Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2)

Abstract

IMPORTANCE The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery.OBJECTIVE To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019. EXPOSURES Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not. MAIN OUTCOMES AND MEASURES The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality. RESULTS During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P = .22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%];OR, 0.74; 95% CI, 0.56-0.96; P = .02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P < .001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P < .001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P < .001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR,[4][5][6] days; OR, 0.97; 95% CI, 0.96-0.99; P < .001). CONCLUSIONS AND RELEVANCEAn increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

Evolution of enhanced recovery program in French university hospitals: a before-after retrospective survey

“…The general principle of ERP is to enhance recovery, reduce complications with potential related LOS reduction (12). In our survey the incidence of postoperative complications after TKA, colectomy and hysterectomy is comparable to what is described in the literature (9,(13)(14). We observe a reduction of complications only after THA with surprisingly a slight prolongation of LOS.…”

“…We observe a signi cant reduction of LOS after TKA and a slight increase after THA and no modi cation in the other surgical models. The mean LOS in 2017 in our survey for TKA, colectomy and hysterectomy is much longer than the LOS reported presently in the literature (respectively 4 days for TKA and 2 days for colectomy) and underlines mainly the important room for improvement still existing in our institution (9,10). Interestingly in all individual data collected in our survey in 2015 and 2017, a signi cant correlation exists between the number of ERP items applied and LOS.…”

Enhanced Recovery after Surgery (ERAS) for Hip and Knee Replacement—Why and How It Should Be Implemented Following the COVID-19 Pandemic

“…In many hospitals, ERAS is not yet the standard of care. For example, LOS is still around four days after hip and knee replacement in countries such as England and Spain [ 13 , 14 ], compared with 0–2 days in extensive epidemiological studies from Denmark and USA [ 7 , 15 ]. The restarting of services, therefore represents an opportunity to “reset” pathways at a time when limited capacity and increased demand may help to drive positive changes.…”

The Quality Improvement Challenge—How Nurses and Allied Health Professionals Can Solve the Knowing–Doing Gap in Enhanced Recovery after Surgery (ERAS)

“…For example, outpatient surgery for THA and TKA is now possible when implementing ERAS informed peri-operative protocols [20]. However, as highlighted previously, the successful deployment of ERAS protocols across all hospitals has not been universal because of contextual factors, and the relationship between reduced compliance of ERAS components to poorer outcomes has been shown [21].…”