Similar clinical outcome after unicompartmental knee arthroplasty using a conventional or accelerated care program

Abstract

Background and purpose Over the last 5 years, there has been increasing interest in reducing length of hospitalization (LOS) through accelerated programs. We examined the clinical outcome of patients undergoing a unicompartmental knee replacement (UKR) in an accelerated care program (A group) compared to a conventional care program (C group).Methods 40 patients randomized into 2 groups were included (A group: 17 patients; C group: 23 patients). Nausea, micturition problems, lower limb dysfunction, pain (VAS), opiate consumption, Knee Society score (KSS), day of discharge, rehospitalization within 3 months, contact with a general physician or nurse, and level of satisfaction were registered. Patients in the A group attended an information meeting. An intraarticular infiltration with Marcaine and adrenaline was used peroperatively. Patients in the C group had an epidural pump for 2 or 3 days. Patients in the A program were treated with NSAID and paracetamol postoperatively. Opiates were used in both groups in the case of breakthrough pain. The patients were considered ready for discharge when they were able to climb stairs to the second floor within 5 min.Results The median length of stay was 1 (1–3) day in the A group and 6 (4–7) days in the C group. The median pain score (VAS) at day 0 was 1 (0–3) in the A group and 5 (0–8) in the C group (p < 0.001). 11/23 of the patients in the C group had weakness of the lower limbs on day 1 due to the epidural; all patients in the A group were exercising on the day of the operation. Micturition problems necessitating intermediate catherization were more frequent in patients in the C program (19/23) than in patients in the A programme (3/17) (p = 0.001). There were no statistically significant differences between the two groups concerning nausea, average pain on days 1 and 2, use of opioids (during the first week postoperatively), KSS, contact with primary sector, level of satisfaction, or level of confidence.Interpretation We achieved a reduction in LOS of 5 days without affecting the clinical outcome.

Systematic review and meta-analysis of enhanced recovery programmes in surgical patients

“…. Thirty‐eight eligible studies with relevant outcomes were found, including two quasi‐randomized studies. In total 67 papers on these studies were reviewed ( Appendix S1 , supporting information).…”

“…Twenty studies reporting length of stay had standardized discharge criteria. In one the criteria differed between intervention and control groups.…”

“…Most studies reported readmission within 30 or 28 days, but six did not give a time frame and one reported readmission within 14 days. One study reported no readmission within 3 months of surgery, so these data were included.…”

“…Twenty studies 11,20,21,23,25,26,28,31,32,34,36,37,38,39,41,42,45,49,53 reported readmission rates. No studies indicated that staff deciding on readmission were blinded to the allocation of patients or gave standardized criteria for readmission.…”

Fifty ways to reduce length of stay: An inventory of how hospital staff would reduce the length of stay in their hospital

“…And in addition treating patients in a joint care programme [42,43] • Surgical pre-assessment, planning the admission, post-operative care and planning a safe discharge [44], early imaging with CT, MRI, or nuclear scintigraphy, particularly on the day before or the day of admission [45] • Preventing admissions of patients not needing inpatient care [46][47][48] • Utilising specialised nurse practitioners or other advanced professionals [49][50][51] • Creating an observation unit that gives more time to decide whether or not to admit the patient [52] • Stimulating that patients initially are seen by the right specialty [53] • Performing same-day major surgery [47] • Optimising guidelines and protocols or introducing clinical pathways for specific patient groups in order to reduce the length of stay and often with improvements of quality of care • Treating patients in a fast-track or accelerated care programme [54][55][56][57][58][59][60][61][62] • Choosing a laparoscopic rather than a classic intervention (open surgery) [63][64][65][66][67][68][69][70] although readmission rates for laparoscopic treatment may be higher [71] • Implementing an acute stroke unit [72] • Being aware that consultations, transfers and fragmentation of care often lead to delays [73,74] • Reducing waiting times for examinations [8,48] • Stimulating early rehabilitation and physical activity [75]…”