- Email: [email protected]
A Multidisciplinary Approach to Total Joint Replacement
A Multidisciplinary Approach to Total Joint Replacement Nancy Saufl, MS, RN, CPAN, CAPA, Adam Owens, RN, BSN, ONC, PTA, Isabel Kelly, PTA, Beth Merrill, RN, Laura L. Freyaldenhouen, PTA
A multidisciplinary team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon’s office through postdischarge rehabilitation. Project goals for the team were to develop the “ideal” pre and postoperative orders for total joint patients, review and revise current clinical and patient pathways for the total knee replacement patient and the total hip replacement patient, add rehabilitation services to clinical pathways, and develop a patient education class and patient education booklet. This article describes how working together with all disciplines involved resulted in a consolidated order set, clinical and patient pathways that reflected actual care and processes, a userfriendly patient education book, and a multidisciplinary patient education class. The end products led to consistency in the quality of care across the continuum from preadmission through postdischarge rehabilitation for total joint replacement patients. Keywords: orthopaedics, joint replacement, multidisciplinary care. © 2007 by American Society of PeriAnesthesia Nurses.
A MULTIDISCIPLINARY team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon’s office through postdischarge rehabilitation. As part of the hospital’s Human Motion Institute, the Total Joint Team was formed. Team members included registered nurses from the preadmission testing (PAT) department, the OR, the orthopaedic nursing unit, and from home health care, as well as physical therapists involved in inpatient, outpatient, and home health care rehabilitation. Other members of the team included two orthoJournal of PeriAnesthesia Nursing, Vol 22, No 3 (June), 2007: pp 195-206
paedic surgeons, a case manager RN, and staff from the physicians’ offices. An anesthesiologist and hospital-based pharmacist
Nancy Saufl, MS, RN, CPAN, CAPA, is a Coordinator, Preadmission Testing & Teaching Center; Adam Owens, RN, BSN, ONC, PTA, is an Inpatient Orthopaedic Nurse and PICC Team Coordinator; Isabel Kelly, PTA, is an Inpatient Physical Therapy Assistant; Beth Merrill, RN, is a Home Health Clinical Coordinator; and Laura L. Freyaldenhouen, PTA, is a Home Health Physical Therapy Coordinator, Florida Hospital Memorial System, Ormond Beach, FL. All authors participate in the Human Motion Institute. Address correspondence to Nancy Saufl, 114 Pinion Circle, Ormond Beach, FL 32174; e-mail address: [email protected]. © 2007 by American Society of PeriAnesthesia Nurses. 1089-9472/07/2203-0006$35.00/0 doi:10.1016/j.jopan.2007.03.007 195
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attended meetings on a consulting basis as needed. The entire team initially met every two weeks and then divided into two subgroups: Team A and Team B. The teams were named according to the classroom assignments for their meetings—not because one project was more important than the other! Team A and Team B met one to two times per week with ongoing assignments. Progress was reported back to the entire group meeting, which began to meet on a monthly basis only. Team A’s focus was on preoperative and postoperative standard order sets and clinical and patient pathways. Team B was in charge of developing a patient education class and handout. Both team leaders communicated regularly by email, phone, and one-on-one discussions to ensure everyone was “staying on the same page.”
Physician Order Sets The group agreed on the goal to review the current orthopaedic orders and come up with order sets as follows: 1. Preoperative total joint orders 2. Postoperative total joint orders 3. Orthopaedic total joint discharge orders for home health care and/or a rehabilitation center Samples of all the different orders currently being used by the various orthopaedic surgeons on staff were first collected. Preoperative and postoperative orders from 16 orthopaedic surgeons were reviewed, many of which were very individualized orders sets. The order sets were reviewed and compared for commonalities, and the pharmacist was asked to check all medications for accuracy in dosage and administration routes. The director of laboratory services was also requested to review all lab-testing orders for appropriateness. Our goal was to make the order sets specific, concise, and userfriendly in hopes that all the orthopaedic surgeons would choose to use them. An additional goal was to create clinical guidelines and a medical protocol that would help with a sys-
tematic approach to patient care for the total joint patient. Order sets were left flexible enough for the physicians to implement individualized orders as needed. Once the various orders collected from the physician offices were reviewed, we found one order form type that was being used consistently by several of the physicians and decided to focus on formatting the new order set in a similar style. Using that form as a template, we began with the preoperative orders going line by line, choosing the orders being used by the majority of the physicians. The new orders were entitled: “Orthopaedic Preoperative Total Joint Orders,” and began with a place for patient diagnosis and surgical consent order (see Supplementary Fig 1 online at www.jopan.org). The diet guideline was changed to reflect the newly implemented anesthesia protocol for “nothing by mouth” (NPO) guidelines, but an option was left for ordering NPO after midnight if the surgeon so chose. The activity order consisted of “ambulate ad lib.” Preoperative laboratory tests were arranged in an orderly flow with check boxes for easy ordering. Type and screen orders included autologous blood donations. A place for International Classification of Diseases (ICD) diagnosis codes was also included with the chest radiograph and the electrocardiogram orders to help increase adherence to Medicare guidelines when ordering. The physician writes in the specific choice of preoperative intravenous (IV) fluids, and home instructions (ie, chlorhexidine shower) were separated from day-of-surgery operative site preparation orders. Surgical nursing orders (ie, preps, Foley catheter, TED hose, sequential compression devices) were also included. Per the pharmacy’s recommendation, the physician was given three choices for preoperative antibiotics: Ancef (Harvard Pilgrim Health Care, Boston, MA), Vancocin (ViroPharma, Exton, PA), and Cleocin (Pfizer, New York, NY). Generic names were also added to the orders. Many of the physicians wanted a place to write
