Professional Documents
Culture Documents
3 May/June 2014 17
Review of the Literature Abstract: The number of total knee and hip arthroplasty is
Among one of the most effective options for predicted to rise 174% and 673%, respectively, over the next
improving quality of life in individuals with hip 20 years due to the expected rise in the baby boomer population.
or knee osteoarthritis (OA) is an elective to- Along with increased numbers or procedures performed is the
tal joint replacement or arthroplasty (National rise in cost and potential medical complications from hospitaliza-
Center for Health Statistics, 2010). The average tions. The purpose of this study is to describe one rural hospitals
age of individuals electing a total knee arthro- facility-wide procedure to streamline processes and standardize
plasty (TKA) is 70 years of age with over 90% care without compromising patient medical needs prior to, and
of those individuals having OA (Centers for during, the acute phase of total knee and hip arthroplasty. Data
Disease Control and Prevention [CDC], 2011; were compared before and after the facility-wide procedure was
Kane et al., 2003). Similarly, 60% of those implemented. Results found shorter length of hospital stay and
undergoing a total hip arthroplasty (THA) is significantly more discharges directly home all without increas-
65 years of age (Zhan, Kaczmarek, Loyo- ing medical complications after the facility-wide procedure was
Berrios, Sangl, & Bright, 2007). In 2004, an implemented.
estimated $14.3 billion and $9.3 billion was
spent on hospital cost associated with total knee
and total hip replacements, respectively (CDC, been diagnosed with a VTE during or shortly Keywords
2011). It is expected the average number of in- after their hospital stay, the risk for rehospi- acute care
dividuals seeking TKA or THA will rise, along talization and thus associated healthcare costs quality improvement
with costs, due to the large number of aging in- rises (Ollendorf et al., 2002). Therefore, to im- research-quantitative
dividuals in the baby boomer population as well prove cost efficiency and quality, facilities must
as anticipated need in younger people (Kurtz, reduce length of hospital stay while also mini-
Ong, Lau, Mowat, & Halpern, 2007). Projec- mizing health complications.
tions for 20052030 expect the number of THA One approach to reducing hospital costs and
and TKA to rise by 174% and 673%, respec- LOS is utilization of preoperative education.
tively (Kurtz et al., 2007). Thus, it is imperative Studies have suggested preoperative education
for facilities to use cost efficient procedures to reduces patient anxiety related to surgery, hos-
address the increased need for lower extremity pitalization, and the elective procedure, thus
arthroplasties without compromising quality of promoting physical recovery (Sjoling, Nordahl,
care. Olofsson, & Asplund, 2003; Spalding, 2003;
Health complications associated with inpa- Yoon et al., 2010). Preoperative education de-
tient care require an increased length of stay creases LOS by educating patients on what to
(LOS). Common complications after TKA or expect after surgery and how to best avoid com-
THA may include infection, deep vein throm- mon complications (Jones et al., 2011; Yoon
bosis (DVT), or pulmonary embolism (PE). et al., 2010). Additionally, utilization of preop-
Together, DVT and PE are referred to as a erative education that also included preoper-
venous thromboembolism (VTE). Any compli- ative exercise programs have been correlated
cation, however, significantly increases hospi- with hospital discharge locations (Rooks et al.,
tal LOS and leads to a twofold increase in cost 2006). Rooks et al. (2006) found that individ-
(Ollendorf, Vera-Llonch, & Oster, 2002). Per- uals participating in a 6-week land- and water-
centage of patients who develop a VTE within based exercise program before THA or TKA had
the hospital was found to be 0.9% by a large improved odds of a home discharge as compared
retrospective study (White, Romano, Zhou, to individuals who did not partake in the ex- Journal for Healthcare Quality
Vol. 36, No. 3, pp. 1727
Rodrigo, & Bargar, 1998). Once patients have 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 are included in the study. The hospital reserves
preoperative exercise promotes better out- eight patient beds on the medical/surgical
comes after surgery (Ackerman & Bennell, floor specifically for patients after orthopedic
2004). Despite conflicting results for preopera- procedures including total knee and hip re-
tive exercise for both TKA and THA, many hos- placements. Orthopedic surgeon staff includes
pitals are still implementing preoperative exer- three physicians who perform high volumes of
cise programs (Ackerman & Bennell, 2004). elective orthopedic surgeries. (See Figures 1
A reported predictor of improving health- and 2 for number of TKA and THA performed.)
care quality and cost efficiency after arthro- Allied health rehabilitation staff includes one
plasty is discharge to home rather than inpa- fulltime physical therapist (PT) and one full-
tient rehabilitation or skilled nursing facilities time physical therapist assistant (PTA), one oc-
(SNF). A prospective study of 230 patients after cupational therapist, and one certified occupa-
THA or TKA found those patients discharged tional therapist assistant.
directly home were less dependent than those To meet the needs of this patient popula-
who were discharged to inpatient rehabilita- tion, the hospital adopted a facility-wide pro-
tion centers or SNF (Mallinson et al., 2011). cedure to improve efficiency and care of indi-
Other studies have found presurgical mobility viduals before and after elective TKA or THA.
