Vol. 36 No.
3 May/June 2014 17
Comprehensive Facility-Wide Approach
Improves Outcomes after Lower Extremity
Surgical Arthroplasty in an Acute Care
Hospital
Shannon Talatzko, Sara M. Deprey, Nancy Hager
Review of the Literature
Among one of the most effective options for
improving quality of life in individuals with hip
or knee osteoarthritis (OA) is an elective to-
tal joint replacement or arthroplasty (National
Center for Health Statistics, 2010). The average
age of individuals electing a total knee arthro-
plasty (TKA) is 70 years of age with over 90%
of those individuals having OA (Centers for
Disease Control and Prevention [CDC], 2011;
Kane et al., 2003). Similarly, 60% of those
undergoing a total hip arthroplasty (THA) is
65 years of age (Zhan, Kaczmarek, Loyo-
Berrios, Sangl, & Bright, 2007). In 2004, an
estimated $14.3 billion and $9.3 billion was
spent on hospital cost associated with total knee
and total hip replacements, respectively (CDC,
2011). It is expected the average number of in-
dividuals seeking TKA or THA will rise, along
with costs, due to the large number of aging in-
dividuals in the baby boomer population as well
as anticipated need in younger people (Kurtz,
Ong, Lau, Mowat, & Halpern, 2007). Projec-
tions for 20052030 expect the number of THA
and TKA to rise by 174% and 673%, respec-
tively (Kurtz et al., 2007). Thus, it is imperative
for facilities to use cost efficient procedures to
address the increased need for lower extremity
arthroplasties without compromising quality of
care.
Health complications associated with inpa-
tient care require an increased length of stay
(LOS). Common complications after TKA or
THA may include infection, deep vein throm-
bosis (DVT), or pulmonary embolism (PE).
Together, DVT and PE are referred to as a
venous thromboembolism (VTE). Any compli-
cation, however, significantly increases hospi-
tal LOS and leads to a twofold increase in cost
(Ollendorf, Vera-Llonch, & Oster, 2002). Per-
centage of patients who develop a VTE within
the hospital was found to be 0.9% by a large
retrospective study (White, Romano, Zhou,
Rodrigo, & Bargar, 1998). Once patients have
Abstract: The number of total knee and hip arthroplasty is
predicted to rise 174% and 673%, respectively, over the next
20 years due to the expected rise in the baby boomer population.
Along with increased numbers or procedures performed is the
rise in cost and potential medical complications from hospitaliza-
tions. The purpose of this study is to describe one rural hospitals
facility-wide procedure to streamline processes and standardize
care without compromising patient medical needs prior to, and
during, the acute phase of total knee and hip arthroplasty. Data
were compared before and after the facility-wide procedure was
implemented. Results found shorter length of hospital stay and
significantly more discharges directly home all without increas-
ing medical complications after the facility-wide procedure was
implemented.
been diagnosed with a VTE during or shortly Keywords
after their hospital stay, the risk for rehospi- acute care
talization and thus associated healthcare costs quality improvement
rises (Ollendorf et al., 2002). Therefore, to im- research-quantitative
prove cost efficiency and quality, facilities must
reduce length of hospital stay while also mini-
mizing health complications.
One approach to reducing hospital costs and
LOS is utilization of preoperative education.
Studies have suggested preoperative education
reduces patient anxiety related to surgery, hos-
pitalization, and the elective procedure, thus
promoting physical recovery (Sjoling, Nordahl,
Olofsson, & Asplund, 2003; Spalding, 2003;
Yoon et al., 2010). Preoperative education de-
creases LOS by educating patients on what to
expect after surgery and how to best avoid com-
mon complications (Jones et al., 2011; Yoon
et al., 2010). Additionally, utilization of preop-
erative education that also included preoper-
ative exercise programs have been correlated
with hospital discharge locations (Rooks et al.,
2006). Rooks et al. (2006) found that individ-
uals participating in a 6-week land- and water-
based exercise program before THA or TKA had
improved odds of a home discharge as compared
to individuals who did not partake in the ex- Journal for Healthcare Quality
Vol. 36, No. 3, pp. 1727
ercise program (Rooks et al., 2006). However, C 2013 National Association for
Healthcare Quality
18 Journal for Healthcare Quality
an earlier systematic review did not confirm
preoperative exercise promotes better out-
comes after surgery (Ackerman & Bennell,
