Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI.
Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI.
J Arthroplasty. 2018 Aug;33(8):2440-2448. doi: 10.1016/j.arth.2018.03.053. Epub 2018 Mar 27.
Total knee arthroplasty volume is increasing significantly in the United States. Reducing hospital length of stay may represent the best method for accommodating expanding volume and reducing costs. We hypothesized that tailoring a clinical pathway to facilitate early ambulation would decrease costs and resource utilization.
We conducted a sequential before-and-after study of total knee arthroplasty patients after a phased implementation of a clinical pathway that includes multimodal oral analgesic protocols, adductor canal nerve block, and standardized day of surgery ambulation protocols. Primary outcomes measured were hospital length of stay, total opioid consumption, total antiemetic use, and perioperative pain scores.
Two hundred ninety-five patients were divided into 3 sequential cohorts. Cohort 1 received spinal anesthesia, femoral nerve block, and was not placed into postop day 0 ambulation therapy. Cohort 2 received spinal anesthesia, adductor canal block, and postop day 0 ambulation therapy. Cohort 3 received spinal anesthesia, adductor canal block, postop day 0 ambulation therapy, and standardized oral multimodal analgesic protocol. Cohort 3 had significantly reduced hospital length of stay. Cohorts 2 and 3 had significantly less opioid consumption. Cohort 3 had significantly less total ondansetron consumption compared with cohort 1. Cohort 3 had significantly reduced average pain scores compared with cohort 1.
The data demonstrate that tailored clinical pathways designed to facilitate early ambulation can reduce hospital length of stay, reduce opioid consumption, reduce antiemetic use, and improve pain control. The results establish that refined clinical pathways can assist in improving care while increasing value to patients, providers, and systems.
在美国，全膝关节置换术的数量正在显著增加。减少住院时间可能是适应手术量增加和降低成本的最佳方法。我们假设通过制定临床路径来促进早期活动可以降低成本和资源利用。
我们对接受临床路径分期实施的全膝关节置换术患者进行了前后顺序研究，该临床路径包括多模式口服镇痛方案、收肌管神经阻滞和标准化手术当天活动方案。主要结果测量是住院时间、总阿片类药物消耗量、总止吐药使用量和围手术期疼痛评分。
295 名患者分为 3 个连续队列。队列 1 接受脊髓麻醉、股神经阻滞，且未进行术后第 0 天的活动治疗。队列 2 接受脊髓麻醉、收肌管阻滞和术后第 0 天的活动治疗。队列 3 接受脊髓麻醉、收肌管阻滞、术后第 0 天的活动治疗和标准化口服多模式镇痛方案。队列 3 的住院时间明显缩短。队列 2 和 3 的阿片类药物消耗量明显减少。与队列 1 相比，队列 3 的总昂丹司琼消耗量明显减少。与队列 1 相比，队列 3 的平均疼痛评分明显降低。
数据表明，旨在促进早期活动的定制临床路径可以缩短住院时间、减少阿片类药物的消耗、减少止吐药的使用，并改善疼痛控制。结果表明，精细的临床路径可以在提高患者、提供者和系统价值的同时，帮助改善护理。
