Enhanced recovery programmes for lower limb arthroplasty in the UK

Introduction: Enhanced recovery programmes (ERPs) reduce patient morbidity and mortality, and provide significant cost savings by reducing length of stay. Currently, no uniform ERP guidelines exist for lower limb arthroplasty in the UK. The aim of this study was to identify variations in ERPs and determine adherence to local policy. Methods: Hospitals offering elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) (23 and 22 centres respectively) contributed details of their ERPs, and performed an audit (15 patients per centre) to assess compliance. Results: Contrasting content and detail of ERPs was noted across centres. Adherence to ERPs varied significantly (40–100% for TKA, 17–94% for THA). Analysis identified perioperative use of dexamethasone, tranexamic acid and early mobilisation for TKA, and procedures performed in teaching hospitals for THA as being associated with a reduced length of stay. Conclusions: This study highlights variation in practice and poor compliance with local ERPs. Given the proven benefits of ERPs, evidence-based guidelines in the context of local skillsets should be established to optimise the patient care pathway

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Enhanced recovery programmes for lower limb arthroplasty in the UK

Introduction: Enhanced Recovery Programmes (ERPs) reduce patient morbidity and mortality and provide significant cost savings by reducing length of stay (LOS). Currently no uniform ERP guidelines exist for lower limb arthroplasty in the UK and this study aimed to identify variations in ERPs across the NHS and determine adherence to local policy. Materials and Methods: Directed through BONE (British Orthopaedic Network Environment, an online system from BOTA), NHS hospitals offering elective TKA (23 centres) or THA (22 centres) contributed details of their ERPs and performed an audit (15 patients/centre) to assess compliance. Results: Contrasting content and detail of ERPs was noted across centres. Adherence to ERPs varied significantly (40-100% for TKA, range 17-94% for THA). Analysis identified perioperative use of dexamethasone, tranexamic acid, and early mobilisation for TKA and procedures performed in teaching hospitals for THA, as being associated with a reduced length of stay. Discussion: There is no consensus regarding the ERP gold standard with protocols contradicting the evidence base. Despite meta-analysis questioning efficacy of pre-operative education it continues to be commissioned. Conversely, utilisation of drugs such as tranexamic acid and dexamethasone remains suboptimal despite evidence of efficacy. This study highlights variation in practice and poor compliance with local ERPs in the NHS. Considering proven benefits of ERPs, evidence-based guidelines in the context of local skillsets should be established to optimise the patient care pathway