Enhanced recovery after surgery: first better, then faster

  • Hands on knee
Assoc Prof Allan Molloy, Dr Myles Coolican, Dr Sam Martin
Assoc Prof Allan Molloy, Specialist in Anaesthesia and Pain Medicine, Royal North Shore Hospital and University of Sydney;
Dr Myles Coolican, Specialist Orthopaedic Surgeon, Royal North Shore Hospital, Sydney;
Dr Sam Martin, Specialist Orthopaedic Surgeon, Grafton, NSW

Dorothea Mackellar’s ‘droughts and flooding rains’ in her 1904 poem highlights the large variations that occur in Australia’s climate. The recent Royal Commission noted that Australia has a long history of disasters linked to natural hazards. The impact of disasters is related to many factors including how well people and communities are prepared, supported and cared for during and after disasters.

The current stop-start status quo around elective surgery has resulted in avoidable suffering and costs to the community. Most would agree that newer models of care are needed to manage interruptions to elective surgery associated with the current and future pandemics. Australia has quickly rolled out an impressive array of technology-enhanced care models including telehealth and a range of digital devices. Virtual preoperative clinical reviews are also being scaled.

Where Australia has some catching up to do is in the implementation of rapid recovery pathways after surgery. The ability to achieve the stellar outcomes seen in these models of care was significantly advanced by a homegrown discovery.

Over 25 years ago in a small private hospital in Sydney, anaesthetist Dr Kerr and surgeon Professor Kohan showed that very simple, high-volume local anaesthetic infiltration (LIA) for primary hip (THR) and knee (TKR) replacements, reduced the severe postoperative pain to the equivalent of a sporting injury, allowing mobilisation within two hours of surgery and discharge home the next day – safely and comfortably (with minimal narcotics).

This further stimulated others to follow and it is the norm internationally that 15 to 20 per cent of patients in socialised health systems are safely discharged home on the same day as their surgery after THR and TKR, and 70 per cent by the next day. During the pandemic, reports from the United States are that up to 60 per cent of patients can achieve this outcome.

History has shown this technique has contributed to the surgical revolution termed enhanced recovery after surgery (ERAS). ERAS pathways – also called rapid recovery or fast-track programs – are multidisciplinary, evidence-based perioperative pathways, designed to achieve early and safer recovery for patients undergoing major surgery. As ERAS has evolved, surgical ‘traditions’ that potentially impair early recovery, such as urinary catheterisation, use of tourniquets and drains, are being eliminated.

The efficiencies that have resulted from the introduction of ERAS have been a major driver in many countries including Canada, the United Kingdom, New Zealand and the United States. However there is little evidence that ERAS pathways are routinely used in Australian hospitals. Many claim they are using ERAS, but usually they are cherrypicking from the list of items. This is not ERAS. Improved outcomes are the result of consistent application of the key ERAS elements across the entire surgical period. Some components of ERAS are really just good care, such as antimicrobial measures and venous thromboembolism prophylaxis. Others such as LIA are items that shorten length of stay.

Studies in Canada have shown that a return on investment of up to eight dollars can be achieved for every one dollar invested for rapid recovery pathways. In Ballarat, average savings of $9,000 and four days in hospital per TKR patient were achieved. That allows five TKRs per hospital bed each week instead of one. This is important as, by 2030, the predicted 240,000 THRs/TKRs per year in Australia will cost $5.32 billion, which is likely unaffordable.

So it is time to do what we know and align the incentives.

A word of caution from Professor Kehlet in Copenhagen: aim for ‘first better, then faster’.

This will take time, but surely not another 25 years.


Presenter at the National Rural Health Conference

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