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Coumadin (Bristol-Myers Squibb Co, Princeton, NJ) instructions for the patient to take at home the night before surgery; a statement was added reading: “Ask patient to call the physician’s office the day before surgery for Coumadin instructions, if needed.” We felt this instruction must come directly from the physician, not the preadmission testing nurse. An option for medical consultation is also available if consult is desired. Additionally, an order for “other” was also added for the physician to write in any specific requests. A line for physician signature is on the orders and a standard hospital physician order form is used, which includes “do not use” abbreviations for compliance with the Joint Commission’s National Patient Safety Goals.1 Postoperative Orders
The postoperative orders were titled “Orthopaedic Postoperative Joint and Fracture Orders” because, in addition to the total joints, they can be used for patients having open reduction internal fixation or Intramedullary roddings (see Supplementary Fig 2 online at www.jopan.org). There is a place for the physician to check off what specific procedure (including unicondylar) the patient had, and also a place to delineate between anterior and posterior approaches for the total hip replacement. The physical therapists felt this information was important to help ensure proper precautionary measures are used to prevent dislocation. Routine orders for IV fluids, diet, and vital signs were used. Activity was further delineated to ensure specific instructions and consistency in postoperative care. Weight bearing status was added to clarify the patient’s weight bearing status so that all disciplines caring for the patient are aware, thereby maintaining safety and preventing injury. Lab parameters for hemoglobin and prothrombin time were clarified. Nursing orders include TED hose, splints, incision care, etc. Physical therapy orders to “evaluate and treat” were also included. All “PO” or “PT” abbreviations were changed to read “postoperative” and
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“physical therapy,” respectively, to avoid confusion. Once again the physician was given the choice of Ancef (Harvard Pilgrim Health Care), Vancomycin, or Cleocin (Pfizer) for postoperative antibiotics. Analgesic choices were categorized together. If the physician chose patient-controlled analgesia (PCA), they filled out the separate PCA order sheet. Medications for bowel care and anticoagulant therapy were also categorized appropriately. Enoxaparin (Lovenox, sanofi-aventis), Fondaparinux (Arixtra, Organon Sanofi-Synthelabo, Roseland, NJ), and Coumadin (Bristol-Myers Squibb) were included for the physician to order as indicated; along with international normalized ratio (INR) activity. Because The Joint Commission discourages,2 and the hospital policy prohibits writing “resume preop meds” or “take meds as at home,” all medications that need to be restarted after surgery must be written out on the postoperative orders to avoid confusion and avoid the nurse having to call the surgeon regarding home medications. This took some education on the part of the physicians because many had been writing, “resume home meds” or “resume preop meds” for years. Since the implementation of an Electronic Medical Record in 2006, we have found that the Admission Medication Reconciliation form has greatly enhanced the process for reordering patient medications in the postoperative period. Also included on the postoperative orders are places for “medical consultation” and “case management consultation.” A case manager sees all of the total joint patients on the first postoperative day to help determine postdischarge rehabilitation needs. Patients, along with their physicians, may choose to be (1) discharged directly home with Home Health Care Services or visits to an outpatient clinic, (2) go to a skilled nursing facility that offers rehabilitation services, or (3) go to an acute care rehabilitation center.
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The Total Joint Team felt the changes implemented on the pre and postoperative orthopaedic orders helped to enhance patient safety and facilitate quality patient care. We hoped the orders and pathways would promote teamwork, consistency, and accuracy in patient care. Discharge Orders
The nurses and physical therapists from home health care and from the acute care rehabilitation center identified a need for specific discharge orders for both areas of care. The order sets were developed for use on all home health care and inpatient rehabilitation patients (other than those going to skilled nursing facilities, where the 3008 forms are mandated).3 The order sets (see Supplementary Figs 3 and 4 online at www.jopan.org) include:
● ● ● ● ● ● ● ● ●
Surgical procedure Home health/Rehab disciplines needed Weight bearing status Anticoagulation therapy Wound care orders Splints Continuous passive motion (CPM) Medications Other
The staff felt this information and format would help improve communication upon transfer and would be used to connect the hospital, the intake coordinator, and the physical therapist, resulting in fewer phone calls to the physician, thereby increasing overall employee and physician satisfaction.
Patient Pathways and Clinical Pathways Once the order sets were completed, we had to be sure the pre and postoperative orders corresponded appropriately with the clinical pathways, and that the clinical pathways were current, up-to-date, and reflective of current practice. In addition, we needed to know if the patient pathways were optimal for patients and if they clearly depicted what the patients should expect during their perioperative experience. Patient Pathways
The Patient Pathways (Fig 1) are user friendly at a fifth to six-grade reading level and are easy for patients to follow. Although some of the information may seem redundant from what the patients receive in PAT, the total joint class, and the text of the booklet, the team felt it important to have an easy reference guide for patients and that repetition of information would not be an issue. The patient pathway has the following main titles:
● ● ● ● ● ● ● ●
Education Discharge Planning Tests/Assessments Medications Pain Management Activity/Nutrition Patient Goals Family/Friends
Committee Approval
The patient pathways start “before surgery” and go through the fourth postoperative day. The physician order sets, the clinical pathways, and the current patient pathways were used as a guide to format the pathways.
Feedback from all disciplines was obtained as we developed these order sets. Once they were completed, they were presented to the Orthopaedic Committee and the Clinical Best Practice Committee for approval. The Forms Committee then assigned each order set a form number to facilitate ordering from the copy center. We are happy to report that 88% of our orthopaedic surgeons are using the order sets for preoperative and postoperative care.
