Click on the link below for a PDF copy of the third 12-week Enhanced Recovery After Surgery (ERAS) ‘snapshot’ audit commissioned by the Scottish Government.
It collected data on hip arthroplasties from all Scottish operating hospitals from 20th August 2012 to 30th September 2012, and data on knee arthroplasties from 1st October 2012 to 11th November 2012. In the first period all patients listed for an elective Total Hip Replacement were included, and during the second period all patients listed for an elective Total Knee Replacement for examined. MSK Local Audit Co-ordinators collected data from patient case notes, patient information systems, results reporting and referral management systems.
Across the country ERAS principles have been adopted. Individual units have developed their own ERAS pathways with varying emphasis on different elements to suit their own unique local situation. The table shows the improvements in practice over the last 2 years.
Well done to David McDonald, Kate James and colleagues for putting both the report together, and for running such an impressive programme of support to help facilitate this adoption of enhanced recovery principles across the country.
Dear NHS Scotland Enhanced Recovery Coordinators Network,
Thank you for inviting me to speak at your workshop this morning – I was a enjoyable session and I am sorry that I couldn’t stay for a longer discussion at the end. Here are the slides from the workshop and I hope that it was a useful “back to basics” guide on how to support the implementation of enhanced recovery with measurement and data. Please get in touch with any follow up questions or queries.
I get many questions about data and measurement from people implementing enhanced recovery. In this 10 minute youtube video, Mike Davidge gives an excellent introduction to measurement for improvement. Mike’s explanation of how to measure implementation of an improvement intervention “makes sense” and it is easy to understand. I remain thankful for the day he spent with me in 2008 when he came to visit the Royal Bournemouth Hospital and examined the data I was collecting for our enhanced recovery pathway. The knowledge he passed on that day has underpinned my approach ever since. Thanks Mike!
Today I was talking to a colleague about introducing the principles of enhanced recovery to fractured neck of femur pathways. Amongst other resources I signposted him to this excellent presentation by Dr Swart from Torbay.
The average LOS for fractured neck of femur in the UK is still 18-20 days.
There is work for us all to do in order to improve fractured neck of femur pathways. This presentation from Torbay shows what can be achieved.
Click here or on the picture below to watch his presentation.
The 1st ERAS – Enhanced Recovery after Surgery – Congress will be held in Cannes, France, from Friday 5 to Sunday 7 October 2012.
Visit the ERAS Society website for more information by clicking here.
Click here to download the program.
“The ERAS Society is multidisciplinary. This is based on the insight that best practice is achieved using a multimodal approach to complex care and involving all disciplines. The ERAS Society invites everyone to the 1st International ERAS congress. Doctors, nurses, dieticians, physiotherapists from all disciplines caring for patient undergoing major surgical procedures (general surgery, orthopaedics, gynaecology, urology, thoracic surgery, ENT, anaesthesia, and intensive care) along with hospital administrators and everyone else with a stake at the patient care to a newly formed meeting point for discussions and presentation to further improve care for the patient undergoing major operations. The ERAS congress is the meeting place where we all face the same problems together and work together to solve them.”
The 2nd ERAS UK Conference is being held in Cheltenham on Friday 2nd November 2012. Book your place at the conference before the 14th September to get the “early bird” rate.
Click here for details of the conference.
Click here to register online.
This year the conference is being designed to facilitate maximum interaction and delegate participation. There will be good opportunities for networking, breakout sessions for different specialties or disciplines, and really interactive panel discussions.
There will be presentations and interactive discussions
- What do we measure in ERAS (including patient perspectives)
- Pain Management Update What’s stopping our patients moving?
- Challenges for Enhanced Recovery Across All Specialties
And interactive workshops on topics such as
- Pain management for ERAS
- ER for Emergency Surgery
- ER for MSK / Trauma Surgery
New publication from the Enhanced Recovery Partnership – We talk about enhanced recovery for fractured neck of femur patients
Here is a link to the recently published NHS Improvement guide
It’s 60 plus pages of great information from across the surgical specialties which has been prepared jointly by the Department of Health, NHS Improvement, National Cancer Action Team, Advancing Quality Alliance, National Enhanced Recovery Clinical Leads and Advisors, NHS Improvement Associates, SHA Enhanced Recovery Leads and Patient Advisors.