2004). Despite conflicting results for preopera-
tive exercise for both TKA and THA, many hos-
pitals are still implementing preoperative exer-
cise programs (Ackerman & Bennell, 2004).
A reported predictor of improving health-
care quality and cost efficiency after arthro-
plasty is discharge to home rather than inpa-
tient rehabilitation or skilled nursing facilities
(SNF). A prospective study of 230 patients after
THA or TKA found those patients discharged
directly home were less dependent than those
who were discharged to inpatient rehabilita-
tion centers or SNF (Mallinson et al., 2011).
Other studies have found presurgical mobility
(Jones, Voaklander, & Suarez-Almazor, 2003)
and postoperative physical therapy intervention
(Freburger, 2000) lower acute care costs and in-
crease the probability of discharge home rather
than alternative settings.
Numerous authors have discussed general-
ized preoperative efforts for individuals under-
going TKA and THA (Ackerman & Bennell,
2004; Jones et al., 2011; Rooks et al., 2006;
Sjoling et al., 2003; Spalding, 2003; Yoon et al.,
2010). However, lacking in the literature are
standardized procedures to address the entire
hospital experience, that is, pre- through post-
operative care to increase effective use of time
and human resources while also lowering LOS
and health complications, and improving dis-
charge destinations. The purpose of this ret-
rospective study is to provide a description of
a comprehensive multidisciplinary facility-wide
approach for pre- through postoperative care
to improve patient and facility outcomes in an
acute care hospital for patients electing a TKA
or THA. The following retrospective outcomes
from 2007 to 2010 will be presented: (1) aver-
age LOS; (2) gender, age, and insurance distri-
butions; (3) location of discharge; (4) joint re-
placement volume; (5) complication rates; and
(6) walking distance at discharge.
Methods
Description of Patients and Facility
The patient population for this retrospective
study was chosen from an acute care 32-bed hos-
pital in rural Wisconsin. All patients from 2007
to 2010 (n = 1,087) who underwent TKA or
THA and did not have a diagnosis of dementia
are included in the study. The hospital reserves
eight patient beds on the medical/surgical
floor specifically for patients after orthopedic
procedures including total knee and hip re-
placements. Orthopedic surgeon staff includes
three physicians who perform high volumes of
elective orthopedic surgeries. (See Figures 1
and 2 for number of TKA and THA performed.)
Allied health rehabilitation staff includes one
fulltime physical therapist (PT) and one full-
time physical therapist assistant (PTA), one oc-
cupational therapist, and one certified occupa-
tional therapist assistant.
To meet the needs of this patient popula-
tion, the hospital adopted a facility-wide pro-
cedure to improve efficiency and care of indi-
viduals before and after elective TKA or THA.
The primary goal of the facility-wide procedure
was to optimize resources and costs associated
with the acute phase of TKA and THA without
compromising quality of care. The idea for this
initiative developed when one of the orthope-
dic surgeons researched the concept and along
with the surgery department director and hos-
pital board member, visited a facility that imple-
mented a similar procedure. Once information
was gathered and presented to all departments,
that is, orthopedic surgeons and surgery per-
sonnel, nursing, rehabilitation, and ancillary
staff (e.g., lab, housekeeping, dietary), all were
in agreement to adopt the facility-wide proce-
dure and adapt the process to fit the needs of
the rural hospital.
The initiative began when the orthopedic
surgeons agreed to perform all TKA and THA
on the same day of each week. Thus, every
Monday, (with the exception of holidays), joint
replacement surgeries are performed to keep
all patients on similar acute care phases of
recovery. This influx of patients requires ad-
ditional staffing within the hospital to accom-
modate changes in surgical scheduling includ-
ing an increased nursing, pharmacy, therapy,
housekeeping, lab, and kitchen staff. Volun-
teer staff is also sought to help support ancil-
lary services with the influx of patients at the
beginning of the week. The hospitals effort
to make an organizational-wide change to ac-
commodate the pre- and postoperative needs
of patients electing TKA or THA was imple-
mented in 2008. The entire process from pre-
through postoperative care is referred to as
Joint Camp. The next sections will describe
in detail the preoperative and postoperative
process.

