Early Recovery After Surgery for Total Knee Replacement
Robin G. Major
Chamberlain College of Nursing
NR709 Project and Practicum IV
Abstract
Introduction:
This review synthesizes evidence that can be utilized to assist in developing a protocol for total knee replacement. Information gathered was evidence reviewed by professionals including orthopedic surgeons, anesthesiologists, physicians, and physiotherapists. Advanced nursing perspectives were considered with the inclusion of nursing-specific literature.
Research Methodology:
Search terms included keywords and specific years to identify literature using Chamberlain University library, which included Medline, CINAHL, Journals @ OVID, EBSCOhost, and ProQuest. The ERAS program has evolved over the last 8-10 years, the peer-reviewed and English-language literature were systematically reviewed from 2017-2022. Specific terms such as “surgery”, “preoperative”, “anesthesia”, “postoperative”, “rehabilitation”, and “analgesia” were searched. A reference of lists of available articles was reviewed for other relevant articles including surgery other than total joint replacement.
Keywords included “knee replacement”, “knee arthroplasty”, “knee prosthesis”, “hip replacement”, “hip arthroplasty”, “hip prosthesis,” and “lower extremity joint replacement” and additional keywords depending on the topic. Utilizing the detailed search process above resulted in 1900 article citations, 40 abstracts, and 23 articles that contained evidence related to the clinical question.
Articles were screened and titles and abstracts reviewed to identify potentially relevant articles and reference lists of eligible articles were hand-searched for relevant studies. Meta-analyses, systematic reviews, non-randomized and randomized trials were considered for each topic unless there were a minimal number of papers identified in which all were screened. Qualitative studies were reviewed in specific areas including “hands-on” experience of ERAS programs. While some of the articles were not considered high-level evidence, valuable evidence on specific issues such as how patients perceive, understand, and carry out the ERAS pathway was necessary. The specifics of nurse involvement were shown to shed light on the topic. The literature was selected and discrepancies were noted and further reviewed. Studies involving fast-track set-up or ERAS showed improvements in the achievement of discharge criteria, having a positive effect, decreasing complications, and ultimately reducing the length of stay (LOS).
The primary evidence review was combined with current practice and the following themes were found within the literature: 1) the implementation of ERAS pathways reduces hospital costs by improving quality outcomes including length of stay 2) the patient education component of ERAS is associated with reduced the length of stay among postoperative patients 3) benefits of compliance with ERAS guidelines reduces length of stay and mortality rates among patients 4) committed leadership influences ERAS adaptation.
Results:
Fifteen articles were reviewed. Five of the articles were Level 1, Quality A, three were Level 1, Quality B, four were Level 2, Quality A, two were Level 2, Quality B, and one Level 3, Quality A.
Discussion:
The use of ERAS perioperative pain medication has been shown to reduce post-operative pain and decrease the length of stay (Brink et al., 2018; Li & Chen, 2019; Politi et al., 2017; Zhang et al., 2018). Early mobility after total knee replacement decreased the length of hospital stay from 5 days to 3 days. (Pritchard et al., 2020; Soffin et al., 2016; Wainwright et al., 2020; Zhu et al., 2017). ERAS programs decrease the length of hospital stay, decrease patient perceived pain level and increase mobility (Elias et al., 2019; Inacio et al., 2017; Molloy et al., 2017).
Conclusions:
The utilization of an ERAS program has shown to decrease the length of hospital stay in patients undergoing total knee replacement. Early mobilization, perioperative anesthesia, and post-operative pain medication such as peripheral nerve blocks should be utilized. Preferred medication should include non-steroidal anti-inflammatories, gabapentinoids, acetaminophen, and steroids.
Further Recommendations:
Outcomes noted with Early Recovery After Surgery Programs were the return of motor function in a shorter time resulting in decreased length of stay. The rehabilitation process started in the inpatient unit when patients were transferred from post-anesthesia care unit and mobilization on day one had a shorter length of stay than those who started on day two or three which can decrease cost and provide more open beds for inpatient stays.
I would like to thank my family for their continued support throughout my educational journey. My husband Mark Major, children Dalton Major and Brooke Major, and future daughter in law Katherine Lawrence, have supported me unconditionally throughout the process. They have encouraged me to strive for excellence and continue to assist me. I hope my mother, Roseanne Wade, who went to be with our Lord and Savior just nine months ago knows how much I appreciated her. My entire life she helped me reach my goals. We had a long-standing joke when she asked her primary care physician about a medication protocol that I was questioning. He told her that since I was only a nurse practitioner and not a “doctor” that I didn’t know anything about medications. I made it my quest to become a Doctor of Nursing Practice and truly wanted her to see me accomplish that. I know she is very proud of me.
I would like to thank every professor I have had at Chamberlain University. They have been supportive and understanding through some difficult times I have experienced throughout the program. It has been a pleasurable experience. My practicum professors have been amazing through this journey. I would like to thank Dr. Somerall, Dr. Koopman, Dr. Payne and Dr. Toothaker.
Contents
Early Recovery After Surgery in Total Knee Replacements
Significance of the Practice Problem.. 9
Inclusion/Exclusion Criteria. 12
Characterization of the Body of Literature. 13
Conclusions and Further Recommendations. 18
Implications for Nursing Practice. 18
Conclusions and Contributions to the Professions of Nursing. 18
Appendix A John’s Hopkins Evidence Table. 28
Does Early Recovery After Surgery (ERAS) guidelines, compared to current practice, impact the postoperative length of stay in 11-12 weeks?
Long before the COVID-19 pandemic created even greater issues, hospitals faced challenges determining methods to provide care for patients in both an economical and efficient manner to save costs and due to staffing issues. The surgical division creates exorbitant costs. Devising a plan to provide efficient care, decrease negative outcomes, and reduce the length of stay is essential for the life of the hospital. The Early Recovery After Surgery program is a validated and reliable method of achieving optimal care. Utilizing the Early Recovery After Surgery, (ERAS) guidelines can decrease patient length of stay (LOS) by improving pain management and a reducing of postoperative complications. The project facility is also working to improve overall patient satisfaction and data shows that implementing the use of the ERAS program can assist in this endeavor (Bourazani et al., 2021). The DNP student will work with patients prior to surgery to implement the ERAS guidelines to identify potential risks and decrease complications. Currently, patient education is minimal in the surgical unit. The surgery scheduler provides patients with a packet of information, but patients receive no further education. The current method does not guarantee that the patient reads and follows the information in the packet.
