Enhanced Recovery Pathway Research Articles

Epidural Analgesia Is Associated With Prolonged Length Of Stay After Open Hpb Surgery In Over 27,000 Patients

The impact of epidural analgesia (EA) on postoperative morbidity and length of stay (LOS) after HPB surgery remains to be determined. These specific outcomes have been highlighted by the implementation of multiple enhanced recovery pathways (ERAS). The authors hypothesized that EA in the current environment may be associated with LOS and other outcomes. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases from 2014 to 2017 for patients undergoing open hepatopancreaticobiliary (HPB) surgery were included in a retrospective cohort analysis with propensity score matching (PSM) comparing EA with control. Twenty-seven thousand two hundred eighteen patients underwent open HPB surgery, of which 6048 (22%) received EA. There was an increase use of EA over time (from 19.3 to 25.5%, p = 0.001). On PSM, EA was associated with more than half of a day increase in LOS for both pancreatic (p < 0.001) and hepatic surgery (p < 0.001). Furthermore, for pancreatic surgery, there was an increase in urinary tract infection (2.5% vs. 3.3%, p = 0.018), time to drain removal (7.8 vs. 8.7 days, p < 0.001), and discharge to rehabilitation (2.9% vs. 4.3%, p = 0.029). For hepatic surgery, there was an increase in blood transfusion requirements (17% vs. 20%, p = 0.019). There were no differences in overall morbidity and mortality. In this cohort of over 27,000 patients with granular surgical details, there was a significant increase in LOS associated with EA after HPB surgery, along with increased procedure-specific UTI and blood transfusion. With the ever-increasing need for standardized and efficient patient care pathways that reduce LOS, alternative analgesic adjuncts may be considered to optimize patient outcomes.

Utilization Of The Kawaguchi-Gayet Complexity Classification To Stratify Hepatectomy Patients For Distinct Enhanced Recovery Pathways Based On Anticipated Length Of Stay

Utilization Of The Kawaguchi-Gayet Complexity Classification To Stratify Hepatectomy Patients For Distinct Enhanced Recovery Pathways Based On Anticipated Length Of Stay

Impact of caregiver overnight stay on postoperative outcomes

PurposeThe purpose of this paper is to determine the impact of having a patient-designated caregiver remain overnight with ambulatory extended recovery patients on early postoperative clinical outcomes.Design/methodology/approachThis was a retrospective cohort study of patients undergoing surgery requiring overnight stay in a highly resourced free-standing oncology ambulatory surgery center. Postoperative outcomes in patients who had caregivers stay with them overnight were compared with outcomes in those who did not. All other care was standardized. Primary outcomes were postoperative length of stay, hospital readmission rates, urgent care center (UCC) visits within 30 days and perioperative complication rates.FindingsAmong patients staying overnight, 2,462 (57 percent) were accompanied by overnight caregivers. In this group, time to discharge was significantly lower. Readmissions (though rare) were slightly higher, though the difference was not statistically significant (p=0.059). No difference in early (<30 day) complications or UCC visits was noted. Presence of a caregiver overnight was not associated with important differences in outcomes, though further research in a less well-structured environment is likely to show a more robust benefit. Caregivers are still recommended to stay overnight if that is their preference as no harm was identified.Originality/valueThis study is unique in its evaluation of the clinical impact of having a caregiver stay overnight with ambulatory surgery patients. Little research has focused on the direct impact of the caregiver on patient outcomes, especially in the ambulatory setting. With increased adoption of minimally invasive surgical techniques and enhanced recovery pathways, a larger number of patients are eligible for short-stay ambulatory surgery. Factors that impact discharge and early postoperative complications are important.

