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Fast-track joint arthroplasty protocols increasing patient safety and satisfaction
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This decade saw the introduction of fast-track programs — streamlined perioperative practices — in many areas of specialty surgery. Members of the European orthopaedic community told Orthopaedics Today Europe that Henrik Kehlet, MD, who has worked with the Danish government to implement accelerated surgical tracks in various specialties, is considered the “father” of fast-track surgery.
Testament to Kehlet’s influence on the steady adoption of this innovative approach in orthopaedics is the growing body of documented clinical and economic advantages of fast-track total joint arthroplasty (TJA) protocols, which typically incorporate in-depth patient education and a rapid resumption of activities of daily living. Due to his work, Denmark has become one of the leaders in TJA rapid rehabilitation, with several centers now following these protocols. Yet, some surgeons said that centers in other countries still have not adopted them, mostly due to differences in culture, reimbursement and wait lists.
Klaus-Peter Günther, MD, of Dresden, Germany, said in his experience he has seen higher than anticipated start-up costs associated with writing the new protocols, training the staff to use them and related activities, which he said are typically not mentioned in the cost-benefit analyses.
Furthermore, “Not all patients want fast-track surgery,” Günther, an Orthopaedics Today Europe Editorial Board member, said, noting it is not for everyone. Only up to 60% of patients at Günther’s large referral center meet fast-track inclusion criteria. Also, long-term data are needed for this approach. “Surgeons are expecting the same long-term outcomes, but no one knows yet whether they will be the same.”
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Image: Susanne Østergaard, Hvidovre Hospital |
Danish TJA surgeon Henrik Husted, MD, whose patients all undergo rapid rehabilitation, said it has positively impacted their level of satisfaction and length of stay (LOS) following total hip arthroplasty (THA) or total knee arthroplasty (TKA). In fact, based on the literature, patients in Europe, North America and elsewhere may be permitted to be discharged within 24 to 72 hours because they underwent fast-track surgery.
“It is an optimization of both logistical and clinical features,” Husted said. “Of course, we have been focusing intensely on pain treatment and early mobilization.”
In 2003, when THA and TKA LOS was averaging 13.3 days at Hvidovre Hospital in Copenhagen, Husted and a nurse developed a fast-track rehabilitation system which led to an average LOS of 1.5 days at the institution. The system Husted introduced has since expanded to include physiotherapists, anesthesiologists and members of other disciplines on the fast-track team and incorporates features of a commercially available Rapid Recovery program (Biomet), he said.
Multidisciplinary cooperation
The THA rapid recovery program used since 2000 at Reinier de Graaf Hospital in the Netherlands has achieved equally dramatic results, with LOS steadily decreasing. Its early results published in Injury showed 92% of patients were discharged by the fifth postoperative day with discharges for those with wound problems or suspected superficial infections slightly delayed.
In June the hospital-wide LOS was 4.8 days, with shorter stays in the orthopaedic department. This was attributed to changed pain control techniques and operational improvements.
“Rapid recovery is more a philosophy than an actual rigid program. It is a continued willingness to improve care around the orthopaedic patient,” said Peter Pilot, PhD, senior scientist in the orthopaedic department at the hospital.
For rapid recovery to work, “the borders between orthopaedics and anesthetics should disappear,” he said. “From day one we tried to walk this path together with our anesthetic colleagues. This is really essential,” Pilot said.
Enhanced programs
In 2006 Reinier de Graaf Hospital officials met with Kehlet and other experts about changes they might implement to increase quality of care and take orthopaedic rapid recovery to the next level. As a result, 2 years ago the six orthopaedic surgeons at the hospital’s Delft location implemented a new pain protocol supported by the anesthesiologists, Pilot told Orthopaedics Today Europe.
“The major gain of the program is the huge reduction in postoperative nausea and vomiting, which were reduced by two-thirds,” he said. This and other aspects of the protocol help reduce surgical stress, allowing patients to safely and more quickly resume normal postoperative function.
Now, 10 years after they started their program, he and others at Reinier de Graaf Hospital are focused on better mobilizing patients the day of surgery. Despite the challenges that are posed with patients operated on late in the day needing to be mobilized at night when physical therapists do not typically work, Pilot indicated that with time and cooperation the changes will be implemented.
Focusing on the patient
A modified, more-extensive patient education experience has been essential to all these programs, especially those that address and positively impact THA and TKA candidates’ expectations.
In a classroom setting, patients at Husted’s hospital get important information from doctors, nurses and anesthesiologists, including what is expected of them during recovery, and a timeline for the recovery. They also meet a patient who underwent surgery on the previous day.
According to Husted, patients should be motivated to participate in their recovery. Following their being educated on the fast-track system, “they really want to do this and they understand why we want to do it.”
In addition to providing similar preoperative education, Ajay Malviya, MD, and other orthopaedists at Northumbria Healthcare NHS Foundation Trust in Newcastle-upon-Tyne, England, as well as the nurses and health care staff repeatedly emphasize fast-track principles in discussions with patients, saying they can go home in 2 or 3 days depending on how they are doing.
