Standardising fast-track surgical nursing care in Denmark.

Considerable variations in procedures, hospital stay and rates of recovery have been recorded within specific surgical procedures at Danish hospitals. The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by implementation of clinical guidelines based on the principles of fast-track surgery-i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The unit was responsible for guideline construction and implementation using the 'workshop practice method': establishing a website, creating a knowledge centre, coordinating implementation agents, and arranging national workshops and conferences. The UPN has promoted implementation of fast-track regimes in all surgical departments in Denmark. We recommend the workshop-practice method for implementation of new procedures in other areas of patient care.

Room for improvement in the treatment of hip fractures in Denmark.

INTRODUCTION: Treatment of hip fractures has evolved since the introduction of fast-track surgical programs in the late 1990s. The aim of our study was to describe the quality of treatment and care related to fast-track hip fracture surgery in Denmark by external audit of patient records. MATERIAL AND METHODS: This was a national multicenter audit of hospital charts from each hospital treating ≥ 50 hip fracture patients per year (n = 594). RESULTS: The study demonstrated significant variability in treatment and care of patients with hip fractures among the regions of Denmark. Pain management, nutritional screening, ambulation characteristics, training in activities of daily living, and rehabilitation planning were consistently inadequate. Length of stay was 7-11 days. CONCLUSION: Although the principles for fast-track surgery have been adapted to some extent at all departments in Denmark with an annual treatment of at least 50 patients with hip fractures, no single department has implemented the whole package. Hospital stay has been reduced since the introduction of fast-track regimes, and improvements were seen in many of the quality indicators. Implications for future practice include better adherence to clinical guidelines, a more homogeneous documentation system in nursing, promotion of evidence-based standards, and improved treatment and care of the physical and psychological consequences of hospitalization.

What determines length of stay after total hip and knee arthroplasty? A nationwide study in Denmark.

INTRODUCTION: The goal of this study was (1) to identify logistical and clinical areas of importance for length of stay (LOS) by identifying departments with short and long LOS and to evaluate their set-up; and (2) to evaluate patient satisfaction in relation to LOS. MATERIALS AND METHODS: Based on the National Register on Patients in 2004 on LOS following total hip and knee arthroplasty (THA and TKA), departments with short and long LOS were identified. The three departments with the shortest and the three departments with the longest postoperative hospital stay were chosen for evaluation. The logistic setup and the clinical treatment/pathway were examined with on-location focus interviews to identify logistic and clinical factors acting as improvement or barriers for early rehabilitation and subsequent discharge. Also, the patients from these departments answered a questionnaire regarding satisfaction with components of their stay, co-morbidity, sex and age. RESULTS: Mean LOS was 7.4 and 8.0 days after THA and TKA, respectively staying from 4.5 to 12 days. Departments with short hospital stay were characterised by both logistical (homogenous entities, regular staff, high continuity, using more time on and up to date information including expectations on a short stay, functional discharge criteria) and clinical features (multimodal opioid-sparing analgesia, early mobilisation and discharge when criteria were met) facilitating quick rehabilitation and discharge. Patient demographics from departments with the shortest stay were similar co-morbidities than patients from departments with longer stays, but were either as satisfied-or more satisfied-with all parts of their stay. There was no difference in staffing (nurses/physiotherapists) between the two types of departments. CONCLUSION: Nationwide implementation of fast-track THA and TKA would result in a significant decrease in the needed number of hospital beds with similar or better outcome for the patients. Implementation of updated logistical and clinical features is expected to increase rehabilitation and reduce LOS with similar or improved patient satisfaction. These results support the implementation of fast-track total hip- and knee arthroplasty.

[Surgical care guidelines]. / Forekomst af kirurgiske procedurespecifikke kliniske vejledninger.

INTRODUCTION: Evidence-based guidelines for perioperative care facilitate the recovery process and decrease morbidity and hospital stay. The aim of this study was to evaluate the availability and content of guidelines for perioperative care in all departments performing colonic resection, nephrectomy, ovarian cancer surgery, pulmonary resection and total knee replacement. MATERIALS AND METHODS: Based upon nationwide workshops and agreement on clinical guidelines for perioperative care a questionnaire was sent to all surgical departments which perform the five procedures. Where available, the guidelines were assessed for presence of written information at admission and discharge, expected hospital stay, plan for mobilisation, nutrition and pain control as well as information on care after discharge. RESULTS: Between 59% and 88% of the departments within each subspecialty had clinical guidelines for perioperative care. The content in the existing guidelines often lacked accurate information regarding preoperative information, objective pain assessment and well-defined discharge criteria. CONCLUSION: The number of clinical guidelines is increasing, but there is a need for further implementation of clinical guidelines for perioperative care in order to improve outcome.

[Length of stay after primary total hip and knee arthroplasty in Denmark, 2001-2003]. / Indlaeggelsesvarighed ved primaer total hofte- og knaealloplastik i Danmark 2001-2003.