Implementation of an Enhanced Recovery Protocol (ERP) is associated with an increase in the perioperative use of non-opioid multimodal analgesia for non-ERP patients

Study objectiveIncorporation of multimodal, non-opioid analgesic medications into patient care pathways has become a common theme of enhanced recovery pathways (ERPs), which have been shown to improve patient outcomes such as complication rates and length of stay. With surgical care episodes, patients also incur a significant risk of persistent postoperative opioid use, whether the surgery is classified as major or minor surgery. One method that has been shown to reduce perioperative opioid administration is a structured non-opioid multimodal analgesic strategy, widely utilized in ERPs. Despite well-defined benefits, the time to translate evidence-based approaches into clinical practice can be prolonged. This study examines the effect of implementation of an Enhanced Recovery Protocol (ERP) on the adoption of intraoperative multimodal analgesia outside of the auspices of an ERP care pathway, describing factors influencing the clinical implementation of non-opioid multimodal analgesia (NOMA) in routine practice. DesignRetrospective cohort analysis. SettingWe identified all surgical cases between January 2013 and December 2016 at Vanderbilt University Medical Center (VUMC). InterventionsNone. MeasurementsUsing both segmented and logistic regression approaches, we compared non-ERP surgical cases before and after the initial ERP education and implementation in April 2014. Outcomes included provider, patient, and procedural factors associated with utilization of non-opioid multimodal analgesia (NOMA) in the immediate perioperative period. Main resultsWe studied 73,560 non-ERP cases. Cases utilizing any element of NOMA increased from 17.06% to 35.21% (X2 = 2358, df = 1, p < 0.01) before and after the initial ERP pathway implementation. Patient factors influencing this increased adoption of multimodal analgesia included lower American Society of Anesthesiologists Physical Status Class, younger age, and Caucasian race. Cases with in-room providers who were residents or trainees (as opposed to nurse anesthetists) or providers who had a greater number of prior ERP pathway cases were more likely to use multimodal. Procedure-specific factors favoring multimodal included use of laparoscopy. The gynecologic, neurosurgical, and orthopedic cases were more likely to utilize multimodal analgesics. ConclusionsFrom 2013 to 2016, NOMA usage in non-ERP patients increased significantly and in association with departmental education and concomitant implementation of an ERP pathway. Factors associated with increased uptake of multimodal analgesia included the presence of trainees, providers with a higher number of previous ERP pathway cases, patients who were younger, healthier, female, Caucasian race, and having specific types of surgery.

Introduction of an enhanced recovery protocol into a laparoscopic living donor nephrectomy programme.

Living-donor renal transplantation is the optimal treatment for patients with end-stage renal disease. The rate of living donation in the UK is sub-optimal, and potential donor concerns regarding postoperative recovery may be contributory. Enhanced recovery programmes are well described for a number of surgical procedures, but experience in living-donor surgery is sparse. This study reports the impact of introducing an enhanced recovery protocol into a living-donor renal transplant programme. All consecutive patients undergoing laparoscopic living-donor nephrectomy over a 25-month period were included. The principles of enhanced recovery were fluid restriction, morphine sparing and expectation management. Outcome measures were postoperative pain scores and complications for donor and recipients. Standard care was provided for 24 (30%) patients and 57 (70%) followed an enhanced recovery pathway. The latter group received significantly less preoperative intravenous fluid (0ml vs 841ml p < 000.1) and opiate medication (14.83mg vs 23.85mg p = 0.001). Pain scores, postoperative complications and recipient transplant outcomes were comparable in both groups. Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients. Application of these techniques and further refinement should be pursued to enhance the experience of living donors.

Perioperative clinical pharmacy practice: Responsibilities and scope within the surgical care continuum

AbstractCurrent published guidelines for perioperative pharmacy services have limited information on the development and implementation of a robust clinical pharmacy program across the surgical continuum of care. This publication defines the responsibilities and scope of practice of the Perioperative Clinical Pharmacist (PCPh), supporting the PCPh as a critical member of the interprofessional surgical patient care team. Opportunities for pharmacist role integration into perioperative medication management processes are described along with published examples of successful PCPh practice models, including those with interventions targeted toward Enhanced Recovery Pathways (ERP). Recommended training and competencies for future and practicing perioperative pharmacists, in addition to considerations for precepting and scholarly activities, are also outlined. Finally, future developments in perioperative pharmacy practice are discussed, including technological advancements, improved predictive models, and expansion of collaborative practice agreements.

