Enhanced recovery after surgery (ERAS): an orthopaedic perspective

Overwork as a concept to understand health inequities for ethnicised patients in health care

Health inequities for ethnically minoritised patients are well-documented. In this ethnographic study, we follow thirteen patients categorised as 'ethnic minorities' in Danish health care during hospitalisation in three orthopaedic wards across two hospitals. The categorisation of 'ethnic minority patient' has been problematised for its Eurocentric origin and practices within Westernised health care. We use ethnicised to emphasise the process of becoming minoritised based on markers of physical appearance, religious symbols, language or names. Access to health care also rely on perceived legitimacy as health-care recipients which requires work by patients. We demonstrate the workings patients categorised as 'ethnic minorities' engage in by (re)producing othering ideas about non-Danishness, including distancing from other patients perceived as problematic. These were then (counter)produced by positioning oneself as the opposite, as deserving health-care receivers by displaying welfare reciprocity, supporting egalitarian ideas by discounting discriminatory experiences, showing gratitude and identifying staff with good vibes. We propose these doings as creating overwork. This theoretical approach enables a sensitivity towards subtle and covert workings for patients placed in the margins of health care. In this study, overwork is closely related to notions of Danishness and takes on specific forms within a modernised and universalised Danish health-care system.

Beyond the insider/outsider debate in "at-home" ethnographies: Diffractive methodology and the onto-epistemic entanglement of knowledge production

In this article, we discuss the practice of conducting research in one's own field, in this case, from a position as a researcher with a nursing background doing fieldwork in a hospital and in one's own organization, an orthopedic surgical department. We show how an "insider" researcher position paves the way for analytical insights about sleep as an institutional phenomenon in the orthopedic surgical infrastructure and how acute and elective patient trajectories differ but build on the same logic, creating the same dynamics of inclusion and exclusion. Through a situated and sociomaterial perspective, we analyze different clinical interactions in which we follow the hospital bed as an example of a central relational element that co-creates sleep as an institutional phenomenon. Inspired by Karen Barad, we demonstrate how to move diffractively when doing and analyzing fieldwork and argue how moving diffractively as a researcher doing fieldwork "at home" is productive and challenges the concept and demand of "distance" as the phenomenological exercise in fieldwork.

The Application of Enhanced Recovery After Surgery Protocols in Patients With Perforated Duodenal Ulcer

Background Enhanced recovery after surgery (ERAS) protocols are nowadays considered the standard of care for various elective surgical procedures. However, its utilization remains low in tier-two and tier-three cities of India, and there exists a significant variation in the practice. In the present study, we have investigated the safety and feasibility of these protocols or pathways in emergency surgery for perforated duodenal ulcer disease. Methods A total of 41 patients with perforated duodenal ulcers were randomly divided into two groups. All the patients across the study were treated surgically with the open Graham patch repair technique. Patients in group A were managed with ERAS protocols, while patients in group B were managed with conventional peri-operative practices. A comparison was established between the two groups in terms of the duration of hospital stay and other postoperative parameters. Results The study was conducted on 41 patients who presented during the study period. Group A patients (n=19) were managed with standard protocols, and group B patients (n=22) were managed with conventional standard protocols. As compared to the standard care group, patients in the ERAS group showed quicker postoperative recovery and lesser complications. The need for nasogastric (NG) tube reinsertion, postoperative pain, postoperative ileus, and surgical site infections (SSI) were all significantly lower in the patients of the ERAS group. A significant reduction in the length of hospital stay (LOHS) was found in the ERAS group when compared to the standard care group (relative risk {RR}=61.2; p=0.000). Conclusions The application of ERAS protocols with certain modifications in the management of perforated duodenal ulcers yields significant outcomes in terms of reduced duration of hospital stay and fewer postoperative complications in a selected subgroup of patients. However, the application of ERAS pathways in an emergency setup needs to be further evaluated to develop standardized protocols for a surgical emergency group of patients.

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Surgery for Perforation Peritonitis-a Randomized Controlled Trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways have an uncertain role in emergencies. To the best of our knowledge, there are no trials studying ERAS in perforation peritonitis across the GI tract, despite it being a common surgical emergency.

