Revolutionising rapid recovery: a quality improvement project in hip and knee replacement

Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial

OBJECTIVE

To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).

DESIGN

Cluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.

SETTING

20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.

PARTICIPANTS

32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care).

INTERVENTION

The intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken.

MAIN OUTCOME MEASURES

The primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS). The individual indicators were analysed as secondary outcomes. Changes in outcomes from pre-intervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII.

RESULTS

16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 4.32% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95%CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95%CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95%CI 0.67-1.30).

CONCLUSION

The multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes.

TRIAL REGISTRATION NUMBER

NCT04055103.

Rapid implementation of an outpatient arthroplasty care pathway: a COVID-19-driven quality improvement initiative

Background

Hip and knee total joint arthroplasty (TJA) procedures are two of the most common inpatient surgical procedures worldwide. Outpatient TJA has emerged as a feasible option. COVID-19 caused significant constraints on inpatient surgical resources and contributed to a growing surgical backlog. We present a quality improvement (QI) initiative aimed at adding an outpatient TJA pathway to our pre-existing inpatient TJA programme, with the target of performing 25% of our primary TJA as outpatients.

Methods

This was a QI study at a tertiary level arthroplasty centre. To achieve our aim, a patient-centred needs analysis revealed the need to develop patient selection criteria, perform a specific and tailored anaesthetic, provide patient education and conduct virtual care follow-up. Based on these findings, an outpatient TJA intervention bundle was developed and implemented.

Results

After implementing the outpatient pathway, 65 patients were scheduled for outpatient TJA. Fifty-five (84.6%) patients were successfully discharged home on the day of surgery. Successful outpatient TJA accounted for 33.3% of all primary TJAs performed at our intuition throughout the study period. There was excellent adherence to the intervention protocols, with the success hinging on multidisciplinary team and supported QI culture. Thirty-day emergency department visits for inpatient and outpatient TJAs were 8.93% and 6.15%, respectively. No outpatient TJA patients required hospital readmission within 30 days.

Conclusion

Our study demonstrates that implementation of an outpatient TJA pathway in response to inpatient resource constraints during the COVID-19 pandemic is feasible. The findings of this report will be of interest to surgical centres facing surgical backlog and constraints on inpatient resources during and after the pandemic.