Figure 1. Volume and Gender Distribution Across the Years for Patients
Receiving TKA Before (2007) and After (20082010) the Implementation
of Joint Camp
Preoperative Education Process
The preoperative educational process for the
Joint Camp program begins once the patient
and their orthopedic surgeon schedule a date
for their surgery. Typically, the date for surgery
is selected 3 to 4 weeks in advance. All of
the patients are informed, however, to attend
the preoperative educational course that begins
the patients journey through the Joint Camp
program. One of the hospitals experienced
registered nurses was appointed Joint Care Co-
ordinator for the Joint Camp program. The
Joint Care Coordinator contacts the patient
after they have scheduled a surgery date and
schedules them for a preoperative educational
class. The class is offered every Tuesday of each
week and is attended 1 to 4 weeks prior to the
scheduled surgery date. The group class is an
educational effort for patients and their family
members on how to prepare for surgery, what to
expect in the hospital, and how to best prepare
for the discharge location of their preference.
The group lecture is lead by the Joint Care Co-
ordinator via slide show and highlights the main
components of informational handouts.
Although the class is run by the Joint Care
Coordinator, a multidisciplinary approach is
taken to further educate the patients on what
to expect from other caregivers in the acute
Vol. 36 No. 3 May/June 2014 19
care setting such as the anesthesiologist, phar-
macologist, and physical therapy. The PT or
PTA discusses the postsurgical therapy sched-
ule and typical discharge requirements. In ad-
dition, mobility limitations immediately post-
surgery especially after femoral nerve block
is reviewed and safety procedures are em-
phasized. Utilization, as well as safety, of the
equipment in the patients room is also em-
phasized. This is especially true for the spe-
cialized wheeled recliner chairs ordered for
each patients room. Additionally, particular
attention during the discussion is drawn to
specific handouts providing written descrip-
tions and pictures of exercises patients are
encouraged to perform preoperatively. These
exercises are the same as the postoperative
exercises the patient will be performing.
Also preoperatively, wheeled recliner chairs
are special ordered for patient rooms to pro-
vide lower extremity edema control with foot
rest elevation and adjustable head rest (Winco
Model no. 6531, Oscala, FL). The chairs were
also chosen for ease of transport. The therapy
staff, as part of the preoperative education, re-
views how to use the breaks and also how to
manually recline the chair. Importance of icing
and reclining with the legs above the level of the
heart is emphasized to the group of patients.
20 Journal for Healthcare Quality
Figure 2. Volume and Gender Distribution Across the Years for Patients
Receiving THA Before (2007) and After (20082010) the
Implementation of Joint Camp
Postoperative Education and Treatment
Process
After surgeries are performed on Monday each
week, patients are relocated to their private
room on the medical/surgical floor of the hos-
pital. The nursing staff utilizes an intermittent
compression system for acute control of lower
leg edema in the surgical limb immediately af-
ter the patient enters their room (Compres-
sion Therapy Concepts, Vaso Press DVT Model
VP500, Eatontown, NJ). Patients who under-
went a TKA are fitted with a foot compression
garment with the unit adjusted to 80 mmHg
pressure. A calf compression garment set at 40
mmHg is utilized for patients who received a
THA. Nursing staff leave the garment on the en-
tire day of surgery and the following morning,
until the patient sees the physical therapy staff
for evaluation. Nurses will typically wean pa-
tients off the intermittent compression by post
operative day 2 once the patient is able to in-
crease their ambulation. Close communication
between nursing and therapy staff is utilized to
discuss each patients progress in mobility dur-
ing their course of inpatient treatment.
Post operative day 1, Tuesday morning, is the
first time the patients receive a visit from a PT.
The initial evaluation is performed in the morn-
ing and includes not only education on walk-
ing with a wheeled walker, but also individual
training with transfers and exercise. Any given
week may contain two to eight patients who re-
quire a PT evaluation for a joint replacement.
Patients are seen twice each day they remain
in the hospital. After patients receive their ini-
tial PT evaluation, the remainder of their ses-
sions involves both group and individual ther-
apy. Group physical therapy sessions begin on
Tuesday afternoon for all of the patients who
underwent a TKA or THA. Group sessions are
then continued once every morning and after-
noon until discharge with typical discharge by
the end of post op day 3 (Thursday).
Baskets for each patient are assembled prior
to the initial PT evaluation. Contents of the
baskets are located in Appendix I. The every-
day tools within the basket are for patients to
utilize with their therapeutic exercises while in
the hospital. Initial introduction to the exer-
cises and the basket contents are done by the
PTA after the therapy evaluation.
One to two volunteer staff typically assist each
group therapy session with recliner chair and
exercise basket transport as the PT and PTA
assist with ambulation to the therapy room.
Volunteer staff is prohibited from touching pa-
tients in any way including assisting in posi-
tional changes during exercises. Volunteer staff

