Clinical Pathway for
Inpatient and Outpatient
Hip and Knee Arthroplasty
Enhanced Recovery Canada:
A Collaborative to Improve Surgical Care
Version 1. June 2021
A Resource for Healthcare Providers
Y
N
Author List
The Healthcare Excellence Canada (HEC) would like to acknowledge the governance committee,
knowledge management specialist and McGill University Hospital Centre’s (MUHC) Patient
and expertise, including:
Claude LaFlamme, ERC Chair
Carla Williams, Project Manager
Pascal-André Vendittoli
Leah Gramlich
Ahmer Karimuddin
Franco Carli
Gregg Nelson
Erin Ballah
Melinda Baum
Brae Surgeoner
Nancy Posel
David Fleiszer
Matt Evans
Han Han Li
Karen Brown
Pascal-André Vendittoli, MD, MSc, FRCS,
Montreal, QC
Keith Alexander Kennedy
with the McGill University Health Centre
Natalia Gulpa RN MN, Montreal QC
Marceline Quach B Pharm MSc, Montreal QC
Han Ting Wang MD MSc FRFPC, Montreal QC
Montreal QC
Louis-Philippe Fortier MSc MD FRCPC,
Montreal QC
Stephen Choi MD MSc FRCPC, Toronto ON
Mahesh Nagappa MD MSc, London ON
Donald J Young MD FRCPC, Vancouver BC
Brent Lanting MD MSc FRCSC, London ON
Michael Tanzer MD FRCSC FAAOS,
Montreal QC
Thomas Bertoia MD FRCSC, Newmarket ON
Karina Pellei MSc, Montreal QC
Governance Committee Knowledge Management Specialist
MUHC Patient Education Oce
Pathway Chair
Patient Advisors
Registered Nurses
Pharmacist
Internist
Anesthesiologists
Orthopedic Surgeons
Physiotherapists
Table of Contents
About Enhanced Recovery Canada (ERC) Pathways
Scope and Purpose
Target Population
Target Audience
Stakeholder Involvement
Development and Revision History
Editorial Independence
Disclaimer
Key Messages
Patient and Family Engagement
Patient Optimization
Analgesia
Surgical Best Practices
Fluid Management
Nutrition
Overarching Recommendations
1
5
9
11
17
25
31
41
Patient and Family Engagement
Engaging Patients and their Caretakers
Analgesia
Surgical Best Practices
Nutrition and Fluid Management
Patient Optimization
Analgesia
Surgical Best Practices
Nutrition
Preoperative
Patient and Family Engagement
Nutrition and Fluid Management
Analgesia
Surgical Best Practices
Intraoperative
Analgesia
Surgical Best Practices
Fluid Management
Postoperative
Patient and Family Engagement
Analgesia
Surgical Best Practices
Nutrition and Fluid Management
11
13
14
15
16
17
19
23
24
25
26
27
29
31
36
40
41
42
44
46
47
1
2
3
3
3
3
4
5
5
6
6
7
7
8
Preamble
Total Hip
and Knee
Arthroplasty
Pathway
Table of Contents
References*
Patient and Family Engagement
Analgesia
Surgical Best Practices
Nutrition and Fluid Management
Resources
NF
NF
I
S
A
P
M
A S M
Note*
54
54
55
56
61
67
68
Discharge
Patient and Family Engagement
Analgesia
Surgical Best Practice
49
50
51
52
Total Hip
and Knee
Arthroplasty
Pathway
Appendix A. Abbreviations
Appendix B. Discharge Criteria
Appendix C. ERAS Outpatient Protocol Example from
Hôpital Maisonneuve-Rosemont
Appendix D. Data Collection and Measurement
Appendix E. Process and Outcome Variables
Appendix F. Template for Physician Order Sets
69
70
71
77
83
97
I P
49
1
About ERC Pathways
surgery (discharged home on the same calendar day as the surgery) or a day surgery
This clinical pathway is organized in a stepwise approach according to the patient’s
• increase patient engagement
• reduce pain while minimizing opioid use
• avoid patient sedation
•
• minimize postoperative anemia
• decrease wound complication
•
•
•
•
•
• minimal postoperative outpatient care
• reduced costs
Scope and Purpose
2
About ERC Pathways
Inclusion criteria:
•
•
Exclusion criteria for an ERAS outpatient procedure:
•
a contraindication
•
• Systemic disease involvement necessitating special perioperative care
•
•
limitations that prevent movement without technical or physical assistance
•
•
•
Patient characteristics that merit caution and individual evaluation before attempting
an ERAS outpatient procedure with the present pathway:
•
•
•
• Body mass index (BMI) > 35 or 40 kg/m2
•
•
•
test prior to surgery)
Target Population
I
1-6
All adult patients who require total hip arthroplasty (THA) or total knee arthroplasty
(TKA) or unicompartmental knee arthroplasty (UKA) should be considered for ERAS
management using the recommendations provided in this clinical pathway regardless
of the planned hospital length of stay (outpatient or hospitalized).
3
About ERC Pathways
Surgeons, anesthetists, physiotherapists, occupational therapists, nurses, pharmacists,
depends on dynamic harmony amongst the various participants than on reaching an
Note: Drugs and dosages are provided throughout the pathway, where appropriate, as examples;
only non-proprietary (generic) names are provided. Please consult with a pharmacist when developing
your clinical pathway. All medications have side eects that should be taken into consideration on an
individual patient basis prior to administration.
