Purpose
The purpose of this assignment is to synthesize the literature that supports the evidence-based intervention for the quality improvement project.
Course Outcomes
This assignment enables the student to meet the following course outcomes:
CO 2: Demonstrate effective project management strategies (POs 2, 3, 6, 7, 8).
CO 4: Apply theory and evidence from management, policy, and perspectives to support quality improvement and patient safety in healthcare systems (POs 3, 4, 6).
Due Date(s)
The Late Assignment Policy applies to this assignment.
The assignment title is due by Sunday 11:59 p.m. MT at the end of Week 4.
Total points possible: 50
Preparing the Assignment
Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.
Synthesize at least 10 (no more than 5 years old) primary research studies and/or systematic reviews; do not include summary articles. This synthesis should focus on the evidence-based peer-reviewed research articles that support your intervention. This section is all about the scientific evidence rather than someone else’s opinion of the evidence. Do not use secondary sources; read the entire article and make your own decision about the level of evidence, quality of the evidence, and applicability to your question. The evidence cited in this section must relate directly to your intervention. This is a synthesis where you address the similarities, differences, and controversies in the body of evidence to support your intervention.
The Johns Hopkins Individual Evidence Summary Tool and the Johns Hopkins Research Evidence Appraisal Tool are located in the Student Resource Center. You will be submitting the Johns Hopkins Individual Evidence Summary Tool with this assignment.
Consider organizing this section through use of themes inherent in the literature. For example, if you are focusing on falls prevention, organize this section as demonstrated below through use of level II headings.
Falls Prevention: Hourly Rounding Process
Falls Prevention: Team Huddles
Falls Prevention: Additional Strategies
The following are the requirements for the literature synthesis and Johns Hopkins Evidence Table as spelled out in the rubric:
Literature Synthesis Requirements:
- Identifies search strategy utilized to identify sources to include appropriate databases such as CINAHL, Cochrane, and PubMed. Do not use Google Scholar or general search engine. Discusses key words utilized including combination of keywords, total articles found and inclusion/exclusion criteria to narrow search.
- Synthesizes 10-12 research articles that are Evidence Level 1, 2 or 3 (unless faculty approved) to support evidence-based intervention. Describe how the intervention has been utilized to solve a similar problem by defining common themes found in the literature.
- References are less than 5 years old (unless seminal) and professional. PermaLink of all articles is attached.
Literature synthesis table:
- Completed with evidence level and quality (High, Good, Low or major flaws) identified for each article, including appropriate appraisal of the level of evidence.
- Identifies appropriate study design.
- Accurately assesses how the article can inform the project. If article does not inform the project, then it should not be used.
Clarity of Writing
- Use of standard English grammar and sentence structure.
- No spelling errors or typographical errors.
- Organized around the required components using appropriate headers.
APA Formatting/References
All information taken from another source, even if summarized, must be appropriately cited in the manuscript and listed in the references using APA (current edition of the APA manual) format.
- Document setup
- Title and reference pages
- Citations in the text and references
Rubric
NR705 Draft Literature Synthesis JAN21
| NR705 Draft Literature Synthesis JAN21 | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeLiterature Synthesis Requirements:
1)Identifies search strategy utilized to identify sources to include appropriate databases such as CINAHL, Cochrane, and PubMed. Do not use Google Scholar or general search engine. Discusses key words utilized including combination of keywords, total articles found and inclusion/exclusion criteria to narrow search. 2)Synthesizes 10-12 research articles that are Evidence Level 1, 2 or 3 (unless faculty approved) to support evidence-based intervention. Describe how the intervention has been utilized to solve a similar problem by defining common themes found in the literature. 3) References are less than 5 years old (unless seminal) and professional. PermaLink of all articles is attached. |
|
30 pts | ||||
| This criterion is linked to a Learning OutcomeLiterature synthesis table
1) Completed with evidence level and quality (High, Good, Low or major flaws) identified for each article, including appropriate appraisal of the level of evidence. 2) Identifies appropriate study design. 3) Accurately assesses how the article can inform the project. If article does not inform the project, then it should not be used. |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeClarity of Writing Requirements:
1) Use of standard English grammar and sentence structure. 2) No spelling errors or typographical errors. 3) Organized around the required components using appropriate headers. |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeAPA Formatting/References Requirements:
All information taken from another source, even if summarized, must be appropriately cited in the manuscript and listed in the references using APA (6th ed.) format. 2) Title and reference pages 3) Citations in the text and references |
|
5 pts | ||||
| Total Points: 50 | ||||||
Early Recovery After Surgery for Total Knee Replacement
Robin G. Major
Chamberlain College of Nursing
Abstract
Please use the following headings for the abstract. Be brief and concise when addressing each heading keeping to 2-4 sentences per heading. The abstract should be a brief overview of your project.