is available to act as additional coaches for the
patients and to offer their own personal expe-
riences with joint replacements. Various other
volunteers help after group therapy hours to
assemble/disassemble the exercise baskets.
Once patients are all gathered in the group
therapy room, they are positioned in the re-
clined position within their wheeled recliner
chairs with a Plexiglas slide board beneath their
lower extremities.1 This helps promote ease of
movement during their exercises. Patients and
family members learn the exercises through the
instruction of the PT and PTA as well as through
the instructional laminated exercise sheet.
Each patient is issued two 10 15 inch ice
packs that are stored in a common freezer (Pel-
ton Shepherd Industries, Polar Ice, Stockton,
CA). Ice packs are utilized at the end of each
group therapy session as well as around the
clock as needed by the patient. Nursing, physi-
cal therapy staff, and family members of the pa-
tients are permitted in retrieving the ice packs
for the patient. Recommendations for ice dur-
ing hospital stay are 20 min of ice each hour.
Individual rehabilitation is given to each pa-
tient at the start and end of each group therapy
session for gait training. Additional individual
training is received by each patient for stair am-
bulation, which typically occurs on their day
of discharge. Patients have the opportunity to
also receive transfer training into their vehicle
of transport on their day of discharge by the
PTA.
Family members are encouraged to join the
group sessions to act as the patients coach
and supporter. The family members also re-
ceive education from the physical therapy staff
including methods of assistance and reinforce-
ment for the patients exercise program. Ad-
ditional recommendations on gait and transfer
patterns, icing/elevating schedules, and accom-
modations of patient needs are addressed by
the PT and PTA.
Data Collection
Retrospective data were collected between the
calendar years of 2007 and 2010. Per hospi-
tal regulations, medical records of all patients
receiving services at the facility were individ-
ually collected and maintained. Though ap-
proval was granted through the authors aca-
demic institution IRB (IRB no. 11008b), lim-
1 Custom made by Hospital maintenance staff.
Vol. 36 No. 3 May/June 2014 21
ited data were released by the hospitals pri-
vacy department for aggregate analyses. Data
available for analysis included patient age and
gender, discharge location, yearly VTE and in-
fection rates, averages and ranges for length of
hospital stay, and walking distance at discharge.
Data from 2007, before the implementation of
the hospital-wide Joint Camp process was used
as a comparison to 20082010 data, after the
initiation of Joint Camp. In addition to descrip-
tive data recording, analysis for continuous data
used t-test and ANOVA to assess differences be-
tween years before and after Joint Camp. Due
to lack of individual LOS data from medical
records and thus inability to meet the assump-
tions of a parametric ANOVA, nonparametric
Friedmans ANOVA was used to analyze quar-
terly LOS means as matched data from year to
year. Chi Square was used to determine cate-
gorical data differences.
Results
Results of the data collected from 2007 (be-
fore the implementation of the Joint Camp
process) and 20082010 (after the initiation of
Joint Camp) demonstrate positive trends.
Patient Demographics
There were no statistical differences in pa-
tient ages between year 2007 and 20082010,
F(3,1083) = .05 (p = .99). See Table 1 for
mean ages and range. There was also no differ-
ences in ages when looking specifically at TKA
and THA (p = .78 and p = .85, respectively).
There were no statistical differences in gen-
der across the years 20072010, 2 (3) = 2.25
(p = .52). See Figures 1 and 2 for gender dis-
tributions and volume distributions across the
years. Thus, groups who received TKA or THA
were similar in age and gender from year 2007
to 2010.
Table 1. Patient Ages
Mean Age Range p-
Year (yrs) (yrs) valuea
2007 (n = 238) 67.49 2990
2008 (n = 289) 67.14 3792 .70
2009 (n = 282) 67.25 3193 .80
2010 (n = 278) 67.23 3293 .77
a
Two-tailed t-test.
22 Journal for Healthcare Quality

