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Lee WC, Neoh EC, Wong LP, Tan KG. Shorter length of stay and significant cost savings with ambulatory surgery primary unilateral total knee arthroplasty in Asians using enhanced recovery protocols. J Clin Orthop Trauma 2024; 50:102379. [PMID: 38450414 PMCID: PMC10914573 DOI: 10.1016/j.jcot.2024.102379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/16/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Enhanced recovery after surgery (ERAS) in total knee arthroplasty (TKA) has reduced the length of stay (LOS) and cost of TKA in the Western population. Asians had been identified to be at higher odds of non-home discharge following TKA due to cultural differences. The efficacy of ERAS in TKA for Asian patients is less known. We aimed to investigate the efficacy of ERAS in reducing the LOS, transition to ambulatory surgery, improving home discharges, and reducing cost in an Asian population following TKA. Methods Retrospective analysis was performed on 634 TKA patients in 2017 (pre- ERAS) and 584 TKA patients who had undergone ERAS in 2022 in a tertiary hospital. Results Patients in 2022 (ERAS) were older (69 ± 7 vs. 68 ± 7 years old, p < 0.001) and had a higher proportion of patients with poorer function (p < 0.001). The LOS reduced from 5.4 days (95% CI:5.2-5.6) to 2.9 days (95% CI:2.7-3.2) (p < 0.001) with about 49 % of patients transitioning to ambulatory surgery and having a LOS of 1.4 days (95 %CI:1.3-1.5). The proportion of patients being discharged home in 2022 (78.9 %) was higher compared to 2017 (62.2 %) (p < 0.001). This saved the hospital 1817.4 inpatient ward bed days, which translated to S$2,124,540.60 of cost saving in a year, and up to S$2397.28 for the individual patient. Conclusion ERAS after TKA was able to safely achieve LOS comparable to the western population and allowed transition to ambulatory knee replacement in the Asian population. Consequently, this led to higher proportion of home discharges and achieved significant cost saving and hospital bed days.
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Affiliation(s)
- Wu Chean Lee
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore
| | - Eng Chuan Neoh
- Department of Physiotherapy, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore
| | - Luak Pak Wong
- Department of Nursing Speciality, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore
| | - Kelvin Guoping Tan
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore
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Schwenk W, Flemming S, Girona-Johannkämper M, Wendt W, Darwich I, Strey C. [Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]. Chirurgie (Heidelb) 2024; 95:148-156. [PMID: 37947802 DOI: 10.1007/s00104-023-01986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals. METHODS Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay. RESULTS Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ. CONCLUSION Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.
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Affiliation(s)
- Wolfgang Schwenk
- Gesellschaft für Optimiertes perioperatives Management, GOPOM GmbH, Düsseldorf, Deutschland.
- Gesellschaft für Optimiertes Perioperatives Management GOPOPM GmbH, Oberlörickerstr. 390b, 40547, Düsseldorf, Deutschland.
| | - Sven Flemming
- Universitätsklinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | | | - Wolfgang Wendt
- Viszeralchirurgie / Proktologie, Diakonissenkrankenhaus Dresden, Dresden, Deutschland
| | - Ibrahim Darwich
- Klinik für Allgemein- und Viszeralchirurgie, St. Marien Krankenhaus Siegen, Siegen, Deutschland
| | - Christoph Strey
- Klinik für Allgemein- und Viszeralchirurgie, DRK Krankenhaus Clementinenhaus, Hannover, Deutschland
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Pagano L, Hemmert C, Hirschhorn A, Francis-Auton E, Arnolda G, Long JC, Braithwaite J, Gumley G, Hibbert PD, Churruca K, Hutchinson K, Partington A, Hughes C, Gillatt D, Ellis LA, Testa L, Patel R, Sarkies MN. Implementation of consensus-based perioperative care pathways to reduce clinical variation for elective surgery in an Australian private hospital: a mixed-methods pre-post study protocol. BMJ Open 2023; 13:e075008. [PMID: 37495386 PMCID: PMC10373689 DOI: 10.1136/bmjopen-2023-075008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
INTRODUCTION Addressing clinical variation in elective surgery is challenging. A key issue is how to gain consensus between largely autonomous clinicians. Understanding how the consensus process works to develop and implement perioperative pathways and the impact of these pathways on reducing clinical variation can provide important insights into the effectiveness of the consensus process. The primary objective of this study is to understand the implementation of an organisationally supported, consensus approach to implement perioperative care pathways in a private healthcare facility and to determine its impact. METHODS A mixed-methods Effectiveness-Implementation Hybrid (type III) pre-post study will be conducted in one Australian private hospital. Five new consensus-based perioperative care pathways will be developed and implemented for specific patient cohorts: spinal surgery, radical prostatectomy, cardiac surgery, bariatric surgery and total hip and knee replacement. The individual components of these pathways will be confirmed as part of a consensus-building approach and will follow a four-stage implementation process using the Exploration, Preparation, Implementation and Sustainment framework. The process of implementation, as well as barriers and facilitators, will be evaluated through semistructured interviews and focus groups with key clinical and non-clinical staff, and participant observation. We anticipate completing 30 interviews and 15-20 meeting observations. Administrative and clinical end-points for at least 152 participants will be analysed to assess the effectiveness of the pathways. ETHICS AND DISSEMINATION This study received ethical approval from Macquarie University Human Research Ethics Medical Sciences Committee (Reference No: 520221219542374). The findings of this study will be disseminated through peer-reviewed publications, conference presentations and reports for key stakeholders.