Background:
Local Problem:
Methods:
Interventions:
Results:
Conclusions:
Keywords: [Click here to add keywords.]
Dedication
[Directions – a dedication provides the author with the opportunity to thank people who may have special meaning in the author’s life. For example – you may want to thank you spouse or a specific family member for their support during your doctoral education. The deduction does not need to be long but it should convey your appreciation for the contribution this or these individuals made in your life while you were a doctor of nursing practice student. The dedication is written as a part of your final DNP writing in NR709.]
Acknowledgements
[Directions – the acknowledgement page is reserved for the author to acknowledge the important role specific professional people have made toward the successful completion of the project. In the acknowledgement page, you may want to thank your professors, your preceptor, and members of your DNP committee. This is the perfect place to acknowledge the practicum site and your colleagues that supported you through the completion of your doctoral education. Again – the acknowledgement page does not need to be long, but it does need to include professionals that helped you during your education. This page is generally completed in NR709 as a part of your final writing.]
Table of Contents
Literature Synthesis (DONE IN NR 705) 7
Evidence-Based Intervention. 8
Considerations and Challenges for Implementation. 9
Project Management Plan and Gantt Chart 11
Ethical Issues and Considerations. 12
Conclusions and Implications for Nursing Practice. 16
Appendices, Tables, and Figures. 19
Does Early Recovery After Surgery (ERAS) guidelines, compared to current practice, impact the postoperative length of stay in 11-12 weeks?
Long before COVID-19 created even greater issues, hospitals faced issues 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 in order 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. 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.
Patients who undergo a total knee replacement have a current length of stay of two to three days at Franciscan Alliance Hospital. By evaluating other facilities, the surgeons and the hospital administration determined that the goal will be a one to two-day stay 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 increase the 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 (Zhang & Jordan, 2010). 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 (Wolford, 2015). Locally and globally, increased demand for knee replacements causes an increased burden on financial and clinical resources (Sprownson et al., 2013), and an increased demand for lower extremity joint replacements, which greatly impacts the United States healthcare system. 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 (Savaridas et al.,2013). 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 (Lukyanova & Reede, 2015). Due to federal guidelines readmission is then absorbed by the hospital system impacting the hospital system financially.
Practice Question
The following practice question will serve as the basis for the proposed DNP project, “Does Early Recovery After Surgery (ERAS) guidelines, compared to current practice, impact the postoperative length of stay in 11-12 weeks?”
Literature Synthesis
The use of ERAS guidelines has been shown to improve patient outcomes. Orthopedic patients undergoing total joint replacement receiving additional education and training before surgery have demonstrated improved outcomes and decreased length of stay in the hospital (Leiss et al., 2021). A national effort to catalyze the implementation of specific practices to enhance the early recovery of surgical patients. 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.
Literature Search Process
Search terms included key words and specific years to identify literature using Chamberlain University library which includes Medline, CINAHL, Journals @ OVID, EBSCOhost and ProQuest. Peer-reviewed, full-text available and English-language literature was reviewed from 2017 through 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. Key words 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 above detailed search process resulted in 1900 article citations, 40 abstracts and found 23 articles that found 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 and 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, 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 literature 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 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) patient education component of ERAS is associated with reduced 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. Detailed information related to these themes are as described below;
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. Increases length of hospital stay is associated with increased hospital costs whereas reduced length of hospital stay minimizes hospital costs. According to Pritchard et al. et al. (2020), the utilization of enhance recovery pathways after surgery, including total joint replacement, is associated with a shorter length of stay, decreased adverse reactions and decreased hospital cost among postoperative patients. When recovery rate is enhanced among post-operative patients, they tend to leave the hospital within few days. This in turn assists with keeping hospital beds open for emergencies and decreases staff needed. The Agency for Healthcare Research and Quality (AHRQ) started an initiative to increase 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 length of stay among postoperative patients resulted in a reduction in hospital costs. Evidence from the study indicates that 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 lifestyle 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 detailing patient understanding of the program and the importance of support and follow up (Zhu et al., 2017). Preoperative education is unlikely to cause harm and is available through different forms enhancing the need for ERAS program. These findings were further substantiated by Soffin et al. (2016). Through a detailed review of 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 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 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 practice 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 reduce 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 patient 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) indicate that a 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 are able to yield better patient care and outcomes.