Outcomes (p = .002) was significant. A posttest, Dunns

A statistically significant percentage of patients
were discharged directly home after their
hospital stay, 2 (6) = 23.48 (p = .001). See
Figures 3 and 4 for TKA and THA discharge
destinations per year. Average LOS had signif-
icantly decreased since the initiation of Joint
Camp in 2007, Friedmans ANOVA = 14.550
Multiple Comparisons test, confirms that
an effective change occurred that made the
LOS from 2007 different from the years that
followed (p < 0.05). See Table 2 for quarterly,
yearly means and ranges of LOS and Table 3
for Dunns Multiple Comparison test. See
Figure 5 for LOS of TKA and THA. Functional

Figure 3. Location of Discharge for Patients Receiving TKA Before (2007) and
After (20082010) the Implementation of Joint Camp

Figure 4. Location of Discharge for Patients Receiving THA Before (2007) and
After (20082010) the Implementation of Joint Camp
 Vol. 36 No. 3 May/June 2014 23

Table 2. Average Length of Hospital Stay

2007 Mean (days) 2008 Mean (days) 2009 Mean (days) 2010 Mean (days)
Q1 TKA 3.7 Q1 TKA 2.82 Q1 TKA 2.95 Q1 TKA 2.7
THA 4.4 THA 3.44 THA 2.65 THA 2.2
Q2 TKA 3.6 Q2 TKA 2.68 Q2 TKA 3.02 Q2 TKA 3
THA 3.7 THA 2.89 THA 2.61 THA 3
Q3 TKA 3.7 Q3 TKA 2.54 Q3 TKA 2.79 Q3 TKA 2.8
THA 3.8 THA 3.28 THA 2.95 THA 2.8
Q4 TKA 3.3 Q4 TKA 2.76 Q4 TKA 2.64 Q4 TKA 2.8
THA 3.2 THA 2.58 THA 2.94 THA 2.7
Yearly mean 3.675 (111) 2.87 (17) 2.82 (18) 2.75 (17)
(range)

Table 3. Dunns Multiple mentation of Joint Camp in 2007 to 8001000

Comparison Test of LOS ft in 2010.
Rank Sum Complications of VTE although not available
Year Comparison Differences from the year 2007 for comparison, declined
from 2008 to 2010 with an overall VTE rate of
2007 vs. 2008 17.000 p < 0.01
0.99%. There was no statistical differences in
2007 vs. 2009 15.000 p < 0.05
2007 vs. 2010 16.000 p < 0.05
rate of infection from 20072010, 2 (3) = 1.91
2008 vs. 2009 2.000 p > 0.05 (p = .59). The overall rate of infection for
2008 vs. 2010 1.000 p > 0.05 20082010 was 0.5%. See Table 4 for yearly
2009 vs. 2010 1.0000 p > 0.05 VTE and infection rates. The data reflecting
health complications were a comprehension of
the patients rate of infection and VTE dur-
ing their hospital stay and within 30 days after
changes included ambulation distance at time discharge if hospital readmission was required.
of discharge. Typical patient walking distance The number of infections reflects the number
at discharge measured by physical therapy in- of episodes of infection due to a positive culture
creased from an average of 200 ft before imple- of the surgical wound.

