Does implementation of an enhanced recovery after surgery program for hip replacement improve quality of recovery in an Australian private hospital: a quality improvement study

Abstract

BackgroundEnhanced recovery after surgery programs may improve recovery and reduce duration of hospital stay after joint replacement surgery. However, uptake is incomplete, and the relative importance of program components is unknown. This before-and-after quality improvement study was designed to determine whether adding ‘non-surgical’ components, to pre-existing ‘surgical’ components, in an Australian private healthcare setting, would improve patient recovery after total hip replacement.MethodsWe prospectively collected data regarding care processes and health outcomes of 115 consecutive patients undergoing hip replacement with a single surgeon in a private hospital in Melbourne, Australia. Based on this data, a multidisciplinary team (surgeon, anesthetists, nurse unit managers, physiotherapists, perioperative physician) chose and implemented 12 ‘non-surgical’ program components. Identical data were collected from a further 115 consecutive patients. The primary outcome measure was Quality of Recovery-15 score at 6 weeks postoperatively; the linear regression model was adjusted for baseline group differences.ResultsThe majority of health outcomes, including the primary outcome measure, were similar in pre- and post-implementation groups (quality of recovery score, pain rating and disability score, at time-points up to six weeks postoperatively). The proportion of patients with zero oral morphine equivalent consumption at six weeks increased from 57 to 80% (RR 1.34, 95% CI 1.13, 1.58). Mean (SD) length of hospital stay decreased from 5.94 (5.21) to 5.02 (2.46) days but was not statistically significant once adjusted for baseline group differences.Four of ten measurable program components were successfully implemented. Antiemetic prophylaxis increased by 53% (risk ratio [RR] 95% confidence interval [CI] 1.16, 2.02). Tranexamic acid use increased by 41% (RR 95% CI 1.18, 1.68). Postoperative physiotherapy treatment on the day of surgery increased by 87% (RR 95% CI 1.36, 2.59). Postoperative patient mobilisation ≥ three metres on the day of surgery increased by 151% (RR 95% CI 1.27, 4.97).ConclusionsImplementation of a full enhanced recovery after surgery program, and optimal choice of program components, remains a challenge. Improved implementation of non-surgical components of a program may further reduce duration of acute hospital stay, while maintaining quality of recovery.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12615001170516), 2.11.2015 (retrospective).

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies

“… 115 In a prospective before-and-after study, introduction of standardized multimodal, opioid sparing analgesia, and general PONV prophylaxis significantly decreased the risk PONV. 116 …”

“…115 In a prospective before-and-after study, introduction of standardized multimodal, opioid sparing analgesia, and general PONV prophylaxis significantly decreased the risk PONV. 116 Similarly in breast surgeries, effective postoperative analgesia techniques including paravertebral block (PVB) or pectoral nerves block (PECs) can reduce the risk of PONV; [117][118][119] and should be used in addition to nonopioid analgesia and multimodal PONV prophylaxis. [120][121][122] Head and neck surgeries are considered high risk for the development of PONV, and a recent clinical trial has demonstrated that preoperative assessment and multimodal prophylaxis are effective in reducing the risk of PONV.…”

Bayesian adaptive design: the future for regional anesthesia trials?

“…A minimum 8-point difference in QoR15 is regarded as clinically significant 14. Based on a study of hip arthroplasty patients,15 the median (IQR) for controls is assumed to be approximately 107 (85–123). Since the follow-up period is short, it is assumed that there will be minimal missing data over the course of the trial.…”

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

“…Some patients feel reticent about new practices out of either ignorance or fear, so they disagree or need time to decide. The interdisciplinary team should answer each question of the patient and give them the written protocol instructions[ 16 , 20 , 21 ].…”

“…According to ERAS protocols, there are several components of perioperative care that affect stress response and accelerate recovery. These include pre-surgical counselling, short fasting period, early mobilization, bowel and bladder preparation, anesthesia and analgesia, thrombocytopenia, prevention of nausea and vomiting and fluid management[ 20 ].…”