The clinical pathways (Fig 2) start with preadmission and also go through the fourth postoperative day. The clinical pathway focuses on level of responsibility, diagnostic testing, medications, treatments, activity, nutrition, elimination, education, discharge planning, and outcomes. It is noted that the clinical pathway is only a guideline. Interventions and treatments are modified and individualized in accordance
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Total Knee Replacement – Patient Pathway Before Surgery Education Discharge Planning
Tests
Assessments
Treatments & Therapy
Medications
Pain Control
Activity
Nutrition
Patient Goals
Family & Friends Fig 1.
Patient pathway for total knee replacement.
Day of Surgery
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Post Op Day 1
Post Op Day 2
Education Discharge Planning Tests Assessments
Treatments & Therapy
-You will be encouraged to assist with your hygiene needs. The staff will help you.
-You will be asked to rate your pain 0-10. Tell the nurse when you need pain medication. Your physical therapy will be more beneficial if pain medication is taken prior to each session.
Medications
Pain Control
Activity
Nutrition
Patient Goals
Family & Friends
Fig 1.
Continued
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Post Op Day 3 Education Discharge Planning Tests Assessments Treatments & Therapy
Medications
Pain Control
Activity
Nutrition
Patient Goals
Family & Friends
Fig 1.
Continued
Post Op Day 4
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Fig 2.
Clinical pathway for total hip replacement.
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Fig 2.
Continued
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with ongoing evaluation of the patient’s condition. The clinical pathway is not to be used as a substitute or replacement for individual clinical assessment. In addition to the clinical pathways for inpatient care, comprehensive pathways were developed for the rehabilitation unit and the home health care setting. The Total Joint Team felt that the content and format of the total joint order sets helped ensure that the clinical pathways are followed properly and that the orders and the pathways correlate together to ensure the best possible patient outcomes.
Patient Education Booklet and Total Joint Class Patient Education Booklet
When developing the patient education booklet, we questioned if separate booklets for the knee and hip patients were needed, and if our own copy center could print the booklet or if it could be sent out to a professional printing company. After discussing, Team B decided to develop one booklet for both patient groups and to format it along the lines of the hospital’s Open Heart Surgery educational booklets, which the hospital copy center could put together nicely. Members from Teams A and B contributed patient education information for the booklet specific to each health care discipline. Team B took the information and put it in a uniform, easy-toread format.
We gathered information from several hospitals around the state of Florida and used it to develop our class. With the volume of patients receiving total joint replacement at our facilities, we decided to offer the class twice per month at our campus and twice per month at our sister hospital in a separate county. Patients must attend the class at the location where their surgery will be performed. The classes are one hour each (50 minutes discussion and a 10-minute break) and are held in the classroom of the cardiac rehabilitation center. This location was chosen because of its easy access for patients who can park and walk right in, as opposed to having to go to the educational classrooms in the main building. Patients like this because most of them are very uncomfortable from their osteoarthritis or rheumatoid arthritis. Giveaways are provided for the patients attending the class, and they receive their choice of a “Human Motion Institute” t-shirt or tote bag. Cookies and bottled water are also offered to the patients and their family members. In addition, patients receive a certificate of attendance. When the classes were ready to be initiated, we visited each of the orthopaedic surgeons’ offices, giving them a schedule of the classes and instructions on how to schedule the classes for their patients. Patient instructions, in an “invitation” form, with a map and class specifics were also included to minimize any confusion. Most of the office staff members were very receptive to the idea of their patients attending the class, especially because many of them had been involved in the project since its beginning.
Total Joint Class
When Team B began to work on the Patient Education Class, we decided to look at what other facilities were offering, with a specific focus on how the class should be offered, how long it should be, how many people would be needed to teach the class, and whether patients would be receptive to attending a class in addition to their preadmission testing appointment.
Class Presentation
The Total Joint Classes are taught by one or two of the team members, usually one RN and one physical therapist. There is also a PowerPoint presentation that follows along with the patient education handbook. The class reviews the steps along the continuum of care, including preadmission, OR, anesthesia, general nursing
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care, and discharge planning/rehabilitation. The class begins by defining the common causes associated with joint replacement surgery: osteoarthritis, rheumatoid arthritis, injury, obesity, aging, and infection.4 The anatomy of the hip and the knee is then reviewed. Preoperative instructions for the day before surgery (ie, NPO instructions, medications to take on the day of surgery, what to bring to the hospital) are included. The process for the morning of surgery (where to arrive, vital signs, IVs, transfer to the OR, etc.) is discussed next. A brief overview of the anesthesia type is mentioned in the booklet, and a video presentation by one of the staff anesthesiologists is presented in the class. The video reviews the options for anesthesia and assures the patient that, together, on the day of surgery, they and their anesthesia provider will make the anesthesia choice that is best for them. Class instructors follow with what the patient can expect after surgery (vital signs, lab tests, any immobilizing devices, catheters, drains, pain management, etc). Information on how the patient can participate in his or her own care (ie, physical therapy, incentive spirometry, taking pain medication, drinking fluids, eating well) is also reviewed. Patients are instructed about postoperative anticoagulation therapy and specific reminders after posterior hip replacement surgery, anterior hip replacement surgery, and total knee replacement are discussed. Patients are told about the need to take antibiotics before dental work or other invasive procedures once they have their hip or knee replacement. The following “frequently asked questions” are discussed:
● How much pain will I have after surgery? ● When can I return to my normal activities?
● When can I resume intimate relations? ● Will I need special equipment at home after surgery?