Target Audience
I
7
Stakeholder Involvement
Editorial Independence
Development
I
8
4
About ERC Pathways
Disclaimer
5
Key Messages
Clinicians should discuss pain management expectations with patients preoperatively
to help guide treatment decisions, and to help shape realistic patient expectations
While current evidence does not support preoperative physiotherapy as an essential
Patient Optimization
increase patient engagement see
Guide
to
Strategies to increase patient engagement throughout the perioperative process
Patient and Family Engagement
6
Key Messages
A systematic approach to antiemetic prophylaxis that includes limited preoperative
potential adverse events
Analgesia
Surgical Best Practices
7
Key Messages
Balanced IV solutions such as Plasmalyte or Ringer’s Lactate solution are recommended
Unless patients experience nausea or vomiting, an early return to normal diet is
Fluid Management
Nutrition
8
Key Messages
exercise physiology principles
visit or patients should attend an outpatient clinic, where the physiotherapist will assess
Mobility and Physical Activity
9
Overarching Recommendations
1
2
3
6
4
5
I
9
styles, including:
•
10
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Phase 1. Patient and Family Engagement
Phase 2. Patient Optimization
Phase 3. Preoperative
Phase 5. Postoperative
Phase 4. Intraoperative
Phase 6. Discharge
11
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
Engaging Patients in their Care
P1-11
1
Recommendations
•
perioperative exercises
discharge planning
•
•
•
•
•
•
•
• Practice a universal approach when communicating with patients and their caregivers/
•
•
• Highlight the ERC Patient Guide and online videos to the patient and their caregivers/
•
12
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
Engaging Patients in their Care
P1-11
1
Data Collection
Pre-admission counselling and education
Additional Information
•
•
• Health literacy measurement tools
• Health literacy how-to tips
•
•
•
Study
•
•
Tools and Equipment
• Hip and Knee
• Animated Precare Hip and Precare Knee Arthroplasty Guide
?
13
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
Analgesia
A1-2
Recommendations
• Patients should understand that ERAS approaches to analgesia are opioid-sparing,
•
• Clinicians should discuss pain management expectations with patients to help guide
•
•
•
Tools and Equipment
?
1
• Pain assessment scale
• Patient Optimization Booklet
• Animated Precare Hip and Precare Knee Arthroplasty Guide
Additional Information
14
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
1
Surgical Best Practice
S1-2
Recommendations
•
•
• Models or actual prosthetics that patients can look at are recommended to help patients
•
•
•
•
Tools and Equipment
?
• Models or actual prosthetics
• Patient Optimization Booklet
• Animated Precare Hip and Precare Knee Arthroplasty Guide
15
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
1
Nutrition and Fluid Management
NF1
Recommendations
•
•
Tools and Equipment
?
• Patient Optimization Booklet
• Animated Precare Hip and Precare Knee Arthroplasty Guide
• Canada’s Food Guide
16
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
Mobility and Physical Activity
M1-3
Recommendations
•
•
•
Implementation Approaches
• -
and instruction should include:
•
•
•
?
1
Tools and Equipment
?
• Patient Optimization Booklet
• Animated Precare Hip and Precare Knee Arthroplasty Guide
17
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Analgesia
2
Identify Opioid Tolerance
A3-7
Recommendations
Additional Information
•
•
•
•
•
18
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Analgesia
2
Psychological Screening
A8-18
Recommendations
Additional Information
•
• Low preoperative mental health, pain catastrophizing, and unrealistic patient expectations
•
Tools and Equipment
•
•
Use a validated screening tool like the Hospital Anxiety and Depression Scale (HADS) or
?
19
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Surgical Best Practices
2
Preoperative Assessment Clinic
Recommendations
•
•
Risk Assessment/Management
S3-6
Recommendations
•
•
•
•
Tools and Equipment
• The Outpatient Arthroplasty Risk Assessment score
• The Readmission Risk Assessment Tool
?
Malnutrition
Chronic kidney disease
liver cirrhosis)
Depression
Cardiovascular disease
gravis)
Data Collection
Preoperative risk assessment
20
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Surgical Best Practices
2
Infection Prevention
S3, S7
Recommendations
•
•
•
Urinary Problem Prevention
S8
Recommendations
•
•
Tools and Equipment
• International Prostate Symptoms Score (IPSS)
?
Additional Information
• -
sumption, IV drug use, coagulopathy, malnourishment, preoperative anemia and postoper-
•
21
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Surgical Best Practices
2
Medication Discontinuation
S9-11
Recommendations
•
•
surgery:
•
•
Tools and Equipment
• Patient Optimization Booklet
• Animated Precare Hip and Precare Knee Arthroplasty Guide
?
Additional Information
22
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Surgical Best Practices
2
Smoking and Alcohol Use
S3, S12-15
Skin Preparation
S16-17
Recommendations
Recommendations
•
•
• Patients with high alcohol intake should receive an alcohol cessation intervention to
Tools and Equipment
?
Additional Information
•
•
•
23
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Nutrition Screening
NF2
Recommendations
Tools and Equipment
Additional Information
Use a screening tool like the Canadian Nutrition Screening Tool (CNST
?
