Geriatric Joint Replacement Patients Have Reduced Length of Stay after Implementation of Enhanced Recovery After Surgery (ERAS)

General Information 

Institution Name: Kaiser Westside Medical Center

Submitter Name: Richard D. Southgate, MD (Orthopaedic Surgeon, ACS NSQIP Lead); Leah Calvert, MHA (ACS NSQIP Surgical Case Reviewer); Erik W. Kroger, MD (Orthopaedic Surgeon, Chief); Waleed K. Lutfiyya, MD (Colorectal Surgeon, Chief Surgical Officer); and Amanda Lovell, MSN, RN, CNOR, CPHQ, NE-BC, CLSSBB (Regional Quality Improvement Consultant, Perioperative Services)

Name of the Case Study: Geriatric Joint Replacement Patients Have Reduced Length of Stay after Implementation of Enhanced Recovery After Surgery (ERAS)

What Was Done? 

Global Problem Addressed 

Enhanced Recovery After Surgery (ERAS) is a multimodal approach that focuses on optimizing nutrition, early mobilization, and pain management while minimizing narcotic usage. In colorectal and general surgery, ERAS has demonstrated success in improving outcomes, reducing length of stay (LOS), and reducing hospital costs.^1,2 Less has been published about implementing ERAS in the field of orthopaedic surgery or in geriatric patient populations.

Identification of Local Problem 

Our hospital had a length of stay for arthroplasty patients that was significantly greater than that of Kaiser Permanente hospitals in other regions. As more patients joined our health plan, that led to an increasing volume of total joint replacements at the hospital, which led to a bottleneck in our arthroplasty service line. A team was then assembled to work on implementing ERAS principles in the care of total hip and total knee replacement patients. Up until this point, no prior surgical services had ERAS implemented in Kaiser Northwest.

Certain elements of ERAS were already in place with arthroplasty patients, such as mobilization on the day of surgery and a component of multimodal pain management. However, prior to the roll out in October 2017, there was no clearly defined process for all joint replacement patients to follow. Other elements were added to our arthroplasty bundle, including preoperative carbohydrate drink two hours before arrival (approximately four hours before scheduled surgical time), no routine use of urinary catheters, short-acting spinal anesthesia, postoperative mobilization within 12 hours, resuming regular diet within 12 hours, maintaining euvolemia (minimizing intraoperative fluid volume and avoiding hemodilution), and standardizing postoperative nausea and vomiting (PONV) prophylaxis. Additionally, there was no consistent method of documentation to identify improvements and gaps. Standardizing ERAS principles required a culture shift, including familiarizing staff with core concepts (minimizing opioids, early ambulation, optimized nutrition) as well as educating patients about expectations of early discharge and pain management.

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

Kaiser Westside Medical Center (KWMC) is a community hospital located west of Portland, OR. It is one of two hospitals owned by Kaiser Permanente Northwest. The service area includes the Portland metropolitan area (including Vancouver, WA) and extends south to Salem and Eugene. KWMC has 126 licensed beds, approximately 675 privileged physicians, and more than 1,000 employees. The hospital opened in 2013 and prioritizes High Reliability Organization (HRO) principles as we serve our patients. It participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Multispecialty Option, abstracting primarily orthopaedics, general surgery, and urology. The highest-volume service is orthopaedic surgery, specifically hip and knee replacements. In 2017, 2,045 total joint cases were performed, and of these cases, 391 patients were 75+ years old at the time of their surgery. In 2018, that number increased 21 percent, bringing the annual volume to 2,496, (521 of these patient were 75+ years old), thereby making KWMC the busiest joint replacement center in the state of Oregon.

At KWMC, our total joint patients were the first population in the region for which the ERAS multimodal care pathway was implemented. This was the first step of a larger regional project to roll out ERAS across all surgical specialties. Doing so required executive-level sponsorship and agreement between physicians, nursing, and operational leaders.

This region-wide initiative provided the executive-level support needed to implement culture changes specific to our arthroplasty patients. We were able to identify appropriate ERAS process measures with the input of departmental leaders and partner alongside our change champions in each phase of care (orthopaedic clinic, preoperative medicine clinic, preoperative holding area, operating room, post-anesthesia care unit, surgical floor, physical therapy) to facilitate meaningful discussions surrounding opportunities and potential barriers. We were also able to leverage our ACS NSQIP data set for our outcome measures. This project required highly collaborative relationships between multidisciplinary workgroups spanning throughout the hospital.

Planning and Development Process 

• Determined goals for the ERAS program: Reduce length of stay without concomitant increase in readmissions, achieve harm-free surgery (no surgical site infections, wound dehiscence, pneumonia, sepsis, unplanned intubation, VTE, acute renal failure or progressive renal insufficiency, UTI, CVA, MI, cardiac arrest, transfusions)
• Identified stakeholders and subject matter experts
• Developed dashboard team (responsible for data validity and integrity for both process and outcome measures) using ACS NSQIP data for outcomes measures
• Engaged operational and clinical leaders and established ownership of measuring discrete steps in the process (early ambulation, last liquids, multimodal analgesia, carb drink, avoiding use of urinary catheters, and so on)
• Identified all patient touch points to ensure consistent ERAS messaging throughout their care process; collaboration required with outpatient clinic, the preoperative medicine clinic, preoperative total joint class, surgical prep area (preoperative), intraop, PACU, hospital ward, and physical and occupational therapy

The planned changes came, in large part, from Kaiser Permanente Northern California’s experience in using ERAS for elective colorectal resection and emergency hip fracture repair across 20 medical centers in their region. They published their findings on 8,770 patients, which demonstrated earlier and greater ambulation, improved nutrition, and reduced opioid use as well as lower readmission and overall complication rates. Colorectal patients saw a decrease of in-hospital mortality, and hip fracture patients saw increased rates of home discharge. This study concluded that rapid, large-scale implementation of a multidisciplinary ERAS program was feasible and cost-effective in improving surgical outcomes.³