The purpose of the proposed Doctor of Nursing Practice (DNP) project is to decrease the length of stay among adult surgical patients at Franciscan Alliance Hospital in Olympia Fields Illinois through the integration of the Early Recovery After Surgery intervention into the preoperative session. The organization does not currently utilize ERAS guidelines with preoperative patients. Patients who do not receive proper advice on how to manage their health post-operatively are likely to develop complications and stay in the hospital for longer periods. This manuscript will describe the identified practice problem and its significance, discuss the translational science model, methodology, implementation, planned data analysis, and sustainability of the practice change.
Problem Statement
Post-operative complications have negative effects on patient outcomes. This increases the length of stay and impacts negatively on healthcare costs (Bourazani et al., 2021). The following practice question will serve as the basis for the proposed DNP project; “In adult surgical patients (P), does the integration of the Early Recovery After Surgery (ERAS) guidelines into the preoperative session (I), compared to current practice (C), impact the postoperative length of stay (O) in 11-12 weeks (T)?” The population under study in the proposed project is a group of adult surgical patients at Franciscan Alliance Hospital in Olympia Fields Illinois. The project team will integrate the ERAS guidelines into the preoperative session as the study intervention. The comparison element of the PICOT is current practice that does not use ERAS guidelines. The expected outcome is changes in the length of stay and the time period that the intervention is expected to generate observable outcomes is 11-12 weeks.
Significance of the Practice Problem
Patients who undergo a total knee replacement have a current length of stay of two to three days at Franciscan Alliance Hospital. According to Agarwala et al. (2020), surgical patients often experience early postoperative pain and diminished mobility within the first 24 hours. These patients require hospitalization for enhanced monitoring in order to reduce health risks and prevent complications. The goal of every healthcare facility is to reduce the length of stay by ensuring that patients are discharged within the shortest period possible. After evaluating other facilities, the surgeons and the hospital administration staff at Franciscan Alliance Hospital determined that the length of stay for adult patients who undergo a total knee replacement should improve from 2-3 days to 1-2 days with a goal to eventually performing the outpatient procedure on patients with minimal risk of complications.
Globally and nationally, patients who have total joint replacement have an increased need for additional nursing care, staffing, and bed availability when the length of stay is outside the norm, as determined by protocol and insurance guidelines. The average length of stay is five days. The project site average is five to seven days due to issues that could have been prevented with a detailed pre-operative plan, especially dealing with pain management. The prevalence of total knee replacement surgery is due to factors including age, obesity, and osteoarthritis. In the United States, the most common joint disorder is osteoarthritis leading to multiple incidences of elective knee surgery (Christelis et al., 2015). Symptomatic problems affect 13% of women and 10% of men over age 60. The patients over age 60 tend to lead a more active lifestyle than their parents, predisposing them to a greater incidence of joint replacements. The Centers for Disease Control and Prevention (CDC, 2014) note that more than one-third of the United States adults are obese with increasing co-morbidities resulting in complications in the post-operative phase.
It is estimated that in 2012, according to the Smith et. al., (2021), more than $11 billion dollars was spent on total knee replacements and between 2000-2010, the average length of stay (LOS) after joint replacement in patients older than 45 was four days. Locally and globally, increased demand for knee replacements causes an increased burden on financial and clinical resources and an increased demand for lower extremity joint replacements, which greatly impacts the United States healthcare system (Smith et al., 2021). When patients are hospitalized for longer periods of time, the financial impact involves additional staffing and risks for complications by decreased mobility. These complications include blood clots and possible joint infections (Agarwala et al., 2020). Medicare guidelines have changed over the past several years stating that if a patient suffers a joint infection within a year postoperatively, the facility does not receive reimbursement from Medicare. Due to federal guidelines, readmission is then absorbed by the hospital system impacting the hospital system financially. Therefore, preventing post-operative complications and reducing the length of stay will not only reduce preventable hospital expenditures but will also have positive impacts on Medicare and Medicaid reimbursements for Franciscan Alliance Hospital.
Theory or Translation Science Framework
DNP students should utilize translational science framework to successfully move evidence obtained from literature into clinical practice interventions that positively affect patient outcomes. The translational science framework for the proposed project is the Knowledge to Action Model. This model focuses on the nature of the essential context, leadership, and stakeholder engagement within a facility. It addresses two concepts: (a) action cycle to facilitate a practice change and (b) identification of pertinent knowledge that is related to the practice problem to institute change. When a problem within the practice is identified, knowledge assists with presenting specific needs to refine, tailor, and implement change within an action cycle. A key component in the preparation of the action change can assist by providing explicit and clear best practice recommendations for practitioners involved (Lockwood et al., 2016). In their efforts to implement evidence-based practice, healthcare professionals benefit greatly from the Knowledge to Action Model which guides them through problem identification, knowledge synthesis to gather evidence, the implementation of evidence in the local context, evaluation of outcomes, and sustaining knowledge use.
The Knowledge to Action Model guides project planning, implementation, and sustainability by utilizing two components that are distinct but related. The two components are Knowledge Creation and Action Cycle (Lockwood et al., 2016). The Knowledge Creation component describes the process of creating new knowledge that can be utilized to address an identified practice problem. The process of knowledge creation occurs in three phases namely; knowledge inquiry, knowledge synthesis, and the development of knowledge products and tools (Xu et al., 2020). The Action Cycle component describes the process of putting evidence-based knowledge into use to address the problem and generate the desired outcomes. The stages include 1) identifying the problem, 2) adapting knowledge to the local context, 3) assessing barriers to knowledge use, 4) selecting, tailoring, and implementing interventions, 5) monitoring knowledge use, 6) evaluating outcomes, and 7) sustaining knowledge use (Lockwood et al., 2016; Xu et al., 2020). The two components, when used together, effectively facilitate the process of moving evidence into action.
