Elective Hip And Knee Arthroplasty (HAKA) audit looking at anaesthetic technique, post-op pain scores, nausea, vomiting, first mobilisation times, patient satisfaction and days until discharge prior to the implementation of an enhanced recovery pathway at Pilgrim Hospital

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Demand is increasing for elective hip and knee arthroplasties. At Pilgrim Hospital, no consensus existed for the preferred anaesthetic technique. The balance is between anaesthetic technique, good post-op analgesia and early mobilisation. The shared goal is ultimately a good patient journey and early discharge. Enhanced recovery pathways for hip and knee arthroplasties are being used in other hospitals nationwide and their effectiveness studied1,2,3. The aim of this audit is to provide evidence of current management and to roll-out an enhanced recovery pathway. This is a prospective data collection of elective Hip and Knee arthroplasties. Over 11/5/16 to 16/6/16. We included patients receiving Spinals (with or without diamorphine) and general anaesthesia (with or without regional blocks which included femoral, sciatic and/or iliac). We collected: visual analogue pain scores (0–10) in recovery and every six hours for three days; incidence of nausea and vomiting; time until first mobilisation; patient satisfaction and days until discharge. We used a data collection form and ‘WebV’ electronic system. Total 52 patients. 28 Hips (7 Revisions). 24 Knees (1 Revision). Average age 70 yrs and ASA 2. For full results see Table 2. Morphine patient controlled analgesia (PCA) was used for 25 patients with similar usage on day 1 of 19 mg average and satisfaction rating of ‘good/very good’. Without PCA it was ‘good’ despite comparatively less oral morphine. Mobilisation and discharge was delayed for 1) Knees with PCA vs oral morphine (not apply to hips) 2) Hip and knees with blocks. With blocks post-op analgesic requirements were higher with higher pain scores and worse patient satisfaction. Pain, mobilisation and discharge with diamorphine in spinals is comparable to those spinals without diamorphine but incidence of nausea is more with diamorphine. Primary vs revisions: Hip mobilisation and discharge is comparable but for knees is longer for revisions.Table 2Summary of findings.LocationAnaesthetic room: 10Theatre: 6 (pre-bypass: 3)Onset time<30 min: 13; >30 min: 3Cardiac arrest needing CPR1Decision to continue with surgeryPostponed: 10Proceeded: 7Re-operation time4 days-14 months90-day survival100%Allergy clinic review time7 days – 8 months Open table in a new tab There are some limitations such as sample size. Pain scores are subjective and occasionally retrospective which limits their comparison. PCA dose documentation varied. There were three post-op complications reducing weight of discharge data. Experience of operator for regional block not collected. Incidence of Urinary retention not collected. Currently no set standardised management for these cases at Pilgrim. This data supports that 1) Blocks should be considered with caution 2) Spinals without diamorphine should be done 3) Avoid use of PCA in primaries but may benefit in revisions. Action plan from audit was to discuss and implement a standardised anaesthetic practice for elective hip and knee. 1.Paton F, Chambers D, Wilson P, et al . BMJ Open. 2014; Available from http://bmjopen.bmj.com/content/4/7/e005015.2.Christelis N, Wallace S, Sage C, et al. Medical Journal of Australia. 2015; 202 (7): 363–368.3.Available from http://www.qihub.scot.nhs.uk/media/582955/nhs%20improving%20quality%20in%20collaboration%20with%20nhs%20england%20-%20enhanced%20recovery%20care%20pathway%20publication.pdf.