Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Christopher P Childers; Anaar E Siletz; Emily S Singer; Claire Faltermeier; Q Lina Hu; Clifford Y Ko; Gregory J Golladay; Stephen L Kates; Elizabeth C Wick; Melinda Maggard-Gibbons

doi:10.1177/2151458518754451

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Geriatr Orthop Surg Rehabil. 2018 Feb 12:9:2151458518754451. doi: 10.1177/2151458518754451. eCollection 2018.

Authors

Affiliations

¹ Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
² David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
³ American College of Surgeons, Chicago, IL, USA.
⁴ Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA.
⁵ Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA.

Abstract

Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery-a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Study design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format.

Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning.

Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

Keywords: enhanced recovery; patient safety; quality improvement; total hip replacement; total joint replacement; total knee replacement.

Publication types

Review

Abstract

Publication types

Grants and funding