• Nicholas B Scott, David McDonald, Jane Campbell, Richard D Smith, A Kate Carey, Ian G Johnston, Kate R James, and Steffen J Breusch.
• Departments of Anaesthesia and Rehabilitation, Golden Jubilee National Hospital, Clydebank G81 4HX, UK. nickbscott@msn.com
• Arch Orthop Trauma Surg. 2013 Jan 1;133(1):117-24.

ObjectiveTo establish whether a nationally guided programme can lead to more widespread implementation of enhanced recovery after surgery (ERAS), a well-established optimised care pathway for lower limb arthroplasty.DesignIn 2010, National Services Scotland's Musculoskeletal Audit was asked to perform a 'snapshot' audit of the current peri-operative management of patients undergoing total hip and knee arthroplasty in all 22 Scottish orthopaedic units with an identical follow-up audit in 2011 after input and support from the national steering group.PopulationAudit 1 and audit 2 involved 1,345 and 1,278 patients, respectively.ResultsThe number of Scottish units that developed an ERAS programme increased from 8 (36 %) to 15 (68 %). Units that included more ERAS patients had earlier mobilisation rates (146/474, 36 % ERAS patients mobilised same day vs. 34/873, 4 % non-ERAS; n = 22 units, r = 0.55, p = 0.008) and shorter post-operative length of stay (median 4 days vs. ERAS, 5 days non-ERAS, n = 22 units, r = -0.64, p = 0.001). ERAS knee arthroplasty patients had lower blood transfusion rates (5/205, 2 % vs. 51/399, 13 %, n = 22 units, r = -0.62, p = 0.002). Units that restricted the use of IV fluids post-operatively had higher early mobilisation rates (n = 22 units, r = 0.48, p = 0.03) and shorter post-operative length of stay (n = 22 units, r = -0.56, p = 0.007). Reduced use of patient-controlled analgesia was also associated with earlier mobilisation (n = 22 units, r = 0.49, p = 0.02) and shorter length of stay (n = 22 units, r = -0.39, p = 0.07). Urinary catheterisation rates also dropped from 468/1,345 (35 %) in 2010 to 337/1,278 (26 %) in 2011 (n = 22 units, z = 2.19, p = 0.03).ConclusionA clinically guided and nationally supported process has proven highly successful in achieving a further uptake of enhanced recovery principles after lower limb arthroplasty in Scotland, which has resulted in clinical benefits to patients and reduced length of hospital stay.

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