Enhanced recovery programme after TKA through multi-disciplinary collaboration
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1 Enhanced recovery programme after TKA through multi-disciplinary collaboration ChanPK(1), ChiuKY(1), FungYK(6), YeungSS(7), NgT(8), ChanMT(5), LamR(4), WongNY(3), ChoiYY(3), ChanCW(2), NgFY(1), YanCH(1) Queen Mary Hospital (1) Department of Orthopaedics & Traumatology, (2)Department of Anaesthesiology, (3)Department of Nursing, (4)Department of Physiotherapy, (5)Department of Occupational Therapy MacLehose Medical Rehabilitation Centre (6)Department of Nursing, (7)Department of Physiotherapy, (8)Department of Occupational Therapy
2 Introduction Osteoarthritis of Knee (OAK) is the leading cause of chronic disability Total knee arthroplasty (TKA) is cost effective Pain relief Quality of life WHO Global Burden of Disease 2010 Elena Losina et al, Cost-effectiveness of Total Knee Arthroplasty in the United States, Arch Intern Med. Author manuscript; available in PMC Dec 22, 2009
3 Aging population in HK
4
5 Introduction Enhanced recovery programme (ERP) in TKA quicker functional recovery reduced morbidity Principles Preop comprehensive assessment & education Good multimodal pain control Intensive rehabilitation Avoid complications Larsen K et al. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg Am 2009;91:761-72
6 Multidisciplinary Collaboration Specialized team approach to create an optimal regimen of patient-centered care Orthopaedic surgeons Anaesthesiologists Nurses Physiotherapists Occupational therapists MSW
7 1) Preoperative comprehensive assessment Surgeon Anaesthesiology Nurse Allied health : OT, PT
8 2) Preoperative Education
9 3) Good multimodal pain control Intra-operative Periarticular injection of mixture of drug immediate postop pain control Post-op Acute Pain Service by Anaesthesiologist Andersen LØ, Husted H, Otte KS et al. A compression bandage improves local infiltration analgesia in total knee arthroplasty. Acta Orthop 2008;79:806-11
10 4) Intensive rehabilitation
11 Early Postop Mobilization Focus on early mobilization Enhanced rehabilitation Reduces the risks of bed-ridden morbidity eg DVT, pneumonia, UTI
12 Intensive physiotherapy training
13 Postop OT Mx
14 5) To avoid complications
15 Dedicated surgical team Reducing operation time Minimizing complication
16 Dedicated Anaesthesiologist Regional anaesthesia is superior to general anaesthesia reduces postoperative complications by 30-60% Rodgers A, Walker N, Schug S et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493.
17 Patient Blood Management Blood transfusion Prolonged hospital stays Morbidity Reducing the blood loss & transfusion Transfusion guideline Intra-articular tranexamic acid Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008;79:168-73
18 Deep Vein Thrombosis prophylaxis Mechanical Sequential compression Device Chemical Aspirin 300mg for 2/52
19 Objectives Since May 2013, the traditional rehabilitation plan was modified ERP was implemented for patients after primary TKA Aim To review the outcome of the ERP Compare with traditional rehab before May 2013 as control
20 Materials and Methods
21 Methodology Inclusion Patients, who were transferred to the rehabilitation hospital after primary TKA done between May 2013 and January 2014, in the ERP
22 Case-control study Case Patient in ERP Control Methodology Patient traditional rehab in historical cohort (May Jan 2013) Same discharge criteria Statistical Analysis SPSS
23 Outcome measures 1. Rehabilitation outcome at OPD FU in 6/52 Knee Society Knee Score (KSKS) Knee Society Knee Function Score (KSKFS) 2. Length of stay in rehabilitation day Readmission Rate
24 Results
25 Patient s data in Traditional Vs ERP Traditional ERP P-value No of patients Age 73.4± ± Sex (F:M) 123:39 130: Diagnosis (1ºOA :2º OA) 150:18 152: Unilateral : Bilateral 142:26 140: KSKS 50.1± ± KSK Functional Score 38.4± ±
26 Outcome measures Traditional ERP Statistical Sig Rehabilitation Outcome a. KSKS 76.5± ± b. KSK Functional Score 30 day Readmission Rate (%) 80.2± ± % 2.4% 0.74 LOS (day) Uilateral TKA Bilateral TKA 13.4± ±1.8 < ± ±2.1 <0.05
27 Cost-effectiveness Cost of In-patient rehab : $3740/day LOS difference : 7 days Cost Saved in rehab by EPR compared with tradition rehab $4.3 Million ($3740x7x168)
28 Other benefits of ERP Increase bed availability for rehabilitation other orthopaedic condition Spinal cord injury patient
29 Conclusion The ERP after TKA Improving efficiency of rehab reduce length of hospital stays maintaining rehabilitation outcome With aging population of HK, Increasing efficiency of TKA service is important
30 Thank You
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