Orthopaedic Enhanced Recovery After Surgery (ERAS) – Taranaki District Health Board

In March 2012 we completed a series of Enhanced Recovery Masterclass education sessions in Australia and New Zealand.

In this blog post, Greg Sheffield from Taranaki District Health Board describes how he and his team implemented enhanced recovery after attending our Masterclass and visiting us in Bournemouth later that year. Well done to Greg and all of the team at Taranaki DHB!

Enter Greg….

“A working group was set up in July 2012 to look at the potential for ERAS principles to be applied to patients undergoing primary total hip (THR) and knee (TKR) replacements at Taranaki District Health Board (TDHB).

An initial review of our pathways identified several factors to work on:

• Elective THR and TKR were our single biggest pathway
• We had a 6.72 day average length of stay
• We had multiple pathways for different orthopaedic surgeons
• We lacked a structured joint replacement pathway across all specialties
• We had an appreciation of inpatient costs in an increasingly challenging fiscal climate
• Most importantly we wanted to improve patient experience and clinical outcomes

Having identified our challenges, the working group set about reviewing the latest literature and evidence from within New Zealand and overseas. As a result of this, we made a series of changes to our patient pathways – through pre-operative, intra-operative and post-operative phases. The key changes being:

Pre-operative

• Introduced a nurse led triage service five months prior to surgery. This included robust screening and laboratory testing to help identify patients with comorbidities (e.g. anaemia, poorly controlled diabetes, hypo/hypertension) and instigate timely and appropriate onward referral
• Consistent education regarding alcohol and smoking cessation
• A GP ‘fit for listing’ health screening tool
• Allied health screening tool. This helped to identify patient that would benefit from allied health input such as dietician input to manage malnutrition, physiotherapy to regain function or occupational therapy to provide home equipment
• RAPT score – a tool used to predict patients likely to have an extended length of stay – was used to focus services on those patients most likely to benefit
• A comprehensive, anaesthetist led, pre-operative  assessment aimed to provide clear and consistent information to aid patient decision making and informed consent
• Pre-operative education class two weeks prior to surgery – detailing the patient journey through hospital and back home
• Carbohydrate drink two hours before surgery to minimise dehydration and the impact of surgery

Intra-operative

• Default regional anaesthesia +/- sedation
• Standardised analgesic pathway
• Minimising blood loss through the use of tranexamic acid and avoidance of surgical drains
• Standardised prosthesis

Post-operative

• Promotion of patient independence throughout
• Early oral hydration and nutrition
• Regular oral analgesia
• Early removal of catheters and IV lines
• Planned early and regular physiotherapy
• Early return home
• Strong ties to ongoing rehabilitation in the community

Managerial

• Standardised multidisciplinary protocol
• Re-developed critical pathway documents
• New patient information booklets
• Pre-printed medication charts
• Analgesic pathway posters

The changes were trialled with one orthopaedic surgeon in January 2013, and rolled out to the remaining orthopaedic department in August 2013. Having implemented this raft of changes we achieved the following:

• Average length of stay reduced from 6.72 days to 4.30 days
• Average cost per patient reduced by 12%
• Lower  re-admission and complication rates
• Improved DOSA rates
• High degrees of patient satisfaction

In October 2013, a national collaborative for Orthopaedic ERAS was launched by the New Zealand Ministry of Health, with a view to rolling out ERAS nationally by January 2015. We look forward to continuing our work on this project, and hope to achieve further successes yet.”

Greg Sheffield is Orthopaedic ERAS Project Manager and Clinical Lead in Musculoskeletal Physiotherapy at Taranaki District Health Board.