Comparison of Therapeutic Benefit of Bupivacaine HCl Transversus Abdominis Plane (TAP) Block as Part of an Enhanced Recovery Pathway versus Traditional Oral and Intravenous Pain Control after Minimally Invasive Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial

Enhanced recovery pathways (ERPs), when combined with transversus abdominis plane (TAP) blocks, have been proven to reduce the length of stay (LOS) and improve quality outcomes. Nonopioid pain management is an essential component of this pathway, leading to a reduction in immobility, postoperative ileus, and an increase in patient satisfaction. TAP block variations have been studied in general and gynecologic surgery. This study evaluates the effectiveness of laparoscopic TAP blocks in conjunction with the benefit of an ERP. One hundred thirty-seven consecutive laparoscopic and robotic-assisted Colorectal Surgery patients received TAP blocks under laparoscopic guidance while under anesthesia, randomized to a placebo, bupivacaine TAP block, or bupivacaine TAP block with an ERP arm of the trial. Patient demographics, operative techniques, and postoperative outcomes were analyzed using statistical analysis software. Our main objective was to determine short-term benefits of TAP blocks on reducing total narcotic consumption. Secondary objectives included effects of TAP blocks on time to ambulation, time to bowel function, and LOS. To isolate the effect of the TAP blocks, no efforts were made to control nursing or patient education in patients managed without an ERP. Of 137 patients, 14 were withdrawn. All cases were elective, with the main diagnosis colon cancer or dysplastic polyps (47.1%). The median age in each group was comparable (P = 0.12), with female majority in both groups (58.5%). Most procedures were segmental colon resections (74.7%). Thirty-one patients received a placebo, 41 bupivacaine TAP, and 51 bupivacaine TAP plus ERP. In terms of primary endpoints, the bupivacaine plus ERP arm used statistically significant less IV narcotics on postoperative day 1 and in total (P = 0.001, P = 0.008). All patients ambulated on average within the first 24 hours postoperatively, with the TAP plus ERP group approximately 0.5 days sooner (P = 0.001). The TAP plus ERP group also had a return of bowel function and LOS approximately 24 hours early (P = 0.001 and P = 0.001). This study shows that a laparoscopically placed bupivacaine TAP block when used as part of an ERP can reduce LOS, postoperative narcotics, time to ambulation and bowel function, and LOS. Defined pain regimens with auxiliary staff teaching can add to the improvement in quality outcomes in laparoscopic colorectal surgery and, with the addition of the TAP block, can add to patient satisfaction and lower hospital costs.

High Compliance to an Enhanced Recovery Pathway for Patients ≥65 Years Undergoing Major Small and Large Intestinal Surgery Is Associated With Improved Postoperative Outcomes.

This study was performed to evaluate compliance to an Enhanced Recovery Pathway (ERP) among patients ≥65 years and determine the effect of compliance on postoperative outcomes. ERPs improve postoperative outcomes in patients undergoing major surgery. Given the inherent decline of the older surgical patient, the benefit of an ERP in this population has been questioned. Patients undergoing major small and large intestinal surgery prior to and following ERP implementation at the Johns Hopkins Medical Institutions were entered into the ACS-NSQIP database. Outcomes included ERP compliance rates, complications, length of stay (LOS), and 30-day readmission rates were determined for older patients. Nine hundred seventy-four patients (693 < 65 yrs and 281 ≥ 65 yrs) were included. Of those ≥ 65 years, 142 (51%) were entered prior to and 139 (49%) were entered following ERP implementation. More ERP than pre-ERP patients underwent laparoscopic procedures (45.3% vs. 32.4%, P = 0.02), had disseminated malignancies (9.4% vs. 2.8%, P = 0.03), and smoked (14.4% vs. 4.9%, P = 0.01). Overall compliance was 74.5%, and 47% of older ERP patients achieved high compliance (≥75% compliance with ERP variables). High compliance was associated with a 30% decrease LOS (IRR: 0.7 P = 0.001) and 60% decrease in major (CD ≥ II) complications (OR: 0.4 P = 0.05). LOS and complication rates following implementation of an ERP were significantly improved in highly compliant elderly patients. Interventions to further improve outcomes should target decreasing variability by increasing individual compliance with an effective clinical pathway.

Enhanced Recovery After Surgery and Acute Postoperative Pain Management.

