Joint replacement ERAS program reforms surgical care during pandemic

Effective multidisciplinary collaborations with Enhanced Recovery After Surgery (ERAS) pathways result in improved services and deliver continued care despite restrictions caused by the COVID-19 pandemic and same-day admission limitations, according to a single-centre study presented at the Anesthesiology Annual Meeting 2022. To date, feedback from patients has been encouraging.

“ERAS programs incorporate several evidence-based elements in a multidisciplinary approach to the perioperative management of elective surgical patients. At Stony Brook University Medical Center (New York, US), the ERAS Total Joint Replacement pathway was implemented in Fall 2019,” said the researchers led by Dr Sunitha Singh.

“All elective hip and knee replacements were eligible for ERAS. Key elements of the pathway focused on reducing variability of care, preoperative hydration, early mobilization, and improving pain management,” they added.

Singh and colleagues used quality improvement methods, such as data evaluation and Plan-Do-Study-Act cycles, to enhance the pathway, particularly the removal of epidural intraoperative urinary catheter placement. In Spring 2020, periarticular joint infiltrations replaced patient-controlled analgesia.

“The onset of the COVID-19 pandemic placed restrictions on same-day admission elective surgical procedures and resources (eg, staffing, bed availability, etc.),” the researchers said. “To overcome this limitation, we implemented a process to offer a select population ambulatory joint replacement in the main operating room.”

During the pandemic, Stony Brook Orthopedic Anesthesia and the Joint Replacement Orthopedic Surgical teams devised ways, as part of the institutional ERAS quality assurance program, to reduce gaps in patient care. Singh and colleagues made several adjustments to the ERAS pathway to come up with an ambulatory joint replacement program. [Anesthesiology 2022, abstract A428]

These adaptations to the current pathway were as follows: 1) developing a highly selective screening process for surgeons to identify qualified candidates for ambulatory surgery, 2) scheduling surgery before 10 AM, 3) changing spinal anaesthesia from an intermediate-acting to a shorter-acting agent, 4) amending the post-operative urinary retention protocols, 5) developing protocols for physical therapy to assess and mobilize patients in the recovery area prior to home discharge, 6) discharging total knee replacement patients with a non-narcotic elastomeric (Q) pump, and 7) arranging for postoperative home visits by Homecare Nurse and Physical Therapy.

“Only relatively healthy and motivated patients with a strong desire for same-day discharge and committed to active participation in the perioperative and postoperative process were eligible for ambulatory joint replacement,” the researchers said.

At the institution, surgery was finished by 1 PM, and patients were discharged no later than 7 PM. In addition, patients were directed to the newly created patient education page on the Joint Replacement website and urged to attend a virtual patient education class.

Ambulatory joint replacement procedures in the main operating room had been implemented for over a year now, with 152 patients successfully completing this pathway during a 12-month period. Compared to the traditional ERAS pathway, the new one reduced the average length of stay from 1.7 days to just 8 hours, and no readmissions were seen during the study period.

Preliminary data continue to show an improvement in the utilization of resources, the researchers said.