The DNP student will adopt the Knowledge to Action Model to assess the problem within the practice site or local facility, implement evidence-based practice knowledge, and share information within the hospital network for sustainable change in practice. The process of integrating new knowledge into practice must begin with problem identification. In the proposed DNP project, the practice problem is the prolonged length of stay among adult surgical patients due to the lack of ERAS integration into the preoperative session. Using the Knowledge Creation component, the project team will engage in the process of knowledge production and synthesis using the practice problem as the basis for inquiry. During the knowledge inquiry phase, the project team will identify current primary studies that are related to the project topic. This stage will be followed by knowledge synthesis where the project team will synthesize the results of the primary studies to locate the best practice evidence to address the practice problem. The final stage under the Knowledge Creation component will entail the use of relevant tools such as PowerPoint slides to present evidence in a manner that can easily be understood and utilized by healthcare professionals (Lockwood et al., 2016; Xu et al., 2020). At this point, the project team will have created the knowledge that it can use to improve healthcare outcomes and reduce the length of stay among adult surgical patients. The next step after implementing the Knowledge Creation component is the application of the Action Cycle. The project team will identify the knowledge gap in relation to the identified problem, review the literature, and select the best practice to implement. This will be followed by adapting the knowledge to the practice setting; assessing barriers to knowledge use; selecting, tailoring, and implementing interventions; monitoring knowledge use; evaluating outcomes; and sustaining knowledge use.
Methodology
Review Protocol
The articles to be used for the integrative review were obtained from nursing databases. The specific databases that were searched were located from the Chamberlain University library and they included Medline, CINAHL, Journals @ OVID, EBSCOhost, and ProQuest. Specific terms such as “surgery”, “preoperative”, “anesthesia”, “postoperative”, “rehabilitation”, and “analgesia” were searched. Other keywords used during the search included “ERAS guidelines” and “ERAS protocol” and their application to “knee replacement”, “knee arthroplasty”, “knee prosthesis”, “hip replacement”, “hip arthroplasty”, “hip prosthesis,” and “lower extremity joint replacement” and other joint-related surgeries. Utilizing the above detailed search process resulted in 1900 article citations, 40 abstracts, and 23 articles that contained evidence related to the clinical question.
Inclusion/Exclusion Criteria
Only those articles that met the inclusion criteria were used for the integrative review. Notably, the ERAS program has evolved over the last 8-10 years and several studies have been conducted on the topic. Peer-reviewed journals written in the English language and published between 2017 and 2022 were included in the review. Reference lists of available articles were also reviewed for other relevant articles including those that focused on joint surgery other than total knee replacement. Meta-analyses, systematic reviews, non-randomized trials, and randomized trials were considered for the integrative review unless there were a minimal number of papers identified in which all were screened. Articles that used both qualitative and quantitative methodologies were included in the integrative review. Everything that was contrary to these requirements was used as the exclusion criteria for excluding articles from the integrative review.
Data Analysis
Articles that met the inclusion criteria were screened and titles and abstracts reviewed to identify their findings and results. Reference lists of eligible articles were also searched and relevant articles reviewed. Meta-analyses, systematic reviews, non-randomized trials, and randomized trials were considered for each topic, unless there were a minimal number of papers identified in which all were screened. Qualitative studies were reviewed in specific areas including “hands on” experience of ERAS programs. While some of the articles were not considered high-level evidence, the valuable evidence on specific issues such as how patients perceive, understand, and carry out the ERAS pathway was necessary. The specifics of nurse involvement were shown to shed light on the topic. The articles were selected and discrepancies were noted and further reviewed.
The Johns Hopkins Nursing Evidence-Based Practice tool was used to extract data from the fifteen articles that met the inclusion criteria. Individual summary of the fifteen articles was performed using the tool. The summary was done based on the evidence type, sample and sample size of participants used in the articles, the study settings, study findings that helped answer the evidence-based practice question, observable measures, study limitations, as well as evidence level and quality.
Results from the studies were combined based on themes. Findings that expressed similar concepts were combined together. The similarities in sample types, study settings, and outcome measures further guided decision-making when grouping the articles. Thematic analysis is a widely recognized qualitative measure that is used to bring together evidence collected from published literature. Organizing findings into themes make it earlier to bring together the concepts contained in the reviewed articles in order to establish the best practice intervention to answer a clinical question (Antoun et al., 2022). The integrated review in the current project generated themes that were used to select the best practice intervention to address the PICOT question.
Results and Discussion
Characterization of the Body of Literature
Although the original search generated 1963 articles, only 15 of them met the inclusion criteria. The 15 articles were considered for the integrative review. The reviewed articles were those published between 2017 and 2022. Five of the articles were Level 1, Quality A, three were Level 1, Quality B, four were Level 2, Quality A, two were Level 2, Quality B, and one was Level 3, Quality A. Quality A studies contain high-quality evidence which is considered to have “consistent, generalizable results; sufficient sample size for the study design; adequate control; definitive conclusions; consistent recommendations based on a comprehensive literature review that includes thorough reference to scientific evidence (The Johns Hopkins Hospital, n.d.).” Quality B studies contain “good quality evidence which is considered to have reasonably consistent results; sufficient sample size for the study design; some control, fairly definitive conclusions; reasonably consistent recommendations based on a fairly comprehensive literature review that includes some reference to scientific evidence (The Johns Hopkins Hospital, n.d.).” Both Quality A and Quality B evidence can inform evidence-based practice change.
All the articles considered for the integrative review were published in reputable nursing journals. Since they were a mixture of Level 1, Level 2, and Level 3 evidence, they included both systematic reviews and empirical studies. The main strength of using systematic reviews is that they contain evidence from several studies that have used various designs with similar study subjects and settings to collect data. This enhances the external validity of the evidence contained in them. However, their main weakness is that it is difficult to verify the trustworthiness of the documented findings, a factor that limits the internal validity of the evidence contained in such studies (Charrois, 2017). The main strength of using empirical studies is that they allow the use of primary data to draw conclusions which enhances internal validity. However, empirical studies might focus on populations with unique characteristics that do not match those of the population under study. This limits the external validity of the evidence contained in them.