● What will the physical therapy consist of during and after my hospital stay?
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Discharge planning is discussed at length, including a visit by the case manager to discuss the options of inpatient, outpatient, or home health rehabilitation. Equipment needs such as commodes, walkers, etc., are also discussed. The physical therapist then shows the patient various exercises to increase strength and range of motion postoperatively. We also begin to teach the patient proper techniques to get into and out of bed and to transfer to a chair. The use of assistive devices, usually a walker, while maintaining prescribed weight bearing status is reviewed. The goal of physical therapy is for the patient to be at the most independent level possible before they leave the hospital. If the patient is not ready to be discharged home, they have the option of continuing therapy in a rehabilitation center or a skilled nursing facility. For the patients returning home, therapy is continued by home health therapists visiting their home or by the patient going to an outpatient clinic. During the class, we use presentation boards the team developed and show the patients actual implantable components: a CPM machine, a splint, and an abduction pillow. At the end of the class, time is allowed for questions and answers. There is additional information in the patient education booklets that may be reviewed when the patient goes for their preadmission testing visit or at home at the patient’s leisure. If a patient does not attend the total joint class, they are given the booklet at their visit to PAT and the nurse reviews it with them. The additional information includes the members of the health care team, spiritual care and cultural needs, supplemental preoperative instructions, specific arrival time and location, and information on valuables, dentures, glasses, etc. Postoperative nursing care is described at length, as well as the various physical therapy exercises and precautions. The patient pathways for both total hip replacement and total knee replacement
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are included in each booklet. Patients are encouraged to bring the booklet to the hospital with them when they have surgery so they can easily refer to it.
Summary One of the patient education standards of The Joint Commission is to use “patient and family education to improve patient health outcomes by promoting healthy behavior and involving the patient in care and care decisions.” As a multidisciplinary team including surgeons, registered nurses, physical therapists, anesthesiologists, case managers, pharmacists, and others, we developed several important tools that help us meet this standard. These include the clinical and patient pathways, the patient education booklet, and the total joint class. In addition, the physician order sets have been very well received and used. We have received praise from orthopaedic surgeons regarding improved efficiencies in the overall care of the orthopaedic patient undergoing joint replacement surgery, and some surgeons even requested to be a part
of the team. At a Joint Commission survey shortly after implementation of our joint replacement program, our team leader, the Director of the Human Motion Institute, along with one of our team surgeons presented all phases of the project to the surveyors as a qualityimprovement initiative. The surveyors were impressed with the multidisciplinary approach to patient education and patient care and offered rave remarks. Most importantly, the feedback from the patients has been extremely positive. Patients feel well prepared for their surgeries and enjoy being a part of their own health care team.
Acknowledgment We thank Darlinda Copeland, Chief Operating Officer, at Florida Hospital Memorial System, for permission to use the order sets and pathways in this article.
Supplementary Data To access Supplementary Figs 1-4 for this article, visit the online journal at www.jopan.org.
References 1. The Joint Commission. National patient safety goals, #7. Available at: http://www.jointcommission.org/patientsafety/ nationalpatientsafetygoals/07. Accessed December 14, 2006. 2. The Joint Commission. Critical Access Hospital 2006 Medication Management. Available at: http://www.jointcommission. org/NR/rdonlyres. Accessed January 25, 2007.
3. Center for Medicare and Medicaid Services, Department of Health and Human Services. Skilled nursing facility center. Available at: http://www.cms.hhs.gov/center/snf.asp. Accessed January 12, 2007. 4. Bowen B. Orthopaedic surgery. In: Rothrock JC, ed: Alexander’s Care of the Patient in Surgery. St Louis, MO: Mosby; 2003:817-930.
Bibliography 1. Bowen B. Orthopaedic surgery. In: Rothrock JC, ed: Alexander’s Care of the Patient in Surgery. St Louis, MO: Mosby; 2003:817-930. 2. Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation, 2nd ed. St Louis, MO: Mosby; 2003:449-458, 465473. 3. D’Lima DD. The effect of preoperative exercise on total knee replacement. J Clin Orthopaed. 1996;326:174-182. 4. Dimura C. Patient education: Enhancing the potential of the teacher and the learner. In: Buren NB, ed: Ambulatory Surgical Nursing. Philadelphia, PA: Saunders; 2000: 363-380. 5. Drain CB. Care of the orthopaedic surgical patient. In: Drain CB, ed: Perianesthesia Nursing: A Critical Care Approach. Philadelphia, PA: Saunders; 2003:506-516.
6. Enloe LJ. Total hip and knee replacement treatment programs: A report using consensus. J Orthopaed Sports Phys Ther. 1996;23:3-11. 7. Gingerich BS, Ondeck DA. Clinical Pathways for the Multidisciplinary Home Care Team. Gaithersburg, MD: Aspen Publishers, Inc; 1996. 8. Insall JN. Knee arthroplasty: Then, now, and tomorrow. J Orthoped. 1996;18:889-892. 9. Kumar PJ. Rehabilitation after total knee arthroplasty. J Clin Orthopaed. 1996;331:93-101. 10. Lewis CB, Bottomley JM. Geriatric Physical Therapy—A Clinical Approach. Norwalk, CT: Appleton & Lange; 1994:338339, 345. 11. Munin MC. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA. 1998;279:847-852.
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Supplementary Fig 1.
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Orthopaedic preoperative total joint orders.
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Supplementary Fig 1.
Continued
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Supplementary Fig 2.
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Orthopaedic postoperative joint and fracture orders.
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Supplementary Fig 2.
Continued
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Supplementary Fig 2.
Continued
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Supplementary Fig 2.