Nutrition
2
Data Collection
Malnutrition screening
24
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Optimization
Mobility and Physical Activity
M4-5
Recommendations
• While current evidence does not support preoperative physiotherapy as an essential
•
Mobility and Physical Activity
2
25
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Preoperative
3
Patient and Family Engagement
Engaging Patients in their care
Recommendations
•
•
•
•
•
•
• Health On the Net)
26
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Preoperative
3
Nutrition and Fluid Management
Reduced Fasting
NF1
Complex Carbohydrate Loading
NF1, NF3
Recommendations
Recommendations
Additional Information
•
•
•
•
•
Documented gastroparesis
Metoclopramide, domperidone and/or cisapride used to treat gastroparesis
Achalasia
Dysphagia
•
Data Collection
27
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Preoperative
3
Analgesia
Pre-emptive Multimodal analgesia
A19-24
Recommendations
Additional Information
•
Acetaminophen 1 g PO
By giving a single preoperative dose we may prevent or reduce the
•
•
•
Anxiety
Recommendations
Additional Information
28
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Preoperative
3
Analgesia
Pre-emptive Multimodal analgesia
A19-24
Additional Information
•
•
Data Collection
29
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Preoperative
3
Surgical Best Practices
Antiemetic Prophylaxis
S18-19
Recommendations
•
approach to prevention, including:
Aprepitant 125 mg PO, or ondansetron 4 mg PO 1-2 h preoperatively or
intraoperatively
Additional Information
•
•
•
•
•
•
30
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Preoperative
3
Surgical Best Practices
Antimicrobial Prophylaxis
S20-22
Recommendations
•
•
•
•
Additional Information
•
•
•
31
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Analgesia
Additional Information
•
•
•
32
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Analgesia
Anesthesia
A20, A25-38
Recommendations
Spinal anesthesia
• Simple and well-known method
•
•
•
• Associated with orthostatic hypotension
Combined lumbar epidural and propofol sedation, titrated to achieve the
desired clinical eect
•
•
•
•
• Reduces postoperative opioid use
•
General anesthesia
•
•
• Potential risks related to airway management and respiration
•
•
•
33
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Analgesia
Anesthesia
A20, A25-38
Additional Information
Based on expert opinion and retrospective studies, ERAS THA and TKA pathways support
regarding anesthetic practice in THA/TKA surgery and a recent large retrospective study
Data Collection
34
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Analgesia
Local Inltration Analgesia (LIA)
A20, A25, A34, A39-47
Recommendations
Additional Information
•
•
•
•
•
•
•
•
35
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Analgesia
Regional Nerve Block for TKA
A44, A48-51
Recommendations
Additional Information
•
•
•
•
•
Data Collection
36
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Surgical Best Practices
Skin Preparation
S3, S23-24
Recommendations
Additional Information
•
•
Prevention of Blood Loss
S25-27
Recommendations
•
•
•
Additional Information
• Recommended administration method, dose, and timing:
•
• Tranexamic acid administration to high-risk THA and TKA patients is not associated
Data Collection
37
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Surgical Best Practices
Surgical Approach
S12
Recommendations
•
•
Use of Tourniquets
S12, S28
Use of Drains
S12, S29-33
Recommendations
Recommendations
•
•
Data Collection
Additional Information
38
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Surgical Best Practices
Local Antimicrobials
S34
Recommendations
•
•
Maintaining Normothermia
S35-36
Recommendations
•
•
Tools and Equipment
•
•
•
?
Additional Information
Intraoperative and postoperative hypothermia are common in patients who have
39
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Surgical Best Practices
Wound Closure
S37-52
Recommendations
•
•
Use skin glue to seal the incision and prevent wound discharge or retrograde
contamination, and
Data Collection
Optimized wound closure
Additional Information
•
•
•
•
40
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Intraoperative
4
Nutrition and Fluid Management
Fluid Management
NF1, NF4-5
Recommendations
•
• Balanced IV solutions such as Plasma-Lyte or Ringer’s Lactate solution are
•
Additional Information
•
•
41
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
Postoperative
5
Involving Patients in their Care
P9-10
Recommendations
•
•
Hip and Knee
•
•
42
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Analgesia
Postoperative
5
Pain Assessment
Recommendations
Tools and Equipment
•
•
•
•
?
43
ERC CLINICAL PATHWAYS FOR COLORECTAL SURGERY
Postoperative
5
Multimodal Opioid-Sparing Pain Management
A20, A52
•
•
•
Additional Information
Data Collection
Recommendations
•
•
•
• Recommended pain control using a multimodal analgesia protocol:
Regular medication
•
200 mg/day
Analgesia
44
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Surgical Best Practices
Postoperative
5
Urinary Retention Prevention
S12, S53-58
Venous Thromboembolism (VTE) Prophylaxis
S12, S18, S59-64
Recommendations
Recommendations
•
•
•
•
•
•
Additional Information
Additional Information
•
•
•
Acetylsalicylic acid (ASA) 80 mg
)
•
45
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Surgical Best Practices
Postoperative
5
Venous Thromboembolism (VTE) Prophylaxis
S12, S18, S59-64
Data Collection
Antimicrobial Prophylaxis
S20, S65
Hip and Knee Precautions
S66-69
Recommendations
Recommendations
Additional Information
Additional Information
• There is no good evidence to support whether hip precautions with or without the addition
•
46
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Nutrition and Fluid Management
Postoperative
5
Nutrition and Fluid Management
NF1, NF6
Recommendations
• Unless patients experience nausea or vomiting, an early return to normal diet is
•
•
Additional Information
47
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Assessment Prior to Early Mobilization
In-Hospital Mobilization
M5-M12
Recommendations
Recommendations
•
•
•
•
•
•
•
•
•
Mobility and Physical Activity
Postoperative
5
Additional Information
•
•
48
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
In-Hospital Mobilization
M5-M12
Mobility and Physical Activity
Postoperative
5
Additional Information
Data Collection
Implementation Approaches
Tools and equipment
•
in the immediate postoperative periods, including:
•
•
•
?
?
49
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient and Family Engagement
Discharge
6
Engaging Patients in their Care
Recommendations
•
•
Hip and Knee
•
•
•
Additional Information
50
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Analgesia
Discharge
6
Multimodal Opioid-Sparing Pain Management
A20, A53-56
Recommendations
•
•
•
•
•
•
•
•
Additional Information
•
•
51
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Surgical Best Practices
Discharge
6
Patient Education
S70-72
Surveillance
Recommendations
Recommendations
•
•
•
•
•
52
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Patient Education Prior to Discharge
Recommendations
•
•
Implementation Approaches
•
•
?