Findings Synthesis
Detailed analyses of the identified themes are as described below. The Individual Evidence Summary tool used to extract findings from the articles used in the integrative review is shown in Appendix 1. The study findings were organized into themes as shown below;
Results:
Theme 1: Reduction in postoperative length of stay: ERAS minimizes hospital costs by improving quality outcomes including length of stay
There is a close link between quality measures and healthcare expenditures incurred by hospitals to provide care to hospitalized patients. Prolonged length of hospital stay is associated with increased hospital costs whereas the reduced length of hospital stay minimizes hospital costs. According to Frassanito et al., (2020), the utilization of enhanced recovery pathways after surgery, including total joint replacement, is associated with a shorter length of stay, decreased adverse reactions, and decreased hospital costs among postoperative patients. When the recovery rate is enhanced among post-operative patients, they tend to leave the hospital within a few days. This in turn assists with keeping hospital beds open for emergencies and decreases the number of staff needed to care for patients. The Agency for Healthcare Research and Quality (AHRQ) started an initiative to increase the implementation of ERAS pathways in the United States (Agency for Healthcare Research and Quality, 2017). The cost factor is influenced by a decrease in length of stay and postoperative complications following the implementation of ERAS pathways.
Findings of a study conducted by Molloy et al. (2017) support the evidence documented by Pritchard et al. (2020). Molloy et al. (2017) conducted a study to assess the impacts of inpatient length of stay on hospital costs. The researchers utilized the National Inpatient Sample to gather the demographic data of postoperative patients and average hospital costs between 2002 and 2013. The researchers found that the hospital costs incurred towards joint replacement increased as length of inpatient stay increased. However, reducing the length of stay among postoperative patients resulted in a reduction in hospital costs. Evidence from the study indicates that the length of stay is an important target in a hospital’s efforts to reduce costs.
Theme 2: Reduction in postoperative length of stay: The importance of postoperative patient education component of ERAS
One of the crucial components of the ERAS protocol that contribute to its effectiveness is patient education. Although postoperative patient education was not shown to independently affect patient outcomes such as accelerating the achievement of discharge criteria, it was noted to reduce postoperative anxiety across several systematic reviews (Wainwright et al., 2020). However, it is important to note that conclusion of these reviews may be flawed due to the heterogeneity of the reviewed studies. In this respect, there is a strong need for properly designed controlled and randomized studies that are specifically powered for ERAS settings that allow for discrimination within the outcome parameters.
Additional information regarding types of patients and their lifestyles may add perspective regarding younger active, older active, and older sedentary patients. Strong specific evidence leads to the recommendation of preoperative counseling and education. Qualitative studies detail patient understanding of the program and the importance of support and follow-up in enhancing recovery post-operatively (Zhu et al., 2017). Preoperative education is unlikely to cause harm and is available through different forms enhancing the need for an ERAS program. These findings were further substantiated by Soffin et al. (2016). Through a detailed review of the evidence, Soffin et al. (2016) presented evidence that explains the benefits of ERAS as a standardized approach to patients who have undergone knee and hip arthroplasty. Reports from the study indicate that the implementation of ERAS a standardized approach to care, coupled with pre- and postoperative patient education improves patient outcomes and reduces the length of stay.
Theme 3: Reduction in postoperative length of stay: Benefits of compliance with ERAS guidelines
Positive impacts of evidence-based interventions occur when nurses comply with the requirements of such interventions whenever they are implementing them to address patient care issues. ERAS guidelines are a combination of pathways that when effectively implemented contribute to psychological and physiological impacts in postoperative patients (Elias et al., 2019). As Elias et al. (2019) explain, for a healthcare organization to achieve the best outcomes across surgery patients when implementing the ERAS protocol, it must ensure that its healthcare professionals comply with the ERAS guidelines. They must also follow best practices for reporting related to the guidelines. Pritchard et al. (2020) supported the importance of adhering to ERAS guidelines for a healthcare organization to record a reduction in length of stay and achieve cost-effectiveness.
Compliance with ERAS guidelines reduces mortality rates, incidences of complications, and length of stay among surgery patients. The purpose of a study by Deng et al. (2018) was to examine the impacts of ERAS on recovery rates of patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA). They collected data through a systematic review of published literature. The study showed that compliance with ERAS guidelines significantly reduced complication incidences, length of stay, mortality rates, and rates of transfusion among THA and TKA patients. These findings are further supported by Burn et al. (2018) and Molloy et al. (2017) who documented that compliance with ERAS pathways substantially reduced length of stay among patients undergoing joint replacement.
Theme 4: Reduction in postoperative length of stay: Committed leadership influences ERAS adaptation
An organization’s leadership has an influence on ERAS adaptation to facilitate an improvement in quality outcomes including length of stay. Leaders tend to prioritize ERAS adaptation when they are confident that it will generate positive impacts on quality outcomes for the benefit of both patients and the organization. Evidence documented by Mitchell et al. (2017) indicates that committed leadership is one of the contextual factors that influence the adaptation of quality improvement strategies aimed at improving patient outcomes, with a specific focus on project Re-Engineered Discharge (RED) aimed at reducing readmission rates. An organization can approach the implementation of evidence-based projects for promoting patient safety when they can yield better patient care and outcomes.
Surgery trends in a particular region should influence decision-making by leaders of healthcare organizations regarding the need to improve quality outcomes among patients and reduce hospital costs. In this respect, it is important to utilize tools that enhance the prediction of future surgeries for proper planning on how to reduce length of stay post-surgery (Inacio et al., 2017). Leaders should implement evidence-based strategies such as ERAS guidelines to be able to plan for the implementation of patient care interventions that help to minimize complications post-surgery to reduce length of stay.
Conclusions and Further Recommendations
Implications for Nursing Practice
Results of the integrative review have positive implications for nursing practice. The findings indicate that optimizing patient care using an ERAS protocol is beneficial for the arthroplasty patient. By using multimodal pain management techniques, and decreasing opiate usage, it is hoped that the ERP will reduce pain, recovery, and LOS. However, a recent study found that despite these interventions, as many as 44% of ERAS participants remained in hospital on day 5. They were found to experience several problems, including wound leakage, medical issues, and physiotherapy concerns (Kerr, Armstrong, Beard, Teichmann, & Mutimer, 2017). Despite the challenges experienced in different practice settings, nurses can still implement the results of the integrative review in clinical settings with adult surgical patients to prevent complications and reduce length of stay.
