Each year, a level 4 rural facility in the south of NSW performs around 86 elective total knee replacements (TKRs) and 84 elective total hip replacements (THRs). Before 2020, for patients going to the rehabilitation ward after surgery, the average number of days of discharge from physiotherapy was around 3.75 days for TKRs and 3.56 days for THRs (median of three days). Local feedback had also identified that the occupational therapists were not getting advance notice of discharge. Hence, they could not get equipment for the patient (e.g. crutches, bed at home) ready on time, further increasing the length of hospital stay.
This prompted the implementation of enhanced recovery after surgery (ERAS) intervention at this facility in 2020. A local anaesthetist, with prior experience in implementing ERAS protocols in South Australia and in the UK, led the implementation locally. They had seen evidence that the ERAS intervention would likely:
- reduce the length of stay
- reduce the number of patients representing to hospital with complications following surgery
- improve patient outcomes.
For example, in South Australia, the implementation of ERAS had reduced the length of hospital stay from five days to two days for hip replacements and three days for knee replacements.
ERAS components
- Facilating an early review of the patient by the anaesthetist (on receipt of the Referral for Admission or RFA) and providing follow-on referral for physiotherapy, occupational therapy and dietetics (for patients with a BMI over 40) to support optimisation and early occupational therapy discharge planning before surgery.
- Providing occupational therapists (OT) with access to the patient administration system (or PAS) several months in advance to organise assessments and equipment.
- Reviewing patients in the pre-admission clinic for medical optimisation at least nine to ten months before the surgery. Regular follow-up phone calls to assess their progress with prehabilitation exercises.
- Using standard protocols for anaesthetics and pain management to minimise variation and errors.
- Managing patient expectations around pain management. Patients are discharged with 2 weeks of short-acting opioids (not long-acting opioids).
- Calculating length of stay for two points in time: day of discharge from physiotherapy and physical discharge from the hospital (the difference accounting for the social barriers/medical complications impeding discharge). The average and median length of stay are monitored routinely.
Implementation
A multidisciplinary group of surgeons, anaesthetists, physiotherapists, OTs and dietitians was formed to support the implementation. It took six-eight months to embed the practice change at the facility.
Implementation enablers
Relative advantage demonstrated: the lead anaesthetist had seen the benefit and outcome of ERAS nationally and internationally.
Champions: the lead anaesthetist drove implementation efforts and collaborated with a close knit team of orthopaedic surgeons, physiotherapists, anaesthetics and the perioperative nurse manager.
Intervention source and adaptability: ERAS components were developed internally and tailored to local needs and context.
Evidence strength and quality: research evidence, education and anecdotal stories helped foster buy-in among impacted groups (e.g. surgeons, physiotherapists, OTs, dietitians) and patients.
Patient needs and resources: building rapport with patients and managing their expectations. Check-in points (every three months) helped patients feel valued – and ‘not left in the lurch’ - while waiting for surgery. Patients received an aide-memoire – a memory aid for the recommended exercises.
External incentives: implemented as a quality improvement project, which involved review of performance, including length of stay and outcomes.
There is no excuse not to optimise a patient when it is an elective surgery. There is time. Seeing a patient straightaway does not mean they have to have surgery now
One patient lost 3 kilos before the surgery. He said that doing the exercises before surgery helped him regain confidence and the ability to move his leg. He was able to be discharged from the hospital 24 hours after surgery because he had been doing the exercises
Impact and outcome
- The average length of stay for elective TKR was reduced from 4.05 to 2.89 days.
- The days of discharge from physiotherapy for knee surgery was reduced from 3.75 to 2.66 days. The median length of stay is now two days.
- 95% of TKRs and THRs were mobilised on day 0 after the ERAS rollout compared with 56% TKRs and 35% THRs before the ERAS implementation.
- The learning from implementing ERAS for knees continues to be used to implement ERAS for hips.
Contact
Email ACI-Surgery@health.nsw.gov.au with any questions or to request a copy of the resources.