AIMS

To evaluate the safety, feasibility and efficacy of adapted ERAS protocols in emergency laparotomy for perforation peritonitis.

METHODS

This was an open-labeled, superiority randomized controlled trial conducted between October 2018 and June 2020 in patients with perforation peritonitis assigned to standard care or adapted ERAS groups using block randomization. Patients with refractory shock, ASA class 4E, localized peritonitis, etc. were excluded. Components of the adapted ERAS protocol included epidural analgesia, goal-directed fluid therapy, avoidance of opioids, early mobilization, early removal of tubes, drains and catheters, and early enteral feeding. The primary outcome, length of hospitalization (LOH), and the secondary outcomes, functional recovery parameters, were analyzed between both the groups.

RESULTS

A total of 59 patients in standard care group and 61 patients in adapted ERAS group were included and randomized, and were comparable in terms of demographic and clinico-pathological characteristics. LOH in adapted ERAS group was shorter by 3 days (p < 0.001), and patients showed reduction in time (days) to first flatus (2.84 vs 4.22, p < 0.001), first stool (4.38 vs 6.08, p < 0.001) and solid diet (4.67 vs 8.37, p < 0.001). Post-operative nausea, vomiting (p = 0.05) and surgical site infections (p < 0.001) were reduced in adapted ERAS group. Pre-existing malignancy, respiratory complications and high output stoma were reasons for delayed discharge in adapted ERAS group.

CONCLUSION

Adapted ERAS pathways considerably reduce LOH in patients undergoing emergency surgery for perforation peritonitis, with no adverse events in 30 days after discharge.

TRIAL REGISTRATION

Registered at http://ctri.nic.in/Clinicaltrials/login.php (CTRI/2019/02/017537).

The effects of preoperative neuromuscular electrical stimulation on the postoperative quadriceps muscle strength and functional status in patients with fast-track total knee arthroplasty

This study aimed to investigate the effect of pre- operative neuromuscular electrical stimulation (NMES) on postoperative quadriceps muscle strength, functional status, and quality of life in patients with fast-track total knee arthroplasty (TKA). This prospective study was carried out at Orthopedics department from September 2017 to October 2018. A total of 40 patients were randomly divided into NMES (n=20) and control group (n=20). Patients in NMES group were asked to use home NMES device daily for 20 minutes, 5 times a day, for 6 weeks before surgery. The control group was placed on the 6-week waiting list for surgery without any preoperative intervention. Standard home exercise program was applied to both groups after discharge. The patients were evaluated baseline, preoperatively (6-weeks after baseline) and at the 4th and 12th weeks after surgery. Knee range of motion, quadriceps muscle strength, patient-reported (WOMAC and KOOS) and performance-based activity limitation (30-second chair-stand test, 40-meter fast-paced walk test, and stair-climb test) were evaluated at each visit. Preoperative NMES resulted in significant improvement in KOOS-function in daily living and WOMAC total score (p≤0.05) but had a non-significant trend toward to improve quadriceps muscle strength, KOOS-pain and -other symptoms, performance- based activity limitation, and quality of life scores (p>0.05). However, there was no significant difference between groups in the postoperative period (p>0.05). NMES has beneficial effects in terms of patient- reported and performance-based physical functions and quality of life in preoperative period ; however, it does not provide any additional benefit for post- operative outcomes in patients with fast-track TKA.

It's all about presence: Health professionals' experience of interprofessional collaboration when mobilizing patients with hip fractures

Mobilization is an interprofessional task in the evidence-based care pathway 'Enhanced Recovery After Surgery'; multiple health professionals collaborate when mobilizing patients with hip fractures. Drawing on the theory of relational coordination, and focusing on relationships and communication, we set out to explore how health professionals experience and describe interprofessional collaboration when mobilizing patients with hip fractures treated according to Enhanced Recovery After Surgery. Two rounds of interviews were conducted with 27 participants from 11 different professional groups, and the data were analyzed thematically. The main findings were that functional goals characterize the collaboration on mobilization due to undefined roles and responsibilities, and that specialized knowledge leads to a need for physical presence and formalization of work procedures in the collaboration. We argue that the hospital as a workplace can be characterized by logics of production and belonging. These logics create care work managed by quality, efficacy and scales of fairness that install power relations that must be recognized when engaging in interprofessional collaboration. We conclude that a primary focus on relationships and communication, as suggested by relational coordination, cannot solve the challenges of interprofessional collaboration, as the context in which health professionals work must also be considered.

