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Accelerated tracks in total hip and knee arthroplasty: why and how?

Henrik Husted
1 January, 2008  

Henrik Husted
MD

Gitte Holm
RN
Department of Orthopaedics
H:S Hvidovre University Hospital
Denmark

All main outcomes in total arthroplasty are favoured by accelerated tracks compared with ­conventional stays. Implementation is expected to improve rehabilitation, reduce length of hospital stay (LOS), improve cost savings and increase patient satisfaction. Accelerated tracks include a combination of ­multimodal physiologically and evidence-based treatment modalities and an optimised logistical setup.(1) The goal is to standardise and optimise procedures in order to provide the best available treatment, ­nursing and ­training for the patients and thus reduce morbidity, mortality, complications and convalescence – and ideally increase patient satisfaction. Secondarily, this leads to a reduction in LOS and to cost savings. Conventional stays have not specifically addressed all patient-related issues and logistics from admission to discharge, which has often led to suboptimal hospital stay, prolonged ­convalescence, increased LOS and improper utilisation of resources.

To succeed in developing and implementing accelerated tracks, a multidisciplinary approach and ­partnerships among surgeons, nurses, physiotherapists, anaesthetists and the primary sector is ­mandatory in order to target all aspects of patient care during and after hospitalisation. 

Why?
The main outcomes of any surgical procedure requiring hospitalisation consist of mortality, ­morbidity, readmissions/complications, surgical outcome, LOS, patient satisfaction and costs. Recently, we ­conducted a series of nationwide studies in Denmark comparing accelerated tracks with more ­conventional stays.(2–4) The first study focused on the relationship between duration of hospital stay, surgical ­volume, morbidity and mortality, and resources. We found that the postoperative hospital stay after total hip ­arthroplasty (THA) and total knee arthroplasty (TKA) varied between departments, from 4.5 to 12 days. There was no difference in morbidity regardless of LOS for THA, whereas it was slightly increased for TKA. A short LOS was associated with lower mortality for THA and no difference for TKA. A nationwide reduction of hospital stay after THA and TKA to five days would free 28,000 hospital beds and produce cost savings of approximately €13m.(2)

The second study evaluated hospital stays for patients operated on for THA and TKA in order to identify important logistical and clinical areas for the duration of hospital stay. Departments with short ­hospital stay were characterised by both logistical (homogenous entities, regular staff, high continuity, using more time on and up-to-date information, including expectations of a short stay and functional discharge ­criteria) and clinical features (multimodal pain treatment, early mobilisation and discharge when criteria were met) facilitating quick rehabilitation and discharge.(3)

The third study evaluated patient satisfaction with the hospital stay in relation to LOS in patients ­operated on for THA and TKA. Patients from departments with the shortest stay were neither younger, nor had fewer co-morbidities, than patients from departments with longer stays. Apart from staying for significantly shorter times, they were either as satisfied or sometimes more satisfied with all parts of their stay, as were patients from departments with longer hospital stay or – sometimes – they were more satisfied than the latter patients. There was no difference in satisfaction with the outcome during the first postoperative month and no difference in visits to GPs, physiotherapists or home-based nurses.(4) Two earlier studies found fewer complications and readmissions when implementing an ­accelerated track and reducing LOS from 13.3 days to 7.9 days and even further to 3.8 days. All ­patients were discharged to their homes, and the maximum intended LOS of five days was accomplished by 95% of unselected patients.(5,6) Thus, all main outcomes are favoured by accelerated tracks. Implementation of logistical and clinical features in all departments is expected to improve rehabilitation, reduce LOS, lead to important cost savings and maintain or increase patient satisfaction with all parts of the stay.

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How?
There are different ways to set up accelerated tracks: they can be either value-based or time-based. The former includes daily goals to be achieved by the patients, and the next step cannot be begun before completing the previous one. A time-based accelerated track does not include any daily goals but focuses on intended discharge within a limited timeframe. The latter gives more flexibility, as it allows patients to progress at their own pace. Both tracks should include fixed discharge criteria, which have to be fulfilled before discharge can take place. It is essential to start by looking at one’s existing track, to re-evaluate each step and replace procedures by searching for evidence-based clinical features and also to monitor and evaluate the above-mentioned outcomes. Accelerated tracks should never remain static but rather be seen as a dynamic continuing process where the ultimate goal is the “risk- and pain-free” operation and subsequent stay.

The future?
It is key to “first make it better, then faster”, and it is imperative to combine improvements in both clinical­ features and logistical ones. One should ask the question: “Why is the patient in hospital ­today?” ­Issues such as pain treatment and early mobilisation should be addressed aggressively, and the new techniques with injection of large volumes of local analgesics at the surgical site are very promising and lead to ­immediate postoperative pain-free mobilisation. Further evaluation, however, is necessary.

References

  1. Kehlet H, et al. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-41.
  2. Husted H, et al. Length of stay in total hip and knee arthroplasty in Denmark I: volume, morbidity, mortality and resource utilization. A national survey in orthopaedic departments in Denmark. Ugeskr Læger 2006;168:2139-43.
  3. Husted H, et al. Accelerated versus conventional hospital stay in total hip and knee arthroplasty II: organizational and clinical differences. Ugeskr Læger 2006;168:2144-8.
  4. Husted H, et al. Accelerated versus conventional hospital stay in total hip and knee arthroplasty III: patient satisfaction. Ugeskr Læger 2006;168:2148-51.
  5. Husted H, et al. Reduced length of hospital stay after total hip and knee arthroplasty without increased utilization of other resources. Ugeskr Læger 2004;166:3194-7.
  6. Husted H, et al. Accelerated course: high patient satisfaction and four days’ hospitalisation in unselected patients with total hip and knee arthroplasty. Ugeskr Læger 2005;167:2043-8.