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Affiliation(s)
- Lisa Pagano
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Cameron Hemmert
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Hirschhorn
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Emilie Francis-Auton
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Graham Gumley
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Kate Churruca
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Partington
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Cliff Hughes
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David Gillatt
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Louise A Ellis
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Luke Testa
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Romika Patel
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Mitchell N Sarkies
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Campagner A, Milella F, Guida S, Bernareggi S, Banfi G, Cabitza F. Assessment of Fast-Track Pathway in Hip and Knee Replacement Surgery by Propensity Score Matching on Patient-Reported Outcomes. Diagnostics (Basel) 2023; 13:diagnostics13061189. [PMID: 36980497 PMCID: PMC10047673 DOI: 10.3390/diagnostics13061189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Total hip (THA) and total knee (TKA) arthroplasty procedures have steadily increased over the past few decades, and their use is expected to grow further, mainly due to an increasing number of elderly patients. Cost-containment strategies, supporting a rapid recovery with a positive functional outcomes, high patient satisfaction, and enhanced patient reported outcomes, are needed. A Fast Track surgical procedure (FT) is a coordinated perioperative approach aimed at expediting early mobilization and recovery following surgery and, accordingly, shortening the length of hospital stay (LOS), convalescence and costs. In this view, rapid rehabilitation surgery optimizes traditional rehabilitation methods by integrating evidence-based practices into the procedure. The aim of the present study was to compare the effectiveness of Fast Track versus Care-as-Usual surgical procedures and pathways (including rehabilitation) on a mid-term patient-reported outcome (PROs), the SF12 (with regard both to Physical and Mental Scores), 3 months after hip or knee replacement surgery, with the use of Propensity score-matching (PSM) analysis to address the issue of the comparability of the groups in a non-randomized study. We were interested in the evaluation of the entire pathways, including the postoperative rehabilitation stage, therefore, we only used early home discharge as a surrogate to differentiate between the Fast Track and Care-as-Usual rehabilitation pathways. Our study shows that the entire Fast Track pathway, which includes the post-operative rehabilitation stage, has a significantly positive impact on physical health-related status (SF12 Physical Scores), as perceived by patients 3 months after hip or knee replacement surgery, as opposed to the standardized program, both in terms of the PROs score and the relative improvements observed, as compared with the minimum clinically important difference. This result encourages additional research into the effects of Fast Track rehabilitation on the entire process of care for patients undergoing hip or knee arthroplasty, focusing only on patient-reported outcomes.
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Affiliation(s)
| | - Frida Milella
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
| | | | | | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
- Faculty of Medicine and Surgery, Università Vita-Salute San Raffaele, 20132 Milano, Italy
| | - Federico Cabitza
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
- Dipartimento di Informatica, Sistemistica e Comunicazione, University of Milano-Bicocca, 20126 Milano, Italy
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Deans CF, Buller LT, Ziemba-Davis M, Meneghini RM. Same-Day Discharge Following Aseptic Revision and Conversion Total Joint Arthroplasty: A Single-Institution Experience. Arthroplast Today 2022; 17:159-164. [PMID: 36158463 PMCID: PMC9493283 DOI: 10.1016/j.artd.2022.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/21/2022] [Accepted: 07/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background With hospital inpatient capacity increasingly limited and primary total joint arthroplasty (TJA) rapidly transitioning to outpatient settings, the feasibility of outpatient aseptic revision and conversion TJA (rTJA) has been considered. Before the widespread adoption of outpatient rTJA, guidelines must be established to prevent patient harm. To this end, this study describes our initial experience with same-day-discharge (SDD) aseptic rTJA. Methods All aseptic rTJAs performed between May 8, 2015, and December 30, 2021, were retrospectively reviewed. Revision indications, patient selection criteria, and outcomes including SDD success rate, predischarge complications, all-cause emergency department visits, inpatient readmissions, and unplanned clinic encounters within 90 days of surgery were recorded. Results Thirty-five SDD aseptic rTJAs were performed. Conversion total hip arthroplasty (55.0%) and instability (27.3%) were the most common indications for hip revision. Instability (50%) and conversion total knee arthroplasty (20.8%) were most common for knee revision. SDD was achieved in 97% (34/35) of cases. One hip patient failed SDD due to persistent hypoxia requiring an overnight hospital stay and also underwent closed reduction for dislocation in the emergency department within 90 days of discharge. Two additional patients had unplanned clinic encounters within 90 days of the index procedure. There were no hospital readmissions or reoperations within 90 days. Conclusions Our initial experience suggests SDD aseptic rTJA can be safe and effective when modern perioperative outpatient protocols and surgical techniques are implemented. Future studies should further define patient selection criteria to optimize outcomes and minimize complications in this population.
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