(Jones, Voaklander, & Suarez-Almazor, 2003) The primary goal of the facility-wide procedure
and postoperative physical therapy intervention was to optimize resources and costs associated
(Freburger, 2000) lower acute care costs and in- with the acute phase of TKA and THA without
crease the probability of discharge home rather compromising quality of care. The idea for this
than alternative settings. initiative developed when one of the orthope-
Numerous authors have discussed general- dic surgeons researched the concept and along
ized preoperative efforts for individuals under- with the surgery department director and hos-
going TKA and THA (Ackerman & Bennell, pital board member, visited a facility that imple-
2004; Jones et al., 2011; Rooks et al., 2006; mented a similar procedure. Once information
Sjoling et al., 2003; Spalding, 2003; Yoon et al., was gathered and presented to all departments,
2010). However, lacking in the literature are that is, orthopedic surgeons and surgery per-
standardized procedures to address the entire sonnel, nursing, rehabilitation, and ancillary
hospital experience, that is, pre- through post- staff (e.g., lab, housekeeping, dietary), all were
operative care to increase effective use of time in agreement to adopt the facility-wide proce-
and human resources while also lowering LOS dure and adapt the process to fit the needs of
and health complications, and improving dis- the rural hospital.
charge destinations. The purpose of this ret- The initiative began when the orthopedic
rospective study is to provide a description of surgeons agreed to perform all TKA and THA
a comprehensive multidisciplinary facility-wide on the same day of each week. Thus, every
approach for pre- through postoperative care Monday, (with the exception of holidays), joint
to improve patient and facility outcomes in an replacement surgeries are performed to keep
acute care hospital for patients electing a TKA all patients on similar acute care phases of
or THA. The following retrospective outcomes recovery. This influx of patients requires ad-
from 2007 to 2010 will be presented: (1) aver- ditional staffing within the hospital to accom-
age LOS; (2) gender, age, and insurance distri- modate changes in surgical scheduling includ-
butions; (3) location of discharge; (4) joint re- ing an increased nursing, pharmacy, therapy,
placement volume; (5) complication rates; and housekeeping, lab, and kitchen staff. Volun-
(6) walking distance at discharge. 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-
Methods
commodate the pre- and postoperative needs
Description of Patients and Facility of patients electing TKA or THA was imple-
The patient population for this retrospective mented in 2008. The entire process from pre-
study was chosen from an acute care 32-bed hos- through postoperative care is referred to as
pital in rural Wisconsin. All patients from 2007 Joint Camp. The next sections will describe
to 2010 (n = 1,087) who underwent TKA or in detail the preoperative and postoperative
THA and did not have a diagnosis of dementia process.
Vol. 36 No. 3 May/June 2014 19
Figure 1. Volume and Gender Distribution Across the Years for Patients
Receiving TKA Before (2007) and After (20082010) the Implementation
of Joint Camp
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 ing with a wheeled walker, but also individual
Process training with transfers and exercise. Any given
After surgeries are performed on Monday each week may contain two to eight patients who re-
week, patients are relocated to their private quire a PT evaluation for a joint replacement.
room on the medical/surgical floor of the hos- Patients are seen twice each day they remain
pital. The nursing staff utilizes an intermittent in the hospital. After patients receive their ini-
compression system for acute control of lower tial PT evaluation, the remainder of their ses-
leg edema in the surgical limb immediately af- sions involves both group and individual ther-
ter the patient enters their room (Compres- apy. Group physical therapy sessions begin on
sion Therapy Concepts, Vaso Press DVT Model Tuesday afternoon for all of the patients who
VP500, Eatontown, NJ). Patients who under- underwent a TKA or THA. Group sessions are
went a TKA are fitted with a foot compression then continued once every morning and after-
garment with the unit adjusted to 80 mmHg noon until discharge with typical discharge by
pressure. A calf compression garment set at 40 the end of post op day 3 (Thursday).
