12th May 2017, Volume 130 Number 1455

Suzanne Proudfoot, Brandon Bennett, Simon Duff, Julie Palmer

Orthopaedic services in New Zealand traditionally struggle to achieve waiting time requirements set by the Ministry of Health.1 Furthermore, there is considerable variation among district health boards (DHBs) in intervention…

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Eighteen district health boards (DHB) have introduced Enhanced Recovery After Surgery (ERAS), a new way of caring for people who need a hip or knee joint replacement or who have a fractured neck of femur (hip). ERAS is a patient-centred care pathway that aims to ensure people are in the best possible condition for surgery, have the best possible management during and after their operation and participate in the best possible rehabilitation after surgery. The National Orthopaedic ERAS Collaborative used collaborative quality improvement methodology to implement ERAS in the DHBs. Compliance with the elements that make up ERAS increased from 33% to 75% for knee replacements, from 31% to 78% for hip replacements and from 29% to 51% for fractured neck of femur. The length of time patients spent in hospital for knee joint replacement fell from 5.4 days to 4.5 days, and for hip replacement from 5.1 days to 4.3 days. ERAS is known to significantly improve surgical outcomes for patients and the cost-effectiveness of care. It has also been found to reduce the surgical death rate.



The National Orthopaedic Enhanced Recovery After Surgery (ERAS) Collaborative was launched in November 2013 to implement ERAS protocols for hip and knee total joint arthroplasty (TJA) and fractured neck of femur (NOF) in participating district health boards (DHBs) by December 2014. This paper reports on the results.


ERAS protocols were developed for hip and knee TJA and fractured NOF. Breakthrough Series collaborative methodology was used to implement the ERAS protocols in 18 DHBs. We collected monthly data on compliance with protocols and average length of stay (ALOS). Data were analysed using run charts and Shewhart control charts.


The national percentage of ERAS components achieved across all DHBs rose from 33% to 75% on the elective knee TJA pathway, from 31% to 78% on the elective hip TJA pathway and from 29% to 51% on the acute fractured NOF pathway. The ALOS for knee TJA reduced from 5.4 days to 4.5 days. The ALOS for hip TJA reduced from 5.1 days to 4.3 days. There was no change in the ALOS for fractured NOF.


The National Orthopaedic ERAS Collaborative increased uptake of ERAS protocols across all three pathways and decreased ALOS for the elective pathways among participating DHBs. There was no decrease in ALOS for the fractured NOF pathway. Collaborative improvement methodology can be used successfully to implement orthopaedic ERAS across New Zealand DHBs.

Author Information

Suzanne Proudfoot, Projects and Campaigns Manager, Ko Awatea, Auckland; Brandon Bennett, Improvement Advisor, Improvement Science Consulting, Washington DC, USA; Simon Duff, Team Leader, Service Improvement Team, Electives, Performance, Accountability, Monitoring and Funding, Ministry of Health, Wellington; Julie Palmer, Programme Manager, Service Improvement Team, Electives, Performance, Accountability, Monitoring and Funding, Ministry of Health, Wellington.


We thank the 18 district health boards for their time and commitment in making this programme a success; national clinical lead, Mr Jacob Munro; the clinical leads at each of the DHBs; and Trish Hayward for her invaluable leadership and direction in terms of the writing and editing of this paper. We also thank the Ministry of Health for sponsoring this programme.


Suzanne Proudfoot, Projects and Campaigns Manager, Ko Awatea, Private Bag 93311, Otahuhu, Auckland 1640.

Correspondence Email


Competing Interests

We declare that Ko Awatea was funded by the Ministry of Health to provide improvement advisor expertise for the National Orthopaedic ERAS Collaborative.


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