Description of the Quality Improvement Activity 

• September 2017: Development of ERAS protocol for arthroplasty patients
• October 2017: ERAS go-live date with implementation of new protocols
  • Development of ERAS education materials for both staff and patients
• January 2018: Home recovery (also known as same-day discharge, outpatient arthroplasty) implemented
  • Home recovery piloted by four surgeons, outcomes were closely monitored
  • Q2/Q3 2018: Home recovery was adopted by remaining surgeons after seeing initial successes with early adopters
• Q2 2018: Development of ERAS rounding tool for both staff and patients
  • Staff education and rounding on ERAS core principles (quarterly)
    • Operational leaders responsible for rounding on staff, supported by their partners in hospital quality
  • Patient rounding on ERAS principles and experience (preoperative carbohydrate beverage, pain management expectations, avoidance of urinary catheters) (quarterly)
    • Operational leaders responsible for rounding on patients, supported by their partners in hospital quality

Resources Used and Skills Needed

Staff

• Quality Consultant
• Surgeon Champion
• Anesthesia Lead
• Hospitalist Co-Management Program
• Nursing Leadership: Preoperative, Intraop, Postoperative, Hospital Floor
• Nurse Educators from Perioperative and Hospital Floor
• ACS NSQIP Surgical Case Reviewer
• Data Analytics
• Physical Therapy

Costs

There were no additional costs beyond normal hospital operations to implement and maintain the QI program. No additional funding sources were necessary to implement this program.

What Were the Results?

Overall Results 

This was a retrospective study aimed at determining what effects ERAS had on arthroplasty patients age 75 years and older. ERAS was implemented on October 1, 2017. Patients were divided into two groups: pre-ERAS and post-ERAS. Each group consisted of 12 months of geriatric arthroplasty patients; 10/1/2016–9/30/2017 for pre-ERAS and 10/1/2017–9/30/2018 for post-ERAS. There were 276 patients in the post-ERAS (experimental) group and 253 in the pre-ERAS (control) group.

Table 1 shows that, despite having a similar breakdown of comorbidities as measured by ASA class, after implementation of the ERAS protocol there was a significantly greater proportion of patients with a length of stay of only one day (64.5% vs. 45.5%, p < 0.0001) (Figure 1). Similarly, after ERAS there were fewer patients with a length of stay of two days (16.0% vs. 32.8%, p < 0.0001) or three or more days (13.8% vs. 21.0%, p = 0.03). Not many patients over the age of 75 participated in the home recovery program. There was no significant difference in the proportion being discharged home or to a skilled nursing facility (Figure 2). Similarly, there was no difference in unplanned return to the operating room or readmissions.

All data were analyzed using R statistics package version 3.5.3 (R Foundation for Statistical Computing, Vienna, Austria). When comparing the proportions between groups, a t-test for proportions was used with an alpha of 0.05.

Setbacks

• Barriers encountered during the QI activity implementation
  • Delays in dashboard build out from other high priorities at the regional level
  • Staffing in PACU for home recovery patients: Procured additional full time employees (FTEs) from leadership for PACU nurses
  • Identification of home recovery patients: Surgeon reluctance because of perceived increased workload from earlier discharge, potential need for more narcotic refills
  • Patient and family preference to stay longer: Educate on the benefits of earlier discharge, be it same day or postoperative day one
• Solutions to barriers
  • Educate staff and MD about the benefits of ERAS
  • New scripting of preoperative patient education class; inform that discharge on postoperative day zero is the norm for healthy patients
• Revisions in original QI plan due to limitations encountered during the process
  • Expectation management, changing deadlines
  • Focus on patient, collaboration to ensure successful change management
  • Modify protocol as needed: Switched from IV to PO acetaminophen (because of cost issues), did not implement postoperative chewing gum protocol (used in Kaiser Northern California)

Cost Savings

There was no money directly invested in implementing the ERAS pathway for geriatric arthroplasty patients. Health plan leadership allocated 0.25 FTE of our perioperative regional quality improvement consultant who had the assistance of a project manager and a senior administrator to help achieve this goal. Further studies are under way to estimate direct reductions in cost from reduced length of stay.

Tips for Others 

Getting started (funding needed, staff, pilot test, how to obtain buy-in from key participants):

• Achieve consensus on measurable objective rooted in best practice
• Establish reasonable deadlines with accountability
• Identify change champions (subject matter experts who are respected and can solicit buy-in from peers and their groups of influence)
• Solicit support from executive leadership (both physicians and health plan operations)
• Reach out to other hospitals that have implemented similar programs; solicit recommendations and shortcomings
• Identify unit-based, front-line champions for specific metrics
• Standardize messaging regarding the change to both staff and patients
• Establish clear budget and strategy for data analytics and marketing

How to sustain the activity (meetings, regular monitoring and feedback, and so on):

• Monitor data through smaller monthly dashboard meetings
• Hold leadership report-outs at quarterly meeting regarding progress on arena-specific action items
• Establish focused ERAS rounding with staff and patients
• Share the patient voice and ERAS experience
• Solicit and share staff feedback

Other tips and considerations:

• Develop video for patients educating them on what ERAS is and why it is important for their recovery
• Implement a web-based collaborative platform such as SharePoint for the team to access current data and resources
• Stay flexible as priorities may change
• Anticipate delays
• Develop meaningful relationships across multiple departments to facilitate success

References

1. Fearon KC, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2006;21:466-477. 
2. Ljungqvist O, et al. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3)292-298. 
3. Liu VX, et al. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. J Amer Med Assoc Surg. 2017;152(7):e171032.