Continued
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Supplementary Fig 3.
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Acute rehabilitation center order set.
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Supplementary Fig 3.
Continued
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Supplementary Fig 4.
Home health order set.
A multidisciplinary team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon’s office through postdischarge rehabilitation. Project goals for the team were to develop the “ideal” pre and postoperative orders for total joint patients, review and revise current clinical and patient pathways for the total knee replacement patient and the total hip replacement patient, add rehabilitation services to clinical pathways, and develop a patient education class and patient education booklet. This article describes how working together with all disciplines involved resulted in a consolidated order set, clinical and patient pathways that reflected actual care and processes, a userfriendly patient education book, and a multidisciplinary patient education class. The end products led to consistency in the quality of care across the continuum from preadmission through postdischarge rehabilitation for total joint replacement patients. Keywords: orthopaedics, joint replacement, multidisciplinary care. © 2007 by American Society of PeriAnesthesia Nurses.
A MULTIDISCIPLINARY team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon’s office through postdischarge rehabilitation. As part of the hospital’s Human Motion Institute, the Total Joint Team was formed. Team members included registered nurses from the preadmission testing (PAT) department, the OR, the orthopaedic nursing unit, and from home health care, as well as physical therapists involved in inpatient, outpatient, and home health care rehabilitation. Other members of the team included two orthoJournal of PeriAnesthesia Nursing, Vol 22, No 3 (June), 2007: pp 195-206
paedic surgeons, a case manager RN, and staff from the physicians’ offices. An anesthesiologist and hospital-based pharmacist
Nancy Saufl, MS, RN, CPAN, CAPA, is a Coordinator, Preadmission Testing & Teaching Center; Adam Owens, RN, BSN, ONC, PTA, is an Inpatient Orthopaedic Nurse and PICC Team Coordinator; Isabel Kelly, PTA, is an Inpatient Physical Therapy Assistant; Beth Merrill, RN, is a Home Health Clinical Coordinator; and Laura L. Freyaldenhouen, PTA, is a Home Health Physical Therapy Coordinator, Florida Hospital Memorial System, Ormond Beach, FL. All authors participate in the Human Motion Institute. Address correspondence to Nancy Saufl, 114 Pinion Circle, Ormond Beach, FL 32174; e-mail address: [email protected]. © 2007 by American Society of PeriAnesthesia Nurses. 1089-9472/07/2203-0006$35.00/0 doi:10.1016/j.jopan.2007.03.007 195
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attended meetings on a consulting basis as needed. The entire team initially met every two weeks and then divided into two subgroups: Team A and Team B. The teams were named according to the classroom assignments for their meetings—not because one project was more important than the other! Team A and Team B met one to two times per week with ongoing assignments. Progress was reported back to the entire group meeting, which began to meet on a monthly basis only. Team A’s focus was on preoperative and postoperative standard order sets and clinical and patient pathways. Team B was in charge of developing a patient education class and handout. Both team leaders communicated regularly by email, phone, and one-on-one discussions to ensure everyone was “staying on the same page.”
Physician Order Sets The group agreed on the goal to review the current orthopaedic orders and come up with order sets as follows: 1. Preoperative total joint orders 2. Postoperative total joint orders 3. Orthopaedic total joint discharge orders for home health care and/or a rehabilitation center Samples of all the different orders currently being used by the various orthopaedic surgeons on staff were first collected. Preoperative and postoperative orders from 16 orthopaedic surgeons were reviewed, many of which were very individualized orders sets. The order sets were reviewed and compared for commonalities, and the pharmacist was asked to check all medications for accuracy in dosage and administration routes. The director of laboratory services was also requested to review all lab-testing orders for appropriateness. Our goal was to make the order sets specific, concise, and userfriendly in hopes that all the orthopaedic surgeons would choose to use them. An additional goal was to create clinical guidelines and a medical protocol that would help with a sys-
tematic approach to patient care for the total joint patient. Order sets were left flexible enough for the physicians to implement individualized orders as needed. Once the various orders collected from the physician offices were reviewed, we found one order form type that was being used consistently by several of the physicians and decided to focus on formatting the new order set in a similar style. Using that form as a template, we began with the preoperative orders going line by line, choosing the orders being used by the majority of the physicians. The new orders were entitled: “Orthopaedic Preoperative Total Joint Orders,” and began with a place for patient diagnosis and surgical consent order (see Supplementary Fig 1 online at www.jopan.org). The diet guideline was changed to reflect the newly implemented anesthesia protocol for “nothing by mouth” (NPO) guidelines, but an option was left for ordering NPO after midnight if the surgeon so chose. The activity order consisted of “ambulate ad lib.” Preoperative laboratory tests were arranged in an orderly flow with check boxes for easy ordering. Type and screen orders included autologous blood donations. A place for International Classification of Diseases (ICD) diagnosis codes was also included with the chest radiograph and the electrocardiogram orders to help increase adherence to Medicare guidelines when ordering. The physician writes in the specific choice of preoperative intravenous (IV) fluids, and home instructions (ie, chlorhexidine shower) were separated from day-of-surgery operative site preparation orders. Surgical nursing orders (ie, preps, Foley catheter, TED hose, sequential compression devices) were also included. Per the pharmacy’s recommendation, the physician was given three choices for preoperative antibiotics: Ancef (Harvard Pilgrim Health Care, Boston, MA), Vancocin (ViroPharma, Exton, PA), and Cleocin (Pfizer, New York, NY). Generic names were also added to the orders. Many of the physicians wanted a place to write
