5 Reducing acute hospitalization length of stay after total knee arthroplasty: a quality improvement study. (2nd December 2020) - Gleicher, Yehoshua
Abstract : Background: The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve the quality of care while minimizing costs. We identified LOS and the percentage of patients discharged to inpatient rehabilitation for primary TKA patients as potential targets for reducing costs, improving the quality of patient care, and ultimately improving our performance within the bundled payment model. Objectives: The aim of our quality improvement project was to reduce the acute hospitalization length of stay (LOS) to less than two days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery (ERAS) bundle. Methods: This study used a before-and-after design. The pre-intervention period was January – December 2017 and the post-intervention period was January 2018 – August 2019. A root (figure 1 ) cause analysis (RCA) was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: 1) perioperative placement of peripheral nerve block; 2) prophylactic antiemetic medication; 3) avoidance of routine pre-operative urinary catheterization; and 4) pre-operative patient education regarding surgical recovery. Results: The pre- and post-intervention groups included 232 and 383 patients, respectively (table 1 ). Mean LOS decreased from 2.82 to 2.13 days (P<0.001) (table 2 ). The need for inpatient rehabilitation decreased by 10% (p=0.002). Mean 24-hour oral morphine consumption decreased by 37% (p<0.001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24-hours decreased by 25% and 15%, respectively (p<0.001). 30-day emergency department visits following discharge decreased by 5% (p=0.030) (table 3, figures 2 and 3 ). Conclusions: Significant improvements in the recovery of patients after TKA were achieved by performing a RCA and implementing a multi-disciplinary, patient-centered ERAS bundle.