ERAS has long been proven to help reduce hospital length of stay (LOS) and complications following total knee replacement (TKR) surgery. Guy’s and St Thomas’ NHS Foundation Trust’ (GSTT) ERAS programme targets an inpatient stay of three nights as best practice for TKR's; yet in 2018 this was not being met. Anecdotal data was suggestive of a growing cohort of multi-morbid older adults undergoing surgery with associated complex post-operative management and discharge planning. Despite Guy’s Orthopaedic Outreach Team (GOOT) being an established service it was being under-utilised to facilitate discharges potentially due to poor MDT communication. The aim of this service improvement project was to determine the MDT acceptance of a daily geriatrician-led multidisciplinary meeting and its impact on LOS.
A daily morning MDT board round was initiated in August 2018 following quality improvement methodology and benchmarking of local services. Demographic and length of stay data over a 12 month period post-intervention was collected. This was compared to retrospective data collected over a 12 month period directly preceding the intervention. GOOT productivity and discharge barriers were recorded for both cohorts. A staff survey was also completed at 12 months post-intervention to assess staff’s perception of the change
Results: From August 2018 to August 2019, post-board round, 393 patients (mean age 67, SD 9.1) underwent a TKR +/- revision with a median LOS of 3 days. Pre-board round 420 patients (mean age 66.5, SD 10.2) underwent TKR +/- revision with a median LOS of 4 days; a reduction of 25%. Both cohorts had similar distributions of age and sex. Identified themes for delaying LOS included pain, nausea, wound complications and discharge planning for patients requiring increased support at home. The number of GOOT visits increased by 27%. The staff survey had a 73% response rate, of which 86% of staff felt the daily board round improved communication between MDT members enabling earlier escalation of medical and discharge concerns.
Conclusion(s): Implementation of the daily MDT board round has assisted in reducing the length of stay for patients undergoing TKR’s by one day. This has obvious cost implications and based on the standard tariff of £382 for an orthopaedic bed per day, is suggestive of a £169,000 saving. It is worth noting during the 12 month period a positive change in MDT motivation led to additional service changes within elective orthopaedics. Consultant buy in was sought to allow TKR patients to be discharged once set milestones were achieved regardless of post-operative day, whilst the geographical catchment area for GOOT was widened to increase uptake. The board round has found to be beneficial for MDT working by increasing ease of communication and earlier escalation of medical and discharge concerns. Future work will include addressing the specific discharge barriers and processes to improve the patient pathway into the community.
Cost and savings
The project results are promising, impacting not only patient care but inter professional working and utilising community rehabilitation services.
Top three learning points
No further data