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VA adopts enhanced recovery for total knee, total hip patients

Jan. 7, 2021, 9:06 AM


by Paul Govern

For patients receiving total knee or total hip replacements at the Nashville VA Medical Center, the use of opioids for inpatient pain management and the total time patients spent in the hospital were both greatly reduced following the January 2016 adoption of sweeping quality improvement measures.

That’s according to a study reported in the Canadian Journal of Anesthesiology by Vanderbilt University Medical Center anesthesiologists Bret Alvis, MD, Christopher Hughes, MD, and colleagues. (The VA facility is adjacent to the VUMC campus and its patients are served by physicians from VUMC.)

“Next door at the VA, we were successful in implementing enhanced recovery protocols similar to those that have been associated with improved patient outcomes for many of our surgical service lines here at VUMC,” said Alvis, assistant professor of Anesthesiology and Biomedical Engineering.

The VA quality initiative hinged on establishment of an Anesthesia Perioperative Care Service (APCS) and adoption of a set of clinical protocols known in the literature as enhanced recovery after surgery, or ERAS. (At VUMC, a house-wide initiative to adopt ERAS pathways is well underway.)

Compared to analgesics, opioids bring a slower functional recovery. Accordingly, ERAS pathways discourage use of opioids in favor of multi-modal analgesia, that is, more use of adjuncts like acetaminophen (Tylenol), ibuprofen and gabapentin. This approach to pain management supports the other chief components of ERAS, including earlier feeding and oral hydration after surgery and earlier ambulation.

ERAS pathways for total hip and total knee were created with the involvement of anesthesiologists and APCS staff, surgeons, physical therapists, pharmacists and social workers. Under the APCS, a critical care physician provides daytime in-hospital coverage (and overnight home call) and nurse practitioners provide continuous in-hospital coverage.

For the study, the team collected data on total hip/total knee patients admitted to the VA during the 400 days before and 400 days after the initiative’s start date of Jan. 1, 2016 — 282 patients in all.

  • Among the bulk of patients — that is, those falling in the interquartile range, statistically speaking — the median hospital length of stay decreased from three days to two.
  • Among the bulk of patients, median inpatient opioid intake by IV decreased from 11.2 to zero morphine milligram equivalents (MME), while median inpatient oral opioid intake decreased from 105 to 68 MME.

Other patient outcomes targeted by the quality initiative remained statistically unchanged, including overall costs per patient, outpatient opioid use and unexpected hospital readmission (within 30 days).

“In this initial study we would of course also liked to have seen improvements in these additional key outcomes of care. Our data appear to indicate that, as we continue to refine our clinical protocols, we can expect to realize additional benefits across the board,” Alvis said.

Other authors on the study included Roland Amsler, BBA, Philip Leisy, MD, Xiaoke Feng, MS, Matthew Shotwell, PhD, Pratik Pandharipande, MD, Muhammad Ajmal, MD, Michael McHugh, MD, and Ann Walia, MD.

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