An enhanced recovery after surgery program for hip and knee arthroplasty

Objective: To institute and evaluate the benefits of an enhanced recovery after surgery (ERAS) program across three hospitals in Victoria. Design, setting and participants: We used a before-and-after quality improvement study design consisting of three phases: pre-ERAS program data collection from March to September 2012; ERAS training and implementation during September 2012; and change performance measurement following ERAS implementation from October 2012 to May 2013. Main outcome measures: The primary end point was duration of hospital stay after knee or hip arthroplasty. Secondary end points were adherence to the ERAS bundle, and process and patient recovery characteristics. Results: We enrolled 412 patients to the pre-ERAS (existing-practice) phase and compared them with 297 patients in the ERAS phase. For ERAS patients, compared with existing-practice patients, hospital stay was reduced (geometric mean, 5.3 [SD, 1.6] v 4.9 [SD, 1.6] days; P < 0.001) and there was a significant improvement in the proportion of patients ready for discharge on Day 3 after surgery (41% v 59%; P < 0.001). The most common reason for delayed discharge was patients waiting for review or access to rehabilitation services. 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. Conclusion: We found that an ERAS program could be successfully implemented in elective joint arthroplasty, leading to a shorter duration of hospital stay. We recommend this orthopaedic ERAS pathway.