Nurses at Franciscan Alliance Hospital in Olympia Fields Illinois should follow clear steps to ensure the successful integration of the ERAS guidelines into current practice. When testing the new evidence in the practice setting, in the first stage, one identified surgeon’s patients will receive education preoperatively that is designed to improve pain control, increase mobility immediately after surgery and decrease length of stay. The DNP will contact each patient by phone, or an in-person visit with each patient scheduled for a total knee replacement by the orthopedic surgeon prior to surgery to discuss the ERAS program. Information will be provided for each week before the surgery, immediately following, and up to the two-week follow-up appointment.
Stage two will be a phone call to the patient within two days of discharge from the hospital. Stage three will be when the patient is seen at the two-week postoperative visit. Information will be pulled from the chart in the electronic medical record Epic regarding the length of stay, pain control, and initiation of physical therapy. At the two-week visit, the patient will be further educated on recovery and rehabilitation. The fourth stage will include a patient evaluation to establish whether the intended healthcare outcomes have been met.
To overcome the barrier of patients not participating, follow-up phone calls and instructions will be used to assist the patient by providing a continuation and continuity of care. Staff involvement will be of utmost importance by assisting the patients with guidelines and a liaison for questions during the pre-operative period. During the postoperative period, patients will again have the opportunity to have a specific liaison for questions. The failure to participate in therapy or to take pain medication can cause adverse effects on the treatment and be a potential barrier that affects the outcomes.
Conclusions and Contributions to the Professions of Nursing
Studies involving fast-track set-up or ERAS showed improvements in the achievement of discharge criteria, having a positive effect, decreasing complications, and ultimately reducing length of stay (LOS). Utilization of an ERAS protocol has been shown to contribute to decreased pain, reduced length of stay, and decreased hospital costs (Brink et al., 2018; Li & Chen, 2019; Politi et al., 2017; Zhang et al., 2018). Perioperative education is essential for patients to understand the benefits of participating in such a program. To assist with educational goals, evidence has proven that the programs yield great benefits. The standard ERAS program may improve the knowledge of not only of the nursing staff but also of the clinic and surgical staff as well. The ERAS protocols would need to include the recent drug developments contributing to continued improvement in anesthesia and post-operative care. This in turn would enhance current practice by allowing patients to recover faster by maintaining normal physiology and avoiding complications that lead to longer length of stay (Pritchard et al., 2020; Soffin et al., 2016; Wainwright et al., 2020; Zhu et al., 2017). Financially, the advantage is beneficial to the organization and leads to savings needed to meet budgets, allows for additional staffing/beds and continued educational opportunities. A detailed strategy includes coordinating current practice with patient needs.
The ERAS protocol should be tailored to each patient as necessary. Most surgical staff lack knowledge regarding ERAS programs. However, many surgical nurses, advanced nurse practitioners, and participants lack knowledge of ERAS protocols. Additionally, many patients lack understanding of long-acting vs short-acting pain medication. Leaders of healthcare organizations should understand that the sustainability of the project depends on healthcare professionals’ adherence to the ERAS protocol guidelines which can best happen when nurses are educated on how to implement the ERAS guidelines (Elias et al., 2019; Inacio et al., 2017; Molloy et al., 2017). Many studies focused on total joint replacement and therefore, future research should implement evidence-based, multidisciplinary postoperative protocols associated with safe early recovery and decreased length of stay without compromising clinical outcomes.
Alignment with Expected Outcomes
The results of the integrative review are adequately aligned with the expected outcomes. The outcome that was defined in the PICOT was to assess the impacts of ERAS guidelines on length of stay in adult surgical patients. The results revealed that the integration of the ERAS guidelines into the care protocols for adult surgical patients decreased length of stay while also decreasing complications and pain. Those who utilized the Early Recovery After Surgery Program were found to return to everyday motor function sooner and length of stay was reduced by almost 50% (den Hertog et. al., 2012). The specific outcomes noted with Early Recovery After Surgery Programs were the return of motor function in a shorter time, resulting in decreased length of stay (den Hertog et. al, 2012). Chen et. al., (2012) noted that a prospective cohort study among post-operative total knee replacement patients focused on the physical effects of surgery and therapy interventions beginning on the day of surgery. The rehabilitation process started in the inpatient unit when patients were transferred from post-anesthesia care unit and found that mobilization on day one had a shorter length of stay than those who started on day two or three. The goal of implementing the program include improving function and mobility, pain control, support from others, involvement and understanding of care decisions, coping mechanisms, and concern regarding sleeping and fatigue.
Recommendations
The nursing profession and society, in general, should utilize the best practice evidence gathered from the integrative review to change clinical practice with adult surgical patients in their settings with the aim of improving patient outcomes. Results of the integrative review indicate that improvements in narcotic consumption, mobility, pain, and hospital LOS are to be expected in patients undergoing total knee replacement procedures. The evidence further indicates that the inclusion of the ERAS protocols into the patient care sessions can prevent patients from developing complications thereby reducing length of hospital stay. However, more evidence is necessary to develop a nationally adopted ERAS protocol that enhances postoperative patient outcomes. Therefore, further research on early mobility, pre-operative education, and medication along with anesthesia and analgesia modalities within ERAS protocols for total knee replacement patients is necessary to observe variations in patient outcomes.
ERAS guidelines are associated with both quality and cost benefits in contemporary healthcare settings. One of the three key recommendations to consider based on the integrative review is to use evidence-based pain management medications and interventions to manage pain and increase blood flow. The other recommendation is to educate healthcare professionals on the effective implementation of the ERAS guidelines with surgical patients to improve health outcomes. Again, leaders of contemporary healthcare facilities should support the incorporation of ERAS guidelines into the standard operating procedures of their organization to improve the quality of care received by their surgical patients. These recommendations, when taken into consideration will reduce length of stay and minimize healthcare hospitalizations in hospitals.