Surgery trends with 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 meet the anticipated needs of patients when the volume of surgery patients increase.
Purpose of the Project
Over the past several years, Early Recovery After Surgery (ERAS) programs provide this pre-operative education and enhance the patient experience leading to decreased length of stay, reduced cost, and improved recovery time. The providers, staff, and leaders at the project organization work hard to ensure total care aspects are upheld by patients, ancillary staff, and other providers involved in the care; however, they identified an opportunity to impact the postoperative length of stay. Increased hospital LOS has been associated with increased complications, including deep venous thrombosis, pulmonary embolism, urinary retention, and infection. Reducing LOS has been shown to also improve functional recovery (Yakattani et al., 2019). The purpose of the proposed DNP project is to decrease the length of stay and improve orthopedic patients’ LOS post knee replacement surgery, through the implementation of the ERAS guidelines. Adult patients scheduled for a single total knee replacement performed by Dr. Payne will receive pre- and post-operative instruction about the use of the ERAS in order to empower the patient toward a more successful operative outcome. The specific aim of the project is to improve patient outcomes of pain control, movement post-operatively and decrease length of stay.
This aim is supported by the following objectives: (a) to educate the staff at Franciscan Alliance Hospital about the ERAS program, reinforcing and supporting the program’s outcomes to improve the quality of patient care; (b) to empower adult patients to take an active role in the pre- and post-operative care through the use of the ERAS guidelines; and (c) to establish a plan for a timely post-operative discharge so that patients are aware of care needed after discharge from the acute care facility.
The Proposed Evidence-Based Intervention
The implementation of an Early Recovery After Surgery (ERAS) program can reduce the length of stay, pain and assist with early rehabilitation according to Lam et. al., (2017). This evidence-based intervention consists of utilizing techniques prior to surgery to enhance the recovery period. The intervention focuses on improving patient self-care knowledge, improving healthcare outcomes and reducing hospital length of stay after total knee replacement. It is crucial that patients are educated for understanding the steps to early recovery, beginning at the scheduling phase, and reinforcing throughout the surgical experience. The first phase of the program will provide education to the patients upon scheduling total knee replacement. Several weeks prior to surgery, the patients will attempt a walking program to begin therapy immediately postoperatively. The patient will also attend a mandatory total joint replacement class. The teacher of the class is a registered nurse who will work with the patients on the floor postoperatively.
One week prior to surgery, patients will begin a medication protocol designed to decrease post-operative pain which includes starting Gabapentin and Tylenol. Implementation of the program will include hospital staff, anesthesia, and surgical residents to prescribe a specific medication for pain management. Oseka & Pecka (2018, p.1) note that “the administration of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentinoids, and corticosteroids resulted in shorter hospital LOS and decreased postoperative pain and opioid consumption. A spinal anesthetic block provided benefits over general anesthesia, including decreased 30-day mortality rates, hospital LOS, blood loss, and complications”.
To implement a new program, specific criteria must be reviewed and examined. The specific patient population being addressed can benefit from a service or intervention and specific methods should be utilized for appropriate mechanisms realizing there will be certain limitations. Specific information includes approaches used in surgery, for example, anterior vs posterior total hip arthroplasty. Lengurreand et al., (2016) found that there were significant improvements in function and pain after surgery within the global 90-day period without evidence of further complications as well as decreased LOS when implementing an ERAS program.
Transitional science method for this project is the Knowledge to Action model and it focuses on the nature of the essential context, leadership, and stakeholder engagement within the facility. The model focuses on 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).
The Knowledge to Action Model assists the project by utilizing seven stages including knowledge inquiry and synthesis. The steps are 1) monitor knowledge use, 2) evaluate outcomes, 3) sustain knowledge use, 4) identify the problem, 5) adapt knowledge to the local context,6) assess barriers to knowledge use, and 7) select, tailor, and implement interventions (Lockwood et al., 2016). The DNP student can adopt these methods to assess the problem within the local facility and share information within the hospital network.
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 by phone or an in-person visit each patient schedule for a total knee replacement by Dr. Payne 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 presentation to the stakeholders providing the evidence-based findings.
Organizational Setting for the Project
The DNP will be completing the practicum project within Franciscan Alliance in Olympia Fields, Illinois at the Specialty Physicians of Illinois, (SPI) which is a part of the Franciscan system. There are three surgeons in the current practice. Collectively, approximately 290 patients are seen in the clinic weekly. The surgeon who will be involved with the project, Dr. Payne, provides medical care to approximately 100 patients per week. Patients are insured through private companies and Medicare. The clinic does accept certain forms of Medicaid. A few private pay patients are treated in the clinic and a discount is provided for cash payment.