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Coumadin (Bristol-Myers Squibb Co, Princeton, NJ) instructions for the patient to take at home the night before surgery; a statement was added reading: “Ask patient to call the physician’s office the day before surgery for Coumadin instructions, if needed.” We felt this instruction must come directly from the physician, not the preadmission testing nurse. An option for medical consultation is also available if consult is desired. Additionally, an order for “other” was also added for the physician to write in any specific requests. A line for physician signature is on the orders and a standard hospital physician order form is used, which includes “do not use” abbreviations for compliance with the Joint Commission’s National Patient Safety Goals.1 Postoperative Orders
The postoperative orders were titled “Orthopaedic Postoperative Joint and Fracture Orders” because, in addition to the total joints, they can be used for patients having open reduction internal fixation or Intramedullary roddings (see Supplementary Fig 2 online at www.jopan.org). There is a place for the physician to check off what specific procedure (including unicondylar) the patient had, and also a place to delineate between anterior and posterior approaches for the total hip replacement. The physical therapists felt this information was important to help ensure proper precautionary measures are used to prevent dislocation. Routine orders for IV fluids, diet, and vital signs were used. Activity was further delineated to ensure specific instructions and consistency in postoperative care. Weight bearing status was added to clarify the patient’s weight bearing status so that all disciplines caring for the patient are aware, thereby maintaining safety and preventing injury. Lab parameters for hemoglobin and prothrombin time were clarified. Nursing orders include TED hose, splints, incision care, etc. Physical therapy orders to “evaluate and treat” were also included. All “PO” or “PT” abbreviations were changed to read “postoperative” and
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“physical therapy,” respectively, to avoid confusion. Once again the physician was given the choice of Ancef (Harvard Pilgrim Health Care), Vancomycin, or Cleocin (Pfizer) for postoperative antibiotics. Analgesic choices were categorized together. If the physician chose patient-controlled analgesia (PCA), they filled out the separate PCA order sheet. Medications for bowel care and anticoagulant therapy were also categorized appropriately. Enoxaparin (Lovenox, sanofi-aventis), Fondaparinux (Arixtra, Organon Sanofi-Synthelabo, Roseland, NJ), and Coumadin (Bristol-Myers Squibb) were included for the physician to order as indicated; along with international normalized ratio (INR) activity. Because The Joint Commission discourages,2 and the hospital policy prohibits writing “resume preop meds” or “take meds as at home,” all medications that need to be restarted after surgery must be written out on the postoperative orders to avoid confusion and avoid the nurse having to call the surgeon regarding home medications. This took some education on the part of the physicians because many had been writing, “resume home meds” or “resume preop meds” for years. Since the implementation of an Electronic Medical Record in 2006, we have found that the Admission Medication Reconciliation form has greatly enhanced the process for reordering patient medications in the postoperative period. Also included on the postoperative orders are places for “medical consultation” and “case management consultation.” A case manager sees all of the total joint patients on the first postoperative day to help determine postdischarge rehabilitation needs. Patients, along with their physicians, may choose to be (1) discharged directly home with Home Health Care Services or visits to an outpatient clinic, (2) go to a skilled nursing facility that offers rehabilitation services, or (3) go to an acute care rehabilitation center.
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The Total Joint Team felt the changes implemented on the pre and postoperative orthopaedic orders helped to enhance patient safety and facilitate quality patient care. We hoped the orders and pathways would promote teamwork, consistency, and accuracy in patient care. Discharge Orders
The nurses and physical therapists from home health care and from the acute care rehabilitation center identified a need for specific discharge orders for both areas of care. The order sets were developed for use on all home health care and inpatient rehabilitation patients (other than those going to skilled nursing facilities, where the 3008 forms are mandated).3 The order sets (see Supplementary Figs 3 and 4 online at www.jopan.org) include:
● ● ● ● ● ● ● ● ●
Surgical procedure Home health/Rehab disciplines needed Weight bearing status Anticoagulation therapy Wound care orders Splints Continuous passive motion (CPM) Medications Other
The staff felt this information and format would help improve communication upon transfer and would be used to connect the hospital, the intake coordinator, and the physical therapist, resulting in fewer phone calls to the physician, thereby increasing overall employee and physician satisfaction.
Patient Pathways and Clinical Pathways Once the order sets were completed, we had to be sure the pre and postoperative orders corresponded appropriately with the clinical pathways, and that the clinical pathways were current, up-to-date, and reflective of current practice. In addition, we needed to know if the patient pathways were optimal for patients and if they clearly depicted what the patients should expect during their perioperative experience. Patient Pathways
The Patient Pathways (Fig 1) are user friendly at a fifth to six-grade reading level and are easy for patients to follow. Although some of the information may seem redundant from what the patients receive in PAT, the total joint class, and the text of the booklet, the team felt it important to have an easy reference guide for patients and that repetition of information would not be an issue. The patient pathway has the following main titles:
● ● ● ● ● ● ● ●
Education Discharge Planning Tests/Assessments Medications Pain Management Activity/Nutrition Patient Goals Family/Friends
Committee Approval
The patient pathways start “before surgery” and go through the fourth postoperative day. The physician order sets, the clinical pathways, and the current patient pathways were used as a guide to format the pathways.
Feedback from all disciplines was obtained as we developed these order sets. Once they were completed, they were presented to the Orthopaedic Committee and the Clinical Best Practice Committee for approval. The Forms Committee then assigned each order set a form number to facilitate ordering from the copy center. We are happy to report that 88% of our orthopaedic surgeons are using the order sets for preoperative and postoperative care.