Figure 5. Average Hospital LOS for Patients Receiving TKA and THA Before
(2007) and After (20082010) the Implementation of Joint Camp
24 Journal for Healthcare Quality

Table 4. Complication Rates for Discussion

all Patients Receiving Joint Camp has been an ongoing process to
TKA and THA Before strive for excellence at this hospital. The pro-
(2007) and After cess was initiated not as an experimental study
(20082010) the but as a way to optimize hospital resources
Implementation of Joint yet empower patients through education and
group exercise. As hospital staff reviewed out-
Camps Pre- and comes quarterly and positive trends were iden-
Postoperative Education tified, more patients were discharged directly
and Treatment Procedure to their homes, more were mobile upon dis-
Venous charge and leaving the hospital sooner without
Thromboembolism an increase in medical complications; it was be-
a, *
Year Infection (VTE)a lieved the process would benefit other facili-
ties. Therefore, the purpose of this study was
2007 (n = 238) 0.4% x
2008 (n = 289) 0.35% 1.2%
to describe a comprehensive multidisciplinary
2009 (n = 282) 0.35% 1.3% facility-wide approach for pre- through postop-
2010 (n = 278) 1.1% 0.3% erative education and care for patients electing
a
a TKA or THA at an acute care rural hospital.
Rates analyzed from post-op day 130.
*No statistical difference between years (p = .59).
The impetus for this hospital-wide undertak-
ing was to streamline facility processes for qual-
ity management without compromising patient
care. The process focused on increasing staff
Payment source of patients receiving TKA early in the week when surgical acuity was high-
and THA are displayed in Figure 6. Medicare est and lessen weekend requirements for staff as
was the most common insurance. Other pay- well as promoted pre- and postoperative group
ment sources included commercial insurances exercise and encouraged patient and family
or self-pay. involvement.

Figure 6. Payment Sources for all Knee and Hip Joint Replacements Before
(2007) and After (20082010) the Implementation of Joint Camp. *Other:
Commercial Insurance, Self-Pay, etc

