achieve 1–3 days hospital length of stay, a reduced incidence of cardiac and venous thromboembolism complications and reduced postoperative delirium and cognitive dysfunction. The authors further showed that the mean length of stay can be decreased from 76.6 hours to 56.1 hours after implementation of the evidence-based orthopedic ERAS pathway (P < 0.001). This improvement was possible without a concomitant increase in readmission rates. Another study compared 1500 primary hip and knee replacement patients on an ERAS pathway with 3000 patients using a traditional protocol. The authors found that the median LOS decreased from 6 to 3 days, saving 5418 bed days.4 The 90-day mortality rate was also significantly reduced, as well as transfusion requirements. Other studies have found ERAS pathways feasible and safe for more complex groups of patients such as the elderly,5 with a decrease in LOS for patients aged ≥85 years, and no negative effects on morbidity and mortality rates. Additionally, the beneficial effects of ERAS are not limited to the routine primary hip and knee replacements. More complex and surgically variable procedures such as revision joint replacement, shoulder replacement, and in non-elective procedures such as fractured neck of femur patients have found outcomes to similar to those for primary total knee replacement with respect to LOS and morbidity,6 where median LOS was 2 days, no morbidity within 3 months, low readmission rates, and high levels of patient satisfaction. Major spine surgery is another specialty area that the application of ERAS principles has potential to improve patient outcomes.7 When ERAS principles are incorporated into existing or new clinical pathways, they improve the value of care delivery. Risk-adjusted 12 Conclusion Evidence exists to support the increased use of ERAS pathways. High-volume orthopedic surgeries such as total joint arthroplasty as well as spine surgery are ideal for such clinical pathways. Such high-volume procedures also allow for individual centers to track data and feedback data to help optimize the future use of pathways. Adaptation of ERAS patient outcomes, patient safety, and optimizing the use of resources are used for performance and quality indicators.8 2009 meta-analysis suggested that clinical pathways and care organization have significantly impacted the quality of care in joint replacement surgery with reduced postoperative complications, shorter length of stay and potentially lower cost of care.9 Recent, large sample analysis on perioperative fluid administration variability in the hip and knee replacement surgeries concluded that both low and high fluid volumes associate with worse outcomes.10 Suggested orthopedic ERAS care bundles Preoperative Patient education and expectation setting Preoperative nutritional assessment and optimization Carbohydrate loading Minimal preoperative fasting Anemia detection and optimization Preemptive pain management Intraoperative Minimally invasive surgery Multimodal analgesia Goal directed fluid management Nausea vomiting prophylaxis Active warming Blood loss prevention Postoperative Early return to oral diet Physiotherapy and early mobilization Early discharge principles as part of integrated care pathways appear feasible and may effectively improve patient outcomes, satisfaction and reduce cost. ERAS concepts perfectly lines up with the accountable care organizational needs to create a platform for the transformational care initiatives. We encourage institutions to identify multidisciplinary service champions to develop ERAS pathway care. A number of professional organizations including the ERAS Society (erassociety.org), and American Society of Enhance Recovery (aserhq. org) provide guidelines and resources to help with development of such pathways at the institutional level. n References 1. Davis MA, Onega T, Weeks WB, Lurie JD. Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions. Spine 2012;37:1693–701. 2. Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ. Prevalence of Total Hip and Knee Replacement in the United States. The Journal of Bone & Joint Surgery 2015;97:1386–97. 3. Aasvang EK, Luna IE, Kehlet H. Challenges in postdischarge function and recovery: the case of fast-track hip and knee arthroplasty. Hardman JG, ed. Br J Anaesth 2015:aev257–6. 4. A. Malviya, K. Martin, I. Harper, et al. Enhanced recovery program for hip and knee replacement reduces death rate. A study of 4500 consecutive primary hip and knee replacement Acta Orthop, 82 (2011), pp. 577–581 5. C.C. Jorgensen, H. Kehlet, on behalf of the Lundbeck Foundation Centre for Fast-track hip and knee replacement collaborative Group Role of patient characteristics for fast-track hip and knee arthroplasty Br J Anaesth, 110 (2013), pp. 972–980 6. H. Husted, S. Kristian Otte, B.B. Kristensen, et al. Fast-track revision knee arthroplasy Acta Orthop, 82 (2011), pp. 438–440 7. Wainwright TW, Immins T, Middleton RG. Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Practice & Research Clinical Anaesthesiology 2016;30:91– 102. 8. Association EP. Clinical/care pathways. Slovenia Board Meeting, 2005. 9. Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the joint replacement: a metaanalysis. BMC Medicine 2009 7:1 2009;7:32. 10. Thacker JKM, Mountford WK, Ernst FR, Krukas MR, Mythen MMG. Perioperative Fluid Utilization Variability and Association With Outcomes. Annals of Surgery 2016;263:502–10. ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org
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