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

2013 November 28
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by webmaster

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:


  • 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


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


  • 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


  • 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:

Taranaki LOS SPC

  • 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.


3rd ERAS UK Conference, 8th November 2013, Birmingham.

2013 November 13
by webmaster

Here are the slides we used in the interactive 1-hour workshop at the 3rd ERAS conference last week.

If you would like a copy of the worksheet that accompanied the slides, please get in touch via the contact form. Many thanks. TW

Workshop 1 Implementing, spreading, refreshing or sustaining ERAS in practice – an interactive workshop


Enhancing Quality and Recovery – NHS Kent, Surrey and Sussex. Enhanced Recovery

2013 June 5
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by webmaster

Dear Members of the Orthopaedic Collaborative,

Here are my slides from this morning’s presentation at Learning Series Seven, Concorde Suite, Academy Conference Centre, Holiday Inn, Gatwick, RH6 0BA.

I really enjoyed the morning and was sorry i couldn’t stay all day. I hope my presentation is useful in your enhanced recovery improvement projects.


EQR Enhanced Recovery Presentation

NHS Scotland – Orthopaedic Enhanced Recovery National Audit Results

2013 March 19
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by webmaster

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.

ERAS Ortho 2012 – Final

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.

NHS Scotland Enhacned Recovery

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.

NHS Scotland Enhanced Recovery Coordinators Network – Supporting Implementation through Measurement

2013 March 1
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by webmaster

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.



Mike Davidge on Measurement for Improvement

2013 March 1
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by webmaster

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!




Enhanced recovery for fractured neck of femur patients

2012 August 31
by webmaster

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.


1st International ERAS Congress – Enhanced Recovery after Surgery Congress

2012 August 21
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by webmaster

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 – Friday 2nd November 2012

2012 August 21
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by webmaster

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

2012 May 8
by webmaster

Here is a link to the recently published NHS Improvement guide

Enhanced Recovery Partnership: Fulfilling the potential. A better journey for patients and a better deal for the NHS.

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.