Enhanced recovery pathways were first developed in colorectal surgery and have since been adapted to other surgical subspecialties including gynecologic surgery. Mounting evidence has shown that the adoption of a standardized perioperative pathway based on evidence-based literature reduces length of hospital stay, reduces cost, reduces opioid requirements with stable to improved pain scores, and accelerates return to normal function as measured by validated patient reported outcomes measurements. The many elements of enhanced recovery may be distilled into 3 concepts: (1) optimizing nutrition before and after surgery, recognizing that nutritional status directly impacts healing; (2) opioid-sparing analgesia, considering the current American prescription opioid crisis and the importance of pain control to regaining functional recovery; and (3) maintenance of euvolemia before, during, and after surgery. Evidence supporting enhanced recovery is presented with reference to international guidelines which were formed based on systematic reviews. Change management and the use of auditing are discussed to assure that patients derive the greatest improvement in surgical outcomes from implementation of an enhanced recovery pathway.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process &amp; Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p &lt; 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p &lt; 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Resident Implementation of an Enhanced Recovery Pathway for Colorectal Surgery in a Rural Community

Resident Implementation of an Enhanced Recovery Pathway for Colorectal Surgery in a Rural Community

Evolving Concepts in the Evaluation and Management of Bladder Cancer in Elderly Men

In this article, the contemporary knowledge regarding specific issues related to the care of older bladder cancer patients is reviewed. The status of radical cystectomy, bladder-sparing strategies, checkpoint inhibition, prostate-sparing surgery, and BCG distribution pertaining to older adults are discussed. The use of minimally invasive approaches for radical cystectomy in patients with invasive bladder cancer is on the rise, including those patients with advanced age. Enhanced recovery pathways are improving time-to-recovery for patients undergoing radical cystectomy which may be especially important in the elderly and frail. Trimodal bladder-sparing strategies are emerging options for patients who are unfit for radical cystectomy. Immunotherapies offer promising options for patients with advanced or treatment-refractory disease. Prostate-sparing surgery does not currently hold a place in the contemporary management of bladder cancer for those patients who are surgical candidates. Older adults may be at risk of disparity in the distribution of scarce BCG resources during times of manufacturing shortage. Older adults, as compared with those younger, face special challenges in their bladder cancer care. There is a clinical imperative that practitioners involved in the evaluation and management of older bladder cancer patients be knowledgeable of the unique issues that stand between them and cancer-free survival.

Implementation of a pediatric enhanced recovery pathway decreases opioid utilization and shortens time to full feeding

BackgroundWe hypothesized that an enhanced recovery after surgery (ERAS) pathway for pediatric patients undergoing surgery for inflammatory bowel disease (IBD) would be beneficial. MethodsThis is a single institution retrospective comparative study comparing patients treated with an ERAS pathway to consecutive patients in a Preimplementation Cohort (PIC) with similar open and laparoscopic surgeries for IBD. The pathway emphasized minimal preoperative fasting, multimodal and regional analgesia, and early enteral nutrition after surgery. Primary endpoints were time to 120 mL of PO intake (POI), length of stay (LOS), opioid utilization, and 30-day surgical outcomes. Continuous and categorical variables were compared (p < 0.05). ResultsThere were 23 PIC and 28 ERAS patients with similar demographic data and surgical and anesthetic approaches. ERAS patients experienced a significant increase in the use of regional anesthesia, faster time to POI, and a nonsignificant decrease in mean LOS. ERAS patients had decreased total and daily opioid use with similar complication rates. ConclusionThis study demonstrates the effectiveness of a pediatric ERAS pathway for IBD patients requiring laparoscopic and (unique to this study) open surgery. The study demonstrates that opioid utilization and time to feeding can be positively impacted using ERAS pathways without negatively impacting outcomes. Type of studyRetrospective comparative study. Level of evidenceLevel III.

