Bypassing the post‐anaesthesia care unit after elective hip and knee arthroplasty: a prospective cohort safety study

Abstract

Summary Following knee and hip arthroplasty, transfer to a recovery area immediately following surgery and before going to ward might be unnecessary in low‐risk patients. Avoiding the recovery area in this way could allow for more targeted use of resources for higher risk patients, which may improve operating theatre flow and productivity. A prospective single‐centre cohort study on the safety of criteria for bypassing the post‐anaesthesia care unit in elective hip and knee arthroplasty was designed. Criteria were: ASA physical status < 3; peri‐operative bleeding < 500 ml; low postoperative discharge‐score (modified Aldrete‐score); and an uncomplicated surgical and neuraxial anaesthesia procedure. The primary outcome was the number of patients in need of secondary readmission to the post‐anaesthesia care unit. Events within the first 24 postoperative hours were recorded, along with readmission and complication rates. A total of 696 patients were included, with 287 (41%) undergoing total hip arthroplasty, 274 (39%) undergoing total knee arthroplasty and 135 (19%) undergoing unicompartmental knee‐arthroplasty. Of these, 207 (44%) bypassed the post‐anaesthesia care unit. Patients all received multimodal analgesia without peripheral nerve blockade. Only one patient in the ward group required secondary readmission to the post‐anaesthesia care unit. Within 24 h, 151 events were reported, with 41 (27%) in the ward group and 110 (73%) in the post‐anaesthesia care unit group. Two events in each group occurred within 2 hours of surgery. No complications were attributed to bypassing the post‐anaesthesia care unit. The use of simple pragmatic criteria for bypassing the post‐anaesthesia care unit for patients undergoing knee and hip arthroplasty with spinal anaesthesia is possible and associated with significant reduction of post‐anaesthesia care unit admission and without apparent safety issues. Confirmation is needed from other studies and external validity should be interpreted cautiously in centres with different peri‐operative regimens, organisational and staffing structures.

Bypassing the post‐anaesthesia care unit after elective hip and knee arthroplasty

“…We thank Drs Egan and Skerritt for their interest and comments [1] regarding our study [2]. They raise several points worthy of elaboration and discussion.…”

Bypassing the post‐anaesthesia care unit after elective hip and knee arthroplasty

“…We thank Drs Hughes and Robertson [1] for their interest in our study [2]. We agree that the implementation process is crucial to successful and safe use of the criteria for bypassing the post-anaesthesia care unit (PACU).…”

“…We read with interest the prospective cohort safety study by Nielson et al [1]. The paper describes what appears to be a safe process of resource utilisation to improve theatre and post‐anaesthesia care unit (PACU) efficiency in their centre.…”

Turning baby steps into big leaps: shifting paradigms in fast‐track joint replacement surgery

“…It is this sticky cultural background that makes the findings of Nielsen et al., published in this issue of the journal, all the more striking [14]. In this prospective cohort study of nearly 700 patients undergoing primary knee and hip arthroplasty, the authors tested the disruptive hypothesis that it was possible to safely bypass admission to PACU and send patients directly to the ward.…”