This article will briefly outline what is meant by an enhanced recovery pathway (ERP), discuss the use of enhanced recovery surgery within orthopaedic settings, and outline the benefits of this approach in hip replacement surgeries.
What is enhanced recovery?
At its core, enhanced recovery is all about improving patient outcomes and speeding up recovery following surgery. An enhanced recovery pathway focuses on optimizing every aspect of a patients journey and promoting the patient as an active participant in their recovery process and rehabilitation. Successful pathways aim to optimize every step of a patients journey in order to accelerate post-operative recovery, reduce complications and general morbidity.
In general the following steps characterize an ERP.
- A thorough pre-operative intervention to optimize health and medical condition.
- Pre-operative education, counseling and exercises “prehab”
- Pre-operative organization of discharge arrangements.
- Minimally invasive surgical techniques aim to reduce the surgical trauma to soft tissue.
- Optimized anesthesia and pain relief protocols – usually regional and local anesthetic techniques with light sedation.
- Promotion of normal blood circulation, temperature and oxygenation during surgery.
- Early physiotherapy to get up and walk
- Regular and effective oral pain control
- Promotion of a wellness model of care where catheters, drips and drains are removed as soon as possible and independence with washing, dressing and socialization promoted.
- Team approach to perioperative management, utilizing medicine hospitalist to optimize medical care during early recovery.
- Patients improve faster and are therefore discharged home earlier, with a goal of one to two night hospital stays.
- Patients have clear instructions on how to progress rehabilitation at home and have visits from the physiotherapist to ensure that they are progressing well.
- Goal to discharge all patients directly home with home health services and minimize the use of skilled nursing facilities.
The use of enhanced recovery pathways within elective orthopaedic surgery has increased in recent years and systematic reviews of the literature have shown that the introduction of such clinical pathways can significantly improve the quality of care and outcome for patients.
For total knee replacements and total hip replacements, the patient undergoes a thorough pre-operative checkup and is admitted on the day of surgery. The patient is allowed clear fluids up to 6 hours prior and solid food and other liquids 8 hours prior. Pre-op medications include antibiotics within an hour of incision, and pre-emptive non-narcotic pain medications. DVT prophylaxis is tailored to the individual patient’s risk factors, and begins with mechanical prophylaxis initiated at check in.
As well as improvements to patient satisfaction and good clinical outcomes, enhanced recovery pathways are proven to reduce length of hospital stay. In the United States units using ERP have lengths of hospital stay which are considerably lower than national averages and this appears to be a win-win situation for the hospital, payer and patient as the ERP can deliver high quality and also provide cost effective and efficient treatment.
In summary the Enhanced Recovery Pathway experience has shown great promise in reducing patient discomfort and pain, allowing early mobilization and improving patient outcomes.