“The same message is passed on by various team members so [patients] believe that, yes, it is possible. I think the first thing for them to believe is it is possible,” said Malviya, who reported positive early clinical results and cost effectiveness with a fast-track protocol at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).
At hospitals where fast-track protocols have been adopted, the majority, if not all, of the patients undergoing THA and TKA benefit from these new procedures. Husted and colleagues apply their protocol across the board, and are now also studying results in patients who discontinue deep venous thrombosis (DVT) prophylaxes at discharge because the early mobilization may be an effective antithrombotic method. They expect to elucidate outcome differences in those who receive DVT therapy for the mandatory amount of time in Denmark — 10 postoperative days with TKA, 35 days minimum for THA — and those under the fast-track system.
Husted explained that because every patient in his joint arthroplasty ward stands to benefit from the protocol, it is used in bilateral and revision cases as well, eliminating the time and cost of selecting the “best” patients, special anesthesia or pain medications on a per-case basis.
“This gives the patient the best treatment available, and also optimizes the logistics … It is our philosophy that every patient would benefit. We call it fast-track, but it should actually be called ‘best-track’ or ‘right-track’ because it is what we do. It is giving the patient the best available documented treatment, including mobilization, pain treatment, care and so forth,” he said.
Anesthesia modifications
According to Malviya, “Any surgery with accelerated rehabilitation that leads to early discharge and improves the patient experience is a fast-track surgery.”
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To meet those endpoints, he uses a modified anesthesia protocol involving local spinal anesthetic supplemented with light general anesthesia obviating the need for intrathecal opioids which may be associated with postoperative nausea and vomiting and grogginess, both of which can inhibit same-day mobilization.
Pain management for THA and TKA cases improved at Malviya’s center once he and his colleagues started infiltrating layers of wound, from the capsule to the subcutaneous layer, with 100 mL levobupivacaine, 0.125% concentration. Subsequently, as a later supplement they leave an epidural catheter in the joint for introducing boluses of gabapentin or OxyContin (oxycodone; Purdue Pharma), sometimes followed by tramadol. Patients having morning surgery receive a dose of gabapentin the previous night.
“The advantage of all these is they are not strong opioids so they avoid the effect of the opioid, like the sedative effect,” Malviya said. “That will help us get the patients up the same day after the operation.”
This accelerated rehabilitation protocol is for all comers, including those not expected to rehabilitate quickly. “It has a definite beneficial effect even in the relatively ill patients because it takes away the anesthesia stress of the operation, so it helps them. We have shown actually that even the outliers — the patients who stayed beyond 15 days before we introduced the protocol — are significantly reduced,” said Malviya, whose hospital started using the protocol once physicians, nurses, physiotherapists, occupational therapists and others observed it in use at Golden Jubilee National Hospital in Clydebank, Scotland.
The bottom line
From an administrative standpoint, the rapid rehabilitation programs used at Hvidovre Hospital met economic and patient care goals, according to Vice Director Torben Mogensen, MD. Seeing the improved physical status of patients and their earlier discharge after colonic surgery was the impetus for adopting these practices in orthopaedics, he said.
“We have seen a low complication rate and high patient satisfaction with the treatments,” which was evident right after implementing rapid recovery in THA and TKA, Mogensen said.
Reducing the surgical waiting list was yet another reason to adopt fast-track orthopaedic protocols since Danish law made public hospitals pay to send patients to private hospitals if they could not treat them within 1 month. The waiting list, which was 6 months long in 2003 when the program began, no longer exists. “Now we don’t send any patients to the private hospital,” according to Mogensen.
The short 2- to 3-day surgical stays sometimes mean empty beds on the arthroplasty ward come Friday or Saturday, but foot and ankle surgery patients may use them. To resolve that issue in the orthopaedic and gastric surgery wards, he said more major procedures are performed Monday to Wednesday. Straightforward ones are done Thursday or Friday so that the beds are closed down Friday evening or Saturday morning.
Recently the Hvidovre Hospital emergency department staff started delving into fast-track practices so that a 21-day LOS for hip fracture patients is down to 9 to 11 days. “With fragile patients who have many comorbidities, I think it was important to use it in the emergency department,” Mogensen said, noting that reducing morbidity and mortality was critical.
Regional preferences
Luigi Zagra, MD, in the Hip Department at Istituto Ortopedico Galeazzi in Milan, Italy, is in favor of using accelerated rehabilitation, but explained to Orthopaedics Today Europe that the obstacles to adopting them in his region are great.
He said patients from throughout Italy who are referred to his department in the northern part of the country for treatment cannot be quickly discharged to home if they require medically supervised postoperative rehabilitation. Therefore, they would not be fast-track candidates. For local patients, two factors impact the speed of rehabilitation.
“It depends on the patient and, here, it depends a lot on the family organization,” said Zagra, an Orthopaedics Today Europe Editorial Board member, whose patients are discharged to home within 5 or 6 days of surgery — excluding older patients, who may stay in the orthopaedic or rehabilitation department up to 3 weeks.
But Zagra’s patients often feel they need to stay longer. “In Italy, there is sort of an environment that favors having rehabilitative care at the hospital or going home and having someone come and help you,” he said.
