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BADS Hip and Knee

Day case surgery is defined as admission and discharge on the same day, with day surgery being the intended management. In England & Wales approximately 160,000 total hip and knee replacements are performed annually, with 66% of procedures funded by the NHS occurring in NHS managed hospitals.1 These procedures have traditionally been associated with in-patient admission, often for a duration of many days. However, several UK centres are now successfully performing both total hip and total knee replacement surgery as day case procedures.

It has been long recognised that enhanced recovery programmes for lower limb arthroplasty can both safely reduce length of stay and enhance patient experience[2,3]. Such programmes have demonstrated themselves to be:

  • Safe with no increased risk of complications or readmission
  • Clinically effective through equivalent patient-recorded outcome measures and patient satisfaction levels
  • Cost effective with clear efficiency and bed saving days it has been estimated that day case arthroplasty reduces the cost of the patient episode by up to a third.

The development of a day case pathway for lower limb arthroplasty represents a natural progression of this evidence-based, patient-centred approach to care.

Estimates from unselected cohorts of patients at Northumbria Healthcare NHS Foundation Trust (NHFT), NHS Fife and Torbay & South Devon NHS Foundation Trust (TSDFT) suggest up to 20% of patients are potentially suitable for day case hip or knee replacement surgery. In 2019, National Joint Registry (NJR) data recorded 68,000 NHS hip replacements, with projected demand for both hip and knee replacements expecting to rise considerably in the future. Being able to achieve even a small percentage of these procedures as a day case will offer substantial benefits to both hospitals and patients in times of hospital escalation when many elective surgical procedures are cancelled. Day case surgery enables the patient to undergo their procedure on the planned date and time with greatly reduced risk of surgical cancellation and in addition, most patients believe that home is the best place to recover[4]. Building an effective patient pathway, with staff engagement, ensuring thorough patient preparation and appropriate preoptimisation are all critical factors for success.

The aim of this handbook is to provide guidance for centres looking to develop a day case lower limb arthroplasty pathway. In doing so, general advice about the principles underlying such service development and implementation are outlined with specific examples from centres illustrating the diverse approaches that can be taken to successfully achieve this.

This handbook primarily describes approaches to day case hip arthroplasty. Although there is considerable overlap with the principles underlying day case total knee arthroplasty, some specific guidance for the latter is also provided.

Although this may appear daunting at the outset, introducing a day case surgery service more often than not represents an adaptation of pre-existing pathways and resource allocation, rather than a totally de novo process. Start by thoroughly reviewing your current in-patient pathways and also consider what other successful day case surgery pathways exist in your hospital. Irrespective of speciality this will help identify examples of good clinical practice from which learning can be taken and applied to the pathway you wish to develop.

The key stages for developing a day case pathway include:

  1. Identifying a named clinician(s) with an interest in developing a lower limb arthroplasty day case service (locate your trust ‘champions’)
  2. Promote multidisciplinary staff engagement
  3. Map the clinical pathway to determine where the key patient interaction points are
  4. Clarify current and desired patient outcomes in order to define ‘key success’ requirements to achieve these
  5. Build patient confidence and engagement into the core of the pathway
  6. Run a pilot patient or pilot list
  7. Learn, refine, and roll out the pathway

Determining what happens to patients undergoing total hip replacement surgery during their in-patient admission is a crucial first step. Consideration needs to be given to all the reasons identified as to why patients are not being discharged from hospital in a timelier manner. These may include pain, nausea, dizziness, weakness, urinary retention and leaking wounds.

Mechanisms to either reduce or manage all of these will need to be built into the pathway. Time and effort spent gathering robust data at the beginning to inform changes will pay dividends in the longer term.

Mapping out who and when there are patient contact points is also vital. Care of any patient is a true multidisciplinary effort and when looking to evolve any process, effective teamwork is essential, with early engagement and input from the whole team being key. There may be areas of activity duplication which can be refined, new collaborative working processes introduced and shared learning gained. The most important factor is team commitment. If everyone is not ‘on the same page’ either due to reluctance about day case management or lack of familiarity with protocols, the chance of successful day case discharge will be considerably reduced. Enjoy your development journey as a team!

