National survey of protocols for day-case hip and knee arthroplasty in the UK

Day-case joint arthroplasty, where patients are discharged on the day of surgery, is increasingly used to meet rising demand in a resource-efficient manner. NHS England guidance states that all patients should be placed on an ambulatory pathway (zero to one night stay). However, little is known about the prevalence, structure, and implementation of day-case protocols across the UK.

An online survey was sent to all NHS institutions performing hip or knee arthroplasty. Respondents reported the presence of day-case, ambulatory (zero to one night stay), or generic enhanced recovery protocols. Data were collected across 21 questions covering key perioperative domains and analyzed descriptively, and model health system data was used to assess length of stay (LoS).

Overall, 63 responses were received covering 86 hospitals (56 trusts), of which 78 (91%) perform day-case surgery. In total, 41 (48%) had a dedicated day-case protocol, 23 (27%) had ambulatory protocols, and 15 (17%) used generic enhanced recovery pathways. Only 22% of hospitals with a day-case pathway placed all patients on it by default. Protocol content showed substantial variation, including the use of sedation as part of anaesthesia (49%), presence of therapy services beyond 17:00 (59%), and nurses competent in assessing day zero mobility (56%). One third of hospitals had no mechanism for patients to contact out-of-hours support. LoS was shorter in hospitals using day-case or ambulatory protocols when compared with those that did not, however, this did not reach statistical significance.

While day-case joint arthroplasty is widely performed in the NHS, dedicated protocols are used in fewer than half of hospitals, and considerable variation exists. These results can be used collaboratively by hospitals that are trying to establish pathways, and to guide further research aiming to identify best practice and provide standardization for day-case protocols.