What role could further implementation of ERAS across elective Orthopaedic and Spinal Procedures play in helping to ease the current NHS capacity challenges?

Abstract

Objectives: The National Health Service (NHS) in England is currently under severe capacity and economic pressures. Within acute NHS hospitals, the demand for beds from emergency admissions is resulting in increased waiting times and cancellations of non-urgent surgical operations, such as orthopaedic and spinal procedures. Enhanced Recovery after Surgery (ERAS) has been proven to reduce length of stay across a range of orthopaedic procedures. This analysis aimed to assess the extent to which the further implementation of ERAS could affect bed capacity on a national scale. Methods: Data on average length of stay (LOS) for elective (non-trauma) orthopaedic and spinal procedures were analysed from 131 English NHS trusts over the last available 12 months (October 2016-September 2017) using hospital episode statistics (HES) sourced from Dr Foster. Procedures were organised through Office of Population Censuses and Surveys (OPCS) classification of intervention and procedures codes (OPCS-4). A Pareto analysis was undertaken to understand which procedures have the greatest impact on LOS and demand for hospital beds. This was further analysed by removing day case surgeries and then stratifying LOS by number of days stay. Results: 598,823 surgical procedures were analysed. 376,690 procedures were removed due to being day cases and then the following 97,884 stayed 1-2 days, 68,655 stayed 3-4 days and 55,594 stayed longer than 5 days. Of the 55,594 procedures who stayed more than 5 days, 80% of these cases were total hip replacement (THR), total knee replacement (TKR), total shoulder replacement (TSR), total ankle replacement (TAR), revision total hip replacement (REV THR), revision total knee replacement (REV TKR) and lumbar spinal procedures. A conservative estimate of reducing all procedures over 3 days by one day would result in 124,249 days bed saving per year across the NHS, or 948 bed days per hospital. Conclusion: The procedures that make up 80% of all elective orthopaedic and spinal surgeries where patients stay in hospital for longer than three days should be a priority for future ERAS implementation. Application of ERAS principles to these procedures is feasible and safe. Reducing LOS in these procedures may have a considerable benefit to the capacity and financial problems that the NHS is currently facing.