Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study

Background: The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle. Methods: This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education. Results: The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P <.001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P <.001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P <.001). Thirtyday emergency department visits following discharge decreased from 12.9% to 7.3% (P =.030). Conclusion: Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle. (C) 2020 Elsevier Inc. All rights reserved.