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Balasundaram Ramesh, S Shenoy and Evan Moore (BCUHB)

Betsi Cadwaladr University Health Board with industry partner, B Braun Medical Ltd

This Bevan Exemplar project aims to improve patient experience and free up vital resources by completing knee replacement surgery and discharging patients within a single day.


Knee replacement is one of the most common orthopaedic procedures. There are around 900,000 of these procedures performed in England and Wales annually.

The technique and the technology are constantly improving to improve health outcomes for patients. The size of the incision is getting smaller almost by 50% and blood loss has also decreased to around 200 ml per case from 1200 ml. This is primarily due to anaesthetic and perioperative infiltrations of medications, in line with enhanced recovery guidelines.

As a result patients feel less pain, less sickness and are able to move their knee immediately following the surgery. Generally, the patients are relatively fitter for their age. Therefore there is a natural instinct to get them up and about following the surgery, and to arrange for them to be discharged on the same day with adequate support.


The aim of this project is to enable patients to have total knee replacement surgery and be discharged within a single day. This approach improves patient experience primarily, but a decrease in length of stay is a helpful by-product.

The project team wants to harness technology to overcome barriers, such as using a pain modifier (like Cryo cuff) and state-of-the-art telemonitoring devices to monitor physiotherapy progress. The project also requires the patient to have a buddy (such as a family member) to support them during the first 48 hours following surgery.


There are many barriers to the success of this project. The most important of these is overcoming a traditional mindset and approach. It is difficult to persuade staff to mobilise the patient following surgery. This due to a traditional approach to patient discharge, along with staff shortages, for example physiotherapists.

The project lead had to demonstrate the steps to mobilise the patients himself at times, in order to show the effect of enhanced recovery.

Although this project was successful in getting selected by Bevan Commission and it has their seal of approval, getting the financial support for a therapist to support the project was very difficult. Finally, however, the project lead has managed to get some limited support to prove that this approach will work.


As NHS is under tremendous strain, everyone needs to think differently. Looking at the process carefully, the total knee replacement procedure itself is getting simpler and the patient’s experience is also positive. The short hospital stay following the surgery is the natural progression. The project team developed a partnership with patients and their families, so they can identify a buddy who can support the patient immediately following surgery with basic nursing skills.

The current stay post-surgery is 4-5 days, and therefore this approach will save 4 days of inpatient stay per patient. If this approach is implemented in 40% of cases in this hospital, the expected economic saving for the Health Board is £350,000 per year.

Next steps:

The project lead has visited various hospitals to study the technique, including in France, Newcastle and York. The team now has the method and protocol ready. As part of the trial, 2-3 patients were trialed on a short-stay basis (overnight) and were discharged within 24 hours. The feedback from these trial patients was very good. Therefore the project lead will extend the trial shortly once a therapist is identified, and it is hoped that many more knee replacement patients will benefit from the same-day discharge approach.

This has changed my approach to my profession. I follow prudent principles meticulously and I take immense pride in being associated with the Bevan Commission. Think different, act different and be Bevan.”

Balasundaram Ramesh