Appropriate preoperative preparation is vital for achieving patient optimisation as well as generating patient engagement and confidence. Highlighting benefits of early discharge such as reduced morbidity and mortality attributable to fewer venous thrombotic events (VTE), increased oxygen saturations, reduced muscle loss, earlier functional recovery, improved satisfaction with pain management and the privacy of your own environment help reinforce why the ‘best bed’ is your home bed.

Ensuring patient information is of high quality is also extremely important. Patients need to clearly understand any requirements to take or stop medications, fasting instructions, what specific preparations they should make for surgery and what postoperative support will be available. Effective preoperative assessment alongside dedicated orthopaedic preparation is the cornerstones of this. Hospitals have various methods to achieve this and may include combinations of small group ‘joint school’ sessions, patient videos, 1:1 sessions with physiotherapists or occupational therapists and patient information booklets.

1. Patient selection

This usually occurs at the time of listing for surgery in the orthopaedic clinic. It is recognised that not all patients are suitable for day case discharge following total hip replacement hence some centres have specific day case criteria to aid appropriate patient identification. Examples include:

  • Age 75 years
  • BMI <35 kgm2
  • ASA 1 or 2
  • No preoperative requirements for high dose opioid-based analgesia

When introducing a lower limb arthroplasty day case pathway, it may be prudent to adopt some or all of these criteria, ‘relaxing’ some of these thresholds as patient numbers increase and experience develops. Two other significant ‘selection’ factors are the degree of social support the patient has access to and their personal receptiveness with the principle of day surgery. The patient must believe in the process right from the beginning which means the staff involved in their care have to be supportive of day case management and consistent in their advice.

In contrast, some centres do not identify patients preoperatively to be listed as a day case. Instead, all undergo the same care pathway but patients are selected for discharge on the day of surgery, if this is considered appropriate. Disadvantages associated with this include:

  • Scheduling the list order can be substantially more challenging
  • Only patients who are identified preoperatively and booked as a day case will contribute towards day case numbers and performance indicator tables.
  • If a patient is booked for in-patient admission, it is necessary to book a bed for their postoperative care. If there are no beds available due to hospital escalation the patient is more likely to have their surgery cancelled than if on a planned day case

I. Preoperative Assessment
Most centres have well established nurse led preoperative assessment services with recourse to anaesthetic consultant referral if necessary. Thorough review allows specific areas to be addressed on an individual patient basis and provides a dedicated opportunity to support and educate patients about their coming surgical episode. Evidence suggests patient education prior to surgery may directly contribute towards reducing length of stay.[5] Screening for MRSA and MSSA can be performed, along with pertinent blood tests, for example FBC, U&E’s and a group and save if no historical sample is available. Verbal fasting and medication instructions are supported by written information including the timed cessation of any anticoagulant medications. Many centres also provide preoperative carbohydrate drinks to enhance effective patient hydration status and improve postoperative well-being[6].

II. Patient Optimisation
Optimising reversible preoperative conditions and addressing specific risk factors will reduce peri-operative stress, enhance physiological function, decrease the risk of complications, accelerate the discharge process and shorten length of stay.

a. Anaemia
This associated with increased risk of transfusion, length of stay, infection, morbidity and readmission rates[7]. The prevalence of anaemia in elective lower limb arthroplasty surgery ranges from 15-39%[8]. anaemia screening programmes should therefore be established and the cause of anaemia must be investigated and managed prior to elective surgery[9]. Many centres have established processes for this and utilisation of intravenous iron therapy may be indicated. An example of one approach developed at NHFT is summarised in Appendix 1.

b. Smoking Cessation
Smoking increases the length of stay and risk of postoperative complications. There is evidence that referral to a smoking cessation programme for four weeks prior to surgery is associated with fewer problems associated with surgery[10].

c. Alcohol
Patients undergoing lower limb arthroplasty who abuse alcohol also have a longer length of stay and are more likely to have medical and surgical complications postoperatively. Alcohol cessation programmes prior to surgery can be advantageous to minimise such risks in individuals with a history of alcohol abuse[11].

d. Opioid Dependency
Many patients presenting for joint replacement surgery have pre- existing non-cancer pain and are on opioid-based analgesic regimes. Of those on high-dose opioids (e.g. >120mg of morphine, >60mg oxycodone or >25mcg fentanyl patch daily) several will have long term dependence, underlying depression and mental health issues. Their management can be challenging particularly with implications for inadequate postoperative pain relief due to associated tolerance, opioid-induced hyperalgesia and an increased risk of adverse effects[12]. They frequently require complex care planning, involvement of pain teams and are unlikely to be managed successfully as day cases.

