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.
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)
Enhanced Recovery at the International Forum for Quality and Safety in Healthcare
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.
Follow the link below to view Enhanced Recovery video podcasts on the Wessex Health Innovation and Education Cluster (HIEC) Partnership website. The website is called PIPER and it’s purpose is to identifies and accelerate the spread of good ideas in health and care services that improve outcomes for patients and that make the best use of health and care service resources. The aim is to make the transfer of good ideas simple, immediate, and accessible.
Click here to view the video podcasts.
Are you going to the NHS Improvement Enhanced Recovery Summit on the 30th April 2012 at the Lancaster London Hotel?
The summit is free for NHS clinicians and managers from primary and secondary care, commissioners, social care, patients, carers and charitable organisations from across the health and social care community.
The day will draw on a wide range of local, national and international expertise, covering policy, managerial, clinical and commissioning knowledge. The summit aims to support the adoption of Enhanced Recovery principles and practices’ in elective and emergency pathways (surgical and medical) across England: with key note speakers, debates, Q&A, and show and tell sessions.
Click here for more information and to register
Click here to submit an abstract
Earlier this year Bernarda Cavka visited the UK to attend the 1st National Enhanced Recovery Conference in Bath. During her stay she also visited some hospitals utilising enhanced recovery pathways, seeking to learn from the sites in order to help inform her own hospital’s implementation of enhanced recovery.
Bernarda works as a Physiotherapy Team Leader at he Royal Melbourne Hospital, Australia and after her visit she sent us the following guest blog with her reflections of her visit to Bournemouth.
Enter Bernarda…
In August this year I had the opportunity to visit the Royal Bournemouth Hospital (RBH) to observe the multidisciplinary team management of their elective hip and knee arthroplasty patients and gain a further understanding of how the team have achieved such great results with patient satisfaction, clinical outcomes, and length of stay. I was particularly interested to hear about RBH’s experiences with the implementation of the principles of enhanced recovery which is a relatively new concept in public health in Australia.
From the outset it was evident that a cohesive, innovative and highly structured team is the key ingredient to drive any change and achieve success with short term and long term goals. The team had the same vision and objectives regarding patient care which were consistently communicated to the patients and family members at varied stages of the pathway. In particular, the preoperative MDT education sessions provided patients with a clear understanding of what to expect from the time they were admitted onto the unit until discharge home including the importance of effective pain management, day of surgery mobilisation and the promotion of independence with self care.
Discussions with Tom Wainwright reinforced the importance of data collection to monitor processes and clinical outcomes along the patient journey, in engaging staff and as a mechanism of feedback to the MDT and executive management regarding the performance of the unit. Their use of SPC charts provides live information regarding LOS which facilitates more timely detection of variance in clinical practice which may be adversely affecting the patient experience and outcomes.
Overall, visiting the RBH was a fantastic experience which demonstrated how the patient experience and clinical outcomes can be improved through the implementation of an enhanced recovery pathway which is aligned with best practice guidelines. Thanks to Tom and Rob for their hard work in developing and sustaining the Enhanced Recovery Blog. The site has been a valuable tool for us in Melbourne as we move forward in reviewing our own hip and knee arthroplasty pathway.
Bernarda Cavka, Physiotherapy Team Leader, Acute Orthopaedics, The Royal Melbourne Hospital, Australia (Bernarda’s trip to the UK was funded by a grant from the Felice Rosemary Lloyd Trust which is managed by ANZ Trustees).
If you are based in Australia or New Zealand and would like to learn more about how to design, implement, and manage a high performing enhanced recovery pathway in orthopaedics, follow the link below to get details of upcoming masterclasses near you.
Orthopaedic Enhanced Recovery Master Classes with Change Champions
Much of the focus when introducing enhanced recovery pathways is about reducing length of stay. However, we must never forget that the primary focus of the approach is to improve patient care. In this blog post I link to an article recently published in the journal BMJ Quality and Safety and written by a noted French ethnographer.
In the article he describes his care in a French private hospital for a hip replacement. He recounts a number of events that are probably typical of many patients’ hospital experiences, and are essential for all of us to always keep in mind. The observations are probably similar to those patients might make after exposure to any modern healthcare system, except that they offer a level of detail few would provide. The account focuses on the contradiction between excellent technical operations and the absence of compassionate patient care, basic civility and the needs of patient safety.
Here is the link to the article
For want of a four-cent pull chain
If you are unable to access, get in touch via the contact form and we will email you a copy.
In the 2011 Dr Foster Good Hospital Guide Questionnaire every english hospital was asked questions about their joint replacement pathway.
The questions asked about compliance to widely agreed and understood elements of an enhanced recovery (rapid recovery) pathway and were then analysed against length of hospital stay. To see the full report go to page 34 of the guide by clicking on this link 2011 Dr Foster Guide
Click here to see the recently published article by David McDonald and colleagues.
David and his colleague Dr Scott will both be at the National conference later this week sharing their experiences and expertise.