Five year review of an enhanced recovery program following knee arthroplasty at a UK general district hospital

A hospital-based mixed-methods observational study to evaluate a hip and knee replacement quality improvement project

Purpose

Health services continue to face economic and capacity challenges. Quality improvement (QI) methods that can improve clinical care processes are therefore needed. However, the successful use of current QI methods within hospital settings remains a challenge. There is considerable scope for improvement of elective clinical pathways, such as hip and knee replacement, and so the use and study of QI methods in such settings is warranted.

Design/methodology/approach

A model to manage variability was adapted for use as a QI method and deployed to improve a hip and knee replacement surgical pathway. A prospective observational study, with a mixed-methods sequential explanatory design (quantitative emphasised) that consisted of two distinct phases, was used to assess its effectiveness.

Findings

Following the use of the novel QI method and the subsequent changes to care processes, the length of hospital stay was reduced by 18%. However, the interventions to improve care process highlighted by the QI method were not fully implemented. The qualitative data revealed that staff thought the new QI method (the model to manage variability) was simple, effective, offered advantages over other QI methods and had highlighted the correct changes to make. However, they felt that contextual factors around leadership, staffing and organisational issues had prevented changes being implemented and a greater improvement being made.

Originality/value

The quality of QI reporting in surgery has previously been highlighted as poor and lacking in prospective and comprehensively reported mixed-methods evaluations. This study therefore not only describes and presents the results of using a novel QI method but also provides new insights in regard to important contextual factors that may influence the success of QI methods and efforts.

Enhanced recovery protocol after single-stage bilateral primary total knee arthroplasty decreases duration of hospital stay without increasing complication rates

PURPOSE

With an increasing number of total knee arthroplasty (TKA), protocols for better standard of patient care and shorter duration of hospital stay are necessary. Enhanced recovery (ER) protocols are becoming popular to meet these objectives. The current study aims to evaluate the clinical outcome of fast-track TKA using ER protocol in terms of length of hospital stay, perioperative complications and functional outcomes.

METHODS

Patients undergoing single-stage bilateral primary TKA were prospectively included in the study. All patients went through a pre-defined ER protocol of TKA. Length of hospital stay, readmission rates, pain scores and functional scores of patients operated under ER protocol were compared with another matched historical control-group. Factors delaying the discharge of the patients by 48 h after the surgery were noted.

RESULTS

We compared 275 patients undergoing single-stage bilateral primary TKA through ER protocol (Group 1) with 190 patients who had undergone bilateral primary TKA before the ER protocol was initiated (Group 2). The length of hospital stay (3.9 ± 2.1 days in group 1 and 7.5 ± 3.2 days in group 2, p 0.0001) and post-operative pain scores at 12 h (5.2 ± 2.9 in group 1 and 5.7 ± 2.1 in group 2, p 0.03) and 24 h (4.1 ± 1.6 in group 1 and 4.6 ± 1.4 in group 2, p 0.0005) were found to be significantly better with ER protocol. There was no difference in Oxford knee scores, infection rates, readmissions or mortality between the two groups.

CONCLUSION

ER protocol in single-stage bilateral primary TKA resulted in decreased length of hospital stay without increasing complications and compromising the clinical outcome. It requires an integrated approach and adherence to clinical pathways.

LEVEL OF EVIDENCE

Level II, Prospective comparative study.