mmHg is utilized for patients who received a Baskets for each patient are assembled prior
THA. Nursing staff leave the garment on the en- to the initial PT evaluation. Contents of the
tire day of surgery and the following morning, baskets are located in Appendix I. The every-
until the patient sees the physical therapy staff day tools within the basket are for patients to
for evaluation. Nurses will typically wean pa- utilize with their therapeutic exercises while in
tients off the intermittent compression by post the hospital. Initial introduction to the exer-
operative day 2 once the patient is able to in- cises and the basket contents are done by the
crease their ambulation. Close communication PTA after the therapy evaluation.
between nursing and therapy staff is utilized to One to two volunteer staff typically assist each
discuss each patients progress in mobility dur- group therapy session with recliner chair and
ing their course of inpatient treatment. exercise basket transport as the PT and PTA
Post operative day 1, Tuesday morning, is the assist with ambulation to the therapy room.
first time the patients receive a visit from a PT. Volunteer staff is prohibited from touching pa-
The initial evaluation is performed in the morn- tients in any way including assisting in posi-
ing and includes not only education on walk- tional changes during exercises. Volunteer staff
Vol. 36 No. 3 May/June 2014 21
is available to act as additional coaches for the ited data were released by the hospitals pri-
patients and to offer their own personal expe- vacy department for aggregate analyses. Data
riences with joint replacements. Various other available for analysis included patient age and
volunteers help after group therapy hours to gender, discharge location, yearly VTE and in-
assemble/disassemble the exercise baskets. fection rates, averages and ranges for length of
Once patients are all gathered in the group hospital stay, and walking distance at discharge.
therapy room, they are positioned in the re- Data from 2007, before the implementation of
clined position within their wheeled recliner the hospital-wide Joint Camp process was used
chairs with a Plexiglas slide board beneath their as a comparison to 20082010 data, after the
lower extremities.1 This helps promote ease of initiation of Joint Camp. In addition to descrip-
movement during their exercises. Patients and tive data recording, analysis for continuous data
family members learn the exercises through the used t-test and ANOVA to assess differences be-
instruction of the PT and PTA as well as through tween years before and after Joint Camp. Due
the instructional laminated exercise sheet. to lack of individual LOS data from medical
Each patient is issued two 10 15 inch ice records and thus inability to meet the assump-
packs that are stored in a common freezer (Pel- tions of a parametric ANOVA, nonparametric
ton Shepherd Industries, Polar Ice, Stockton, Friedmans ANOVA was used to analyze quar-
CA). Ice packs are utilized at the end of each terly LOS means as matched data from year to
group therapy session as well as around the year. Chi Square was used to determine cate-
clock as needed by the patient. Nursing, physi- gorical data differences.
cal therapy staff, and family members of the pa-
tients are permitted in retrieving the ice packs
for the patient. Recommendations for ice dur- Results
ing hospital stay are 20 min of ice each hour. Results of the data collected from 2007 (be-
Individual rehabilitation is given to each pa- fore the implementation of the Joint Camp
tient at the start and end of each group therapy process) and 20082010 (after the initiation of
session for gait training. Additional individual Joint Camp) demonstrate positive trends.
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 Patient Demographics
of transport on their day of discharge by the There were no statistical differences in pa-
PTA. tient ages between year 2007 and 20082010,
Family members are encouraged to join the F(3,1083) = .05 (p = .99). See Table 1 for
group sessions to act as the patients coach mean ages and range. There was also no differ-
and supporter. The family members also re- ences in ages when looking specifically at TKA
ceive education from the physical therapy staff and THA (p = .78 and p = .85, respectively).
including methods of assistance and reinforce- There were no statistical differences in gen-
ment for the patients exercise program. Ad- der across the years 20072010, 2 (3) = 2.25
ditional recommendations on gait and transfer (p = .52). See Figures 1 and 2 for gender dis-
patterns, icing/elevating schedules, and accom- tributions and volume distributions across the
modations of patient needs are addressed by years. Thus, groups who received TKA or THA
the PT and PTA. were similar in age and gender from year 2007
to 2010.
Data Collection
Retrospective data were collected between the Table 1. Patient Ages
calendar years of 2007 and 2010. Per hospi-
Mean Age Range p-
tal regulations, medical records of all patients Year (yrs) (yrs) valuea
receiving services at the facility were individ-
ually collected and maintained. Though ap- 2007 (n = 238) 67.49 2990
proval was granted through the authors aca- 2008 (n = 289) 67.14 3792 .70
2009 (n = 282) 67.25 3193 .80
demic institution IRB (IRB no. 11008b), lim-
2010 (n = 278) 67.23 3293 .77
a
Two-tailed t-test.
