Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, 76 Stuart Street, Kingston, ON K7L 2V7, Canada.
Can J Anaesth. 2011 Oct;58(10):902-10. doi: 10.1007/s12630-011-9565-8. Epub 2011 Aug 6.
A safe efficient care pathway is needed to address the increasing need for arthroplasty surgery in Canada. Our primary objective was to determine whether a fast-track model of care can reduce length of hospital stay following total hip and knee arthroplasty while maintaining patient safety and satisfaction.
In this historical cohort study, 100 patients treated in a newly implemented fast-track program for total joint arthroplasty were compared with 100 patients treated before the introduction of the program. The fast-track program emphasizes preoperative patient education, postoperative multimodal analgesia with periarticular injections, early physiotherapy and rehabilitation, and discharge home with an outpatient rehabilitation program. The primary outcome was hospital length of stay. Secondary outcomes were concerned with patient safety and involved evaluating postoperative side effects, transfers to the tertiary care hospital, and emergency department (ED) visits and readmissions to hospital within 30 days of discharge.
Length of hospital stay adjusted for age, sex, smoking, comorbidities, American Society of Anesthesiologists' physical status classification, body mass index, and surgical procedure was reduced significantly for patients in the fast-track program compared with the standard program (mean 47 hr; 95% confidence interval [CI] 41 to 53 vs mean 116 hr; 95% CI 110 to 122, respectively). Patients in the fast-track program were discharged from hospital 69 hr earlier than patients in the standard program (95% CI -60 to -78). Despite significantly less morphine utilization, pain scores trended lower in the fast-track patients, both at rest and with activity, than in patients in the standard group (median 7.5 vs 35 mg, respectively). There were no significant differences between the two groups in the rate of ED visits or readmissions in the first 30 days.
Our multimodal multidisciplinary fast-track protocol reduced hospital stay and opioid consumption while maintaining a high level of patient safety. Program implementation is feasible both in tertiary care and in community hospitals.
需要一种安全有效的护理途径来满足加拿大日益增长的关节置换手术需求。我们的主要目标是确定快速通道护理模式是否可以在保持患者安全和满意度的前提下，减少全髋关节和膝关节置换术后的住院时间。
在这项回顾性队列研究中，将 100 例在新实施的全关节置换快速通道计划中治疗的患者与 100 例在该计划实施前治疗的患者进行比较。快速通道计划强调术前患者教育、关节周围注射术后多模式镇痛、早期物理治疗和康复以及在家中进行门诊康复计划。主要结局是住院时间。次要结局涉及患者安全，包括评估术后副作用、转至三级护理医院以及出院后 30 天内急诊（ED）就诊和再次入院。
与标准方案相比，快速通道方案中患者的住院时间调整为年龄、性别、吸烟、合并症、美国麻醉医师协会身体状况分类、体重指数和手术程序，显著缩短（平均 47 小时；95%置信区间 [CI] 41 至 53 与平均 116 小时；95%CI 110 至 122 分别）。快速通道方案的患者从医院出院的时间比标准方案的患者早 69 小时（95%CI -60 至 -78）。尽管吗啡用量明显减少，但快速通道患者的疼痛评分在休息时和活动时均低于标准组（中位数分别为 7.5 与 35mg）。两组在出院后 30 天内急诊就诊或再次入院的比例均无显著差异。
我们的多模式多学科快速通道方案减少了住院时间和阿片类药物的使用，同时保持了高水平的患者安全。该方案在三级护理和社区医院均可行。