Mobility and Physical Activity
Discharge
6
53
ERC Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty
Post-Discharge Physical Activity
M13-15
Recommendations
•
visit or patients should attend an outpatient clinic, where the physiotherapists will assess
•
•
•
swimming, cycling, and walking are encouraged (at low intensity levels) in the early
weeks post-surgery once the wound is healed, swelling is controlled, and as the patient
• Higher impact activities may start at 3 months post-surgery according to the surgeon’s
Implementation Approaches
?
Mobility and Physical Activity
Discharge
6
Data Collection
Outcome Measures:
Complication rate
Return to work
54
REFERENCES
Introduction
I
55
REFERENCES
Patient and Family Engagement
P
56
REFERENCES
Analgesia
A
57
REFERENCES
Analgesia
A
58
REFERENCES
Analgesia
Increased Adverse Events Compared With Spinal Anesthesia in Patients Undergoing Unicompartmental
A
59
REFERENCES
Analgesia
013-2928-4
A
60
REFERENCES
Analgesia
A
61
REFERENCES
Surgical Best Practices
Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee
S
62
REFERENCES
Surgical Best Practices Pathway
Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total
S
63
REFERENCES
Surgical Best Practices Pathway
-
S
64
REFERENCES
Surgical Best Practices Pathway
-
S
65
REFERENCES
Surgical Best Practices Pathway
Patients Undergoing Elective Hip and Knee Arthroplasty - Evidence-Based Guideline and Evidence
orthopaedic-surgery
S
66
REFERENCES
Surgical Best Practices Pathway
S
67
REFERENCES
Nutrition and Fluid Management
NF
68
REFERENCES
Mobility and Physical Activity
M
69
Abbreviations
ACB
ACTH, adrenocorticotrophic hormone
ASA, acetylsalicylic acid
BID, twice a day
BMI
CDC
COPD
CNST, Canadian Nutrition Screening Tool
CPSI
DVT
ERC, Enhanced Recovery Canada
ERAS
FNB
HADS, Hospital Anxiety and Depression Scale
HMR, Hôpital Maisonneuve Rosemont
IPACK
IPSS, International Prostate Symptoms Score (IPSS)
IV, intravenous
LIA
MUHC, McGill University Hospital Centre
MRSA
NPO
NRS, numeric rating scale
NSAID
PACU, post anesthesia care unit
PJI
PO
POD, postoperative day
PONV, postoperative nausea and vomiting
PRN, as needed
PROMIS
QHS
QID
SC
SSI
THA, total hip arthroplasty
TKA, total knee arthroplasty
TID, three times a day
TIVA, total intravenous anesthesia
UKA, unicompartmental knee arthroplasty
WHO, World Health Organization
Appendix A
70
Appendix B
Discharge Criteria
to know when discharge should occur
1
•
•
•
•
•
•
•
•
•
•
•
•
•
1
71
Appendix C
ERAS Outpatient Hip and Knee Arthroplasty Example
from Hôpital Maisonneuve-Rosemont (HMR), Montreal QC
1
complications, including: pain, nausea, vomiting, dizziness, headache, constipation, hypotension,
1
Paent selecon
Inclusion criteria:
•
•
Absolute exclusion criteria for an ERAS outpatient procedure:
•
• Systemic disease involvement necessitating special perioperative care (intensive care,
•
• -
•
•
•
Patient characteristics that merit caution and individual evaluation before attempting
an ERAS outpatient procedure:
•
• BMI > 35 or 40 kg/m2
•
•
•
72
Appendix C
Pre-surgery evaluaon and invesgaon
Preparing for day surgery
Nurse intervention
• Review selection and exclusion criteria
•
•
• Provide patient and caregiver education on the ERAS program
•
•
•
Internal medicine
•
•
Anesthesiologist
•
Physiotherapist
• Physical assessment
•
*Patients are encouraged to visit www.precare.ca for animated information about
their surgery.