We were asked to write the Musculoskeletal update which we share below.
Applying enhanced recovery to trauma procedures in musculoskeletal surgery leads to highly significant improvements to quality of care and productivity To date, the focus within orthopaedics has been on implementing enhanced recovery to hip and knee joint replacement pathways.
The Enhanced Recovery Partnership Programme helped to; raise the profile of enhanced recovery within orthopaedics, increase the evidence base for it’s implementation, engage multi-disciplinary teams and key stakeholders, and create some important drivers for change . Consequently, the results achieved by pioneering sites have been replicated widely across the country, and a national reduction to average LOS with high levels of patient experience has been achieved.
However, whilst the results for hip and knee replacement patients are encouraging, two key challenges remain if we are to further improve patient outcomes and significantly increase hospital productivity throughout the country. The first challenge is that more work is required to support the adoption of enhanced recovery as the standard practice for all hip and knee replacement patients across all units. This is because there remains evidence of considerable variation in outcomes, such as case-mix adjusted length of stay across units, and also variations in pathway content, with non-adoption of recognised enhanced recovery steps in some units.
Secondly, the challenge for hospitals that have successfully implemented enhanced recovery for hip and knee replacement patients is for them to apply the same principles to other orthopaedic procedures. Importantly, this work should not be limited to elective surgery, especially given that exemplar units are now reporting excellent results when implementing enhanced recovery pathways for their fractured neck of femur patients.
For example, at Poole Hospital, LOS has reduced and the number of patients discharged home has increased following the introduction of enhanced recovery principles. The average LOS at Poole for fractured neck of femur patients is now 12 days which is 9.3 days lower than expected for their case-mix and 8 days less than the national average of 20 days . They are further applying the principles of enhanced recovery in orthopaedic trauma, and have significantly increased the number of trauma procedures completed as day surgery over the last 2 years . This has improved both patient experience and improved efficiency. This success is not in isolation; other sites such as Torbay are also reporting reduced LOS for fractured neck of femur patients following the implementation of enhanced recovery.
The potential impact, if this work in fractured neck of femur is replicated across the country is highly significant. This is because of the high volumes of fractured neck of femurs that occur annually (There were 62,453 inpatient spells in 2011) and the current variations in LOS and mortality rates. Whilst implementing enhanced recovery within trauma surgery will present different challenges, the factors that have underpinned success in hip and knee replacement such as strong clinical and managerial leadership, a multi-disciplinary team approach, a standardised pathway, and a highly organised logistical framework, remain the same.
We therefore propose that the immediate focus of our efforts should be not only to ensure the spread of enhanced recovery through elective care, but more importantly to improve clinical outcomes and patient experience for our most vulnerable patients such as those with a fractured neck of femur. It is here that we will have the biggest impact on improving the quality of care for patients, and the potential for productivity gains across the country is highly significant.
Recent articles from the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement in Denmark
During our recent lecture tour of Australia we were fortunate to meet lots of people doing some great work in orthopaedics. One person who really impressed us was Joanne Kenny from Austin Health in Melbourne. During the course of our conversations I spoke to her about the current evidence-base in orthopaedic enhanced recovery and I mentioned the impressive research work being completed in Denmark at the Lundbeck Centre. I recently shared a list of useful references with Joanne from the centre which I have detailed below. It’s a great reading list for anyone involved in orthopaedic enhanced reocvery.
1. Husted H, Andersen KV, Soballe K. Convalescence and sick leave following total knee and hip arthroplasty. Ugeskr Laeger 2009; 171:2892-2896.
2. Holm B, Kristensen MT, Myhrmann L, Husted H, Andersen LO, Kristensen B, Kehlet H.The role of pain for early rehabilitation in fast track total knee arthroplasty. Disabil Rehabil 2010; 32:300-306.
3. Andersen LO, Husted H, Kristensen BB, Otte KS, Gaarn-Larsen L, Kehlet H. Analgesic efficacy of subcutaneous local anesthetic wound infiltration in bilateral knee arthroplasty: a randomized, placebo-controlled, double-blind trial. Acta Anaesthesiol Scand 2010; 54:543- 548.