Endeavour should be made to reduce opioid intake prior to surgery and where this is impractical or unachievable, the risks and benefits of surgery should be carefully re-evaluated at the time of listing.

Preoperative referral to pain services is recommended.

e. Psychological preparation
Ensuring patients receive appropriate preoperative education is another important element of optimisation. This can be achieved by one or several of the following;

  • Small group ‘joint school’ sessions
  • 1:1 sessions with therapists
  • Web-based or digital resources
  • Patient videos and DVDs

This is key in the context of day case joint replacement whereby patient preparation and expectation management can strongly influence suitability for discharge on the day of surgery. All verbal information should be supported in written format.

I. List Order
Patients listed for a day case hip replacement will be usually be placed first or second in the morning of the list. This maximises time for recovery, mobilisation and safe discharge.

II. Fasting
Typical instructions for patients are:

  • To stop solid foods six hours prior to surgery
  • Clear fluids can be taken in an unrestricted manner up to two hours prior to surgery but this usually results in excessive fasting times as it is difficult for staff to judge when that 2-hour period begins. Recent evidence shows that allowing patients free access to water and encouraging drinking is not associated with no increase in adverse events and a reduction in postoperative nausea and vomiting[13].
  • European fasting guidelines, which permit tea and coffee with milk until 2 hours preoperatively (endorsed by The Association of Anaesthetists) should now be embraced, as this encourage patients to have a morning drink prior to coming to hospital for their surgery[14].

Use of preoperative carbohydrate drinks is encouraged and should ideally be issued to patients at their preoperative assessment visit along with instructions for them to be taken 2 hours before surgery. High energy protein drinks are also frequently given to patients for them to sip (e.g. x 3 drinks) on the day before their admission. Evidence shows their consumption before elective surgery improves patient subjective wellbeing, reduces thirst, hunger, postoperative insulin resistance and physiological stress[14]. In many centres diabetic patients are excluded from receiving them, however, European guidance suggests that diabetes should not necessarily be considered a contraindication to their use[14]. Postoperative carbohydrate drinks also have a role in improving postoperative well-being.

III. Premedication
Examples of regimens used in difference trusts are shown below

Table 1: Premedication protocols for day case total hip arthroplasty

Table 1: Premedication protocols for day case total hip arthroplasty

* Patients are asked to omit these medications the day before surgery and the day of surgery. Management of their reintroduction postoperatively is detailed in the section on postoperative medications.

IV. Warming
Pre-warming reduces the risk of hypothermia and hence the risk of cardiac dysfunction, coagulopathy, transfusion, synthetic dysfunction, infection and duration of hospitalisation.[15] This is typically performed in the 30 minutes prior to the patient being sent for and continued in the anaesthetic room. Increasing total body heat content reduces core-to-peripheral heat redistribution and the development of phase 1 hypothermia. Any phase 2 hypothermia is also blunted by a higher ‘starting’ point. Warming should continue throughout the intraoperative period and any fluids administered should also be warmed.

V. Anaesthetic Techniques
Those currently used at three different hospitals performing successful day case hip replacements are summarised in Table 2. Whilst there are differences in approach, if the technique minimises complications and optimises recovery, there is no ‘single recipe’. Ideally ‘protocol’ should be agreed within your hospital to ensure consistency of approach and allow for refinement and learning, especially in the early development stages.