The clinic utilizes only medical assistants and one advanced practice nurse. The clinic is open Monday through Friday, 8:00 am – 5:00 pm. Weekend availability is through the surgical residents who are on call.
Population Description
The organization is a suburban hospital south of Chicago, Illinois. The hospital is part of a 16-hospital system under the Franciscan Alliance umbrella located in Indiana. The hospital has 283 inpatient beds. Most patients are insured with private, group or Medicare and Medicaid. The patients included can self-refer depending on insurance criteria or in the case of an HMO, are referred to the orthopedic specialty by their primary care provider. There are currently three orthopedic surgeons, one nurse practitioner, two podiatrists, no nurses, and eight medical assistants in the clinic. The project will mainly involve the patients, one advanced practice nurse, age 56 with 25 years’ experience, and one surgical scheduler who will provide the surgical patient’s information and guidance to contact the advanced practice provider. Patient population includes Hispanic, African American and Caucasian patients, male and female, ranging from 40 to 80 years old.
Considerations and Challenges
A potential barrier to implementing an Early Recovery After Surgery (ERAS) program will be staff involvement and the staff seeing a change as a negative or increase in their workload. Surgical clinics with a greater staff involvement noted that patients were more engaged with the program due to understanding the information provided to them. It has been determined by staff interviewing patients that many patients do not read the pre-op information or do not understand the impact of such education. The protocol presently includes medical clearance from primary care physician, BMI <40, fasting labs with CBC >11, HgA1c <7.5 within the last three months, Albumin >3.5. Patients with obstructive sleep apnea will undergo pulmonary function tests prior to surgery after implementation. Pain management includes decreasing or discontinuing narcotics at least four weeks prior to surgery. Patients are to undergo a total joint class at the hospital prior to surgery.
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).
To overcome the barrier of patients not participating, follow-up phone calls and instruction will 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 to the opportunity to have a specific liaison for questions. The failure to participate in therapy or to take pain medication can cause adverse effects to the treatment and be a potential barrier that affects the outcomes.
Expected Outcomes
The outcomes are defined by the PICOT question which is to determine a method of intervention that will decrease length of stay while also decreasing complication 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).
Outcomes noted with Early Recovery After Surgery Programs were 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 on 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.
Data Management Plan
The data management plan identifies the outcome measure analysis to determine if the evidence-based intervention is effective in impacting the practice problem at the practicum site. The data collection for the Early Recovery After Surgery Action/Management Plan project will be nominal/categorical based on the yes or no length of stay rates of patients who undergo a total knee replacement. Patient records will be used as the evaluation tool, which will be tracked throughout the implementation stage and in weeks two through nine will be interviewed, and information collected regarding compliance with pre and post-operative interventions.
Project Management Plan and Gantt Chart
The implementation of the Early Recovery After Surgery Program, (ERAS) will be studied over 10 weeks. The detailed project proposal, planning, data management and analysis, and dissemination plan can be found in the 32-week Gantt chart (Appendix B). The pre-implementation phase of the ERAS program will be implemented into the pre-operative process. The DNP student will meet with stakeholders and unit staff to ensure multidisciplinary buy-in for implementing the project. During the pre-implementation period, the DNP student will prepare materials for the ERAS program information session and implementation phase.
Week One of implementation of the project will be data collection which will consist of a chart review of the eight weeks prior to the project implementation of patients who underwent total knee replacement by Dr. Payne and length of stay and if the patient experienced any type of complication that would contribute to the length of stay. The DNP student will train the staff during the implementation phase. Weeks two through ten of Implementation will be implementing the ERAS program in the preop teaching and following up on patients who received the intervention. Week ten will be data collection of the implementation period, assessing the data found and presenting the findings to the stakeholders.
Proposed Budget
The budget is based the pre implementation teaching, implementation and post implementation process.
Table 1
Budget
| EXPENSES | REVENUE | ||
| Direct | Billing | ||
| Salary | $500 | Salary paid by employer | $500 |
| Supplies
Copy paper and staples Packet of printed information, 10 sheets at .05 cents per sheet for 30 patients |
$15 | Institutional budget support
|
$15
|
| Services | |||
| Statistician | $150 | Paid for by DNP Scholar | $150 |
| Indirect | |||
| Overhead | |||
| Total Expenses | $680 | Total Revenue | $680 |
Ethical Issues and Considerations
The scholarly project proposal will be submitted to Chamberlain University’s IRB for a predetermination process, and implementation of the project will commence once the project approval letter has been received. Additional IRB approval by the practicum site is not needed (Appendix C). Patient protection will be at the forefront of this project. Information will be collected without identifying data, and the scores will be reported in aggregate form, and data will be stored in a password-protected computer in an encrypted electronic file and kept for seven years.