The clinical pathways (Fig 2) start with preadmission and also go through the fourth postoperative day. The clinical pathway focuses on level of responsibility, diagnostic testing, medications, treatments, activity, nutrition, elimination, education, discharge planning, and outcomes. It is noted that the clinical pathway is only a guideline. Interventions and treatments are modified and individualized in accordance
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Total Knee Replacement – Patient Pathway Before Surgery Education Discharge Planning
Tests
Assessments
Treatments & Therapy
Medications
Pain Control
Activity
Nutrition
Patient Goals
Family & Friends Fig 1.
Patient pathway for total knee replacement.
Day of Surgery
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Post Op Day 1
Post Op Day 2
Education Discharge Planning Tests Assessments
Treatments & Therapy
-You will be encouraged to assist with your hygiene needs. The staff will help you.
-You will be asked to rate your pain 0-10. Tell the nurse when you need pain medication. Your physical therapy will be more beneficial if pain medication is taken prior to each session.
Medications
Pain Control
Activity
Nutrition
Patient Goals
Family & Friends
Fig 1.
Continued
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Post Op Day 3 Education Discharge Planning Tests Assessments Treatments & Therapy
Medications
Pain Control
Activity
Nutrition
Patient Goals
Family & Friends
Fig 1.
Continued
Post Op Day 4
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Fig 2.
Clinical pathway for total hip replacement.
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Fig 2.
Continued
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with ongoing evaluation of the patient’s condition. The clinical pathway is not to be used as a substitute or replacement for individual clinical assessment. In addition to the clinical pathways for inpatient care, comprehensive pathways were developed for the rehabilitation unit and the home health care setting. The Total Joint Team felt that the content and format of the total joint order sets helped ensure that the clinical pathways are followed properly and that the orders and the pathways correlate together to ensure the best possible patient outcomes.
Patient Education Booklet and Total Joint Class Patient Education Booklet
When developing the patient education booklet, we questioned if separate booklets for the knee and hip patients were needed, and if our own copy center could print the booklet or if it could be sent out to a professional printing company. After discussing, Team B decided to develop one booklet for both patient groups and to format it along the lines of the hospital’s Open Heart Surgery educational booklets, which the hospital copy center could put together nicely. Members from Teams A and B contributed patient education information for the booklet specific to each health care discipline. Team B took the information and put it in a uniform, easy-toread format.
We gathered information from several hospitals around the state of Florida and used it to develop our class. With the volume of patients receiving total joint replacement at our facilities, we decided to offer the class twice per month at our campus and twice per month at our sister hospital in a separate county. Patients must attend the class at the location where their surgery will be performed. The classes are one hour each (50 minutes discussion and a 10-minute break) and are held in the classroom of the cardiac rehabilitation center. This location was chosen because of its easy access for patients who can park and walk right in, as opposed to having to go to the educational classrooms in the main building. Patients like this because most of them are very uncomfortable from their osteoarthritis or rheumatoid arthritis. Giveaways are provided for the patients attending the class, and they receive their choice of a “Human Motion Institute” t-shirt or tote bag. Cookies and bottled water are also offered to the patients and their family members. In addition, patients receive a certificate of attendance. When the classes were ready to be initiated, we visited each of the orthopaedic surgeons’ offices, giving them a schedule of the classes and instructions on how to schedule the classes for their patients. Patient instructions, in an “invitation” form, with a map and class specifics were also included to minimize any confusion. Most of the office staff members were very receptive to the idea of their patients attending the class, especially because many of them had been involved in the project since its beginning.
Total Joint Class
When Team B began to work on the Patient Education Class, we decided to look at what other facilities were offering, with a specific focus on how the class should be offered, how long it should be, how many people would be needed to teach the class, and whether patients would be receptive to attending a class in addition to their preadmission testing appointment.
Class Presentation
The Total Joint Classes are taught by one or two of the team members, usually one RN and one physical therapist. There is also a PowerPoint presentation that follows along with the patient education handbook. The class reviews the steps along the continuum of care, including preadmission, OR, anesthesia, general nursing
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care, and discharge planning/rehabilitation. The class begins by defining the common causes associated with joint replacement surgery: osteoarthritis, rheumatoid arthritis, injury, obesity, aging, and infection.4 The anatomy of the hip and the knee is then reviewed. Preoperative instructions for the day before surgery (ie, NPO instructions, medications to take on the day of surgery, what to bring to the hospital) are included. The process for the morning of surgery (where to arrive, vital signs, IVs, transfer to the OR, etc.) is discussed next. A brief overview of the anesthesia type is mentioned in the booklet, and a video presentation by one of the staff anesthesiologists is presented in the class. The video reviews the options for anesthesia and assures the patient that, together, on the day of surgery, they and their anesthesia provider will make the anesthesia choice that is best for them. Class instructors follow with what the patient can expect after surgery (vital signs, lab tests, any immobilizing devices, catheters, drains, pain management, etc). Information on how the patient can participate in his or her own care (ie, physical therapy, incentive spirometry, taking pain medication, drinking fluids, eating well) is also reviewed. Patients are instructed about postoperative anticoagulation therapy and specific reminders after posterior hip replacement surgery, anterior hip replacement surgery, and total knee replacement are discussed. Patients are told about the need to take antibiotics before dental work or other invasive procedures once they have their hip or knee replacement. The following “frequently asked questions” are discussed:
● How much pain will I have after surgery? ● When can I return to my normal activities?
● When can I resume intimate relations? ● Will I need special equipment at home after surgery?
● What will the physical therapy consist of during and after my hospital stay?
