Is ERAS now the routine standard care in English NHS Hospitals for total hip replacement and total knee replacement?

Abstract

Objectives: For total hip replacement (THR) and total knee replacement (TKR), Enhanced Recovery after Surgery (ERAS) pathways have reduced length of stay (LOS) to 1-3 days for unselected patients and outpatient surgery is possible. Although the evidence base supports routine 1-3 day discharge, we hypothesise that this is not a reality for most National Health Service (NHS) patients. The NHS has considerable economic and capacity challenges. Reducing LOS for high volume procedures in line with published best practice could provide highly significant efficiency benefits. We aimed to assess if ERAS is now the routine standard care in English NHS hospitals for THR and TKR by using LOS as a proxy indicator. Methods: Data on average LOS following THR and TKR were analysed from 131 English NHS trusts from Oct 2016-Sept 2017 using hospital episode statistics sourced via Dr Foster. The relative risk (RR) of a long LOS was calculated, which considers contributing exposure factors to staying longer than expected in hospital. Results: 52,271 THR and 62,666 TKR superspells were analysed. Mean national LOS for the 12 months analysed was 4.81 for THR and 4.77 for TKR. There was wide variation in the RR of patients having a long LOS across providers. The mean national RR of a long LOS for THR was 115.31 (range 44.74-273.45), which is significantly higher than the benchmark of 100. 17 trusts have a significantly lower number of long stay patients compared to 50 trusts with a higher number of long stay patients than expected. The mean national RR of a long LOS for TKR was 120.38 (range 46.11–258.04), which is significantly higher than the benchmark of 100. 15 trusts have a significantly lower number of long stay patients compared to 55 trusts with a higher number of long stay patients than expected. Conclusion: Mean LOS for both THR and TKR is appreciably greater in NHS hospitals than reported in the ERAS literature. There is a wide variation in the case-mix adjusted RR of a long LOS across trusts. This demonstrates that exemplar sites exist and are achieving outcomes in line with ERAS literature; however this is not a reality across the majority of trusts. As the data is case-mix adjusted and there is a wealth of evidence and clinical expertise in ERAS, it is likely that either external catalysts or a more strategic national implementation of best-practice is required for quality improvement to occur.