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Table 1 Galeazzi Hospital - Conventional treatment and ERAS pathway

From: Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment


Conventional (up to February, 2018).

ERAS (from March, 2018).


Preoperative visit with orthopaedic surgeon and anaesthesiologist (diagnostic exams included).

Informed consent.

Standard preoperative visit.

1-h preoperative group education with a physiotherapist and a nurse, in which details on the pathway are given to the patient in order to facilitate engagement.

The patient is given life-style advice about the risks of smoking, alcohol and bad nutrition in order to maximize postoperative recovery.

The physical therapist describes the muscle strengthening exercises to be performed before surgery and the information which the patient needs to get in advance (crutches, walkers, elastic stockings, etc.). The social conditions of the patients are taken into evaluation in order to verify the presence or not of a caregiver.

In order to reduce preoperative fasting as much as possible, the patient is given a Carbohydrate loading (2 maltodextrins flasks) with relative instructions for consumption (1 at midnight before day of surgery, 1 at 6.00 AM the day of surgery).

Blood management (identification and correction of anaemia).

Informed consent.

Pre-emptive oral analgesia.


Surgery according to the surgeon’s choice.

Sub-arachnoid anaesthesia.

Drains and catheterization.

Tranexamic acid is administered before incision in order to reduce perioperative bleeding.

Tissue-sparing surgery according to the surgeon’s choice.

Selective sub-arachnoid anaesthesia in order to maintain vital parameters as stable as possible.

Adductor canal block for total knee arthroplasty (TKA).

Local Infiltration Analgesia (LIA) before surgical suture, if needed, depending on the evaluation of the anaesthesiologist.

Possibly no drains and catheterization.


Pain management according to the surgeon’s choice.

Mobilization and physiotherapy from 1 day after surgery, once a day, for half an hour.

Pharmacological treatment in case of nausea and vomiting, followed by light dinner or fasting.

Multimodal pain management according to the surgeon’s choice, including if possible opioid-sparing analgesia.

Postoperative nausea and vomiting prophylaxis.

Feeding 3 h after surgery, with tea and rusks.

Mobilization 4–6 h after surgery, assisted by 2 physioterapists, once safety conditions are guaranteed by the anaesthesiologist. Assisted walking with crutches.

Light dinner. Pharmacological treatment of nausea and vomiting if needed.

Gastric protection and intestinal prokinetics treatments in order to prevent paralytic ileus.

Two physiotherapy sessions from 1 day after surgery, half an hour each.

Average Length of Stay (LOS).

Average 5.2 days in the acute ward, then

a) If the patient does not reach a sufficient level of autonomy, or is not supported by family caregiving: transfer to the rehabilitation unit. Average LOS for rehabilitation: 20 days.

b) If the patient reaches a sufficient level of autonomy to face home discharge: direct home discharge.

a) If the patient is affected by clinical and social conditions of fragility resulting from the preoperative assessment; or by risk factors and complications that emerged later: 3 days LOS in acute orthopaedic ward + internal rehabilitation depending on the need.

b) If the recovery proceeds normally: up to 5 days LOS in acute orthopaedic ward + direct home discharge.

Functional exams are performed depending on the surgeon’s choice.


No audit between the professionals involved in the treatment.

Dedicated nurses.

Non-dedicated physical therapists (turnover between different wards and procedures).

Internal audit (ward data analysis and problem solving) every 4 months.

Dedicated acute ward, physiotherapists and nurses.