Enhanced Recovery After Surgery implementation in practice: an ethnographic study of services for hip and knee replacement

Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial

BACKGROUND

Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown.

HYPOTHESIS OBJECTIVE

To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain.

STUDY DESIGN

Observational feasibility study of a randomized controlled trial.

METHODS

Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes.

RESULTS

Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001).

CONCLUSIONS

An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.

[Translated article] Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway

INTRODUCTION

There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure.

OBJECTIVE

To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS).

METHODS

A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed.

RESULTS

Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASA II. The significantly associated factors to an increased length of stay are: age (p=.001), ASA scale (p=.04), day of surgery (p<.001), blood transfusion (p<.001), postoperative haemoglobin level at 48-72h (p<.001), the time of first postoperative mobilisation to ambulate and climb stairs (p<.001), the need for analgesic rescues (p=.003), and the presence of postoperative nausea and vomiting (p=.008).

CONCLUSIONS

There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimise the quality of care and available health resources.

Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway

INTRODUCTION

There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure.

OBJECTIVE

To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS).

METHODS

A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed.

RESULTS

Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASAII. The significantly associated factors to an increased length of stay are: age (P=.001), ASA scale (P=.04), day of surgery (P<.001), blood transfusion (P<.001), postoperative hemoglobin level at 48-72h (P<.001), the time of first postoperative mobilization to ambulate and climb stairs (P<.001), the need for analgesic rescues (P=.003), and the presence of postoperative nausea and vomiting (P=.008).

CONCLUSIONS

There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimize the quality of care and available health resources.

Content and delivery of pre-operative interventions for patients undergoing total knee replacement: a rapid review

BACKGROUND

Total knee replacement (TKR) is a common operation typically performed for end-stage knee osteoarthritis. Patients awaiting TKR often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-TKR. Pre-operative TKR interventions could improve pre- and post-operative outcomes, but future research is required to inform their design. This review aimed to identify and synthesize recent literature on the content and delivery of pre-operative TKR interventions to help guide future research and clinical practice.

METHODS

This rapid review included randomized trials of pre-operative TKR interventions ("outcomes studies") and primary studies exploring patients' and/or health professionals' views of pre-operative TKR interventions ("views studies"). Medline, Embase, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials were searched for English language studies published between January 2009 and December 2020. Eligible studies' reference lists were screened. Studies were appraised using the Mixed Methods Appraisal Tool. The findings were narratively synthesized using a convergent segregated approach.

RESULTS

From 3263 records identified, 52 studies were included (29 outcomes studies, 21 views studies, two outcomes/views studies). The studies' methodological quality varied but was generally highest in qualitative studies. The outcomes studies investigated education (n=5), exercise (n=20), psychological (n=2), lifestyle (n=1), and/or other interventions (n=5). The views studies addressed education (n=20), exercise (n=3), psychological (n=1), lifestyle (n=4), and/or other interventions (n=1). Only three outcomes studies (two randomized controlled trials (RCTs) and a pilot study) compared the effectiveness of intervention components/delivery approaches. The two RCTs' results suggest that pre-operative TKR exercise interventions are equally effective regardless of whether they include strength or strength plus balance training and whether they are hospital- or home-based. Personal tailoring and using more than one delivery format were associated with improved outcomes and/or perceived as beneficial for multiple intervention types.

CONCLUSIONS

Definitive evidence on the optimal design of pre-operative TKR interventions is lacking. Personal tailoring and employing multiple delivery formats appear to be valuable design elements. Preliminary evidence suggests that including balance training and hospital versus home delivery may not be critical design elements for pre-operative TKR exercise interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019143248 FUNDER: National Institute for Health and Care Research (ICA-CDRF-2018-04-ST2-006).

Hip and Knee Arthroplasty

Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.

Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Background

With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully.

Main body

Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary.

Conclusion

The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

Differences in preoperative function and outcome of patients with versus without sarcopenia after total hip arthroplasty

[Purpose] Public attention regarding sarcopenia has increased in recent years. Patients with sarcopenia reportedly show worse return home rates and activities of daily living at discharge. However, no reports have described the function and outcomes of hip osteoarthrosis patients with sarcopenia after total hip arthroplasty. This study aimed to clarify differences in preoperative physical function and outcomes of hip osteoarthrosis patients with versus without sarcopenia after total hip arthroplasty. [Participants and Methods] Twenty-five patients with hip osteoarthrosis who underwent total hip arthroplasty were included. Evaluation items were preoperative skeletal muscle mass of the extremities, isometric strength of the lower extremities (hip abduction and knee extension), grip strength, and the 10-m timed gait test results. [Results] The prevalence of sarcopenia was 8% (2/25 patients). The sarcopenic group displayed lower skeletal muscle mass index, grip strength, and 10-m timed gait test values. The sarcopenic group showed lower muscle mass in the upper and lower limbs and trunk and lower hip abductor strength than the non-sarcopenic group. [Conclusion] Eight percent of patients developed sarcopenia after total hip arthroplasty. Due to the low average age (66.0 ± 9.5 years), the prevalence was lower than that of other orthopedic diseases.

