What influences hospital length of stay for patients having elective hip or knee surgery? A Realist Evaluation of an Orthopaedic Enhanced Recovery Programme

This research thesis comprises a realist evaluation of an Orthopaedic Enhanced Recovery Programme (ERP) in a Large Teaching Hospital in the United Kingdom. The ERP is an intervention that uses evidence based standardised care at each stage of a patient journey to enable optimum recovery following a hip or knee replacement operation. Implementation of ERP has become increasingly prominent in the NHS in England as it can improve quality of care for patients and enables efficient use of resources. Published research into ERP has focused on pre and post-implementation analysis, commonly examining the impact on reducing length of stay as the primary outcome. There is a lack of research into understanding how and why the ERP enables reduced length of stay, so this research aimed to fill that void by using realist evaluation of the ERP to understand the relationships between programme activities, contexts, mechanisms and outcomes. The aims of the research were to understand how the ERP worked, for whom and under which circumstances, so that new knowledge could be gained and applied for refinements to the ERP at the research site and in other hospital settings. Mixed methods were used to obtain data from multiple sources including length of stay data, documentary evidence interviews and a focus group with clinical and non-clinical members of the ERP implementation team. The data was analysed against the ERP programme theory to determine how the programme worked and the different contexts under which the programme was effective.

This evaluation has found that supportive contexts for the ERP to be effective include organisational support, consistent leadership, consistent service pressure, sustained stakeholder meetings, sufficient resources, widespread programme knowledge, a consistent protocol, a dedicated unit, an external site visit, regular data and feedback, and understanding of the role of patient’s complexity on outcomes. Where facilitative contexts exist then this can trigger mechanisms for motivation, confidence, shared understanding, shared purpose, enthusiasm and prioritisation of the work. The outcomes of this were consistent delivery of the ERP, the establishment of a patient-staff recovery ‘contract’, programme ownership and responsibility and increased expertise. These outcomes then enabled optimum recovery and length of stay to be achieved for patients. This research provides new knowledge to the field of Orthopaedic Enhanced Recovery and provides a refined programme theory for the ERP which could be used for effective implementation of the programme on other NHS hospital settings.