Results
Sample: This portion should describe in detail the setting, the target or accessible population, the number contacted, the percentage participating, and the details of who participated. For inferences, an analysis of the representativeness of your sample characteristics should be done by comparing your sample to your accessible or target population. These data is best presented in tables detailing those demographic details that are important to the project. An analysis of the demographic data is required.
Table 2
[Table Title]
| Column Head | Column Head | Column Head | Column Head | Column Head |
| Row Head | 123 | 123 | 123 | 123 |
| Row Head | 456 | 456 | 456 | 456 |
| Row Head | 789 | 789 | 789 | 789 |
| Row Head | 123 | 123 | 123 | 123 |
| Row Head | 456 | 456 | 456 | 456 |
| Row Head | 789 | 789 | 789 | 789 |
Note: [Place all tables for your paper in a tables section, following references (and, if applicable, footnotes). Start a new page for each table, include a table number and table title for each, as shown on this page. All explanatory text appears in a table note that follows the table, such as this one. Use the Table/Figure style, available on the Home tab, in the Styles gallery, to get the spacing between table and note. Tables in APA format can use single or 1.5 line spacing. Include a heading for every row and column, even if the content seems obvious. A default table style has been setup for this template that fits APA guidelines. To insert a table, on the Insert tab, click Table.]
Findings: This portion provides an interpretation of the major findings in the context of the overall purpose of the project. Present the statistical analyses of your primary outcome and process measures. Discuss how your major findings provide new knowledge or support previous findings that you found in the literature. Note how these findings add to the body of knowledge on this topic and support or expand on the theoretical framework you provided in the framework section of the proposal. There should be a clear relationship between the theory that drove the project to the findings presented and analyzed.
Figures Title
Figure 1. [Include all figures in their own section, following references (and footnotes and tables, if applicable). Include a numbered caption for each figure. Use the Table/Figure style for easy spacing between figure and caption.]
For more information about all elements of APA formatting, please consult the APA Style Manual, 6th Edition.
Discussion
This is where you can, and should, express your opinions regarding the results, implications, recommendations and the strengths and limitations of your project. Every project has strengths and limitations, so these should be stated.
If your results are similar to those found in previous studies, you may cautiously infer the results beyond your population and setting. However, if your results are completely different and/or contradict previous studies, you should let the reader know that these results cannot be used beyond the project population and setting.
Recommendations
Recommendations based on the findings should be for the nursing profession and society in general, and to specific nursing leaders as mentioned in the significance portion. A summary of the major findings concludes the findings and interpretations portion with a transitional paragraph introducing the recommendations portion. Recommendations should follow the same logical flow as the findings and interpretations. Include a narrative of topics that need closer examination to generate a new round of questions. Be sure to make specific recommendations for leaders in the nursing field and policy makers. Recommendations for future research should be detailed and extensive. This is a key area that students often fail to elaborate. What could other researchers do with the new information to find out more gaps as indicated by the new results? New doctoral learners often look in this portion for ideas on problems that remain to be solved so elaborating with detail leaves a legacy to new doctoral students to continue.
Conclusions and Implications for Nursing Practice
Conclusions should relate directly to your purpose and project question. They are generalizations that loop back to the existing literature on your topic. For each conclusion you make, cite the sources that support or contradict your findings. The conclusion should represent the contribution your practice project has made to the body of scientific knowledge on this topic and relate this to the significance of the project, which is always, in some way, to improve nursing practice. Conclusions indicate what is now known regarding nursing practice when your results and results from prior literature are considered together. Implications for nursing should report findings in Section I not reported by any other literature. Why should nursing leaders care? Meanings of any gaps or similarities to literature are critically analyzed and discussed for every unusual finding. What do the findings mean to nurse leaders, and would society care about the results?
Plans for Sustainability
Explain what will be done to sustain the project over time. What strategies will you put into place for the practicum site to ensure the project has ongoing evaluation and modification as needed to ensure its success after your implementation phase is complete?
References
Agency for Research Health and Quality. (2017.) A collaborative program to enhance the
recovery of surgical patients. https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/enhancedrecovery/index.html
American Society of Colon and Rectal Surgeons. (2016). Enhanced recovery after surgery
overview. https://www.fascrs.org/sites/default/files/downloads/publication/enhanced_recovery_overview_2016.pdf
An, D. (2014). Cochrane review brief: Discharge planning from hospital to home. The Online Journal of Issues in Nursing, 20(2).