INTRODUCTION: We studied length of stay (LOS) after operation with total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Denmark from 2001 to 2003 to determine whether experiences from published accelerated tracks had been implemented in Denmark, resulting in reduced LOS. MATERIALS AND METHODS: Through the National Patient Registry (Landspatientregistret) we obtained information on numbers, sex, age and LOS for each year during the period 2001-2003, inclusive. RESULTS: In 2003 the male-female sex ratios for THA and TKA were 1:1.4 and 1:1.7, respectively. In 2003, the mean age at operation with THA was 66.0 years for men and 69.9 years for women; 66.9 years for men and 69.0 years for women operated on with TKA. During the period studied, LOS was reduced for both operations: 16% for THA, to a mean of 8.1 days, and 17% for TKA, to a mean of 8.6 days, in 2003. LOS increased with age for both THA and TKA. Men had shorter LOS than women. DISCUSSION: The LOS shows that accelerated tracks - with accompanying shorter LOS in the area of 4 to 6 days - have not been implemented on a nationwide basis, and we find a need to review the principles for rehabilitation after operation with THA and TKA in the direction of accelerated tracks. This could be expected not only to generate large savings in LOS but also to reduce the need for rehabilitation and possibly reduce morbidity.

[Length of stay in total hip and knee arthroplasty in Danmark I: volume, morbidity, mortality and resource utilization. A national survey in orthopaedic departments in Denmark]. / Indlaeggelsesvarighed efter operation med hofte- og knaealloplastik i Danmark. I: volumen, morbiditet, mortalitet og resurseforbrug. En landsdaekkende undersøgelse på ortopaedkirurgiske afdelinger i Danmark.

INTRODUCTION: The goal of this study was to evaluate hospital stays for patients operated on with primary total hip- and knee-arthroplasty (THA and TKA) in Denmark in order to focus on the relationship between duration of hospital stay, surgical volume, morbidity and mortality and resources. MATERIALS AND METHODS: According to the National Register on Patients in 2004 concerning postoperative length of hospital stay, readmissions (30 days) and mortality (30 and 90 days), departments with short and long hospital stay were compared and potential economical savings were estimated if all departments reduced their stays to match the departments with the shortest hospital stay. RESULTS: Postoperative hospital stay varied between departments from 4.5 to 12 days. Two-thirds of the departments had stays of more than seven days. A high surgical volume tended to correlate with short hospital stay and reduced mortality. A nation-wide reduction of hospital stay after THA and TKA to five days would free 28,000 hospital beds and produce economic savings of approx. 13 million Euro. CONCLUSION: Nation-wide implementation of fast-track THA and TKA would result in a significant decrease in the needed number of hospital beds and generate economic savings with similar or better outcome.

[Accelerated versus conventional hospital stay in total hip and knee arthroplasty II: organizational and clinical differences]. / Kort vs. lang hospitalisering efter hofte- og knaealloplastik. II: organisatoriske og faglige forskelle.

INTRODUCTION: The goal of this study was to evaluate hospital stays for patients operated on with primary total hip- and knee-arthroplasty (THA and TKA) in order to identify important logistical and clinical areas for the duration of the hospital stay. MATERIALS AND METHODS: According to the National Register on Patients, the three departments with the shortest and the three departments with the longest postoperative hospital stay at the end of 2003 were chosen for evaluation. This took place from late 2004 to mid 2005, and all written material and 25 journals from each department were evaluated, and interviews with the heads of the departments as well as the staff were conducted. The logistical set-up and the clinical treatment/pathway were examined in an attempt to identify logistical and clinical factors acting as improvements or barriers for quick rehabilitation and subsequent discharge. RESULTS: Departments with short hospital stay were characterised by both logistical (homogenous entities, regular staff, high continuity, using more time on and up-to-date information including expectations of a short stay, functional discharge criteria) and clinical features (multi-modal pain treatment, early mobilization and discharge when criteria were met) facilitating quick rehabilitation and discharge. CONCLUSION: Implementation of logistical and clinical features, as shown in this study in all departments, are expected to increase rehabilitation and reduce the length of hospital stay.

[Accelerated versus conventional hospital stay in total hip and knee arthroplasty III: patient satisfaction]. / Patienttilfredshed efter hofte- og knaealloplastik med kort vs. lang indlaeggelse. III: patienttilfredshed.

INTRODUCTION: The goal of this study was to evaluate patient satisfaction with the hospital stay in relation to the length of stay for patients operated on with primary total hip- and knee-arthroplasty (THA and TKA). MATERIALS AND METHODS: According to the National Register on Patients, the three departments with the shortest and the three departments with the longest postoperative hospital stay at the end of 2003 were chosen for evaluation. The patients, operated on with THA or TKA from September 2004 to April 2005, from the selected departments answered a questionnaire regarding satisfaction with elected parts of their stay, co-morbidity, sex and age. RESULTS: The patients from the departments with the shortest stay were not younger nor had they less co-morbidities than patients from departments with longer stays. Apart from staying a significantly shorter time, they were either as satisfied--or sometimes more satisfied--with all parts of their stay compared to patients from the departments with longer hospital stay. CONCLUSION: Patients in accelerated stays are not less satisfied with their hospital stay (or any part of it) compared to patients with longer and more conventional hospital stays. These results support the implementation of fast-track total hip- and knee arthroplasty.