Cannulated screw fixation versus plate fixation in treating displaced intra-articular calcaneus fractures: a systematic review and meta-analysis

BACKGROUND

Operative treatment has become the current trend for displaced intra-articular calcaneus fracture (DIACF), while using cannulated screw fixation or plate fixation is still controversial for treating DIACF. The purpose of this meta-analysis is to compare the outcome of the two fixation methods.

METHODS

We searched literature comparing cannulated screw fixation and plate fixation from PubMed, Embase, Web of Science, and Cochrane Library. Only randomized controlled trials were included. The outcomes of post-operative function, radiological measurement, time efficiency, and wound complications were pooled in the meta-analysis.

RESULT

Seven RCTs with 902 cases of DIACF were included. Pooled results showed the two fixation methods that had similar function satisfactory of AOFAS score (RR = 0.95, 95% CI = [0.83, 1.09], P = 0.47, I² = 0%) and Maryland Foot score (RR = 0.93, 95% CI = [0.68, 1.28], P = 0.66, I² = 84%). Compared to plate fixation, cannulated screw fixation had better improvement of Bohler's angle (WMD = 0.56, 95% CI = [0.20, 0.91], P = 0.002, I² = 34%) and Gissane's angle (WMD = 1.36, 95% CI = [0.56, 2.16], P = 0.0008, I² = 7%), better recovery of calcaneal height (WMD = 0.49, 95% CI = [0.02, 0.95], P = 0.04, I² = 6%), shorter time to operation (WMD =  - 2.91, 95% CI = [- 4.99, - 0.84], P = 0.006, I² = 97%), less operation time (WMD =  - 21.58, 95% CI = [- 37.31, - 5.85], P = 0.007, I² = 98%), reduced length of hospital stay (WMD =  - 2.00, 95% CI = [- 3.69, - 0.31], P = 0.02, I² = 97%), and less wound complications (RR = 0.16, 95% CI = [0.08, 0.32], P < 0.00001, I² = 0%).

CONCLUSION

Cannulated screw fixation and plate fixation have similar postoperative functional satisfactory. Cannulated screw fixation is superior to plate fixation in reduction quality, time efficiency, and wound complications.

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial

BACKGROUND

Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures.

AIMS

To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery.

METHODOLOGY

This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed.

RESULTS

Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001).

CONCLUSION

Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery.

Orthopaedic surgery after COVID-19 - A blueprint for resuming elective surgery after a pandemic

Background

The COVID-19 outbreak was fraught with danger and despair as many medically necessary surgeries were cancelled to preserve precious healthcare resources and mitigate disease transmission. As the rate of infection starts to slow, healthcare facilities and economies attempt to return to normalcy in a graduated manner and the massive pent-up demand for surgeries needs to eventually be addressed in a systematic and equitable manner.

Materials and methods

Guidelines from the Alliance of International Organizations of Orthopaedics and Traumatology, Orthopaedic Trauma Association, American College of Surgeons, American Society of Anaesthesiologists, Association of perioperative Registered Nurses, American Hospital Association, Centers for Medicare and Medicaid Services, World Health Organization and Centers for Disease Control and Prevention were evaluated and summarized into a working framework, relevant to orthopaedic surgeons.

Results

The guiding principles for restarting elective surgeries in a safe and acceptable manner include up-to-date disease awareness, projection and judicious management of equipment and facilities, effective human resource management, a fair and transparent system to prioritize cases, optimization of peri-operative workflows and continuous data gathering and clinical governance.

Conclusion

The world was ill prepared for the initial COVID-19 outbreak. However, with effective forward planning, institutions can ramp-up elective surgical caseload in a safe and equitable manner.

