Implementation of a fast-track program to improve quality of recovery after total hip replacement in an Australian private healthcare setting.

Abstract

INTRODUCTION: Fast-track program have been shown to improve functional recovery and reduce mortality, morbidity, and length of hospital stay after joint replacement. We routinely utilize a minimally invasive anterior hip replacement, local infiltration analgesia, no wound drains or urinary catheters. However, there was wide variation in non-surgical perioperative processes involving multiple medical specialists, nursing and allied health staff on 4 orthopaedic wards. Our aim was to determine whether implementation of a multi-disciplinary fast-track program would improve patient recovery after THR. METHODS: This prospective, before-and-after interventional study took place at Epworth Richmond from January 2015 to August 2016, with approval from Epworth's HREC. Data on patient demographics, perioperative care processes and postoperative outcomes up to 6 weeks was collected from 115 consecutive consenting patients. Multidisciplinary team discussion of pre-implementation findings and program design was followed by a 1-month implementation period, then assessment of program implementation and outcomes. The 11 program items for implementation were preoperative patient education, reduction in perioperative fasting, increased use of spinal anaesthesia with decreased use of general anaesthesia, oral multimodal analgesia, antiemetic prophylaxis, intraoperative administration of tranexamic acid, patient warming, early physiotherapy assessment and mobilization, and predefined discharge criteria. No additional funding was used. RESULTS: Five of 9 measurable package items were successfully implemented. 3 further items had pre-implementation rates of 90% which remained unchanged. There was no significant difference in the primary outcome of adjusted Quality of Recovery-15 score at 6 weeks (mean difference 1.34, SD-2.91, 5.78). Length of acute hospital stay (mean (SD), negative binomial regression) decreased from 5.94 (5.21) to 5.02 (2.45) days (p=0.09) in the whole cohort of patients, and from 5.91 (5.35) to 4.89 (1.97) days (p=0.048) in the subset undergoing a primary procedure (n=103, n=105). There was no difference in WHO Disability Assessment Schedule score, pain at rest and movement, 10-metre walk test, readmission or complication rates. CONCLUSION: Implementation of non-surgical components of a fast-track program significantly reduced length of acute hospital stay by 1 day.