Over 3 years of Joint Camp, it was observed
more people were discharged directly home
rather than a subacute facility. There was a
reduction in LOS after surgery and discharge
walking distance suggested patients were able to
walk four times farther than before the process
of Joint Camp. The outcome data on infection
rates suggested the facilitys ability to maintain
a relatively low infection rate despite a change
in process. From 2007 to 2009, there was one in-
fection per year with the exception of 2010. In
2010, three infections were reported. However,
an overall 3-year infection rate of 0.5% (for
the years when Joint Camp was implemented
20082010) is consistent with other total hip
and knee arthroplasty studies (Blom, Taylor,
Pattison, Whitehouse, & Bannister, 2003; Cram,
Cai, Lu, Vaughan-Sarrazin, & Miller, 2012;
Jamsen, Huotari, Huhtala, Nevalainen, & Kont-
tinen, 2009).
Comparison data for 2007 VTE data are lack-
ing. However, the rate of VTE remained rela-
tively constant from 2008 to 2010 with an av-
erage VTE rate of 0.99%. Hospital protocol
for prevention of VTEs contribute to the low
incidence. Prophylaxis protocol at the facility
included Warfarin, either the night before or
the night of surgery. International Normalized
Ratios (INRs) were calculated every day during
a patients surgical stay with dosing adjusted on
a daily basis. Labs were repeated 1-day postdis-
charge and the Anticoagulation Clinic sched-
uled further blood draws and adjusted dosing
after discharge. The INR range is maintained
between 1.52.5 or 2.02.5. Patients remain on
Warfarin for 34 weeks.
All points of care, pre- and postoperatively,
are supported by best practices. It has been sug-
gested that offering preoperative education to
patients receiving knee or hip arthroplasty can
reduce hospital LOS by 1 day (Spalding, 2003;
Yoon et al., 2010). Though, a study in Denmark
did not find a difference in LOS after arthro-
plasty in 712 patients (Husted, Holm, & Jacob-
sen, 2008). In addition, Parvizi et al. (2007) ar-
gued that discharge within 23 days postjoint
replacement increases risk of health complica-
tions related to hip dislocation and VTE (Parvizi
et al., 2007). Nonetheless, VTE and infection
data from the present study demonstrate low
rates of complications during patients hospital
stay and 30 days post discharge, which are lower
than the national rates from Medicare data de-
scribed by Kurtz et al. (2009).
Vol. 36 No. 3 May/June 2014 25
There were several barriers to address when
implementing this multidisciplinary process.
First a hospital-wide agreement by physi-
cians and staff was required for the ap-
proach. Additionally, Joint Camp pre- through
postoperative approach eliminated commonly
accepted modalities such as continuous pas-
sive range of motion machines (CPMs),
compression stockings, and individualized
physical therapy treatment sessions while in-
tegrating preoperative education, intermittent
compression machines, and group therapy
sessions.
CPMs have been a tool utilized within in-
patient care as a way to promote early ROM.
Several authors contend that there is no ad-
ditional benefit to the CPM when compared
to active exercise in the first few weeks post-
operative (Denis et al., 2006). The rural hos-
pital in this study chose not to implement
the CPM into the patients plan of care due
to the cost and inconclusive research, which
did not seem to hinder the patients ambu-
lation ability and ability to return home after
surgery.
This hospital also chose not to utilize graded
compression stockings for the lower extrem-
ity due to the cost and limited storage abil-
ity. Compression garments are typically cho-
sen to provide intermittent compression of the
lower extremity after surgery to decrease edema
and reduce risk of VTE (CLOTS Trial Col-
laboration, 2010). This hospital instead chose
to utilize a machine that provides intermit-
tent compression with washable foot and calf
garments. Research is lacking on the effec-
tiveness of this machine compared to com-
pression stockings but the hospital made its
decision based upon the current unit being
a reusable resource located within each pa-
tients hospital room. In addition to the in-
termittent compression machine, active exer-
cise and ambulation are encouraged to help
reduce risk of VTE. The VTE rates at this hos-
pital since 2008 have decreased and are lower
than VTE rates reported at 0.9% by White et al.
(1998).
Group versus individual therapy sessions
were used as an effective means of pro-
viding essential therapy services with an in-
flux of patients on the same postoperative
day, that is, Tuesday. A cohort study sup-
ports group rehabilitation classes for patients
with TKA or THA and suggests that it is a
26 Journal for Healthcare Quality
cost-effective approach without sacrificing qual-
ity of patient outcomes when compared to one-
on-one treatment (Coulter, Weber, & Scarvell,
2009). The rationale for implementing a group
atmosphere at our hospital for treatment is
not only to increase hospital efficiency and
cost effectiveness, but also to promote patient
and family members socialization and com-
munication about their personal experiences.
Teamwork, camaraderie, and moral support
are also some of the outcomes the hospital
wants to promote between staff and patients
with a group approach. In addition, data from
this studys discharge ambulation outcomes
have supported effectiveness of group therapy
sessions.
There are many variables that may have af-
fected our outcomes other than Joint Camp,
such as individual comorbidities and body mass
index of patients that were not analyzed in this
study. However, we believe our study reflects the
broad spectrum of patients who seek lower ex-
tremity arthroplasties. Furthermore, the skills
of the physicians at the hospital and the tech-
nological advancements in arthroplasty proce-
dures and prosthesis over the past 4 years con-
tribute considerably to the hospitals continued
successful outcomes.
Limitation to the present study is the retro-
spective nature of the review. Our data were
not collected for aggregate analysis but for
individual hospital care and medical record
keeping. This limited the statistical power of
the analysis on LOS. However, we believe
a decline in one hospital day reduces cost
(though not analyzed in this study) and as-
sist with patients overall well being. Future
analysis for our facility and suggestions for
others who may implement Joint Camp is
to analyze cost as well as patient and staff
satisfaction.
Conclusion
Observations after the implementation of
a hospital-wide comprehensive pre- through
postoperative procedure involving group edu-
cation and treatment at a rural acute care hospi-
tal demonstrated significantly increased home
discharges after total knee and hip arthro-
plasty and reduced hospital stay without in-
creasing VTE or infection rates over a 3-year
period.
Acknowledgment
Thank you to Matthew Scheel, PhD, Carroll
University for his statistical assistance.
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education before hip or knee arthroplasty lowers
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States. The Journal of Bone and Joint Surgery. American Vol- For more information on this article, contact Sara M.
ume, 89, 526533. doi:10.2106/JBJS.F.00952 Deprey at sdeprey@carrollu.edu.