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Li, Z., & Chen, Y., (2019). Ketamine reduces pain and opioid consumption after total knee arthroplasty: A meta-analysis of randomized controlled studies. International Journal of Surgery (London, England), 70, 70-83. https://doi.org/10.1016/j.ijsu.2019.08.026
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Appendices, Tables, and Figures
Appendix A
Johns Hopkins Nursing Evidence-Based Practice
Appendix G Individual Evidence Summary Tool
© The Johns Hopkins Hospital/Johns Hopkins University. May not be used or reprinted without permission.
|
Article Number |
Author and Date |
Evidence Type |
Sample, Sample Size, Setting |
Findings that Help Answer the EBP Question |
Observable Measures |
Limitations |
Evidence Level, Quality |
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| 1 | Brinck et al., 2018
|
Systematic review
(Cochrane review) Level 1 |
130 studies with 8341 participants. Ketamine was given to 4588 participants and 3753 participants served as controls. | The use of intraoperative ketamine reduces
opioid consumption by 8mg morphine equivalents at 24 hours and by 13mg at 48 hours. Intraoperative ketamine decreased postoperative pain scores at 24 and 48 hours. |
Results were consistent in different operation types or timing of ketamine administration, with larger and smaller studies, and by higher and lower pain intensity. CNS adverse events were little different with ketamine or control. Perioperative intravenous ketamine probably reduces postoperative nausea and vomiting by a small extent, of arguable clinical relevance. | Various types of surgeries were utilized, not only total knee replacement which could affect differences in perceived pain.
Types of surgery included ear, nose or throat surgery, wisdom tooth extraction, thoracotomy, lumbar fusion surgery, microdiscectomy, hip joint replacement surgery, knee joint replacement surgery, anterior cruciate ligament repair, knee arthroscopy, mastectomy, haemorrhoidectomy, abdominal surgery, radical prostatectomy, thyroid surgery, elective caesarean section, and laparoscopic surgery |
Level 1
Quality A |
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| 2 | Burn et al. (2018) | Systematic Review
Level 1 Cross-sectional study using routinely collected data. |
National Health Service primary care records from 1995 to 2014 in the Clinical Practice Research Datalink were linked to hospital inpatient data from 1997 to 2014 in Hospital Episode Statistics Admitted Patient Care. | 10 260 primary TKR, 10 961 primary THR, 505 revision TKR and 633 revision THR were included.
Expected length of stay fell from 16.0 days (95% CI 14.9 to 17.2) in 1997 to 5.4 (5.2 to 5.6) in 2014 for primary TKR and from 14.4 (13.7 to 15.0) to 5.6 (5.4 to 5.8) for primary THR, leading to savings of £1537 and £1412, respectively.
Length of stay fell from 29.8 (17.5 to 50.5) to 11.0 (8.3 to 14.6) for revision TKR and from 18.3 (11.6 to 28.9) to 12.5 (9.3 to 16.8) for revision THR, but no significant reduction in reimbursement was estimated.
The estimated effect of year of surgery remained similar when patient characteristics were included. |
To measure changes in length of stay following total knee and hip replacement (TKR and THR) between 1997 and 2014 and estimate the impact on hospital reimbursement, all else being equal. Further, to assess the degree to which observed trends can be explained by improved efficiency or changes in patient profiles. | Routinely collected data provided real-world information on trends in length of stay following primary knee and hip replacement and revision procedures.
Patient characteristics were controlled for to assess whether trends in length of stay and associated hospital reimbursement were explained by changes in patient characteristics or improved efficiency. Codes used to identify diagnoses of osteoarthritis have not been fully evaluated.
|
Level 1
Quality A |
|||||||||
| 3 | Cram et al., (2021) | Systematic Review
Level 1 |
Observational cohort of 3,271,851 patients (aged ≥65 years) who underwent primary TKA and 318 563 who underwent revision TKA identified in Medicare Part A data files. | Between 1991 and 2010 annual primary TKA volume increased 161.5% from 93,230 to 243,802 while per capita utilization increased 99.2% (from 31.2 procedures per 10,000 Medicare enrollees in 1991 to 62.1 procedures per 10,000 in 2010). Revision TKA volume increased 105.9% from 9650 to 19,871 while per capita utilization increased 59.4% (from 3.2 procedures per 10,000 Medicare enrollees in 1991 to 5.1 procedures per 10,000 in 2010). For primary TKA, LOS decreased from 7.9 days (95% CI, 7.8-7.9) in 1991-1994 to 3.5 days (95% CI, 3.5-3.5) in 2007-2010 (P < .001). For primary TKA, rates of adverse outcomes resulting in readmission remained stable between 1991-2010, but rates of all-cause 30-day readmission increased from 4.2% (95% CI, 4.1%-4.2%) to 5.0% (95% CI, 4.9%-5.0%) (P < .001). For revision TKA, the decrease in hospital LOS was accompanied by an increase in all-cause 30-day readmission from 6.1% (95% CI, 5.9%-6.4%) to 8.9% (95% CI, 8.7%-9.2%) (P < .001) and an increase in readmission for wound infection from 1.4% (95% CI, 1.3%-1.5%) to 3.0% (95% CI, 2.9%-3.1%) (P < .001). | To examine longitudinal trends in volume, utilization, and outcomes for primary and revision TKA between 1991 and 2010 in the US Medicare population. | Limitation includes only Medicare patients and not those with standard healthcare insurance. | Level 1
Quality A |
|||||||||
| 4 | Deng et al., (2018)
|
Systematic review with meta-analysis. | A total of 25 studies involving 16 699 patients met the inclusion criteria and were included in the meta-analysis. | Compared with conventional care, ERAS was associated with a significant decrease in mortality rate (relative risk (RR) 0.48, 95% CI 0.27 to 0.85), transfusion rate (RR 0.43, 95% CI 0.37 to 0.51), complication rate (RR 0.74, 95% CI 0.62 to 0.87) and LOS (mean difference (MD) -2.03, 95% CI -2.64 to -1.42) among all included trials.
5However, no significant 6ifference was found in ROM 7MD 7.53, 95% CI -2.16 to 87.23) and 30-day 9eadmission rate (RR 0.86, 95% CI 0.56 to 1.30).