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As COVID-19 resolves, the pent-up demand for surgeries needs to be addressed in a systematic and equitable manner.

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Up-to-date disease awareness is necessary for projection and judicious management of equipment and facilities.

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Effective human resource management and optimization of peri-operative workflows will improve clearance of elective caseload.

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A fair and transparent system to prioritize cases is required to reduce patient confusion and vexation.

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Continuous data gathering and clinical governance ensures continuity of operative services in the event of a second wave.

Protocol for enhanced recovery after surgery with 3D laparoscopic excision for choledochal cysts can benefit the recovery process

OBJECTIVE

To explore the clinical value of enhanced recovery after surgery (ERAS) with laparoscopic choledochal cyst (CDC) excision in children.

METHODS

A retrospective review was performed on the clinical data from 33 in-patients whose final diagnosis was CDC. We included 18 patients who underwent the traditional treatment for CDC from April 2017 to October 2017 as the control group and 15 patients who underwent the enhanced recovery protocol (ERP) from November 2017 to May 2018 as the ERAS group. All the patients had received three-dimensional (3D) laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy by the same group of pediatric surgeons. The time of initial water intake, postoperative time to total enteral nutrition (TEN), postoperative hospital stay, total cost in hospital, postoperative complications, and readmission rate within 30 days were analysed.

RESULTS

The postoperative time of initial water intake, postoperative time to TEN, postoperative hospital stay, and total cost in hospital were (21.5 ± 2.1) h, (4.3 ± 0.5) days, (5.3 ± 0.6) days, and (35,945.49 ± 6071.46) China Yuan (CNY) in the ERAS group and (44.1 ± 3.5) h, (7.7 ± 2) days, (9.1 ± 2.5) days, and (45,609.08 ± 11,439.80) CNY in the control group, respectively. These values in the ERAS group were significantly lower than those in the control group (p < 0.05). There was no significant difference between the two groups in terms of postoperative complications. No readmission patient within 30 days was encountered in either of the two groups.

CONCLUSION

Enhanced recovery protocols can shorten postoperative hospital stay, relieve perioperative discomfort, lighten the financial burden, and result in substantial improvements.

The application of the Nice knots as an auxiliary reduction technique in displaced comminuted patellar fractures

PURPOSE

To evaluate intraoperative and early postoperative clinical outcomes using the Nice knot as an auxiliary reduction technique in displaced comminuted patellar fractures.

METHODS

Thirty-nine patients with unilateral closed displaced comminuted patellar fractures received open reduction and internal fixation (ORIF), utilizing either Nice knot (the NK group, 24 patients) or traditional reduction (the TR group, 23 patients) techniques, were retrospectively reviewed in this study. Intra-operative surgical time and peri-operative hemoglobin were recorded. Post-operative clinical outcomes were measured using visual analgesic score, range of motion of the knee joint and the Böstman scales, and radiographic outcomes were used to evaluate fracture healing. Complications including infection, bone non-union, implant loosening, fragment displacement and painful hardware were also assessed.

RESULTS

In-hospital records indicated significantly shorter surgical duration (32.6 min) in the NK group than in the TR group (63.9 min). Intraoperative blood loss was also significantly decreased in the NK group (64.7 ml) compared to the TR group (189.1 ml). Patients in the NK and TR groups were followed for mean of 12.9 months and 12.5 months respectively. The union rate was 100% (24/24) in the NK group and 91.3% (21/23) in the TR group. In the TR group, there were two non-unions, including one infected non-union. There was no difference in the visual analgesic score, the range of motion of the knee joint or the Böstman scale at last follow-up between the two groups.

CONCLUSION

The sliding, self-stabilizing Nice knot was associated with reduced surgical time, decreased intraoperative blood loss, and satisfactory postoperative outcomes in the treatment of displaced patellar fractures. Future studies are needed to ensure the generalizability of these findings to additional patient populations at other institutions.

An enhanced recovery after surgery program in orthopedic surgery: a systematic review and meta-analysis

Objectives

There is an increased interest in enhanced recovery after surgery (ERAS) minimizing adverse events after orthopedic surgery. Little consensus supports the effectiveness of these interventions. The purpose of present systematic review and meta-analysis is to comprehensively analyze and evaluate the significance of ERAS interventions for postoperative outcomes after orthopedic surgery.