Table 2: Anaesthetic techniques

Table 2: Anaesthetic techniques

* if 0.25% is used in spinals it is recommended that the racemic preparation used is not the enantiopure levobupivacaine. There has been a higher incidence of patchy sensory blockade with 0.25% levo preparations which is not seen with the 0.25% racemic formulation

VI. Blood Conservation Strategies

a. Tranexamic acid
Whilst there is consensus to administer Tranexamic acid to patients undergoing day case lower limb arthroplasty, variation exists in the dose regimens used. Examples are shown in Table 4.

b. Cell Salvage
At TSDFT, cell salvage is undertaken for all total hip and knee replacement procedures (primary, revision and day case arthroplasty surgeries). Since 2018, collection has been routine and processing only performed if sufficient volumes are collected. This change in practice was introduced as a cost neutral intervention based on the cessation of taking routine ‘on the day’ repeat group and save sample. Prior audit revealed that despite more than 30% of in-patients having a postoperative haemoglobin of less than 100 g/L the number receiving allogenic transfusion was negligible. Since the introduction of routine collection, 65% of day case joint replacement patients receive cell salvage autologous transfusions, the mean volume transfused being 157mls. These transfusion rates and volumes are similar to the in- patient arthroplasty patient population (unpublished data, C Blandford). This principle of care is also supported by review of literature identifying transfusion requirement as the single most common complication following day case total joint arthroplasty[17].

Table 4 Tranexamic acid regimens

Table 4 Tranexamic acid regimens

The key components of postoperative care are the promotion of enhanced recovery principles and early, safe mobilisation, which include:

  • Early discontinuation of IV fluids and encouragement of oral fluids
  • Administration of a postoperative carbohydrate drink (at TSDFT this is given in stage 1 recovery and has been found to be helpful in reducing orthostatic hypotension on initial mobilisation)
  • Early commencement of solid food
  • Aggressive management of any nausea, vomiting or dizziness
  • Prompt treatment of pain
  • Monitoring patient ability to void urine

Early mobilisation is necessary for same day discharge. Patients need to be able to safely demonstrate a range of skills including the following:

  • Transferring between bed, chair, toilet and standing positions
  • Ability to negotiate stairs (if required for their discharge environment)
  • Use of mobility aid equipment
  • Confidence in mobilising, commensurate with safe discharge

Availability and working hours of physiotherapists and or physiotherapy assistants may determine whether day case discharge can be achieved, so this must be considering and addressed in advance of planning service change.

Prior to standing, if a patient has had a spinal anaesthetic, they must be assessed to confirm adequate block resolution and regardless of whether a spinal or general anaesthetic technique has been used, vital signs should be appropriate and stable. NHS Fife have specific ‘pre-stand’ requirements of administering Ephedrine 30mg PO and a solid food meal before attempting to stand and mobilise. Consensus is also required when planning the day surgery pathway from the surgical teams as to whether hip precautions are to be followed postoperatively and if an X-ray is necessary following surgery.

A minimum set of criteria need to be met to ensure a patient is suitable for safe day of surgery discharge. Examples of such include:

  • Presence of a relative or friend to provide overnight care and support
  • Any pain, nausea or vomiting to be controlled with oral medication
  • The patient should be able to eat and drink appropriately
  • Mobilising and transferring satisfactorily as reviewed by suitably trained member of staff (e.g. physiotherapist, extended role nursing staff)
  • No surgical complications or symptomatically large intraoperative blood loss (e.g. > 500mls)
  • Vital signs satisfactory and stable
  • Spontaneous urination*
  • Patient motivated and keen for discharge
  • Timings within the ‘appropriate for discharge’ timescale for the individual day surgery unit g. 20:30 hrs
  • Discharge medications available
  • Postoperative ‘SOS’ contact details provided

* At TSDFT, if a patient has not passed urine spontaneously but is otherwise fit for discharge, this is not considered an automatic obstacle to day case discharge. The patient is sent home with a urinary catheter and the following day, the Trust’s orthopaedic outreach team manage a ‘trial without catheter’ in the patient’s home. This is well-established practice at TSDFT day surgery unit, built on experience from other surgical procedures.

It is recommended patients are discharged with written information and a medication table to assist in the self-administration of their postoperative medication. Examples of protocols are shown in Table 5. Of note, at NHFT and TSDFT, the use of gabapentin and pregabalin respectively have been withdrawn from protocols due to side effects including hyponatraemia and dizziness, without any detriment.