Bourazani, M., Asimakopoulou, E., Magklari, C., Fyrfiris, N., Tsirikas, I., Diakoumis, G., Kelesi, M., Fasoi, G., Kormas, T., & Lefaki, G. (2021). Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery. World Journal of Orthopedics, 12(6), 346–359. https://doi.org/10.5312/wjo.v12.i6.346
Burn, E., Edwards, C. J., Murray, D. W., Silman, A., Cooper, C., Arden, N. K., Pinedo-Villanueva, R., & Prieto-Alhambra, D. (2018). Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: evidence from linked primary care and NHS hospital records from 1997 to 2014. BMJ Open, 8(1), e019146. https://doi.org/10.1136/bmjopen-2017-019146
Centers for Disease Control and Prevention (2014). Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000–2010. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db186.htm
Chen, A. F., Stewart, M., K., Heyl A. E., & Klatt, B. A. (2012). Effect of immediate postoperative physical therapy on length of stay for total joint arthroplasty patients. The Journal of Arthroplasty, 27(6), 851-856.
Childers, C., Siletz, A. E., Singer, E. S., Faltermeier C., Hu, Q. L., Ko, C. Y., Golladay, G. J., Kates, S. L., Wick, E. C., & Maggard-Gibbons, M., (2018) Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for AHRQ Safety Program for Improving Surgical Care and Recovery. Geriatric Orthopaedic Surgery & Rehabilitation, 9, 2151458518754451.
Christelis N, Wallace S, Sage CE, Babitu U, Liew S, Dugal J, Nyulasi I, Mutalima N, Tran T, Myles PS. An enhanced recovery after surgery program for hip and knee arthroplasty. Med J Aust. 2015 Apr 20;202(7):363-8. doi: 10.5694/mja14.00601. PMID: 25877118.
den Hertog, A., Gloiesch, K., Timm, J., Mulbauer, B., & Zebrowski, S., (2012). Pathway controlled fast-track rehabilitation after total knee arthroplasty: A randomized prospective clinical study evaluating the recovery pattern , drug consumption and length of stay. Archives of Orthopedic and Trauma Surgery, 132(8), 1153-1163
Deng, Q. F., Gu, H. Y., Peng, W. Y., Zhang, Q., Huang, Z. D., Zhang, C., & Yu, Y. X. (2018). Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: results from a systematic review and meta-analysis. Postgraduate Medical Journal, 94(1118), 678-693. doi: 10.1136/postgradmedj-2018-136166. Epub 2019 Jan 21. PMID: 30665908.
Elias, K. M., Stone, A. B., McGinigle, K., Tankou, J. I., Scott, M. J., Fawcett, W. J., Demartines, N., Lobo, D. N., Ljungqvist, O., Urman, R. D., & ERAS® Society and ERAS® USA (2019). The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies. World journal of surgery, 43(1), 1–8. https://doi.org/10.1007/s00268-018-4753-0
Goncalves-Bradley, D. C., Lannin, N. A., Clemson, I. D., & Shepperd, S. (2016). Discharge planning from hospital (Review). Cochrane Database of Systemic Reviews, Issue 1. doi: 10.1002/146518558.
Gray, E. A., Santiago, L., Dimalanta, M. I., Maxton, J., & Aronow, H. U. (2016). Discharge by 11:00 a.m.: The significance of discharge planning. Medical Surgical Nursing, 25(6), 381-384.
Inacio, M., Graves, S. E., Pratt, N. L., Roughead, E. E., & Nemes, S. (2017). Increase in total joint arthroplasty projected from 2014 to 2046 in Australia: A conservative local model with international implications. Clinical Orthopaedics and Related Research, 475(8), 2130–2137. https://doi.org/10.1007/s11999-017-5377-7
Jiang, H.H., Jian X. F., Shangguan Y. F., Qing J, Chen L. B., Effects of enhanced recovery after surgery in total knee arthroplasty for patients older than 65 Years. Orthop Surg., 2019:11 (2):229-35.
Kerr HL, Armstrong LA, Beard L, Teichmann D, Mutimer J. Challenges to the orthopaedic arthroplasty enhanced recovery programme. J Perioper Pract. 2017 Jan; 27(1-2):15-19. doi: 10.1177/1750458917027001-202. PMID: 29328839.