Best Practices in Data Use for Achieving Successful Implementation of Enhanced Recovery Pathway

Although enhanced recovery pathways (ERPs) have demonstrated promising results in published literature, their effectiveness has been inconsistent. The objective of this study was to identify the most important data use practices associated with successful implementation of ERPs. As part of a national ERP implementation initiative, data regarding hospitals' previous ERP implementation experience were collected. Specifically, 4 data use practices (data collection, report generation, feedback to leadership, and feedback to frontline providers) and 2 data types (process measures and outcome measures) were correlated with ERP implementation outcomes (hospital-reported success and patient outcomes from the American College of Surgeons [ACS] NSQIP data). Of 140 hospitals evaluated, 73 (52.1%) reported previous ERP implementation, with wide variations in data use practices. Of these, 33 (45.2%) reported successful implementation. Feedback of both process and outcome measure data was performed by only 15.1% of hospitals, but was associated with significantly higher likelihood of successful implementation when compared with no feedback (relative risk [RR] 2.45, 95% CI 1.69 to 3.56; p < 0.001) and feedback of only outcome measure data (RR 2.73, 95% CI 1.06 to 7.00; p= 0.037). Using ACS NSQIP data from 6,888 colorectal surgery patients from 52 hospitals with colorectal ERPs, hospital-reported success was associated with significantly lower surgical site infection rates (6.6% vs 8.1%; p= 0.011) and shorter length of stay (6.2 vs 7.0 days; p < 0.001). The most important data use practice associated with successful ERP implementation was data feedback to frontline providers of both process and outcome measures. However, this was rarely performed in a national cohort of hospitals and represents a substantial but straightforward opportunity for improvement.

Challenges to concordance: theories that explain variations in patient responses.

To meet the challenges of an increasingly ageing and multimorbid population, patients must be fully engaged to work in partnership with their health professional (HP) in the management of their condition(s). The NHS Long Term Plan (2019) outlines goals to manage the increasing demands on the health service-hospital admission avoidance, shorter length of hospital stays through enhanced recovery pathways, increased management of patients within primary care and ensuring a person-centred approach to care provision. Meeting these goals is predicated on HPs being equipped to activate patients using the skills of motivational interviewing, person-centred care and a willingness to share decision making. This article presents a range of psychological theories that could explain the everyday challenges faced in care delivery. Awareness of these theories may help HPs target their approach to care delivery more effectively, to understand patient responses and, therefore, optimise the provision of person-centred care.

Application of enhanced recovery pathway in abdominal wall reconstruction surgery in a tertiary care hospital in Andhra Pradesh

Aim & Objective: Enhanced recovery pathways are well-defined perioperative evidence based interventions in a protocol manner for standardising techniques involved in drug selection, dose, reduce cost and facilitate in early discharge by monitoring mortality rates. The hypothesis of the study is the application of enhanced recovery pathway after surgery in abdominal wall reconstruction could result in potential decrease in hospital stay. Methods: The study is performed in the period of February 2017 to June2019 and a total of 100 cases and 100 controls undergoing abdominal wall reconstruction were included. Enhanced recovery pathway after surgery is used to identify the results with respect to duration of the stay. Results: It was observed from the study results that, there was no change noted in the duration of stay and regular diet. The readmission rate is decreased and in analysis of subgroups we found, factors associated with duration of the stay were < 5 days with hernia. Conclusion: To conclude, administration of enhanced recovery pathways after surgery could not show a limitation in duration of stay. It was obviously noted that quality of baseline life scores, less operative times and small hernia defects were in co-ordination with duration of stay.

The role of gabapentinoids in acute and chronic pain after surgery.

Gabapentinoid use has increased substantially in the past several years after initial promising data with regard to acute perioperative pain control. The purpose of this review is to critically appraise the evidence for the use of gabapentinoids for acute pain management and its impact on the development of chronic pain after surgery. Recent meta-analyses have revealed that prior data likely have overestimated the beneficial effects of gabapentinoids in acute perioperative pain while underestimating the associated adverse effects. The utility of gabapentinoids in the setting of enhanced recovery pathways and for the prevention of chronic postsurgical pain is still unclear. Moreover, there has been increasing concern regarding the potential for misuse and abuse of gabapentinoids. Current evidence does not support the routine use of gabapentinoids as part of a multimodal analgesic regimen in enhanced recovery pathways. We recommend being selective with regard to using gabapentinoids for acute postoperative pain management after careful consideration of the potential side effect profile based on patient comorbidities as well as the expected severity of postoperative pain. Large, high-quality trials are needed to identify the impact of gabapentinoids in the context of multimodal anagelsia.