Preparing for day surgery
•
•
ERAS Outpatient Hip and Knee Arthroplasty Example
from Hôpital Maisonneuve-Rosemont (HMR), Montreal QC
73
Appendix C
Day of surgery
•
Preoperative medication within 2 h before surgery:
• Acetaminophen 1 g PO,
• Oxycontin 10 mg PO,
•
• Lyrica 150 mg PO,
• Aprepitant 125 mg PO,
•
IV medications preoperatively
•
•
•
Anesthetic protocol
•
1-2
•
ERAS Outpatient Hip and Knee Arthroplasty Example
from Hôpital Maisonneuve-Rosemont (HMR), Montreal QC
74
Appendix C
Day of surgery
Surgery
•
• Surgical approach
•
•
posterolateral approach)
•
•
• 1g IV tranexamic acid (max 15 mg/kg) prior to closing the surgical site
•
•
•
•
Recovery room
•
•
ERAS Outpatient Hip and Knee Arthroplasty Example
from Hôpital Maisonneuve-Rosemont (HMR), Montreal QC
75
Appendix C
Outpaent unit
Home medicaon and instrucon
•
• Breathing exercises
•
•
Promote oral dietary intake as early as wanted
•
physiotherapist or physiotherapy assistant or nurse
•
•
•
•
• First physiotherapist session
First attempt to stand and walk
•
•
•
•
•
•
• Provide patient and their caregiver with summary sheet
•
• Ensure patient leaves the hospital with caregiver
ERAS Outpatient Hip and Knee Arthroplasty Example
from Hôpital Maisonneuve-Rosemont (HMR), Montreal QC
76
Appendix C
Home medicaon and instrucon
Home care
•
Assess wound / dressing and vital signs
Further visit as needed or according to the local procedures
•
Teach and supervise exercise protocol
Further visit according to local protocol
• Standard outpatient clinic visits per standard care pathways (4-8 weeks postoperative)
ERAS Outpatient Hip and Knee Arthroplasty Example
from Hôpital Maisonneuve-Rosemont (HMR), Montreal QC
77
Appendix D
Data Collection and Measurement
Summary
Study Population
ICD-10 Code Description of Procedure
0SR9019
Replacement of Right Hip Joint with Metal Synthetic Substitute, Cemented, Open
Approach
0SR901A
Replacement of Right Hip Joint with Metal Synthetic Substitute, Uncemented,
Open Approach
0SR901Z
Replacement of Right Hip Joint with Metal Synthetic Substitute, Open Approach
0SR9029
Replacement of Right Hip Joint with Metal on Polyethylene Synthetic Substitute,
Cemented, Open Approach
0SR902A
Replacement of Right Hip Joint with Metal on Polyethylene Synthetic Substitute,
Uncemented, Open Approach
0SR902Z
Replacement of Right Hip Joint with Metal on Polyethylene Synthetic Substitute,
Open Approach
0SR9039
Replacement of Right Hip Joint with Ceramic Synthetic Substitute, Cemented,
Open Approach
0SR903A
Replacement of Right Hip Joint with Ceramic Synthetic Substitute, Uncemented,
Open Approach
0SR903Z
Replacement of Right Hip Joint with Ceramic Synthetic Substitute,
Open Approach
This resource will guide clinicians through data collection and measurement to
support the implementation of the Enhanced Recovery Canada (ERC) total hip and
knee replacement surgery pathway. It includes information about how to identify your
study population, how to calculate the appropriate sample size, as well as identifies
what specific data points to be collected on each patient.
It is helpful for teams to collect data on patients undergoing the same total hip and
knee replacement surgeries to allow for data aggregation and comparisons. This is
possible because each Canadian acute care institution reviews patient’s charts after
discharge and classifies their surgeries based on a universal coding system.
The World Health Organization created an international coding system of medical
classifications; the International Statistical Classification of Diseases and Related
Health Problems (ICD), version 10. Within ERC, we will use this coding system to
describe the total hip and knee replacement surgeries which should be included in
your patient population. By providing your Health Care Information Management and
Technology Department with the following list of ICD-10 codes they should be able to
provide data on the number of total hip and knee replacement surgeries performed
monthly and details about the acute care stay of the patients who endured these
procedures.
78
Appendix D
Data Collection and Measurement
ICD-10 Code Description of Procedure
0SR9049
Replacement of Right Hip Joint with Ceramic on Polyethylene Synthetic Substitute,
Cemented, Open Approach
0SR904A
Replacement of Right Hip Joint with Ceramic on Polyethylene Synthetic Substitute,
Uncemented, Open Approach
0SR904Z
Replacement of Right Hip Joint with Ceramic on Polyethylene Synthetic Substitute,
Open Approach
0SR9069
Replacement of Right Hip Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Cemented, Open Approach
0SR906A
Replacement of Right Hip Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Uncemented, Open Approach
0SR906Z
Replacement of Right Hip Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Open Approach
0SR90J9
Replacement of Right Hip Joint with Synthetic Substitute, Cemented, Open
Approach
0SR90JA
Replacement of Right Hip Joint with Synthetic Substitute, Uncemented, Open
Approach
0SR90JZ
Replacement of Right Hip Joint with Synthetic Substitute, Open Approach
0SRB019
Replacement of Left Hip Joint with Metal Synthetic Substitute, Cemented, Open
Approach
0SRB01A
Replacement of Left Hip Joint with Metal Synthetic Substitute, Uncemented, Open
Approach
0SRB01Z
Replacement of Left Hip Joint with Metal Synthetic Substitute, Open Approach
0SRB029
Replacement of Left Hip Joint with Metal on Polyethylene Synthetic Substitute,
Cemented, Open Approach
0SRB02A
Replacement of Left Hip Joint with Metal on Polyethylene Synthetic Substitute,
Uncemented, Open Approach
0SRB02Z
Replacement of Left Hip Joint with Metal on Polyethylene Synthetic Substitute,
Open Approach
0SRB039
Replacement of Left Hip Joint with Ceramic Synthetic Substitute, Cemented, Open
Approach
0SRB03A
Replacement of Left Hip Joint with Ceramic Synthetic Substitute, Uncemented,
Open Approach
0SRB03Z
Replacement of Left Hip Joint with Ceramic Synthetic Substitute, Open Approach
0SRB049
Replacement of Left Hip Joint with Ceramic on Polyethylene Synthetic Substitute,
Cemented, Open Approach
0SRB04A
Replacement of Left Hip Joint with Ceramic on Polyethylene Synthetic Substitute,
Uncemented, Open Approach
0SRB04Z
Replacement of Left Hip Joint with Ceramic on Polyethylene Synthetic Substitute,