Lam, J., Howlett, A., McLuckie, D., Stephen, L. M., Else, S. D. N., Jones, A., Beaudry, P., & Brindle, M. E. (2021). Developing implementation strategies to adopt Enhanced Recovery After Surgery (ERAS®) guidelines. BJS Open, 5(2). https://doi.org/10.1093/bjsopen/zraa011
Leiss, Schindler, M., Götz, J. S., Maderbacher, G., Meyer, M., Reinhard, J., Zeman, F., Grifka, J., & Greimel, F. (2021). Superior Functional Outcome and Comparable Health-Related Quality of Life after Enhanced Recovery vs. Conventional THA: A Retrospective Matched Pair Analysis. Journal of Clinical Medicine, 10(14), 3096–. https://doi.org/10.3390/jcm10143096
Lenguerrand, E., Whitehouse, M. R., Wylde, V., Gooberman-Hill, R., & Blom, A. W. (2016). Pain and function recovery trajectories following revision hip arthroplasty: Short-term changes and comparison with primary hip arthroplasty in the ADAPT cohort study. PloS One, 11(10).
Lockwood, C, Stephenson, M., Lizarondo, L., van Den Hoek, J., & Harrison, M. (2016). Evidence implementation: Development of an online methodology from the knowledge-to-action model of knowledge translation. International Journal of Nursing Practice, 22(4), 322–329. https://doi.org/10.1111/ijn.12469
McCann-Spry, L., Pelton, J., Grandy, G., & Newell, D. (2016). An interdisciplinary approach to reducing length of stay in joint replacement patients. Orthopedic Nursing, 35(5), 279-298.
Mitchell, S. E., Weigel, G. M., Laurens, V., Martin, J., & Jack, B. W. (2017). Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study. BMC Health Services Research, 17(1), 291. https://doi.org/10.1186/s12913-017-2242-z
Molloy, I. B., Martin, B. I., Moschetti, W. E., & Jevsevar, D. S. (2017). Effects of the Length of Stay on the Cost of Total Knee and Total Hip Arthroplasty from 2002 to 2013. The Journal of Bone and Joint Surgery. American Volume, 99(5), 402–407. https://doi.org/10.2106/JBJS.16.00019
Pritchard, M. G., Murphy, J., Cheng, L., Janarthanan, R., Judge, A., & Leal, J. (2020). Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence. BMJ Open, 10(1), e032204. https://doi.org/10.1136/bmjopen-2019-032204
Oseka, L., & Pecka, S., (2018). Anesthetic management in early recovery after surgery protocols for total knee and total hip arthroplasty. AANA Journal, 86(1), 32–39.
Pottenger, B. C., Davis, R. O., Miller, J., Alien, L., Sawyer, M. & Provonost, P. J. (2016). Comprehensive unit-based safety program (CUSP) to improve patient experience: How a hospital enhanced care transitions and discharge processes. Quality Management in Health Care, 25(4), 197-202.
Ripollés-Melchior J, Fuenmayor Varela M, Camargo S, Fernández P. (2018). Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgey. A
single center cohort study. Brazilian Journal of Anesthesiology, 30(3), 56-78.
Sarpong, N. O., Boddapati, V., Herndon, C.L., Shah, R.P., Cooper, H.J., Geller, J.A. Trends in length of stay and 30-Day complications after total knee arthroplasty: An analysis from 2006 to 2016. J Arthroplasty. 2019 Aug;34(8):1575–1580.
Sloan, M., Premkumar, A., Sheth, N.P Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am. 2018 Sep 05;100(17):1455–1460. doi: 10.2106/JBJS.17.01617.
Smith, M. A., Smith, W. T., Atchley, D., & Atchley, L. (2021). Total Knee Arthroplasty in the Ambulatory Surgery Center Setting: Best Practices for Cost Containment and Clinical Care Delivery. Orthopaedic Nursing, 40(1), 7–13.
Soffin, E. M., & YaDeau, J. T. (2016). Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. British Journal of Anaesthesia, 117(3), iii62–iii72. doi: 10.1093/bja/aew362.
Strickland, L., Kelly, L., Hamilton, T. W., Murray, D. W., Pandit, H. G., & Jenkinson, C. (2018). Early recovery following lower limb arthroplasty: Qualitative interviews with patients undergoing elective hip and knee replacement surgery. Initial phase in the development of a patient‐reported outcome measure. Journal of Clinical Nursing, 27(13-14), 2598–2608. https://doi.org/10.1111/jocn.14086
Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91(1), 3–19. https://doi.org/10.1080/17453674.2019.1683790.
Wolford ML, Palso K, Bercovitz A. (2015). Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000–2010. NCHS data brief, no 186. Hyattsville, MD: National Center for Health Statistics.