A352 Two-year Outcomes after Implementation of an Enhanced Recovery Protocol for Bariatric Surgery

Sleeve Gastrectomy is currently the most commonly performed bariatric surgical procedure in the US. Enhanced Recovery after Surgery (ERAS) Pathways have been successfully used in colorectal surgery with improved overall outcomes. ASMBS released a sleeve specific enhanced recovery pathway (ENERGY) for limited participation.

Presurgical optimization and opioid-minimizing enhanced recovery pathway for ambulatory knee and hip arthroplasty: postsurgical opioid use and clinical outcomes.

BackgroundEnhanced recovery after surgery (ERAS) pathways offer approaches to achieve successful ambulatory primary total knee and total hip arthroplasty (TKA/THA) while meeting the “Triple Aim” of healthcare: patient satisfaction, population health, and value. We evaluated outcomes from an ERAS pathway designed to maximize patients’ eligibility for ambulatory TKA/THA while reducing costs, complications, and postsurgical opioid use.MethodsThis retrospective study included 220 consecutive unique commercially insured patients who underwent TKA (n = 113) or THA (n = 138) in an ambulatory surgery center between June 1, 2015 and November 16, 2017. The ERAS pathway encompassed early presurgical through home recovery periods. Key elements included presurgical patient engagement; creation of realistic expectations; optimization of modifiable medical, physical, and social factors; and creation of individualized multimodal opioid-sparing pain management. No home services were used. Adverse events and unplanned admissions within 30 and 60 days, satisfaction, and opioid use were analyzed descriptively.ResultsAll patients (mean [range] age, 58 [22-84] years; 49% women) had same-day discharge. Within 30 days, 7 (2.8%) patients experienced an adverse event, 3 (1.2%) had an emergency department or urgent care visit without admission, and 8 (3.2%) had an unplanned admission. Within 60 days, 3 additional patients had an emergency department/urgent care visit. Most patients (206 [82.1%]) did not require a second opioid prescription. Patient satisfaction was high.ConclusionsThis ERAS pathway may help meet the Triple Aim for outpatient joint replacement, expand the eligible patient population, and reduce postsurgical opioid use. Further research is warranted.

Patient-optimizing enhanced recovery pathways for total knee and hip arthroplasty in Medicare patients: implication for transition to ambulatory surgery centers.

BackgroundMedicare-insured patients may be candidates for outpatient total knee and hip arthroplasty (TKA/THA) because postsurgical complications are often age unrelated. We evaluated an opioid-minimizing enhanced recovery after surgery (ERAS) pathway in an inpatient setting designed to presurgically optimize and prepare patients to reduce risk of avoidable postsurgical complications and maximize feasibility of same-day discharge.MethodsThis single-center retrospective chart review included 601 unique consecutive Medicare-insured patients who underwent TKA (n = 337) or THA (n = 308) between June 1, 2015 and November 16, 2017. The ERAS pathway included presurgical nonarthroplasty treatment of osteoarthritis; physical, medical, and social optimization; and medication trials to individualize perioperative analgesia. All patients were discharged directly home without home services. Adverse events, satisfaction, and opioid use were analyzed descriptively.ResultsMean (range) age was 72 (32-92) years; 56.7% of patients were women; 84.0% were discharged the same day, 13.8% in 1 day, and 2.2% in >1 day. Rates of minor and severe adverse events within 30 days were 0.5% and 1.1%, respectively. There were no intubations, sepsis, or deaths. Twelve patients (1.9%) had unplanned readmissions within 30 days. Patient-reported satisfaction with facility, analgesia, and communication were high. Most patients (84.2%) did not require >1 seven-day opioid prescription from the surgeon within 8 weeks postsurgery.ConclusionsUsing a patient-optimizing, opioid-minimizing ERAS pathway without home services, Medicare-insured patients undergoing TKA/THA experienced low complication rates and high satisfaction. Exploratory analysis suggests limited postsurgical opioid use. This presurgical patient-engagement approach may aid transition to freestanding ambulatory surgery centers.