Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: Fast-track experience in 712 patients

Figures & data

Table 1.  The Hvidovre fast track protocol (ANORAK-HH)

Information

– oral and written information on intended maximum LOS of 5 days and motivation of the patient to be active.

– detailed information to patients and relatives meeting at a preoperative multidisciplinary patient clinic, on hospital stay, goals, and discharge.

Staff and logistics

– dedicated staff. Physiotherapy once a day at weekdays. Nurse staffing identical to that of rest of ward (0.98 nurses per bed during weekdays, 0.80 during weekends).

– setting up of a specialized ward where all THR and TKR patients are admitted.

– patients admitted on day of surgery.

Operation and pain treatment

– use of regional analgesia: spinal for patients undergoing THR; combined spinal and epidural for patients undergoing TKR (2 days for primary TKR and revision TKR, 1 day for single knees, and 3 days for bilateral TKR).

– opioid in tablet form × 4 until discharge, paracetamol × 4 and NSAID × 1 (which is also used after discharge).

Drains

– not used (no effect, and increases the sickness role).

Blood transfusion

– is standardized (postoperative drop by 25% compared to preoperative level of Hb and clinical manifestation).

KAD

– patients operated on with TKR use a catheter for 1 day.

Antithrombotic prophylaxis

– low-molecular-weight heparin × 1 daily, starting 6 h postoperatively and given only until discharge.

Discharge criteria

– unchanged; the patients must be independent, able to walk with crutches or better, able to get in and out of bed, and into and up from a chair. Sufficient pain treatment. Accept of discharge.

– all patients are discharged to their homes.

Monitoring: 22 patient characteristics and 11 patient satisfaction parameters were registered in a database in order to monitor the stays continuously:

– Patient characteristics: age, sex, living situation, weight, height, body mass index (BMI), smoking, American Society  of Anaesthesiology (ASA) score, pre- and postoperative hemoglobin (second day), preoperative use of walking aid,  intraoperative and total blood loss, blood transfusion, type of surgery, co-morbidities, surgeon, day of surgery and  case number that day (1st, 2nd, 3rd), mobilization on the day of surgery, preoperative use of opioids, and participation  in the patient meeting preoperatively.

– Patient satisfaction parameters: information, patient meeting, operating room stay, recovery ward stay, nursing, doctors' rounds, pain treatment, physiotherapy, LOS, physical conditions in the ward, and the entire stay.

Table 2.  Distribution of 712 patients regarding type of surgery, age, LOS, readmissions, blood transfusions, and overall patient satisfaction

Operation	n	Age		LOS		Discharged (%) by the		Readmissions		Blood transfusions (%)	Overall satisfaction, mean
		mean	range	mean	range			without	with
						fifth day	third day	surgery	surgery
THR	370	69	31–91	3.8	1–17	93	43	18 (4.9)	7 (1.9)	22	9.4
TKR	342	69	33–91	3.9	1–17	92	39	19 (5.6)	8 (2.3)	12	9.3
THR+TKR	712	69	31–91	3.8	1–17	92	41	37 (5.2)	15 (2.1)	17	9.4

Table 3.  Significance of patient characteristics for length of stay (LOS) and overall satisfaction

Variable	Test	P-value for
		LOS	satisfaction
Age	Sp	0.001	0.008
Sex	MW	0.001	0.2
BMI	Sp	0.2	0.2
Living situation	MW	0.001	0.02
Co-morbidities	MW	0.03	0.2
Preop. walking aid	MW	0.001	0.2
Preop. opioid	MW	0.3	0.02
Weekday surgery	KW	0.001	0.5
Surgeon	KW	0.7	0.4
ASA score	KW	0.001	0.6
Preop. hemoglobin	Sp	0.001	0.8
Postop.	Sp	0.001	0.5
Blood loss	Sp	0.5	0.3
Blood loss perop. (THA)	Sp	0.04	0.2
Blood transfusion	MW	0.001	0.7
Blood transfusion, number	KW	0.001	0.6
Mobilization, day of surgery	MW	0.001	0.1
Smoking	MW	0.3	0.1
Case number (1st, 2nd, 3rd)	KW	0.8	0.06
Patient clinic	MW	0.5	0.7

Sp: Spearman's test; MW: Mann-Whitney test;

KW: Kruskal-Wallis test.