Open Approach
0SRB069
Replacement of Left Hip Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Cemented, Open Approach
0SRB06A
Replacement of Left Hip Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Uncemented, Open Approach
0SRB06Z
Replacement of Left Hip Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Open Approach
0SRB0J9
Replacement of Left Hip Joint with Synthetic Substitute, Cemented, Open
Approach
0SRB0JA
Replacement of Left Hip Joint with Synthetic Substitute, Uncemented, Open
Approach
79
Appendix D
Data Collection and Measurement
ICD-10 Code Description of Procedure
0SRB0JZ
Replacement of Left Hip Joint with Synthetic Substitute, Open Approach
0SRC069
Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene
Synthetic Substitute, Cemented, Open Approach
0SRC06A
Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene
Synthetic Substitute, Uncemented, Open Approach
0SRC06Z
Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene
Synthetic Substitute, Open Approach
0SRC0J9
Replacement of Right Knee Joint with Synthetic Substitute, Cemented, Open
Approach
0SRC0JA
Replacement of Right Knee Joint with Synthetic Substitute, Uncemented, Open
Approach
0SRC0JZ
Replacement of Right Knee Joint with Synthetic Substitute, Open Approach
0SRC0L9
Replacement of Right Knee Joint with Medial Unicondylar Synthetic Substitute,
Cemented, Open Approach
0SRC0LA
Replacement of Right Knee Joint with Medial Unicondylar Synthetic Substitute,
Uncemented, Open Approach
0SRC0LZ
Replacement of Right Knee Joint with Medial Unicondylar Synthetic Substitute,
Open Approach
0SRC0M9
Replacement of Right Knee Joint with Lateral Unicondylar Synthetic Substitute,
Cemented, Open Approach
0SRC0MA
Replacement of Right Knee Joint with Lateral Unicondylar Synthetic Substitute,
Uncemented, Open Approach
0SRC0MZ
Replacement of Right Knee Joint with Lateral Unicondylar Synthetic Substitute,
Open Approach
0SRC0N9
Replacement of Right Knee Joint with Patellofemoral Synthetic Substitute,
Cemented, Open Approach
0SRC0NA
Replacement of Right Knee Joint with Patellofemoral Synthetic Substitute,
Uncemented, Open Approach
0SRC0NZ
Replacement of Right Knee Joint with Patellofemoral Synthetic Substitute, Open
Approach
0SRD069
Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Cemented, Open Approach
0SRD06A
Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Uncemented, Open Approach
0SRD06Z
Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic
Substitute, Open Approach
0SRD0J9
Replacement of Left Knee Joint with Synthetic Substitute, Cemented, Open
Approach
0SRD0JA
Replacement of Left Knee Joint with Synthetic Substitute, Uncemented, Open
Approach
0SRD0JZ
Replacement of Left Knee Joint with Synthetic Substitute, Open Approach
0SRD0KZ
Replacement of Left Knee Joint with Nonautologous Tissue Substitute, Open
Approach
0SRD0L9
Replacement of Left Knee Joint with Medial Unicondylar Synthetic Substitute,
Cemented, Open Approach
0SRD0LA
Replacement of Left Knee Joint with Medial Unicondylar Synthetic Substitute,
Uncemented, Open Approach
80
Appendix D
Data Collection and Measurement
ICD-10 Code Description of Procedure
0SRD0LZ
Replacement of Left Knee Joint with Medial Unicondylar Synthetic Substitute,
Open Approach
0SRD0M9
Replacement of Left Knee Joint with Lateral Unicondylar Synthetic Substitute,
Cemented, Open Approach
0SRD0MA
Replacement of Left Knee Joint with Lateral Unicondylar Synthetic Substitute,
Uncemented, Open Approach
0SRD0MZ
Replacement of Left Knee Joint with Lateral Unicondylar Synthetic Substitute,
Open Approach
0SRD0N9
Replacement of Left Knee Joint with Patellofemoral Synthetic Substitute,
Cemented, Open Approach
0SRD0NA
Replacement of Left Knee Joint with Patellofemoral Synthetic Substitute,
Uncemented, Open Approach
0SRD0NZ
Replacement of Left Knee Joint with Patellofemoral Synthetic Substitute, Open
Approach
Sampling
A suggested sampling calculation is provided below.
1
This calculation recommends
how many patient charts should be reviewed during the baseline period selected and
the ongoing data collection through the implementation phase. This sampling is
based on the number of total hip and knee replacement surgeries performed monthly.
Average Monthly Population Size “N”
Minimum required sample “n”
<20
No sampling; 100% of population required
20 - 100
20
> 100
15-20% of population size
81
Appendix D
Data Collection and Measurement
Collection Strategy
1. Perla RJ, Provost LP, Murray SK. Sampling considerations for health care improvement. Qual Manag
Health Care. Oct.-déc. 2014;23(4):268-79. doi: 10.1097/QMH.0000000000000042
Process Variables
Surgical Phase Process Variables
Preoperative
• Pre-admission counselling and education
• Preoperative risk assessment
• Reduced fasting protocol
• Use of pre-emptive medication
Enhanced Recovery programs are the implementation of evidence-based
recommendation in the preoperative, intraoperative and postoperative phases. Thus,
there are various process variables to be collected along the surgical continuum to
ensure compliance to these recommendations. A process variable evaluates whether
the recommended intervention is being followed. For example, if an organization is
trying to reduce the need for blood transfusion in patients it may measure the process
of administering tranexamic acid.
It is anticipated that process variables will be found via manual chart review, whether
your organization document on paper or electronically. The recommended process
variables are listed below, with a full description found in Appendix D.
Before implementing the pathway, specific data points must be identified for
collection which will demonstrate the process changes (process variables) or the
impact of these changes (outcome variables). These data points must be obtained
before any changes are made, then at scheduled time periods throughout the
implementation to reflect progress.
Baseline data collection should occur over a 3-month period to ensure an accurate
reflection of the surgical care provided. Monthly data collection and reporting is
recommended to reflect the process changes and improvements in postoperative
patient outcomes. Data should continue to be collected monthly until the team has
determined that a level of sustainability has been reach.