Prophylaxis against VTE should be locally determined in line with individual hospital policy. Most centres utilise mechanical compressive foot and calf pumps on the nonoperative leg during surgery and bilaterally in the immediate postoperative phase until mobilisation. Discharge regimens for chemical VTE prophylaxis will also need to be agreed. Examples of current practice include:

  • NHS Fife THR: Rivaroxaban 10mg od for 35 days
  • NHFT THR: Tinzaparin for 10 days then Aspirin 75mg for 28 days TKR: Tinzaparin for 10 days then Aspirin 75mg for 14 days
  • TSDFT THR: Dalteparin 5000units sc for 3 days* then Aspirin 150mg od for 28 days

Unicompartmental and TKR: Dalteparin 5000units sc for 3 days* then Aspirin 150mg od for 14 days

* {if 50-100kg, otherwise dose adjusted}

Table 5: Discharge ‘TTA’ medications – examples from three trusts

Table 5: Discharge ‘TTA’ medications – examples from three trusts

It is essential patients discharged as a day case following joint replacement have easy access to expert support once they have left the hospital. This not only represents good clinical practice from a safety point of view but is very important for patients’ psychological well-being once they’ve been discharged[18]. Centres typically provide a nurse-led follow-up telephone call within the first 24 hours of discharge and there will also be ongoing support services available beyond 24 hours. Some examples are included below.

NHS Fife: Have a dedicated orthopaedic helpline, manned 24/7 by specialist orthopaedic nurses. Patients are encouraged to use this method of contact for all queries and to refrain from contacting their general practitioners for post-surgical advice. Escalation mechanisms are in place for any concerns to be passed onto the patient’s responsible consultant.

NHFT: Patients receive a call from the nurse practitioners on the ward on the evening of their discharge. There is also a dedicated ‘orthopaedic helpline’ available for patients to contact, once again they are requested to direct all queries in this direction to ensure specialist advice is given and this can often reduce the need for an unnecessary re-admission to hospital. A telemedicine link service also allows consultants to review any patient’s wounds presenting to peripherally located hospital sites thus potentially saving patients from making long journeys to hospital.

TSDFT: Patients receive a follow-up phone call from day surgery nurses on the day after their discharge. In addition to checking on patient wellbeing, a standardised questionnaire is completed ensuring patient feedback is recorded on a dedicated database. This resource is frequently audited and can used to provide feedback for individual surgeons and anaesthetists and inform care quality indicators. Post discharge patients are also supported in their own homes via a community ‘orthopaedic outreach’ service. This is comprised of a team of 2 nurses and 3 health care assistants who visit patients on days one, five, ten and fourteen. Additional visits between these times are arranged, if required, on an individual patient basis. The initial visit typically takes about 30 to 40 minutes, with subsequent reviews lasting a maximum of half an hour. During their recovery, patients are able to make telephone contact either via the outreach team or the orthopaedic ward.

Examples of some of the activities the outreach team will undertake are listed in the table below. These nurses have direct access to escalate any concerns to consultant level anaesthetists or surgeons as required. If it is not possible to establish a similar trust-based service, it may be possible to use this as a basis to explore community-based solutions.

Table 6: TSDFT ‘orthopaedic outreach’ activities

Table 6: TSDFT ‘orthopaedic outreach’ activities

Many hospitals are now undertaking successful day case total knee replacements[16]. Whilst this may be considered to present more challenges than day case total hip arthroplasty with respect to managing postoperative pain, it illustrates, that with careful planning, pathways can be developed to make this possible. TSDFT started performing day case unicompartmental knee replacements in 2011 and now over 60% are managed as a day case[19]. The experience gained built confidence to progress to day case total knee replacement surgery. In a hospital where no day case knee arthroplasty takes place, commencing with unicompartmental surgery would be a pragmatic approach.

