The impact of implementing a multicomponent recovery pathway for patients undergoing unicompartmental knee replacement on length of stay

ABSTRACT

Keywords unicompartmental, pathway, outcomes Purpose: Unicompartmental knee replacement (UKR) is the gold standard surgical management of patients with unicompartmental osteoarthritis of the knee. As UKR surgery is less invasive, this potentially allows patients to be discharged quicker than those patients undergoing total knee replacement. During the COVID-19 pandemic, elective surgeries were postponed and new ways of working were required to restart procedures. In order to minimise the risk of exposure to COVID-19, we established a new multicomponent recovery pathway (MRP) for patients undergoing UKR to facilitate earlier discharge. Objective: To evaluate the impact of the MRP on length of stay. Methods: The MRP was introduced in August 2020 to provide day-case surgery where possible. All patients undergoing UKR at St Cross Hospital, Rugby were eligible for inclusion in the trial. Exclusion criteria was lack of support at home and uncontrolled co-morbidities. Patients who were assessed preoperatively, but unsuitable for the day-case service followed all other aspects of the enhanced recovery pathway (ERP). The ERP included a new anaesthetic protocol of prilocaine spinal anaesthesia, limiting tourniquet use, and multimodal postoperative analgesia. From a physiotherapy perspective, new individualised pre-operative assessment and education sessions were introduced, with mobilisation commencing on the day of surgery. Patients were discharged with their knee in full extension and returned at day 4 for postoperative review and initiation of flexion. Data was collected prospectively for patients receiving the MRP and compared to a historical cohort from the previous year. Primary outcome was hospital length of stay (LOS). LOS data was assessed for normality and analysed using the students t-test. Results: Following introduction of the MRP 30 patients underwent UKR and were included in the analysis. Patients in the MRP group were significantly older (65.6 vs. 60.1 years, p < 0.05), although no other baseline differences were observed. Whilst there was a reduction in the use of general anaesthesia (30% vs 59%, p = 0.0917) and tourniquets (53% vs 68%, p = 0.3925), this did not reach statistical significance although there was a significant increase in the use of Prilocaine (30% vs 0%, p < 0.01). Following the introduction of the MRP, LOS reduced significantly (1.4 vs 2.9 days, p < 0.001), with no significant differences observed in joint range of motion (ROM) between groups. Within the MRP group, 9 patients (30%) received all key components (prilocaine spinal anaesthesia, no tourniquet and enhanced physiotherapy), 8 of which were discharged as day-case. Conclusion(s) The MRP was successful in reducing LOS in patients undergoing UKR, with no impact on joint ROM. The biggest impact was observed for those patients who received all components. Future work should explore methods to improve compliance with the pathway to maximise patient benefit. Impact The positive results seen through introducing the MRP has a number of potential benefits. Alongside a reduction in LOS with benefits to patients and cost savings to the trust, the additional bed capacity released will allow increased throughput of patients which could be significant for the waiting list accrued as a result of the cessation of elective surgery due to Covid-19. Funding acknowledgements n/a