It is recommended to collect both process and outcome variables
82
Appendix D
Data Collection and Measurement
Intraoperative
• Use of tranexamic acid
• Approach to anesthesia minimizes opioids, sedatives, and motor function
loss
• Use of tourniquet
• Use of LIA/regional nerve block
• Optimized wound closure
Postoperative
• Use of multimodal pain management
• Chemical VTE prophylaxis prescribed
• First postoperative mobilization
Outcome Variables
An outcome variable determines if a specific intervention is having the desired effect
on a clinical measure, such as reducing postoperative infection rates.
Recommended outcome variables are listed below, with full description found in
Appendix D.
• Outpatient surgery failure
• Acute length of stay
• Complication rate
• Visits to Emergency Department within 30 days after discharge
• Readmission within 30 days after discharge
• Return to work
As previously mentioned, patient charts are reviewed and coded on discharge.
This information is entered into the Discharge Abstract Database (DAD), including
postoperative complications, acute care length of stay and readmissions to hospital.
It is suggested to liaise with your organization’s Health Care Information
Management and Technology Department to extract this data, as it would
significantly reduce data collection time and ensure consistency in collection methods
between sites. By providing the Health Care Information Management and
Technology Department with the list of ICD-10 codes used to define the hip and knee
arthroplasty population, they can provide the number of hip and knee arthroplasties
and the patient outcomes from information which has already been collected in your
organization.
83
Appendix E
Process Variables
Preoperative Phase
• Pre-admission counselling and education
Intent of Variable
Denition
Criteria
•
•
Options
• Yes
• No
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
• N/A
Notes
surgery videos, or having their own similar
instructions which address elements such as preoperative skin
84
Appendix E
Process Variables
Preoperative Phase
• Preoperative risk assessment
Intent of Variable
To capture whether or not the patient received a
Denition
Criteria
A preoperative risk assessment prior to surgery includes the most
common pre-existing medical conditions:
• Allergies to drugs listed in the pathway
•
• Malnutrition
•
• Chronic kidney disease
•
• Depression
• Cardiovascular disease
•
•
•
• Excessive alcohol consumption
•
•
• Prostatic symptoms (males)
•
• MRSA carrier
Options
• Yes
• No
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
• N/A
Notes
85
Appendix E
Process Variables
Preoperative Phase
• Reduced fasting protocol
Intent of Variable
To capture whether or not the patient was instructed to
Denition
Criteria
unless a patient has documented delayed gastric emptying or
other contraindications
Options
•
• No, patient had stricter preoperative diet restrictions
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
• N/A
Notes
Preoperative diet restrictions may need to
86
Appendix E
Process Variables
Preoperative Phase
• Use of pre-emptive medication
Intent of Variable
To capture what pre-emptive medications the patient
Denition
Pre-emptive medication is administered prior to anesthesia
• Acetaminophen
• NSAID
• Long-acting opioids
• Dexamethasone
• Antiemetics
Criteria
• Yes, patient received all 5 pre-emptive medications listed
• Yes, patient received 3-4 pre-emptive medications
• No, patient received < 3 pre-emptive medications
Options
• Yes, all 5 pre-emptive medications
• Yes,3-4 pre-emptive medications
• No, < 3 pre-emptive medications
Scenarios to Clarify
(Assign Variable)
Scenarios to Clarify
(Do NOT Assign
Variable)
Notes
87
Appendix E
Process Variables
Intraoperative Phase
• Use of tranexamic acid
Intent of Variable To capture whether a patient received tranexamic acid in the
Denition
Criteria
Indicate whether or not tranexamic acid was administered
Options • Yes, oral
• Yes, IV
• Yes, topic
•
• No
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
• N/A
Notes
methods (oral, IV, topical) and with a single or multiple
88
Appendix E
Process Variables
Intraoperative Phase
• Approach to anesthesia minimizes opioids, sedatives, and motor
function loss
Intent of Variable To capture whether an approach to anesthesia that avoids
employed in the preoperative holding area, operating room,
Denition
Criteria
employed
•
•
•
IV anesthesia was used
•
employed
Options •
• Yes, spinal (intrathecal) injection
• Yes, general anesthesia
•
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
• N/A
Notes
89
Appendix E
Process Variables
Intraoperative Phase
• Use of tourniquet
Intent of Variable
Denition
Criteria
Options •
•
• No
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
• N/A
Notes
90
Appendix E
Process Variables
Intraoperative Phase
• Use of LIA/regional nerve block
Intent of Variable
Denition
• Diluted
• Long-acting
•
•
• Epinephrine
•
Criteria
Options
For THA patients:
• Yes, LIA was used
• No, LIA was not used
For TKA patients:
•
•
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
• N/A
Notes
91
Appendix E
Process Variables
Intraoperative Phase
• Optimized wound closure
Intent of Variable To capture whether an optimized approach to wound closure
Denition
An optimized wound closure method aims to minimize/avoid
postoperative wound discharge, dressing changes and nursing