Yakkanti, R. R., Miller, A. J., Smith, L. S., Feher, A. W., Mont, M. A., & Malkani, A. L. (2019). Impact of early mobilization on length of stay after primary total knee arthroplasty. Annals of Translational Medicine, 7(4), 69. https://doi.org/10.21037/atm.2019.02.02
Zhang, Y. and Jordan, J.M. (2010) Epidemiology of Osteoarthritis. Clinics in Geriatric Medicine, 26, 355-369.
https://doi.org/10.1016/j.cger.2010.03.001.
Zhu, S., Qian, W., Jiang, C., Ye, C., & Chen, X. (2017). Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis. Postgraduate Medical Journal, 93(1106), 736–742. https://doi.org/10.1136/postgradmedj-2017-134991.
Appendices, Tables, and Figures
Appendix A
Johns Hopkins Nursing Evidence-Based Practice
Appendix G: Individual Evidence Summary Tool
Ó The Johns Hopkins Hospital/The Johns Hopkins University
Practice Question: “Does Early Recovery After Surgery (ERAS) guidelines, compared to current practice, impact the postoperative length of stay in 11-12 weeks?”
Date:4/17/22
|
Article Number |
Author and Date |
Evidence Type |
Sample, Sample Size, Setting |
Findings that Help Answer the EBP Question |
Observable Measures |
Limitations |
Evidence Level, Quality |
|||||||||
| 1 | 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 |
|||||||||
| 2 | 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.
However, no significant difference was found in ROM (MD 7.53, 95% CI -2.16 to 17.23) and 30-day readmission 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 |
|||||||||
| 3 | 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 |
|||||||||
| 4 | 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 |
|||||||||
| 5 | 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 |
|||||||||
| 6 |
|
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 |
|||||||||
| 7 | 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 |
|||||||||
| 8 | Soffin et al. (2016) | Systematic Review | Detailed review of published evidence
|
An early study found that explicit pre-anaesthesia education significantly relieved anxiety and emotional stress before hip or knee replacement.
Preoperative education contributes to higher patient confidence, greater patient satisfaction, and early recovery 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 |
|||||||||
| 9 | 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 |
|||||||||
| 10 | 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 randomised 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).
|
The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications.
|
Overreliance on secondary data may affect the reliability of findings. | Level 1
Quality A |
Appendix B
Gantt Chart
| NR702 | NR705 | |||||||||||||||
| Activity | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 | Week 7 | Week 8 | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 | Week 7 | Week 8 |
| Meet with faculty/preceptor | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ |
| Develop DNP project proposal | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☐ | ☐ | ☐ | ☐ |
| Education will be provided staff during a staff meeting | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☒ | ☒ | ☐ | ☐ | ☐ |
| Educate surgical patients | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Follow up with surgical patients | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Preimplementation Data collection | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Full implementation ERAS Program | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Weekly Reports of LOS | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☒ | ☒ |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | |
|
NR707 |
NR709 |
|||||||||||||||
| Activity | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 | Week 7 | Week 8 | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 | Week 7 | Week 8 |
| Meet with faculty/preceptor | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ |
| Full Implementation of ERAS Program | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Data collection of LOS | ☐ | ☐ | ☐ | ☒ | ☒ | ☒ | ☒ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Post implementation data provided to staff and stakeholders | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Data Analysis with Statistician | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Project outcomes discussed with staff | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Project presented to leadership | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Completion of final manuscript | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☒ | ☐ |
| Final Presentation | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | |
Early Recovery After Surgery Program
Appendix C
Plan for Educational Offering
| OBJECTIVES | CONTENT (Topics) | TEACHING METHODS | TIMEFRAME | EVALUATION METHOD |
| 1.Participants will be able to participate in the ERAS program with understanding of steps to be taken
2. Participants will keep track of pre and post-operative methods used for Early Recovery After Surgery 3. Participants will be able to describe steps needed to engage in program 4. Participants will be able to verbalize the expected decrease length of stay by participating
|
What is ERAS?
Weekly phone call script.
Handout of ERAS goals.
Check list and exercise examples listed and explained |
In-person lecture and training
PowerPoint presentation exercises and medications before and after surgery.
Scripted telephone call
Tracking progress with log provided in educational material |
30 minutes
1 hour for reading
Thirty minutes for Q&A |
The teach-back method will be used to evaluate the achievement of the learning objectives.
Weekly phone calls will be made to evaluate progress through the program
Participants will report walking program and adherence to medication schedule |
Appendix D
Appendix E