Guidance for hip and knee surgery outlines measures to support a significant reduction in length of stay

Clinical guidance demonstrating best practice ambulatory care for elective hip and knee patients is now available from the Getting It Right First Time (GIRFT) team.

Exemplar practice from teams across England is captured in the new document, which offers practical advice and key principles to help NHS teams working to recover elective surgery and tackle the backlog.

The aim of the guide – which runs alongside two redefined patient pathways for elective primary total hip replacement (THR) and elective primary total and uni-knee replacement (TKR) – is to support trusts and systems looking to adopt a safe and effective ambulatory pathway for elective primary hip and knee arthroplasty, reducing length of stay (LoS) towards the best practice examples of zero or one day without compromising patient experience or care. As well as enabling patients to return home more quickly, this can in turn free up hospital beds and support the NHS drive to reduce long waiting lists post-pandemic.

“In the wake of the Covid-19 pandemic the pressures on elective surgery are immense, and it’s important to look to those organisations achieving lower lengths of stay to learn by example and share their principles for success. We hope organisations will read these principles and adopt any suggestions they can in these challenging times, as well as using the guide to help shape future improvements when the opportunity arises.”

The elective waiting list for NHS patients in England stands at more than 6.5 million people, up from 4.4 million before the pandemic. The orthopaedic specialty, which includes THR and TKR operations, was severely impacted by Covid-19 and now has both the highest number of patients waiting and the greatest volume waiting for longer than one year.

NHS England’s Delivery Plan for Tackling the Covid-19 Backlog of Elective Care (February 2022) set out how the NHS will address the backlog, including a focus on transforming the way elective care is provided. As part this national drive, clinicians at NHS centres already achieving LoS of one day or less for arthroplasty surgery have worked alongside GIRFT to develop the new pathways and guide, and to share their experiences.

Co-badged by the British Orthopaedic Association (BOA), the focus of the guidance is primarily on the perioperative processes which support hip and knee replacement surgery. For example, one of the key principles outlined is for all suitable patients to be managed on an ambulatory pathway by default, with many discharged the same day and the remainder the following day (this does not include the up to 10% of patients identified as requiring a higher level of care after their operation, who are likely to need a two-night stay or more).

The guide also offers detailed advice on other effective processes which support the success of a shorter-stay pathway, such as managing patients’ expectations about LoS, best practice for admissions, anaesthesia techniques, the provision of physiotherapy to best support the patient, and preparing medication for discharge.

Clinicians from the South West Ambulatory Orthopaedic Centre (SWAOC) in Devon worked with a multi-professional team from a range of trusts in England to develop the guide. The SWAOC centre, which opened in March 2022, has achieved day case rates of 54% for THR and TKR since opening, and 99% of patients are discharged by day one.

“Our ultimate aim is to do what is best for our patients, and we know that most people are keen to get home as quickly as possible after their surgery. By sharing our best practice from SWAOC and other centres, we hope to demonstrate how reduced LoS can be delivered as a by-product of excellent care, which is not only best for the patient, but good for the team and the wider NHS at the same time. We hope that centres can work towards implementing some of these principles as they are able.”

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