The 2004 United Kingdom (UK) National Health Service (NHS) Improvement Plan stated that: “By 2008, no one will have to wait longer than 18 weeks from GP referral to hospital treatment.” Over the same time period, on the other side of the Atlantic, the provincial government of British Columbia (BC) allocated funding for a specialist centre accommodating 2 new operating rooms and a 38 bed inpatient ward. The centre was designed to augment existing surgical capacity for hip and knee joint replacement by 1600 cases per year to help achieve the Canadian waiting time target of 26 weeks. Core design principles were: to improve patient flow through a centralised joint clinic designed to assess patients with osteoarthritis and related disorders; to maintain the connection between patient and surgeon throughout the entire care pathway; to ‘ring-fence’ dedicated operating room capacity and ward space in order to minimise the risk of surgical cancellations; and to reduce the mean length of inpatient post-operative stay to 4 days. Analysis of the programme's results showed: 1609 and 1602 joint replacements were performed during each of the first two respective years of operation – an additional 16% of provincial capacity, thus achieving the headline target; a mean patient satisfaction score of 4.7 out of 5; a self-reported complication rate of 4.4% (47 of the first 1078 patients surveyed); a mean theatre time of 1hr 45min, a mean post-anaesthesia recovery stay of 2hr 4min and a mean post-surgical length of stay of 3.4 days; and delivery of the programme within budget. By maintaining the patient/surgeon relationship and adhering to other key principles a high standard of care has been achieved in this programme with high rates of patient and surgeon satisfaction and a low complication rate.
Rivaroxaban was introduced for thromboprophylaxis at the Royal Cornwall Hospital for hip and knee arthroplasty surgery in October 2009. We identified 140 patients from theatre logbooks who underwent elective joint replacement between October 2009 and March 2010. Patient notes, computer and DVT clinic records and WebPacs data were collected to determine the uptake of the new drug and the incidence of wound problems, DVTs and any other post-operative complications. In our sample 55.7% [78/140] patients received rivaroxaban. 10.3% [8/78] of patients on rivaroxaban suffered wound complications compared with 6.6% [4/62] of patients on alternative anticoagulation. Three patients suffered DVT's, 1 of whom was taking rivaroxaban. There were a further 6 patients, 4 on rivaroxaban, with leg swelling severe enough to merit investigation, all of whom had negative doppler scans. Bleeding events included 4 patients with postoperative haematemesis of which 2 were taking rivaroxaban. Five patients, all under different surgical operators of which 3 had taken rivaroxaban, developed stiff total knee replacements and were offered MUA or physiotherapy.