Many countries’ reimbursement systems are unfavorable for fast-track surgery. In others the government has to make key changes to implement it, Pilot said. He urged those considering implementing rapid recovery protocols to visit one of the Biomet Rapid Recovery board’s orthopaedic surgeons and their anesthesiologists. Pilot, Husted, Kehlet and other board members agree that “seeing is believing” when it comes to rapid recovery. – by Susan M. Rapp
References:
- Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008;79:168-173.
- Kehlet H, Søballe K. Fast-track hip and knee replacement — what are the issues? Acta Orthop. 2010;81(3):271-272.
- Malviya A, Reed MR. Fast track protocol leads to reduction in mortality and morbidity following joint replacement. Paper #631. Presented at the 2010 Annual American Academy of Orthopaedic Surgeons Meeting. March 9-13, 2010. New Orleans, U.S.A.
- Pilot P, Bogie R. Draijer WF, et al. Experience in the first four years of rapid recovery; is it safe? Injury. 2006; 37 Suppl 5:S37-40.
- Klaus-Peter Günther, MD, can be reached at University Carl-Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; +49-351-4-58-31-37; e-mail: klaus-peter.guenther@uniklinikum-dresden.de.
- Henrik Husted, MD, and Torben Mogensen, MD, are at Hvidovre University Hospital, 2650 Hvidovre, Denmark. Husted can be reached at +45-3632-6297; e-mail: henrik.husted@hvh.regionh.dk. Mogensen can be reached at +45-3632-2504; e-mail: torben.mogensen@hvh.regionh.dk. Husted is a member of the Biomet Rapid Recovery board.
- Ajay Malviya, MD, can be reached at Northumbria Healthcare NHS Foundation Trust, 81 Daylesford Drive, Newcastle upon Tyne, NE3 1TW, United Kingdom; +44-191-285-9890; e-mail: drajaymalviya@gmail.com.
- Peter Pilot, PhD, can be reached in the Department of Orthopaedics at Reinier de Graaf Hospital, Delft, the Netherlands; +31-15-2603257; e-mail: P.Pilot@rdgg.nl. His institution received support from Biomet, Zimmer, AstraZeneca and Astratech.
- Luigi Zagra, MD, can be reached at Istituto Ortopedico Galeazzi IRCCS, Milan, Italy; +39-3498838269; e-mail: luigi.zagra@fastwebnet.it.
What factors have impacted your decision for or against adopting fast-track TJA protocols?
Medicolegal concerns
Today, TJA is a standardized procedure performed the same way in every part of the world. On the contrary, however, postoperative regimens now vary according to the local situation.
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My personal experience with the so-called “fast-track” procedure was limited to a small number of patients, after which I decided to abandon it. The main reason was that patients after a course of “fast-track” rehabilitation did not do better than patients who followed a traditional postoperative regimen of rehabilitation. Some had slightly earlier weight-bearing but, on the whole, this was offset by the difficulty of organizing the rehabilitation in the first place and the fact that the final result was identical.
Other reasons associated with our discontinuation of fast-track procedures were that our patients prefer to remain in the hospital in the postoperative period because they feel more protected and happier. I am much more comfortable knowing I can follow the patients’ progress every day while they are in the hospital, possibly correcting any little problems they have as they develop.
Finally, from a medicolegal point of view, it is quite dangerous in my country to dismiss a patient on the same day of the operation or even 2 or 3 days afterwards because if something happens, especially in older patients, such as a serious complication, we would be immediately sent to the court to deal with it legally.
Roberto Binazzi, MD, is the Chairman of the Department of Orthopaedics and Hip Surgery, University of Bologna, Italy.
Need to reduce wait lists
The Swedish government has implemented a national maximum waiting-time guarantee of 3 months from the time the patient is put on the waiting list for surgery until the operation is performed. This has led us to improve accessibility and put the patient’s needs and wishes first. We perform a vast majority of our joint arthroplasties in a smaller specialized elective surgery hospital outside of the university, but in direct cooperation with the university hospital. This has helped us to streamline the joint arthroplasty process and, notably, to shorten the waiting list. Furthermore, it seems that all the personnel involved in this process are working with growing enthusiasm and pride in the positive results.
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I think we must consider how we spend the often limited health care budget in order to make it as efficient and as cost-effective as possible. We must, however, never forget that our primary goal is to provide our patients with the best possible care and highest quality results. I believe a fast-track joint arthroplasty protocol can serve all these purposes. We have shown that with the patients better prepared before an operation and with a more focused and efficient pre- and postoperative care protocol, they become better mobilized and can get home earlier, in better condition and hopefully with less risk of complications. This can be done without ever endangering the quality and longevity of the joint arthroplasty.
Not only does an effective fast-track joint arthroplasty protocol cut the direct hospital treatment costs, but socio-economic gains are probably considerably larger by indirect earnings from patients’ earlier re-entry into a normal healthy life situation.
Gunnar Flivik, MD, PhD, is in the Department of Orthopedics, Skane University Hospital, Lund University, Sweden.