4. Andersen LO, Kristensen BB, Madsen J.L, Otte KS, Husted H, Kehlet H. Wound spread of radio labeled saline with multi- versus few-hole catheters. Reg Anesth Pain Med 2010; 35:200-202.
5. Kehlet H, Soballe K. Fast track hip and knee replacement – where are the issues? Acta Or- thopaedica 2010; 81:271-272.
6. Husted H, Otte KS, Kristensen BB, Ørsnes T, Wong C, Kehlet H. Low risk of thromboembolic complications in a fast track set up with hip and knee arthroplasty. Acta Orthopedica 2010; 81:599-605.
7. Husted H, Solgaard S, Hansen TB, Søballe K, Kehlet H. Care principles of four fast track arthroplasty departments in Denmark. Dan Med Bull 2010;57:A4166 1
8. Andersen LO, Husted H, Kristensen BB, Otte KS, Gaarn-Larsen L, Kehlet, H. Analgesic efficacy of local anaesthetic wound administration in knee arthroplasty. Volume vs. concentration. Anaesthesia 2010; 65:984-990.
9. Andersen LO. Husted H, Kristensen BB, Otte KS, Gaarn-Larsen, Kehlet H. Analgesic efficacy of intracapsular vs. intraarticular local anaesthetics after knee arthroplasty. Anaesthesia 2010;64:904-912
10. Andersen KV, Bak M, Christensen BV, Harazuk, Pedersen NA, Søballe K. A randomized controlled trial of local infiltration analgesia vs. epidural infusion for total knee arthroplasty. Acta Orthopedica 2010; 81:606-610.
11. Husted H Otte KS, Kristensen BB, Ørsnes T, Kehlet H. Readmissions after fast track hip and knee arthroplasty. Arch Orthop Trauma Surg 2010;130:1185-1191
12. Holm B, Kristensen MT, Bencke J, Husted H, Kehlet H, Bandholm T. Loss of knee-extension strength is related to knee swelling after total knee arthroplasty. Arch Phys Med Rehabil 2010; 91:1770-1776.
13. Krenk L, Rasmussen LS, Kehlet H. New insights into the pathophysiology of postoperative cognitive dysfunction. Acta Anaesthesiol Scand 2010;54:951-956
14. Larsen K, Hansen TB, Søballe K, Kehlet H. Patient reported outcome after fast-track hip arthroplasty and the need for additional rehabilitation. Health Quality Life Outcomes 2010; 8:144-154.
15. Jans Ø, Kehlet H, Hussain Z, Johansson P. Transfusion practice in hip arthroplasty – a nationwide study. Vox Sanguinis 2011: 100: 374-380
16. Lunn TH, Kristensen BB, Andersen LØ, Husted H, Otte KS, Gaarn-Larsen L, Kehlet H. Effect of high-dose preoperative methylpredisolone on pain and recovery after total knee arthroplasty: a randomised, placebo-controlled trial. Br J Anaesth 2011; 106:230-8. 2
17. Husted H, Troelsen A, Otte KS, Kristensen BB, Holm G, Kehlet H. Fast-track surgery for bilateral total knee replacement. J Bone Joint Surg 2011; 93-B: 351-6.
18. Holm B, Kristensen MT, Husted H, Kehlet H, Bandholm T. Thigh and knee circumference, knee extension strength, and functional performance after fast-track total hip arthroplasty. Phys Med & Rehabil 2011; 3: 117-24.
19. Jans Ø, Johansson P, Kehlet H. Blood transfusion in major orthopaedic surgery? Ugeskr Laeger 2011; 173: 815-817.
20. Krenk L, Rasmussen L.S. Postoperative delirium and Postoperative cognitive dysfunction in the elderly – what are the differences? Minerva Anestesiologica 2011;7:742-49
21. Lunn TH, Husted H, Solgaard S, Kristensen BB, Otte KS, Kjærsgaard AG, Gaarn-Larsen L, Kehlet H. Intraoperative local infiltration analgesia for Early Analgesia after total hip arthroplasty: A randomized double-blind placebo controlled trial. Reg Anesth Pain Med 2011; 5:424-29.
