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Jenkins C1, Jackson W2, Bottomley N2, Price A3,4, Murray D3,4, Barker K1,4
1Oxford University Hospitals NHS Foundation Trust, Physiotherapy Research Unit, Oxford, United Kingdom, 2Oxford University Hospitals NHS Foundation Trust, Orthopaedics, Oxford, United Kingdom, 3Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom, 4Oxford University, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom
Background: The emphasis on reducing the number of days patients spend in hospital is growing. Performing procedures with shorter stays using enhanced recovery pathways is one method of tackling this issue. Unlike other pathways that adopt strict selection criteria, we wanted a pathway that would allow all patients having knee replacements the opportunity to have day surgery with an option to transfer to the current inpatient pathway if required. This project details the implementation of this pathway.
Purpose: To safely reduce the length of stay for all patients following knee replacement.
Methods: All patients were assessed pre-operatively by medical and nursing staff and given written information. Occupational therapists also screened patients, discussed the pathway and provided assistive devices as necessary. On admission all patients followed the new day surgery pathway and underwent minimally invasive partial knee replacement surgery with general or spinal anaesthesia and local infiltration. They mobilised with a physiotherapist, weight bearing as tolerated, on the day of surgery. This was achieved by a change in physiotherapy shift patterns so patients could be seen up to 22:00. Patients were discharged home was when they had been medically reviewed, had a satisfactory x-ray, received their home medications, and were safe using crutches and on the stairs. At home patients mobilised indoors, kept their knee straight and performed static quadriceps exercises. They returned to a day surgery clinic 5 days later for a wound check by a nurse, and started knee flexion with a physiotherapist. Patients who went home on day 1 followed the same pathway and those who remained in on day 2 began knee flexion then and were discharged when well and mobilising safely, but did not attend the 5 day clinic. All patients were seen again at 6 weeks.
Results: Twelve orthopaedic consultants performed 669 primary unilateral partial knee replacements in the 18 months from September 2016 to February 2018. 264 patients (39%) went home on the day of surgery, 253 (38%) on day 1 and 152 (23%) stayed 2 or more days (range: 2-28 days). Mean length of stay reduced significantly (p=0.001) from 2.6 to 1.2 days (median: 1 day) with a reduction in bed occupancy of 937 days in 18 months. Patient satisfaction at 6 weeks using the Surgical Satisfaction Questionnaire showed 90% of patients discharged on day 0 were very satisfied and 92% would “do it all over again”.
Conclusion(s): Many components of traditional care were altered allowing successful adoption of this pathway. The most important factors were physiotherapists working late evening shifts, delayed knee flexion, a consistent team message and patient education. The results achieved were the effect of marginal improvements in all areas of the pathway, rather than any one major change.
Implications: This pragmatic, non-selective day surgery pathway is safe and acceptable to patients, allowing discharge for 77% of patients by the end of post-operative day 1 with a substantial reduction in bed occupancy.
Keywords: day surgery, Partial knee replacement, arthroplasty
Funding acknowledgements: No external funding.
Purpose: To safely reduce the length of stay for all patients following knee replacement.
Methods: All patients were assessed pre-operatively by medical and nursing staff and given written information. Occupational therapists also screened patients, discussed the pathway and provided assistive devices as necessary. On admission all patients followed the new day surgery pathway and underwent minimally invasive partial knee replacement surgery with general or spinal anaesthesia and local infiltration. They mobilised with a physiotherapist, weight bearing as tolerated, on the day of surgery. This was achieved by a change in physiotherapy shift patterns so patients could be seen up to 22:00. Patients were discharged home was when they had been medically reviewed, had a satisfactory x-ray, received their home medications, and were safe using crutches and on the stairs. At home patients mobilised indoors, kept their knee straight and performed static quadriceps exercises. They returned to a day surgery clinic 5 days later for a wound check by a nurse, and started knee flexion with a physiotherapist. Patients who went home on day 1 followed the same pathway and those who remained in on day 2 began knee flexion then and were discharged when well and mobilising safely, but did not attend the 5 day clinic. All patients were seen again at 6 weeks.
Results: Twelve orthopaedic consultants performed 669 primary unilateral partial knee replacements in the 18 months from September 2016 to February 2018. 264 patients (39%) went home on the day of surgery, 253 (38%) on day 1 and 152 (23%) stayed 2 or more days (range: 2-28 days). Mean length of stay reduced significantly (p=0.001) from 2.6 to 1.2 days (median: 1 day) with a reduction in bed occupancy of 937 days in 18 months. Patient satisfaction at 6 weeks using the Surgical Satisfaction Questionnaire showed 90% of patients discharged on day 0 were very satisfied and 92% would “do it all over again”.
Conclusion(s): Many components of traditional care were altered allowing successful adoption of this pathway. The most important factors were physiotherapists working late evening shifts, delayed knee flexion, a consistent team message and patient education. The results achieved were the effect of marginal improvements in all areas of the pathway, rather than any one major change.
Implications: This pragmatic, non-selective day surgery pathway is safe and acceptable to patients, allowing discharge for 77% of patients by the end of post-operative day 1 with a substantial reduction in bed occupancy.
Keywords: day surgery, Partial knee replacement, arthroplasty
Funding acknowledgements: No external funding.
Topic: Service delivery/emerging roles
Ethics approval required: No
Institution: Oxford University Hospitals NHS Foundation Trust
Ethics committee: Trauma and Orthopaedic Directorate
Reason not required: Reviewed by the directorate governance meeting and deemed to be audit and not requiring formal ethics approval
All authors, affiliations and abstracts have been published as submitted.
