TY - JOUR T1 - Wanting to improve is not always the same as knowing how to improve—an example from a total knee arthroplasty pathway JF - BMJ Open Quality JO - BMJ Open Qual DO - 10.1136/bmjoq-2020-001019 VL - 9 IS - 4 SP - e001019 AU - Thomas W Wainwright AU - James Craig Y1 - 2020/12/01 UR - http://bmjopenquality.bmj.com/content/9/4/e001019.abstract N2 - Enhanced recovery after surgery (ERAS) (or enhanced recovery or fast-track) protocols for total knee arthroplasty (TKA) can be considered a quality improvement (QI) intervention, that is, their implementation may be defined as a purposeful effort to improve care processes that will result in improved patient outcomes.1 ERAS protocols are a multimodal approach that improves the quality of patient care, including reducing length of stay (LOS) for TKA.2 ERAS protocols seek to optimise the perioperative pathway by using and combining techniques such as minimally invasive surgery, regional anaesthetic techniques, multimodal opioid sparing pain management and early mobilisation. ERAS protocols have been detailed and include procedure-specific guidelines for TKA.3This report evaluates efforts to improve an ERAS pathway for patients with TKA at a National Health Service district general hospital, where ERAS had previously been implemented.4 Within the hospital, there was a desire to further reduce LOS. Local audit data were interpreted, and it was proposed that factors related to the anaesthetic (such as pain, motor block, symptoms of orthostatic intolerance) were delaying discharge. The anaesthetic protocol was changed five times in an attempt to reduce LOS and this process is retrospectively evaluated in this report. The stimulus to reflect on past improvement efforts was prompted in order to guide successful future QI efforts.This is a … ER -