Methods

PubMed, EMBASE, and Cochrane databases were totally searched from the inception dates to May 31, 2018. Two reviewers independently extracted the data from the selected articles using a standardized form and assessed the risk of bias. The analysis was performed using STATA 12.0.

Results

A total of 15 published studies fulfilled the requirements of inclusion criteria. We found that the ERAS group showed a significant association with lower incidence of postoperative complications (OR, 0.70; 95% CI, 0.64 to 0.78). Meanwhile, ERAS was also associated with the decline in 30-day mortality rate and Oswestry Disability Index (ODI). However, no significant differences were identified between the two groups regarding the 30-day readmission rate (P = 0.397).

Conclusions

Our meta-analysis suggested that the ERAS group had more advantages in reducing incidence of postoperative complications, 30-day mortality rate, and ODI after orthopedic surgery, but not of 30-day readmission rate. However, further research with standardized, unbiased methods and larger sample sizes is required for deeper analysis.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1116-y) contains supplementary material, which is available to authorized users.

Management of traumatic hemipelvectomy through ERAS pathway: A case report

RATIONALE

Traumatic hemipelvectomy is a rare but life-threatening injury that involves separation of the pelvic ring from pubic symphysis usually results from high energy trauma and associated with other injuries.

PATIENT CONCERN

In this report, we describe a case of traumatic hemipelvectomy, who presented in hemorrhagic shock associated with other injuries such as: right groin injury with limitation of passive movement of right hip and knee joint, left pelvic visceral protruded out, and wrapped by peritoneum, all of the vulva and anal tear, lumbar vertebrae transverse process fracture.

DIAGNOSES

Traumatic hemipelvectomy.

INTERVENTIONS

The patient was managed through enhanced recovery after surgery (ERAS) pathway with multidisciplinary coordination.

OUTCOMES

Patient was able to walk with prosthesis or crutch, with associated injuries managed appropriately. The course was complicated with hemorrhagic shock and infection which were dealt promptly, with good recovery.

LESSONS

In our case, the multimodal management through ERAS path has helped decrease stress level, decrease complication, decrease morbidity, decrease the length of stay in the hospital, and aid in faster recovery.

The introduction of an enhanced recovery pathway for elective caesarean sections

This article will focus on the establishment of an enhanced recovery pathway (ERP) for women undergoing elective caesarean section in a busy maternity unit. It will consider the background to this project, the impact on services and the improvements in service that have been achieved as well as the challenges that have been experienced in this process.

Adapted ERAS Pathway vs. Standard Care in Patients with Perforated Duodenal Ulcer-a Randomized Controlled Trial

OBJECTIVES

The objective of this study was to evaluate the feasibility and efficacy of ERAS pathways in patients undergoing emergency simple closure of perforated duodenal ulcer (PDU).

METHODS

This single-center, prospective, open-labeled, superiority, RCT was carried out from August 2014 to July 2016. Patients of PDU undergoing open simple closure were randomized preoperatively in 1:1 ratio into standard care and adapted ERAS group. Patients with refractory shock, ASA class ≥3, and perforation size ≥1 cm were excluded. Primary outcome was the length of hospitalization (LOH). Secondary outcomes were functional recovery parameters and morbidity.

RESULTS

Forty-nine and 50 patients were included in standard care and ERAS group, respectively. Patients in ERAS group had a significantly early functional recovery (days) for the time to first flatus (1.47 ± 0.18; p < 0.001), first stool (2.25 ± 0.20; p < 0.001), first fluid diet (2.72 ± 0.38; p < 0.001), and solid diet (3.70 ± 0.44; p < 0.001). LOH in ERAS group was significantly shorter (mean difference of 4.41 ± 0.64 days; p < 0.001). There was a significant reduction in postoperative morbidity such as superficial SSI (RR 0.35, p = 0.02), postoperative nausea and vomiting (RR 0.28, p < 0.0001), and pulmonary complications (RR 0.24, p = 0.04) in the ERAS vs. standard care group with similar leak rates (1/50 vs.2/49).