Consensus on pre-operative total knee replacement education and prehabilitation recommendations: a UK-based modified Delphi study

BACKGROUND

Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation.

METHODS

A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n = 30) or professionals (n = 30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists' importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as 'Important' or 'Very important' by at least 70% of all respondents in Round 3 were included in the final set of recommendations.

RESULTS

Fifty-five panellists (92%) (patients n = 26; professionals n = 29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments.

CONCLUSIONS

This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.

A scoping review of the use of ethnographic approaches in implementation research and recommendations for reporting

Background:

Researchers have argued for the value of ethnographic approaches to implementation science (IS). The contested meanings of ethnography pose challenges and possibilities to its use in IS. The goal of this study was to identify sources of commonality and variation, and to distill a set of recommendations for reporting ethnographic approaches in IS.

Methods:

We included in our scoping review English-language academic journal articles meeting two criteria: (1) IS articles in the healthcare field and (2) articles that described their approach as ethnographic. In March 2019, we implemented our search criteria in four academic databases and one academic journal. Abstracts were screened for inclusion by at least two authors. We iteratively develop a codebook for full-text analysis and double-coded included articles. We summarized the findings and developed reporting recommendations through discussion.

Results:

Of the 210 articles whose abstracts were screened, 73 were included in full-text analysis. The number of articles increased in recent years. Ethnographic approaches were used within a wide variety of theoretical approaches and research designs. Articles primarily described using interviews and observational methods as part of their ethnographic approaches, though numerous other methods were also employed. The most cited rationales for using ethnographic approaches were to capture context-specific phenomena, understand insiders’ perspective, and study complex interactions. In reporting on ethnographic approaches, we recommend that researchers provide information on researcher training and position, reflect on researchers’ positionality, describe observational methods in detail, and report results from all the methods used.

Conclusion:

The number of IS studies using ethnography has increased in recent years. Ethnography holds great potential for contributing further to IS, particularly to studying implementation strategy mechanisms and understanding complex adaptive systems.

Researchers have proposed that ethnographic methods may be valuable to implementation research and practice. Ethnographic approaches have their roots in the field of anthropology, but they are now used in many fields. These approaches often involve a researcher spending time in “real-world” settings, conducting interviews and observation to understand a group of people. That said, researchers disagree on the meaning of ethnography, which presents a challenge to its use in implementation science (IS). We searched for articles in the field of IS that described their methods as ethnographic. We then reviewed the articles, looking for similarities and differences in how and why ethnographic approaches were used. Many of these articles said they used ethnographic methods because they were interested in issues like context, research participants’ views, and complex interactions. We found a large amount of variation in how ethnographic methods were used. We developed recommendations for describing ethnographic methods in a way that readers can clearly understand. We also made several observations of the value ethnographic approaches can bring to IS. Ethnographic methods may be especially useful to studying unplanned and unexpected changes that take place during implementation. These recommendations and observations could be helpful to implementation researchers wishing to use ethnographic methods.

Enhanced recovery after surgical correction of adolescent idiopathic scoliosis

BACKGROUND

Few publications in the literature examine enhanced recovery after scoliosis surgery (ERAS) in children, despite significant scientific interest in adults. The objective of the current study was to describe an ERAS protocol for surgical correction of adolescent idiopathic scoliosis (AIS) and its results.

METHODS

ERAS outcomes were measured in two patient cohorts. Historical controls and ERAS groups were selected from patients managed for scoliosis surgery in 2015 and 2018, respectively. The ERAS protocol included fasting minimization, carbohydrate loading, the avoidance of background morphine infusions, perioperative opioid-sparing protocols, the use of a cooling brace, early physiotherapy, feeding and oral medications, and the early removal of urinary catheters and surgical drains. The main outcome of the study was hospital length of stay.

RESULTS

Overall, 82 controls and 81 ERAS patients were recruited. ERAS protocols were observed in over 80% of patients for almost items. Median length of hospital stay was significantly lower in the ERAS group (- 3 [95% confidence interval: -2; -4] days). Median morphine consumption was reduced by 25% and 35% on days 2 and 3, respectively. The incidence of PONV did not differ between the two groups, and the incidence of constipation decreased slightly but significantly in the ERAS group on day 2. Pain intensity at rest and movement were lower in the ERAS group at day 2 and 3.

