From April 2011 all Joint Replacement Operation done in my Private and NHS practice performed under Enhanced Recover Program
Context for the Rapid Recovery Programme
The current environment challenges UK orthopaedic health service providers with delivering high quality care, high levels of patient satisfaction, and improved medical outcomes all within existing or diminishing resources. The numbers of appropriate patients for Hip and Knee Arthroplasty in 2009 was 1470001. This number is expected to grow in the years 2009-2016 by a cumulative growth rate of 6.7% to 217 000 by 2016.
The difficult economic conditions make improving the efficiency and productivity of the National Health Service a priority for the UK Government, and a recent policy document2 emphasised that whilst continuing to focus on clinical outcomes, it was also necessary, given financial constraints, to also look at productivity of healthcare provision. Indeed, the challenges that hospitals are facing can only be met through improvements in the quality of service and operational efficiency.
Currently there is no standardised patient pathway for patients undergoing Hip and Knee replacement procedures. As such, the number of pre-operative appointments, per-operative protocols, length of stay in hospital and post-operative rehabilitation programme, varies not only between hospitals, but also between surgeons in the same hospital.
There is published evidence that an orthopaedic patient in a standard regional district general hospital may have a length of stay of 8.5 days3, whilst published clinical research has reported a length of stay of 5 days4. In addition, a recent published clinical study6 reported that patients on a enhanced recovery programme resulted in a statistically significant saving of $4000, or 20%, from referral to discharge when compared to a standard patient pathway and that the enhanced pathway patients also had a gain in health-related quality of life at the three-month follow-up time point.
Against this background of variability in service, a hospital is paid a fixed tariff for every orthopaedic procedure: at present £4,863 for primary hip replacement and £5,198 for primary knee replacement. Case study analysis within a NHS district general hospital has indicated that patients who stay 3-5 days post operatively in a non rapid recovery hospital may have costs that exceed this tariff by approximately £1,500.
There is increasing interest in pathway management programmes that improve the patient’s experience whilst better utilising existing resources and reduce the length of stay. The Department of Health has developed a programme called Enhanced Recovery. This programme can be used in any surgical specialty and a off the shelf toolkit is supplied to the hospital to aid implementation.
The National Health Service Institute for Innovation and Improvement has already identified the importance of improving efficiency of care through the enhanced recovery programme5. They highlight three main benefits:
1. Better outcomes and reduced length of stay
2. Reduced level of resources necessary, or if demand, Increased numbers of patients being treated
3. Better staffing environment.
They provide a service to support NHS hospitals to implement the changes. At present, for supporting implementation of protocols into operating theatres only, the cost is £290006.
Why is there a need for programmes like Rapid Recovery? A surgeon’s perspective
Henrik Kehlet, Prof. MD, PhD, Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University,Denmark.
Major surgery is usually followed by pain, stress-induced organ dysfunction, catabolism, changes in coagulation and fibronolysis etc, all resulting in a risk of medical complications (cardiopulmonary, infections, thromboembolic, cognitive) as well as functional impairment leading to requirement of hospital stay and rehabilitation. Based on the question “why is the patient in hospital today?” and analyzing the many factors involved in peri operative care, the concept of “fast-track surgery” or “rapid recovery” has evolved based on a multimodal intervention on all peri operative care principles. So far, the concept has been tested across surgical specialities with a large success resulting in faster recovery, improved analgesia, and reduced organ dysfunction and with less medical morbidity.
Although most documentation on surgical pathophysiology and clinical outcome parameters has come from abdominal procedures, significant improvements have been made during the last 5 years with the “rapid recovery” concept in major joint replacement. However, as we have learned across procedures, implementation of the results from scientific clinical studies has been slow calling for more attention to the rapid recovery programme from all professions involved in the health care system.
Henrik Kehlet is world renowned in the field of fast track surgery with hip & knee replacements. His belief is that patients experience an improved recovery once at home and should not be kept in hospital unnecessarily.
Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003;362:1921-1928.
Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast track surgery. Ann Surg 2008;248:189-198.
Barbieri A, Vanhaecht K, Van HP, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med 2009;7:32.
Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434-440.
Rapid Recovery Detailed Service Plan
The Rapid Recovery programme consists of three core service elements:
Audit and reporting of all the existing protocols in the hospital
As part of the programme a team will audit the existing pathway in a hospital to identify efficiencies that can be achieved. There may be multiple pathways within the same hospital, or department, dependent on surgeon preference
Design of Optimised Patient Pathway
The Rapid Recovery team, in conjunction with the MDT, develops an optimised pathway for each individual procedure, based on a department’s existing assets, available headcount and estimated hospital throughput. All members of the MDT are encouraged to collaborate and develop standardised pathways for all care processes.
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