There was no significant difference in complications of TKA (RR 0.84, 95% CI 0.34 to 2.06) and transfusion rate in RCTs (RR 0.66, 95% CI 0.15 to 2.88) between the ERAS group and the control group. |
To evaluate the effects of enhanced recovery after surgery (ERAS) on the postoperative recovery of patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA). | ERAS did not show a significant impact on ROM and 30-day readmission rate. Complications after hip replacement are less than those of knee replacement, and the young patients recover better. | Level 1
Quality B |
|||||||||
| 5 | Elias et al. (2019) | Systematic Review | A checklist and statement were developed by a small working group of volunteers from ERAS® USA (the American chapter of the ERAS® Society). A subcommittee (KME, KM, JIT) from the ERAS® USA Research Committee reviewed ERAS-related publications from across different medical specialties and study designs. In developing the checklist, subcommittee members were asked to review 10–15 manuscripts each from anesthesia, surgery, or general interest journals and tasked to define best practices in ERAS reporting.
|
This subcommittee developed an initial list of 32 items for inclusion in a checklist of best practices. After discussion with the larger committee, this number was reduced to 20 items to focus the checklist on elements related to ERAS rather than to general guidelines for best practices in research reporting. The total number of elements was reduced by removing those redundant with general reporting guidelines, for example the Enhancing Quality and Transparency Of health Research (EQUATOR) network guidelines, or by combining similar elements to make the checklist more concise | Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients.
Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types.
As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. |
Study was not a meta-analysis but designed to implement a guideline for ERAS
|
Level 2
Quality A |
|||||||||
| 6
|
Inacio et al. (2017) | Economic and decision analysis. | Australian State and Territory Health Department data were used to identify TKAs and THAs performed between 1994 and 1995 and 2013 and 2014. The Australian Bureau of Statistics was the source of the population estimates for the same periods and population-projected estimates until 2046. The incidence rate (IR), 95% CI, and prediction interval (PI) of TKAs and THAs per 100,000 Australian citizens older than 40 years were calculated. Future IRs were estimated using a logistic model, and volume was calculated from projected IR and population. The logistic growth model assumes the existence of an upper limit of the TKA and THA incidences and a growth rate directly related to this incidence. At the beginning, when the observed incidence is much lower than the asymptote, the increase is exponential, but it decreases as it approaches the upper limit.
❑ |
A 66% increase in the IR of primary THAs between 2013 and 2046 is projected for Australia (2013: IR = 307 per 100,000, [95% CI, 262-329 per 100,000] compared with 2046: IR= 510 per 100,000, [95% PI, 98-567 per 100,000]).
This translates to a 219% increase in the volume during this period.
For TKAs the IR is expected to increase by 26% by 2046 (IR = 575 per 100,000; 95% PI, 402-717 per 100,000) compared with 2013 (IR = 437 per 100,000; 95% CI, 397-479 per 100,000) and the volume to increase by 142%. |
To determine the projected incidence and volume of primary TKAs and THAs from 2014 to 2046 in the Australian population older than 40 years.
|
Limited to Australian patients although finding a direct correlation to global community | Level 2
Quality A |
|||||||||
| 7 | Li & Chen, (2019) | Meta-analysis
of randomized controlled trials |
Six Randomized control trials | The methodological quality of the six RCTs were evaluated with Cochrane Collaboration’s tool. All RCTs indicated that participants were randomized with a computerized random number generator. Three RCTs reported that an opaque, sealed envelope was used to ensure allocate concealment. Five studies reported the blinding of the participant and personnel. All RCTs provided complete outcome data. | Ketamine reduces postoperative
pain scores and postoperative morphine consumption with less adverse effects. |
Several limitations of this study should be noted. Firstly, we only included six RCTs with 244 patients in our study; more RCTs with higher quality will be helpful for future study. Secondly, there existed significant heterogeneity among studies and the subgroup analysis was not performed due to the small number of included articles, thus the source of heterogeneity was not identified. Thirdly, having been restricted to a limited number of included studies and data extracted, we did not compare the functional recovery between the two groups. Lastly, the lack of uniform doses of ketamine and the start time of administration might contribute to the deviation of the overall results in the present study. | Level 2
Quality A |
|||||||||
| 8 | Molloy et al. (2017) | Meta-Analysis | Procedure, demographic, and economic data were collected on 6.4 million admissions for total knee arthroplasty and 2.8 million admissions for total hip arthroplasty from 2002 to 2013 using the National (Nationwide) Inpatient Sample, a component of the Healthcare Cost and Utilization Project. Trends in mean hospital costs and their association with length of stay were estimated using inflation-adjusted, survey-weighted generalized linear regression models, controlling for patient demographic characteristics and comorbidity. | From 2002 to 2013, the length of stay decreased from a mean time of 4.06 to 2.97 days for total knee arthroplasty and from 4.06 to 2.75 days for total hip arthroplasty.
During the same time period, the mean hospital cost for total knee arthroplasty increased from $14,988 (95% confidence interval [CI], $14,927 to $15,049) in 2002 to $22,837 (95% CI, $22,765 to $22,910) in 2013 (an overall increase of $7,849 or 52.4%).
The mean hospital cost for total hip arthroplasty increased from $15,792 (95% CI, $15,706 to $15,878) in 2002 to $23,650 (95% CI, $23,544 to $23,755) in 2013 (an increase of $7,858 or 49.8%).
If length of stay were set at the 2002 mean, the growth in cost for total knee arthroplasty would have been 70.8% instead of 52.4% as observed, and the growth in cost for total hip arthroplasty would have been 67.4% instead of 49.8% as observed.
|
Utilization of total knee and hip arthroplasty has greatly increased in the past decade in the United States; these are among the most expensive procedures in patients with Medicare. Advances in surgical techniques, anesthesia, and care pathways decrease hospital length of stay. We examined how trends in hospital cost were altered by decreases in length of stay | Although we included same-day joint replacement procedures performed within the hospital setting, we did not include joint replacements performed in an outpatient or ambulatory setting because our data derived from an inpatient database. | Level 1
Quality A |
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| 9 |
|
Qualitative: participant observation and focus group interviews
|
Sample: 64 participants
Setting: Five hospitals in northern California who implemented project RED
|
IV: RED Toolkit: adherence
To 12 RED components
DV: Sustainability: 6 months beyond the implementation period prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study.
There was ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. |
External factors influencing RED adaptation and implementation: federal penalties for high readmission rates, access to external funding and technical support to help hospitals implement RED. Internal factors: committed leadership to RED, RED adaptations, accountability & influence of the implementation team sustainability planning and hospital culture. 3/5 hospitals continued RED beyond the implementation period
|
Modified grounded theory approach with constant comparative analysis.