CONCLUSION

ERAS pathways are safe and feasible in select patients undergoing emergency simple closure of PDU.

The perioperative effects of chronic preoperative opioid use on shoulder arthroplasty outcomes

HYPOTHESIS AND BACKGROUND

Chronic opioid therapy is an increasingly used modality for the treatment of osteoarthritis-associated pain. We hypothesized that chronic opioid use would be associated with adverse outcomes in shoulder arthroplasty.

METHODS

A retrospective analysis of patients undergoing elective anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) at a single institution from 2012-2015 was performed. Patients were stratified by preoperative opioid use (nonusers, short-acting opioid users, and long-acting opioid users), and their postoperative clinical outcomes were assessed.

RESULTS

We identified 262 patients (170 rTSA and 92 anatomic TSA), of whom 138 were using opioids preoperatively (82% short acting and 18% long acting). When non-opioid users, short-acting opioid users, and long-acting opioid users were compared, mean total milligrams of morphine equivalents administered during postoperative hospitalization was significantly higher for those with preoperative opioid use (66.9 mg, 111.4 mg, and 208.3 mg, respectively; P < .001). In addition, postoperative visual analog scale pain scores were higher on postoperative day 0 (2.6, 3.2, and 3.9, respectively; P = .007), day 1 (4.0, 4.9, and 6.0, respectively; P < .001), and day 2 (3.0, 3.9, and 5.1, respectively; P < .001). Opioid use was not associated with a significantly increased hospital length of stay, complications, or readmission rates. For patients who completed 2-year follow-up, both the opioid user and non-opioid user groups demonstrated similarly improved postoperative American Shoulder and Elbow Surgeons shoulder scores.

CONCLUSION

A preoperative history of opioid use before shoulder arthroplasty was associated with significantly higher perioperative opioid consumption and visual analog scale scores. However, unlike in patients undergoing total knee or hip arthroplasty, preoperative opioid use was not associated with increased hospital length of stay, perioperative complications, or 90-day readmission rates for shoulder arthroplasty.

Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study

OBJECTIVES

Outcomes in total hip and knee arthroplasty (THA and TKA), such as allogeneic transfusions or extended length of stay (LoS), can be used to compare the performance of hospitals. However, there is much variation in these outcomes. This study aims to rank hospitals and to assess hospital differences of two outcomes in THA and TKA: allogeneic transfusions and extended LoS, and to additionally identify factors associated with these differences.

DESIGN

Cross-sectional medical record review study.

SETTING

Data were gathered in 23 Dutch hospitals.

PARTICIPANTS

1163 THA and 986 TKA patient admissions.

OUTCOMES

Hospitals were ranked based on their observed/expected (O/E) ratios regarding allogeneic transfusion and extended LoS percentages (extended LoS was defined by postoperative stay >4 days). To assess the reliability of these rankings, we calculated which percentage of the existing variation was based on differences between hospitals as compared with random variation (after adjustment for variation in patient characteristics). Associations between hospital-specific factors and O/E ratios were used to explore potential sources of differences.

RESULTS

The variation in O/E ratios between hospitals ranged from 0 to 4.4 for allogeneic transfusion, and from 0.08 to 2.7 for extended LoS. Variation in transfusion could in 21% be explained by hospital differences in THA and 34% in TKA. For extended LoS this was 71% in THA and 78% in TKA. Better performance (low O/E ratios) in transfusion was associated with more frequent tranexamic acid (TXA) use in TKA (R=-0.43, p=0.04). Better performance in extended LoS was associated with more frequent TXA use in THA (R=-0.45, p=0.03) and TKA (R=-0.65, p<0.001) and local infiltration analgesia (LIA) in TKA (R=-0.60, p=0.002).

CONCLUSIONS

Ranking hospitals based on allogeneic transfusion is unreliable due to small percentages of variation explained by hospital differences. Ranking based on extended LoS is more reliable. Hospitals using TXA and LIA have relatively fewer patients with transfusions and extended LoS.