1 Custom made by Hospital maintenance staff.
22 Journal for Healthcare Quality
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
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
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
Vol. 36 No. 3 May/June 2014 25
Over 3 years of Joint Camp, it was observed There were several barriers to address when
more people were discharged directly home implementing this multidisciplinary process.
rather than a subacute facility. There was a First a hospital-wide agreement by physi-
reduction in LOS after surgery and discharge cians and staff was required for the ap-
walking distance suggested patients were able to proach. Additionally, Joint Camp pre- through
walk four times farther than before the process postoperative approach eliminated commonly
of Joint Camp. The outcome data on infection accepted modalities such as continuous pas-
rates suggested the facilitys ability to maintain sive range of motion machines (CPMs),
a relatively low infection rate despite a change compression stockings, and individualized
in process. From 2007 to 2009, there was one in- physical therapy treatment sessions while in-
fection per year with the exception of 2010. In tegrating preoperative education, intermittent
2010, three infections were reported. However, compression machines, and group therapy
an overall 3-year infection rate of 0.5% (for sessions.
the years when Joint Camp was implemented CPMs have been a tool utilized within in-
20082010) is consistent with other total hip patient care as a way to promote early ROM.
and knee arthroplasty studies (Blom, Taylor, Several authors contend that there is no ad-
Pattison, Whitehouse, & Bannister, 2003; Cram, ditional benefit to the CPM when compared
Cai, Lu, Vaughan-Sarrazin, & Miller, 2012; to active exercise in the first few weeks post-
Jamsen, Huotari, Huhtala, Nevalainen, & Kont- operative (Denis et al., 2006). The rural hos-
tinen, 2009). pital in this study chose not to implement
Comparison data for 2007 VTE data are lack- the CPM into the patients plan of care due
ing. However, the rate of VTE remained rela- to the cost and inconclusive research, which
tively constant from 2008 to 2010 with an av- did not seem to hinder the patients ambu-
erage VTE rate of 0.99%. Hospital protocol lation ability and ability to return home after
for prevention of VTEs contribute to the low surgery.
incidence. Prophylaxis protocol at the facility This hospital also chose not to utilize graded
included Warfarin, either the night before or compression stockings for the lower extrem-
the night of surgery. International Normalized ity due to the cost and limited storage abil-
Ratios (INRs) were calculated every day during ity. Compression garments are typically cho-
a patients surgical stay with dosing adjusted on sen to provide intermittent compression of the
a daily basis. Labs were repeated 1-day postdis- lower extremity after surgery to decrease edema
charge and the Anticoagulation Clinic sched- and reduce risk of VTE (CLOTS Trial Col-
uled further blood draws and adjusted dosing laboration, 2010). This hospital instead chose
after discharge. The INR range is maintained to utilize a machine that provides intermit-
between 1.52.5 or 2.02.5. Patients remain on tent compression with washable foot and calf
Warfarin for 34 weeks. garments. Research is lacking on the effec-
All points of care, pre- and postoperatively, tiveness of this machine compared to com-
are supported by best practices. It has been sug- pression stockings but the hospital made its
gested that offering preoperative education to decision based upon the current unit being
patients receiving knee or hip arthroplasty can a reusable resource located within each pa-
reduce hospital LOS by 1 day (Spalding, 2003; tients hospital room. In addition to the in-
Yoon et al., 2010). Though, a study in Denmark termittent compression machine, active exer-
did not find a difference in LOS after arthro- cise and ambulation are encouraged to help
plasty in 712 patients (Husted, Holm, & Jacob- reduce risk of VTE. The VTE rates at this hos-
sen, 2008). In addition, Parvizi et al. (2007) ar- pital since 2008 have decreased and are lower
gued that discharge within 23 days postjoint than VTE rates reported at 0.9% by White et al.
replacement increases risk of health complica- (1998).
tions related to hip dislocation and VTE (Parvizi Group versus individual therapy sessions
et al., 2007). Nonetheless, VTE and infection were used as an effective means of pro-
data from the present study demonstrate low viding essential therapy services with an in-
rates of complications during patients hospital flux of patients on the same postoperative
stay and 30 days post discharge, which are lower day, that is, Tuesday. A cohort study sup-
than the national rates from Medicare data de- ports group rehabilitation classes for patients
scribed by Kurtz et al. (2009). with TKA or THA and suggests that it is a
26 Journal for Healthcare Quality