the day of surgery (28.1% vs 22.6%, p=0.203) and higher Oxford Hip Scores (non-significant) if they attended joint school. Our retrospective analysis demonstrates that preoperative education for patients undergoing elective total hip arthroplasty produces significantly shorter lengths of stay. There are also effects on mobilisation and outcome scores. These effects are also seen in knee arthroplasty. These results will have clinical and financial implications. Assessing cost of saved bed days alone, joint school saves the trust over £10,000 per year

An enhanced recovery programme for knee arthroplasty was introduced two years ago to our orthopaedic department. It involved the setting up of an educational programme for patients along with an extensive rehabilitation programme. The main aim of the programme is to provide an efficient and personalised service that results in an improved patient experience and fewer bed days following surgery.

We carried out a retrospective study, randomly selecting 100 patients over a period of a year who were enrolled in the enhanced recovery programme. We analysed three main areas involving the pre-, peri- and post-operative period. We looked for any key factors that led to an increase or decrease in bed days. The re-admissions were analysed and the cost benefit was calculated.

99 patients were randomly selected and satisfied the inclusion criteria. We found that with the enhanced recovery programme the average length of stay for a knee arthroplasty was four days. There were no re-admissions within the population.

We would like to share our enhanced recovery programme model as we feel it is a robust and effective way of providing a high level of care and decreasing the length of stay post-operatively.

Introduction. Enhanced recovery programmes (ERP) have recently been adopted in the UK, enabling patients to recover quickly and return home sooner. Choice of anaesthetic is an important factor effecting post-operative outcome; studies show regional anaesthesia is more cost-effective, decreasing the incidence of venous thromboembolic events and reducing intra-operative blood loss, the need for transfusion and the length of hospital stay. Objectives. The objective of this study was to compare the short-term outcome of patients enrolled in our ERP who underwent either general or spinal +/− epidural anaesthesia. Methods. We prospectively studied 1222 patients (age- and sex-matched) who underwent lower limb arthroplasty enrolled in our ERP between March 2010-December 2011. Patients were given the opportunity to discuss their preferred mode of anaesthesia with their anaesthetist. Group 1 underwent general anaesthesia (GA), Group 2 underwent spinal +/− epidural anaesthesia (SA+/−EA). Results. 1222 patients underwent lower limb arthroplasty during our study period; 690 patients underwent GA, and 532 patients received SA+/−EA. There were similar ratios of THRs and TKRs in each group 343:347 and 257:275, respectively. Group 1 had an average age of 67.8 years (range 23–92; 65% female, 35% male), group 2 average age was 70 years (range 29–96; 58% female, 42% male). Average length of stay was 4.65 days in group 1 and 4.75 days in group 2 (Median 4, range 1–23). Similar rates of post-operative wound complications were noted in each group. Both groups had just two incidences of venous thromboembolic events. Conclusion. Enhanced Recovery Programmes have been initiated to reduce hospital stay following lower limb arthroplasty. We have shown no statistically significant difference between the patient being asleep or awake during surgery in the short-term outcome following surgery. The biggest contributing factors to the mode of anaesthesia used were individual anaesthetists' preference and patient choice

Introduction

Rivaroxiban is a direct inhibitor of factor Xa, a licensed oral thromboprophylactic agent that is increasingly being adopted for lower limb arthroplasty. Rivaroxiban has been NICE-approved for use in primary hip and knee arthroplasty following the RECORD 4 trials; proving it more effective in preventing venous thrombo-embolic (VTE) events compared to enoxaparin. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days.

Background. The Enhanced Recovery Programme (ERP) is an evidence based initiative aimed at speeding up patient recovery after major surgery and improving their outcomes. The Royal National Orthopaedic Hospital, Stanmore (RNOH) is a specialist orthopaedic and implemented an ERP for primary knee arthroplasties from October 2010. Aims. To analyse the initial results of patients participating in our ERP for primary knee arthroplasty to identify what factors predict their Length of Stay (LoS) and establish where changes can be made to improve outcomes further. Method. We interrogated our prospective ERP database and determined which patients achieved and which ones exceeded the 5-day LoS target. We then performed a further retrospective notes review to gather supplementary information including non-modifiable patient factors to identify factors which influenced their LoS. Results. 261 patients participated in the Knee ERP at the RNOH between October 2010 and December 2011 including patients undergoing complex procedures and bilateral procedures during the same in-patient episode. Mean age was 64 years (32–85 years). Mean LoS was 6.1 days (2–29 days). ASA grade and attendance at the multidisciplinary Joint School all had a positive influence on the LoS, particularly when combined. The day of mobilisation had the greatest correlation with those mobilising early. Mean LoS was 2.8 (Day 0), 4.41 (Day 1), 6.38 (Day 2), 9.23 (Day 3) and 12.95 (Day 4 or later). Conclusion. Identifying and targeting modifiable variables can further improve the outcomes for this particular group of patients. ASA grade and attendance at the multidisciplinary Joint School are among the positive influences on patient LoS. Adjusting analgesia to reduce unwanted effects may facilitate earlier engagement with the physiotherapy service and thus earlier mobilisation. Early results suggest encouraging patients to attend Joint School with subsequently early postoperative mobilisation can positively influence safe return to the home environment

Introduction

Obesity is a direct contributor to degenerative joint disease, and as the prevalence of obesity increases globally it is likely that more overweight patients will present for hip replacement surgery. There are reports that overweight patients in the UK's National Health Service, typically with a Body Mass Index (BMI) over 30 (BMI 30–39 obese, BMI≥40 morbidly obese), are being denied operations on the premise that they are at risk of significant complications. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days. The aim of this study was to compare the outcome of hip replacements in obese and non-obese patients enrolled in our ERP.

The need for hip and knee replacement surgery is increasing. Enhanced recovery programmes, where patients mobilise quickly and safely after surgery, have been adopted now in many hospitals. There are anecdotal reports of Primary Care Trusts raising thresholds for referral for surgery based on patients' Body Mass Index (BMI). The aim of this study was to evaluate the early outcome of hip and knee arthroplasty in obese patients (BMI>30) enrolled in the enhanced recovery programme. Between March 2010 and January 2011, 672 patients were enrolled in our enhanced recovery programme. 316 patients (47%) were classified as obese (BMI>30, range 30-39). There was no significant difference in the length of stay: 4.58 days in the obese patients and 4.44 days in the non-obese. There was also no difference in the rates of superficial infections or oozy wounds. Knee replacements was performed more commonly than hip replacements in the obese group. There was no significant difference in the early outcome of hip and knee replacement surgery in patients with a higher Body Mass Index when undergoing lower limb arthroplasty through the enhanced recovery programme. These patients should continue to be offered surgery when clinically indicated