CONCLUSIONS

The current study suggests an ERAS protocol after adolescent idiopathic scoliosis surgery is associated with reduced hospital length of stay and improved postoperative care.

Maximization of Non-Opioid Multimodal Analgesia in Ambulatory Surgery Centers

Ambulatory surgery centers aid the healthcare system by not only providing a cost-effective option for delivery of care but also by helping to reduce overwhelming case volumes at inpatient facilities. While outpatient protocols have been designed for an increasing number of surgical procedures, the inpatient to outpatient transition of surgery remains limited by both procedure type and patient comorbidities. This limitation stems in part from the heavy emphasis on accelerated discharge following outpatient procedures, given that prolonged recovery time is associated with delayed turnover and increased nursing care demands. Since its inception, enhanced recovery after surgery (ERAS) has aimed to primarily reduce the disruption of physiologic homeostasis that occurs secondary to surgery. More recently, the aim of ERAS has evolved to help transition inpatient procedures to outpatient settings and may even be useful in more emergent cases. It should be noted, however, that outpatient surgery even in combination with ERAS is not the best option for all patients, and the use of ERAS protocols should be complemented with predictive assessments of patient risk. Beyond augmenting the efficiency of outpatient surgery, ERAS protocols, when used in eligible patients and especially when combined with regional anesthetic techniques, are effective in delivering opioid-sparing pain management while increasing overall outcomes and patient satisfaction rates.

The effect of a new perioperative practice model on length of hospital stay and on the surgical care process in patients undergoing hip and knee arthroplasty under spinal anesthesia: a randomized clinical trial

Background

The shortened length of hospital stays (LOS) requires efficient and patient-participatory perioperative nursing approaches to enable early and safe discharge from hospitals for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The primary aim of this study was to explore the effect comparative to standard perioperative care of a new perioperative practice model (NPPM) on the LOS and the time points of the surgical care process in patients undergoing THA and TKA under spinal anesthesia. The secondary aim was to find out if any subgroups with different response could be found.

Methods

Patients scheduled for elective, primary THA and TKA were assessed for eligibility. A two-group parallel randomized clinical trial was conducted with an intervention group (n = 230) and control group (n = 220), totaling 450 patients. The patients in the intervention group were each designated with one named anesthesia nurse, who took care of the patient during the entire perioperative process and visited the patient postoperatively. The patients in the control group received standard perioperative care from different nurses during their perioperative processes and without postoperative visits. The surgical care process time points for each study patient were gathered from the operating room management software and hospital information system until hospital discharge.

Results

We did not find any statistically significant differences between the intervention and control groups regarding to LOS. Only slight differences in the time points of the surgical care process could be detected. The subgroup examination revealed that higher age, type of arthroplasty and ASA score 3–4 all separately caused prolonged LOS.

Conclusion

We did not find the new perioperative practice model to shorten either length of hospital stays or the surgical care process in patients undergoing THA and TKA. Further studies at the subgroup level (gender, old age, and ASA score 3 and 4) are needed to recognize the patients who might benefit most from the NPPM.

Trial registration

This study was registered in NIH Clinical.Trials.gov under registration number NCT02906033, retrospectively registered September 19, 2016.

The maximal gait speed is a simple and useful prognostic indicator for functional recovery after total hip arthroplasty

PURPOSE

The present study aimed to compare the capabilities of preoperative usual and maximal gait speeds in predicting functional recovery in patients who have undergone total hip arthroplasty (THA).

METHODS

Primary and unilateral THAs were performed in 317 patients, and the proportion of patients who achieved unassisted walking (functional recovery) 5 days postoperatively was recorded as an outcome measure. Preoperative functional assessment included hip pain, leg muscle strength, range of motion (ROM), and gait speed evaluations. The capabilities of preoperative usual and maximal gait speeds in predicting functional recovery were compared based on the areas under the curves (AUCs) of receiver operating characteristic (ROC) curves. Further, ROC curves were constructed using two models: 1. a model of gait speed only and 2. a clinical model including age, sex, leg muscle strength, and ROM.

RESULTS

On the AUCs for predictive ability of functional recovery, maximal gait speed was greater than usual gait speed (0.66 and 0.70, respectively). The AUC for maximal gait speed was as large as that of the clinical model (0.70 and 0.70, respectively).

CONCLUSION

Our results suggest that maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA.

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Background

There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system.

Objectives

To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement.

Design

(1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness.

Setting

Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England.

Participants

Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement.

Interventions

Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation).

Main outcome measures

Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years.

Results

Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole.

Limitations

Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors.

Conclusion

No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts.

Future work

There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals.

Study registration

This study is registered as PROSPERO CRD42017059473.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.