As there is much overlap in the principles underlying the care of patients undergoing day case total hip or knee replacement, almost all of the content of this handbook can be directly applied to the latter. The only discrepancy likely to arise is regarding anaesthetic and analgesic protocols and it would be prudent to review how these might be adapted for total knee replacements. At TSDFT, for knee replacement surgery, the anaesthetic has been modified to include an ultrasound guided adductor canal / saphenous block and consider discharging the patient with Amitriptyline (10mg nocte, 14/7, starting day 1 postoperatively) if it is thought this will be of benefit

Appendix 2: TSDFT total hip, unicompartmental and total knee replacement anaesthetic protocol

Appendix 2: TSDFT total hip, unicompartmental and total knee replacement anaesthetic protocol

Every hospital has very different estate and personnel facilities and much will depend on individual layout as to what solutions can be put in place to develop a day case joint arthroplasty pathway. This includes:

  • Where clean air and laminar flow theatres are located
  • Whether there are separate emergency and elective sites
  • The availability of a dedicated day surgery unit
  • Is orthopaedic surgery performed at certain hospital sites only?

There is no single option, ‘one-size-fits-all’ approach for successful day surgery practice.

At NHS Fife and NHFT, patients are transferred to a postoperative orthopaedic ward following surgery in a laminar flow orthopaedic theatre. Their enhanced recovery is undertaken on the ward and if they fulfil discharge criteria, they are sent home later that day. Same day discharge rates are in the region of 10-20% of patients. This model offers the advantage of co-locating postoperative care resources at the same clinical site so patients on both day case and in-patient pathways can benefit. For the latter, seeing day case patients mobilising successfully and discharged home early can be powerful motivation in their postoperative progress. The pathway developed by NHS Fife and NHFT will work if a hospital has an elective site with a dedicated orthopaedic facility. This may prove difficult, however, if there is no separation of emergency and elective workload. At times of high demand, for example during winter months and when Operational Pressures Escalation Levels scores are high, it will be difficult to proceed with day cases due to reduced access to an inpatient bed, albeit for even just a few hours.

At TSDFT, patients are admitted to the surgical admissions unit, operated on in laminar flow theatres in the main theatre suite and then transferred to the on-site, dedicated day surgery unit to complete their recovery and discharge. If laminar flow theatres were available in the day surgery unit, the whole patient pathway could be managed there. The current pathway allows experienced day surgery nurses to focus completely on the day case arthroplasty patients without potential conflicting demands of a busy in- patient ward. All physiotherapy and occupational health professionals attend to the patient on the day surgery ward. Whilst there is no ‘spill over motivating effect’ for recovering in-patients as with the NHS Fife and NHFT pathway, day surgery ward-based recovery optimises the chance of successful discharge home and allows for proceeding with elective cases at times of extreme bed pressures. To date, at TSDFT, successful day case discharge rates are over 90%.

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Dr Claire Blandford
Consultant Anaesthetist, Torbay & South Devon NHS Foundation Trust Clinical Sub-Dean (Torbay),
University of Exeter Medical School

Mr Ed Dunstan
Consultant Orthopaedic Surgeon, Director of Surgery, NHS Fife Appraisal Tutor NES Scotland,
Appraisal Lead NHS Fife (acute services)
Chair: Scottish Committee for Orthopaedics and Trauma

Contributors to the Previous edition:

The Enhanced Recovery Joint Replacement Team, Northumbria Healthcare NHS Trust (Professor Mike Reed, Consultant Trauma and Orthopaedic Surgeon, Munir Khan and Robert Lawton, British Orthopaedic Association Clinical Leadership Fellow)

The authors would like to acknowledge Dr Mary Stocker, Immediate Past-president, The British Association of Day Surgery

Consultant Anaesthetist, Torbay and South Devon NHS Foundation Trust

Miss Jo Marsden,
Publications Secretary and Editor,
The British Association of Day Surgery

Copyright © British Association of Day Surgery 2020. All rights reserved. No parts of this publication may be reproduced, stored or transmitted by any means without the prior permission in writing of The British Association of Day Surgery

Printed by Catton Print, Norwich, UK Front page illustration from pixabay.com ISBN number 978-1-908427-40-3

Appendix 1: Managing mild anaemia in joint replacement patients

Appendix 1 Managing mild anaemia in joint replacement patients

Appendix 2: TSDFT day case total hip, unicompartmental knee and total replacement anaesthetic protocol

Appendix 2: TSDFT day case total hip, unicompartmental knee and total replacement anaesthetic protocol

Appendix 3: NHS Fife day case hip and knee replacement anaesthetic protocol

Appendix 3: NHS Fife day case hip and knee replacement anaesthetic protocol