Development of the Victoria Enhanced Recovery Arthroplasty (VERA) program

Project Details

  • Departments/Divisions: Orthopedic Surgery
  • Physician Leads: Dr. Duncan Jacks, Orthopedic Surgeon
  • Budget: $22,026.00

About the Project

Dr. Duncan Jacks wanted to make it possible for patients coming into the hospital for hip and knee surgery to return home on the same day. This is made possible by advancement in surgical techniques and better perioperative pain protocols but has not yet been the practice in Victoria. Getting patients home safely on the same day as their surgery is not only better for patients – it frees up hospital beds for other patients and leads to substantial cost savings for Island Health.

Developing and implementing a pilot for outpatient arthroplasty required cooperation and engagement across multiple disciplines and departments to establish a protocol that met the needs of all participating departments and ensured good quality control. Over the past year, with the assistance of a grant from the South Island Medical Staff Association, Dr. Jacks brought together orthopaedic surgeons, anaesthesiologists, Clinical Nursing Leads in the operating room, PACU, ward, and outpatient Rebalance clinic, pharmacists, physiotherapists, MOAs, and Island Health Directors to establish a successful protocol to enable hip and knee replacement patients to safely go home on the day of surgery.

The group knew that other centers in Canada were performing same-day discharge for Arthroplasty. They traveled to Montreal in December 2018 to view that facility’s processes and protocols, and witness first-hand the experience of patients having their surgeries and discharge on the same day.

Upon return to Victoria, the group started recruiting people from different disciplines to form a smaller working group to see how their protocols could be applied to Victoria’s set up. Once they were satisfied with the protocols, they set about designing a pilot. Eight patients participated in the pilot and provided constructive feedback on their experiences. After these debriefs, the group met again to discuss the feedback and make necessary adjustments, and refine handouts for patient education.

The project has now successfully sought Phase 2 funding to support the engagement of other orthopaedic surgeons and anesthesiologists to scale up this project and apply it to all patients, as well as look at resource requirements and cost savings. Speaking about the value of the funding, Dr. Jacks said “It would have been impossible to do this project without this funding. It’s a lot of ‘volunteer time’ on the part of physicians, often after-hours or early mornings, so I think it really enables us to move forward with this project knowing that there is funding set aside for people’s time”. He reiterated that there was “huge value with different players sharing key ideas for every step of the protocol”.

Phase 2:

When Dr. Duncan Jacks initiated Victoria Enhanced Recovery Arthroplasty (VERA), a same-day arthroplasty program in Victoria in 2019, he did so in recognition of the value of getting patients home safely on the same day as their surgery. Patients appreciated not having to spend the night in the unfamiliar setting of the hospital, and Island Health was able to free up hospital bed space for other patients.

What he could not have anticipated at the time was the advent of COVID-19 just a few months later. For several months in early 2020, all elective surgeries were put on hold. Patients who had been scheduled for a knee or hip arthroplasty had to wait until the immediate threat of a sudden surge of COVID-19 infected patients had subsided. Yet with the constant threat of a second wave, keeping hospital beds free is now doubly important. Suddenly, a same-day discharge arthroplasty program became part of the hospital’s way of managing the limited resources of hospital beds.

Dr. Jacks’ project received funding in its first phase to engage across multiple departments to establish the necessary protocols for the same day program and to design and implement a pilot of the same-day service. Following a meeting with Island Health CEOs in the fall of 2019 where Dr. Jacks presented the results of the pilot, he felt confident that all stakeholders were aligned in support of this initiative.

In Phase 2, Dr. Jacks and colleagues Dr. Jacques Smit and Dr. Tristan Camus completed the Clinical Order Set for Same Day Hip/Knee Arthroplasties by meeting with their Island Health counterparts, physiotherapists, Clinical Nurse Leads, and pharmacists. Gathering the group together via teleconferences, they discussed and debated necessary modifications to make a same-day discharge program function safely, including multimodal pain management, and adjustments in the activity orders for patients post-surgery. They also drafted a health care provider user manual for VERA – a ‘cookbook’ for the initiative – that can be implemented by others in Victoria or at other sites without the direct involvement of Dr. Jacks or his other colleagues.

In an example of parallel initiatives benefiting each other, Dr. Jacks’ project builds on another project initiated by a South Island physician, Dr. Gus Chan. While Dr. Jacks has been working to scale up the VERA project, Dr. Gus Chan and his colleagues in anesthesia have been working to build consensus and refine protocols around the creation of a block room, a designated space to administer regional anesthesia. The absence of a block room was one of the biggest obstacles identified to implementing a same-day discharge for arthroplasty, as patients would have to queue for their spot in the operating room before having anesthesia administered. In May 2020, the Victoria Block Room entered its pilot phase, a shift that will no doubt impact on the efficiency and functioning of the same-day arthroplasty program.

With the continuing imperative of keeping the hospital census to a minimum, the VERA initiative stands out as a leader in same-day discharge. We congratulate the project leads on their hard work getting the project launched and look forward to further scale-up and expansion in the coming year.


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