22. Otte K, Husted H, Ørsnes T, Kehlet H. Bilateral simultaneous total hip arthroplasty in a fasttrack setting. Hip International 2011; 3:336-339.
23. Andersen L, Otte KS, Husted H, Gaarn-Larsen L, Kristensen B, Kehlet H. High volume infiltration analgesia in total hip arthroplasty. A randomized, double blind placebo controlled trial. Acta Orthopedica 2011;82: 23-426
24. Kehlet H, Andersen LØ. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011; 7:778-784.
25. Husted H, Troelsen A, Kehlet H. Undocumented regimes in hip and knee replacement surgery may impair treatment outcome. Ugeskr Laeger 2011;25:1802-1805.
26. Husted H, Otte KS, Kristensen BB, Kehlet H. Fast-track revision knee arthroplasty – a feasibility study. Acta Orthopedica 2011;82 :438-40.
27. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why in hospital after fast-track hip and knee arthroplasty? Acta Orthopedica 2011; 82:679-684. 3
28. Husted H, Munk Jensen C, Solgaard S, Kehlet H. Reduced length of stay following hip and knee arthroplasty in Denmark 2000-2009. Acta Ortop Trauma Surg 2012; 132:101-104.
29. Munk S, Dalgaard J, Bjerggaard K, Andersen I, Hansen T. B, Kehlet H. Early recovery after fast-track Oxford unicompartmental knee arthroplasty, Acta Orthopedica 2012; 83:41-45.
30. Jakobsen TL, Husted H, Kehlet H, Bandholm T. Progressive strength training (10 RM) commenced immediately after fast-track total knee arthroplasty: Is it feasible? Disability Rehabil 2011; (e-pub)
31. Jans O, Bundgaard-Nielsen M, Solgaard S, Johansson PI, Kehlet H Orthostatic intolerance during early mobilization after fast-track total hip arthroplasty. Br J Anaesth 2012;108:436- 43
32. Holm B, Husted H, Kehlet H, Bandholm T. (2011) Effect of knee joint icing on knee- extension strength and knee pain elderly after total knee arthroplasty: A randomized cross- over study. Clinical Rehabilitation (e-pub)
33. Krenk L, Rasmussen LS, Bæk-Hansen T, Bogø S, Søballe K, Kehlet H. Delirium after fast- track hip and knee arthroplasty. Br J Anaesth 2012; 108:607-11.
34. Kjærsgaard-Andersen P, Kehlet H. Deep venous thrombosis prophylaxis in fast-track hip and knee replacement? Acta Orthop. 2012 (e-pub)
35. Lange J, Troelsen A, Thomsen RW, Søballe K. Chronic infections in hip arthroplasties: The risk of infection in one-stage and two-stage revisions – systematic review and meta- analysis. Clin Epidemiol 2012:57-73
36. Larsen K, Hansen TB, Søballe K, Kehlet H. Patient-reported outcome after fast-track knee arthroplasty. Knee Surg Sports Traum Arthrosc 2012 (e-pub)
37. Bandholm T, Kehlet H. Physiotherapy exercises after fast-track total hip and knee arthroplasty – time for reconsideration? Arch Phys Med Rehabil (e-pub) 4
38. Lunn T, Kristensen B, Gaarn-Larsen L, Husted H, Kehlet H. Post Anaesthesia Care Unit stay after total hip and knee arthroplasty under spinal anaesthesia – a prospective, observational study. Acta Anaesthesiol Scand 2012 (in press)
39. Munk S, Jensen NJF. Andersen I, Kehlet, H, Hansen TB. Effect of compression therapy on knee swelling and pain after total knee arthroplast. Knee Surg Sports Traum Arthroscopy 2012 (in press)
40. Jans Ø, Johansson P, Kehlet H. Mortality after primary total hip arthroplasty and possible relations to transfusion. Vox Sanguinis 2012 (in press)
Here are the slides from today’s workshop. Please get in touch via the contact form with any questions or queries.
If you have a good example of enhanced recovery that you would like to share please also get in touch.
The aim is to help the spread of good ideas on enhanced recovery after surgery.
Here are the slides from our recent workshops in Australia and New Zealand. A full reference list will follow in the next couple of days.
Please get in touch with any questions.