Osteoarthritis

Joint surgery recovery program hastens discharge

Wednesday, 22 Apr 2015


Taking part in an enhanced recovery program following hip or knee replacement can improve clinical outcomes and hasten hospital discharge, research shows.

The Victorian study compared 297 patients who took part in an enhanced recovery after surgery (ERAS) program (see box one) with 412 patients who had surgery before the program was implemented.

The program had a small but significant effect on hospital stay, particularly for knee replacement patients, the researchers reported in this week’s MJA.

A “pertinent” finding was that a higher proportion of patients managed through the ERAS care pathway compared with the existing-practice group (59% v 41%, respectively) were deemed ready for discharge on postoperative day 3.

There were markedly improved indicators of processes and outcomes of care, including improved patient education, reduced fasting times, less blood loss, better analgesia, earlier ambulation and improved overall quality of recovery.

The limited effect on actual hospital stay was likely to be due to entrenched hospital practices that prevented earlier hospital discharge even though patients were deemed ready for discharge, they said. 

Box one: 16 predefined enhanced recovery after surgery items for hip or knee arthroplasty 

  • Nurse coordinator counselling in the orthopaedic or preadmission clinic
  • Preadmission review by a physiotherapist and/or dietitian
  • Minimal fasting preoperatively, defined as clear oral fluids up to 2 hours before surgery
  • Preoperative oral carbohydrate loading
  • No sedative premedication (benzodiazepines, opioids or neuroleptics)
  • Pre-emptive analgesia with paracetamol and gabapentinoids according to protocols
  • Spinal anaesthesia (not epidural)
  • Local anaesthesia technique (surgeon-delivered local infiltration of analgesia or anaesthetic femoral nerve block)
  • Minimal (≤ 10 mg) intravenous morphine intraoperatively
  • Intraoperative avoidance of excessive intravenous fluids (knee, > 1 L; hip, > 2 L; both: subtracting blood loss)
  • Active intraoperative warming (forced air warming and/or warmed intravenous fluids)
  • Antiemetic prophylaxis
  • Multimodal oral analgesia for ≥ 3 days postoperatively, to include a non-steroidal anti-inflammatory drug or cyclooxygenase-2 inhibitor
  • Early postoperative (recovery room) oral carbohydrate supplementation
  • Mobilisation within 24 hours
  • Early hospital discharge (≤ 5 days)

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