Criteria
Indicate whether or not an optimized wound closure
Options •
• Yes, with skin staples and optimized dressing
• No, optimized wound closure not used
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
Staples with a large John’s dressing and a splint
Notes
92
Appendix E
Process Variables
Postoperative Phase
• Use of multimodal pain management
Intent of
Variable
To capture whether multimodal approaches to pain
Denition
•
• Acetaminophen
Criteria
Indicate whether a multimodal approach to pain
•
the postoperative period within 12 h
•
•
in the postoperative period within the
Options
• Yes
• No
Scenarios to
Clarify
(Assign Variable)
• N/A
Scenarios to
Clarify
(Do NOT Assign
Variable)
•
Notes
•
• Regional anesthesia
• Cryotherapy
93
Appendix E
Process Variables
Postoperative Phase
• Chemical VTE prophylaxis prescribed
Intent of Variable
medication to prevent DVT or pulmonary
Denition
Criteria
reason, including as prophylactic treatment or
therapeutic management through 14 (TKA), 28 (THA),
medication through 14, 28, and up to
Options
• Yes
• No
Scenarios to
Clarify
(Assign Variable)
•
anti-coagulant
• Aspirin alone
• Low molecular weight heparin
•
Scenarios to
Clarify
(Do NOT Assign
Variable)
• Clopidogrel, ticagrelor, ticlopidine, cilostazol,
• Mechanical device only
•
prophylaxis
•
to 35 (high risk patients) days
Notes •
•
•
• Fondaparinux sodium
•
•
94
Appendix E
Process Variables
Postoperative Phase
• First postoperative mobilization
Intent of Variable
Denition
•
•
Criteria
•
• POD 1
• POD 2
•
•
Options •
• POD 1
• POD 2
•
•
Scenarios to Clarify
(Assign Variable)
• N/A
Scenarios to Clarify
(Do NOT Assign
Variable)
•
• Up to chair
Notes
95
Appendix E
Outcome Variable Denition
Outpatient Surgery
Failure
Acute Length of
Stay*
Complication
Rate*
Complication: a post-intervention condition or symptom that is not
•
• Nausea
• Vomiting
• Bladder retention
• Hypotension
• Dizziness
• Headache
• Pruritus
• Constipation
• Edema
• Hematoma
• Wound discharge >3 days
• Fall
• Orthostatic hypotension
• DVT
• Anemia
•
•
• SSI (deep)
•
•
• Unplanned return to
operating room
• Readmission
• Mortality
•
Outcome Variables
96
Appendix E
Outcome Variable Denition
Complication Rate*
-------------------------------------------------------------------
Visits to Emergency
Department
within 30 Days
after Discharge*
Readmission
within 30 Days
after Discharge*
Return to Work
• Return to work date
Date: DD/MM/YY
Unknown
• Return to work situation
Normal duties
Outcome Variables
97
APPENDIX F
Template for Physician Order Set - Preoperative
Enhanced Recovery
After Hip and
Knee Arthroplasty
Weight: kg Height: cm Allergy(s): Intolerance(s):
TYPE OF INTERVENTION
√
see exclusion criteria and cautions outlined in clinical pathway
Total hip arthroplasty (THA) or Unicompartimental knee arthroplasty (UKA) or
Total knee arthroplasty (TKA)
Inpatient or Outpatient
PREOPERATIVE EVALUATIONS
√
√
CONSULTATIONS
√ Internal medicine
√ Physiotherapy
√ Other(s):
PATIENT AND FAMILY EDUCATION
√
√ Changes to patient medication regimens
√
√
Patient Name
Chronic kidney disease
Depression
Lung disease
Neurologic disorder
Prostatitis symptoms
(smoking, alcohol, drugs)
Hepatic disease
Cardiovascular disease
Malnutrition
Anxiety and depression
98
APPENDIX F
Template for Physician Order Set - Preoperative
PREOPERATIVE PREPARATIONS
√
√
√ Samples: - FSC control, cross-match
PHARMACOTHERAPY
• 1-2 h preoperative
√ Analgesia
Acetaminophen 1 g PO x 1 dose
disease)
Long-acting opioid x 1 dose:
Oxycodone-CR or OxyNEO 10 mg PO or
Hydromorphone-CR or hydromorph contin 3 mg PO or
or
Other:
√ Antiemetic
Aprepitant 125 mg PO x 1 dose or ondansetron 4 mg PO x 1 dose
Enhanced Recovery
After Hip and
Knee Arthroplasty
Patient Name
99
APPENDIX F
Template for Physician Order Set - Intraoperative
Enhanced Recovery
After Hip and
Knee Arthroplasty
Weight: kg Height: cm Allergy(s): Intolerance(s):
Operating Room
√
Tranexamic acid
or
or
Anesthesia, general guidelines:
√
√
√ Avoid opioids
√
√
Local anesthetic infiltration protocol
Ropivacaine 400 mg in 200 cc
adrenaline (1:1000)
Wound closure, general guidelines:
√
and minimize nursing care
TYPE OF INTERVENTION
Patient Name
100
APPENDIX F
Template for Physician Order Set - Intraoperative
Enhanced Recovery
After Hip and
Knee Arthroplasty
CARE AND SURVEILLANCE
•
•
•
•
• Monitor urination:
•
•
•
health care provider
•
• Cryotherapy according to physiotherapy
FLUID AND ELECTROLYTE REPLENISHMENT
•
•
FOOD
•
Patient Name
101
APPENDIX F
Template for Physician Order Set -
In-Hospital Postoperative Prescriptions
Enhanced Recovery
After Hip and
Knee Arthroplasty
Preoperative
Weight: kg Height: cm Allergy(s): Intolerance(s):
PHARMACOTHERAPY
ANALGESIA/COANALGESIA (from the recovery room on departure)
Acetaminophen 1000 mg PO TID until discharge, up to 1000 mg QID
or severe cardiovascular disease)
stepwise approach
Antiemetics
√
Prophylactic Anticoagulotherapy
Patient Name
102
APPENDIX F
Template for Physician Order Set -
Discharge Prescriptions
Enhanced Recovery
After Hip and
Knee Arthroplasty
TYPE OF INTERVENTION
LEAVE AND CONTINUITY OF CARE
•
(appendix B)
•
• Control X-ray
ANALGESIA
√
√
General guidelines:
•
them
•
ANTIEMETICS
√
ANTICOAGULATION
SURVEILLANCE, general guidelines:
•
•
PHYSCIAL ACTIVITY, general guidelines:
•
should attend outpatient clinic, where physiotherapists will
knee exercises
•
Patient Name
103
104