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Discharge planning is discussed at length, including a visit by the case manager to discuss the options of inpatient, outpatient, or home health rehabilitation. Equipment needs such as commodes, walkers, etc., are also discussed. The physical therapist then shows the patient various exercises to increase strength and range of motion postoperatively. We also begin to teach the patient proper techniques to get into and out of bed and to transfer to a chair. The use of assistive devices, usually a walker, while maintaining prescribed weight bearing status is reviewed. The goal of physical therapy is for the patient to be at the most independent level possible before they leave the hospital. If the patient is not ready to be discharged home, they have the option of continuing therapy in a rehabilitation center or a skilled nursing facility. For the patients returning home, therapy is continued by home health therapists visiting their home or by the patient going to an outpatient clinic. During the class, we use presentation boards the team developed and show the patients actual implantable components: a CPM machine, a splint, and an abduction pillow. At the end of the class, time is allowed for questions and answers. There is additional information in the patient education booklets that may be reviewed when the patient goes for their preadmission testing visit or at home at the patient’s leisure. If a patient does not attend the total joint class, they are given the booklet at their visit to PAT and the nurse reviews it with them. The additional information includes the members of the health care team, spiritual care and cultural needs, supplemental preoperative instructions, specific arrival time and location, and information on valuables, dentures, glasses, etc. Postoperative nursing care is described at length, as well as the various physical therapy exercises and precautions. The patient pathways for both total hip replacement and total knee replacement
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are included in each booklet. Patients are encouraged to bring the booklet to the hospital with them when they have surgery so they can easily refer to it.
Summary One of the patient education standards of The Joint Commission is to use “patient and family education to improve patient health outcomes by promoting healthy behavior and involving the patient in care and care decisions.” As a multidisciplinary team including surgeons, registered nurses, physical therapists, anesthesiologists, case managers, pharmacists, and others, we developed several important tools that help us meet this standard. These include the clinical and patient pathways, the patient education booklet, and the total joint class. In addition, the physician order sets have been very well received and used. We have received praise from orthopaedic surgeons regarding improved efficiencies in the overall care of the orthopaedic patient undergoing joint replacement surgery, and some surgeons even requested to be a part
of the team. At a Joint Commission survey shortly after implementation of our joint replacement program, our team leader, the Director of the Human Motion Institute, along with one of our team surgeons presented all phases of the project to the surveyors as a qualityimprovement initiative. The surveyors were impressed with the multidisciplinary approach to patient education and patient care and offered rave remarks. Most importantly, the feedback from the patients has been extremely positive. Patients feel well prepared for their surgeries and enjoy being a part of their own health care team.
Acknowledgment We thank Darlinda Copeland, Chief Operating Officer, at Florida Hospital Memorial System, for permission to use the order sets and pathways in this article.
Supplementary Data To access Supplementary Figs 1-4 for this article, visit the online journal at www.jopan.org.
References 1. The Joint Commission. National patient safety goals, #7. Available at: http://www.jointcommission.org/patientsafety/ nationalpatientsafetygoals/07. Accessed December 14, 2006. 2. The Joint Commission. Critical Access Hospital 2006 Medication Management. Available at: http://www.jointcommission. org/NR/rdonlyres. Accessed January 25, 2007.
3. Center for Medicare and Medicaid Services, Department of Health and Human Services. Skilled nursing facility center. Available at: http://www.cms.hhs.gov/center/snf.asp. Accessed January 12, 2007. 4. Bowen B. Orthopaedic surgery. In: Rothrock JC, ed: Alexander’s Care of the Patient in Surgery. St Louis, MO: Mosby; 2003:817-930.
Bibliography 1. Bowen B. Orthopaedic surgery. In: Rothrock JC, ed: Alexander’s Care of the Patient in Surgery. St Louis, MO: Mosby; 2003:817-930. 2. Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation, 2nd ed. St Louis, MO: Mosby; 2003:449-458, 465473. 3. D’Lima DD. The effect of preoperative exercise on total knee replacement. J Clin Orthopaed. 1996;326:174-182. 4. Dimura C. Patient education: Enhancing the potential of the teacher and the learner. In: Buren NB, ed: Ambulatory Surgical Nursing. Philadelphia, PA: Saunders; 2000: 363-380. 5. Drain CB. Care of the orthopaedic surgical patient. In: Drain CB, ed: Perianesthesia Nursing: A Critical Care Approach. Philadelphia, PA: Saunders; 2003:506-516.
6. Enloe LJ. Total hip and knee replacement treatment programs: A report using consensus. J Orthopaed Sports Phys Ther. 1996;23:3-11. 7. Gingerich BS, Ondeck DA. Clinical Pathways for the Multidisciplinary Home Care Team. Gaithersburg, MD: Aspen Publishers, Inc; 1996. 8. Insall JN. Knee arthroplasty: Then, now, and tomorrow. J Orthoped. 1996;18:889-892. 9. Kumar PJ. Rehabilitation after total knee arthroplasty. J Clin Orthopaed. 1996;331:93-101. 10. Lewis CB, Bottomley JM. Geriatric Physical Therapy—A Clinical Approach. Norwalk, CT: Appleton & Lange; 1994:338339, 345. 11. Munin MC. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA. 1998;279:847-852.
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Supplementary Fig 1.
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Orthopaedic preoperative total joint orders.
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Supplementary Fig 1.
Continued
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Supplementary Fig 2.
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Orthopaedic postoperative joint and fracture orders.
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Supplementary Fig 2.
Continued
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Supplementary Fig 2.
Continued
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Supplementary Fig 2.
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Supplementary Fig 3.
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Acute rehabilitation center order set.
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Supplementary Fig 3.
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Supplementary Fig 4.
Home health order set.