A key limitation is that standard practices have changed over the period covered by the included studies.
|
Level 3
Quality A |
|||||||||
| 10 | Politi et al., (2017) | Randomized
prospective trial comparing the use of intravenous versus oral acetaminophen in total joint arthroplasty |
One hundred twenty patients undergoing hip and knee arthroplasty surgeries performed by one joint arthroplasty surgeon were prospectively randomized into 2 groups. Group 1 (63 patients) received IV and group 2 (57 patients) received PO acetaminophen in addition to a standard multimodal perioperative pain regimen. Each group received 1 gram of acetaminophen preoperatively and then every 6 hours for 24 hours. Total narcotic use and visual analog scale (VAS) scores were collected every 4 hours postoperatively. | The route of administration IV
or PO acetaminophen had no effect on 24 hour hydromorphone equivalents or 24 hour postoperative pain scores. |
Data from article supports the use of
PO acetaminophen when IV acetaminophen is not available due to high cost. |
Only 120 patients were used
Multimodal pain management has had a significant effect on improving total joint arthroplasty recovery and patient satisfaction. There is literature supporting that intravenous (IV) acetaminophen reduces postoperative pain and narcotic use in the total joint population. However, there are no studies comparing the effectiveness of IV vs oral (PO) acetaminophen as part of a standard multimodal perioperative pain regimen. |
Level 2
Quality B |
|||||||||
| 11 | Pritchard et al. (2020) | Systematic review of cost–utility analyses. | We identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. | Consistent results supported and enhanced recovery pathways as a whole.
Ten recovery pathway components were more effective, and cost-saving compared with usual care.
Three recovery pathways were cost-effective, and two were not cost-effective.
|
To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work. | A key limitation is that standard practices have changed over the period covered by the included studies.
We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation. |
Level 1
Quality B |
|||||||||
| 12 | Soffin et al. (2016) | Systematic Review | Detailed review of published evidence
|
An early study found that explicit pre-anesthesia education significantly relieved anxiety and emotional stress before hip or knee replacement.
Preoperative education contributes to higher patient confidence, greater patient satisfaction, and early3recovery and discharge.
It is essential that a preoperative education programme should establish achievable goals for postoperative oral intake, analgesia, physical therapy, and mobilization |
Significant progress has been made in the application of ERAS to hip and knee arthroplasty. Decades of research have improved patient safety, improved outcomes, reduced length of hospital stay, and effected cost savings. However, there is still significant work to be done. | Despite these benefits, it is unknown whether early mobilization is associated with other complications after joint arthroplasty, including loosening, dislocation, and bleeding. High-quality studies of post-discharge rehabilitation are also lacking, including the ideal composition and duration of a course of treatment. | Level 2
Quality B |
|||||||||
| 13 | Wainwright et al. (2020) | Systematic Review | Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies.
Over the last 15 years, the systematic implementation of an evidence-based perioperative care protocol (“fast-track” or “enhanced recovery pathway”), such as that developed by the Enhanced Recovery After Surgery (ERAS) Society, has shown that hospital length of stay and complications can be reduced for a number of surgical procedures. |
When using an ERAS pathway, unselected patients can be routinely discharged from hospital 0–3 days following surgery, with no increased effect on morbidity or mortality.
ERAS protocol reduces length of stay and postoperative complications for a number of surgical procedures.
ERAS guidelines are an important document in summarizing the large volume of heterogeneous studies across all components within hip and knee replacement surgery. |
There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program. | More specifically, work is still required in order to understand how to reduce the inflammatory response postoperatively; how to further reduce pain; how to reduce impairment of physical activity and improve function quicker postoperatively; how to better identify patients at high risk of complications owing to psychiatric disorders, chronic renal failure, and orthostatic intolerance; anemia and transfusion thresholds; postoperative urine retention and urinary bladder catheterization; and how to improve sleep | Level 1
Quality B |
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| 14 | Zhang et al. (2018) | Randomized
control trial |
A total of 84 eligible patients (28 male and 56 female) aged 42–74 years were chosen and randomly separated into four groups using a computer-generated randomization program (REDcap; version 8; National Institutes of Health, Bethesda MD, USA) by an independent statistician. Patients were anesthetized with general anesthesia (as indicated above) followed by IA injection of 20 ml saline (control group; n=23), ketamine (2 mg/kg) infused with saline (ket group; n=21), bupivacaine (0.5 mg/kg) infused with saline (bupi group; n=20), or ketamine (2 mg/kg)+bupivacaine (0.5 mg/kg) infused with saline (ket+bupi group; n=20) using spinal needle between the deep and superficial soft tissue of knee at the end of the surgery. All study opioids were supplied as coded and blinded from both the surgeon and anesthesiologist. | The study demonstrated that the ketamine and bupivacaine group exhibited better post-operative pain control following TKA through improving pain control and patient satisfaction, and decreasing opioid consumption and adverse effects, thereby facilitating early knee mobilization as compared with other groups, due to synergic analgesic activity. | Opioid consumption in
ketamine group was significantly less than control group. Postoperative pain scores at 24 and 48 hours was significantly reduced compared to the control group. |
Therefore, the multimodal analgesic regimen (ket+bupi) may be useful in mitigating post-operative pain and improving knee mobilization following TKA. Further studies with a different dosage, perhaps in a larger clinical trial, are required to justify the mechanism behind the synergic analgesic effect of those drugs. | Level 2
Quality A |
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| 15 | Zhu et al. (2017) | Meta Analysis | A total of 10 published studies (9936 cases) met the inclusion criteria. The cumulative data included 4205 cases receiving enhanced recovery after surgery (ERAS), and 5731 cases receiving traditional recovery after surgery (non-ERAS).
To collect data of randomized controlled trials (RCTs) and clinical controlled trials (CCTs) for evaluating the effects of enhanced recovery after surgery on postoperative recovery of patients who received total hip arthroplasty (THA) or total knee arthroplasty (TKA). |
The meta-analysis showed that LOS was significantly lower in the ERAS group than in the control group (non-ERAS group) (p<0.01).
There were fewer incidences of complications in the ERAS group than in the control group (p=0.03).
However, no significant difference was found in the 30-day readmission rate (p=0.18).
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The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications.
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Overreliance on secondary data may affect the reliability of findings. | Level 1
Quality A |