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Clinical Pathway for Hip and Knee Arthroplasty
Professional articles
Clinical Pathway for Hip and Knee Arthroplasty Summary The objective of this study was to evaluate the implementation of an early discharge programme for patients undergoing hip or knee arthroplasties. This paper examines outcomes pertinent to physiotherapy, and looks at patient movement and function for up to six months after surgery. A case management model of care using clinical pathways provided a means for physiotherapists working on an orthopaedic ward to optimise services and facilitate early patient discharge. Data were collected over a two-year period, with follow-up of 215 patients conducted at six weeks and three and six months after surgery. Data collected looked at length of stay based on day of surgery, range of movement and a timed ten-metre walk test. Results after implementation of the clinical pathway, in comparison to baseline measures, showed that length of stay was reduced, the day that surgery was performed did not affect length of stay, and all patients improved their range of movement and walking capabilities up to six months following surgery. It was concluded from this project that the implementation of clinical pathways enabled the orthopaedic ward to reduce elective joint replacement length of stay with the current physiotherapy service, without any detrimental long-term effects on patient function or movement.
Thomas, K (2003). ‘Clinical pathway for hip and knee arthroplasty’, Physiotherapy, 89, 10, 603-609.
Background and Purpose Osteo-arthritis commonly affects people over 65 years of age and is a major cause of pain and debility of hip and knee joints. Hip and knee arthroplasties are common elective joint procedures to reduce pain and improve function (Enloe et al, 1996; Martin et al, 1998). Hip arthroplasty may also be indicated in rheumatoid arthritis, avascular necrosis, hip fractures and arthritis associated with Paget’s disease (NIHCC, 1995). In Australia as well as the United Kingdom, managed care is in its infancy, with the main focus of healthcare delivery shifting from process to outcomes and ensuring a measurable quality of care is given to consumers (Hale, 1995; Potter, 1998). Organisations therefore recognise
603 Key Words Arthroplasty, clinical pathways, length of stay, physical therapy.
by Kelly Thomas
the need for restructuring the way care is delivered to their patients. In particular, with increasing economic constraints in health organisations, Nepean Hospital in Sydney, Australia, was looking for ways of reducing costs and using resources efficiently while still providing optimal patient care. A pilot project was conducted between July and October 1999 on people needing hip and knee arthroplasty. This study established that the current cost for hip arthroplasty at this hospital was $1,149 per day and for knee arthroplasty $1,080 per day, with average lengths of stay of 10 days for knee arthroplasty and 12 days for hip arthroplasty. Therefore, in October 1999 an early discharge project incorporating clinical pathways was implemented. The project targeted patients undergoing elective hip or knee arthroplasty, aiming to reduce length of stay without compromising patient outcomes. It was important after such an implementation that its effectiveness was evaluated. Before implementation of the early discharge programme and clinical pathways, patients were assessed ad hoc pre-operatively, often attending for tests on more than one occasion. Furthermore, there was no agreed order of or time interval between elements of care, and there was no structured system of physiotherapy intervention. Although patients were followed-up, they were not visited at home, but given outpatient appointments about two weeks after discharge. They were however instructed to continue with their exercises until reviewed at an outpatient appointment. A study by Mabrey et al (1997) examined the effect of introducing clinical pathways for total knee replacements and the effect on length of stay over a two-year period. Such an implementation resulted Physiotherapy October 2003/vol 89/no 10
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in a reduction of length of stay from 11 ± 5 days to 5 ± 1 day which equated to hospital savings of 11% of the total cost of an episode of care. Similarly, a study by Pearson et al (2000) evaluated the implementation of clinical pathways for patients undergoing total knee arthroplasty. Their results showed that such an implementation significantly reduced length of stay from nine to seven days and improved streamlining of services, all without detrimental effects on patient outcomes. In contrast, Hughes et al (1993) and Mahoney et al (1985) found that to achieve a reduction in length of stay following arthroplasty, physiotherapy services had to include weekends. Hughes et al (1993) recognised a concern for patients undergoing their replacement on a Wednesday or Thursday who might therefore not receive consecutive physiotherapy due to the weekend interruption. By providing a weekend physiotherapy service they did reduce length of stay. However, these authors did not examine the use of clinical pathways as an alternative. The present study therefore sought to evaluate patient outcomes following hip and knee arthroplasty with emphasis on the examination of the role of physiotherapy. From the outset, it was recognised that the design did not permit inferences to be drawn about the efficacy of the clinical pathways relative to previous approaches to patient care. Rather, it was the primary objective of this study to carry out an initial empirical examination of this alternative management approach. In view of the paucity of such studies in the literature, this research sought to clarify the potential utility of clinical pathways. Methods Selection of Subjects The study ran from October 1999 to October 2001 and included 215 patients undergoing elective joint replacement. Patients were included if they lived in the local government area to ensure they received post-acute care – from the nursing and physiotherapy outreach ser vice. Thirty-three patients living outside this area were excluded from the study, although they were still casemanaged on a clinical pathway. Patients were also excluded if they had complications after surgery that required Physiotherapy October 2003/vol 89/no 10
a longer hospital stay, for example patients with low haemoglobin, wound ooze, constipation or nausea. The average age of patients undergoing a knee arthroplasty was 69 (SD 10) years, and for hip arthroplasty 67 (SD 12) years. Procedure Patients undergoing elective joint replacements were seen in the preadmission clinic for a full day of assessments before surgery. This included nursing, occupational therapy and specific physiotherapy assessments. Physiotherapy pre-admission data collected included joint range of motion, type of aid used to walk (if any) and time to walk ten metres. Range of movement was measured using universal goniometers, with all therapists standardising measurements as described by Norkin and White (1995). Knee movements were performed with the patients in sitting, and hip movements with the patients in supine (flexion and abduction) or sidelying (extension). Although in this study error attributable to differences between observers was not calculated, studies by Brosseau et al (1997, 2001) found good reliability when measurements were made by one observer on two or more occasions, and when different therapists measured joint angles using the universal goniometer. Pre-operatively patients were taught exercises by a physiotherapist and instructed in the use of walking aids. Patients were provided with information on early exercises and mobility training, and told that a physiotherapist would be involved with their care twice daily on the ward and once daily at home upon discharge. They were also asked to attend the outpatient physiotherapy department for regular appointments until their functional ability had been maximised. Pre-admission physiotherapy data were collected on an individual patient record sheet to be used later for further data collection. Patients were then admitted on their day of surgery and length of stay was calculated from day of surgery to discharge from the ward. Patients underwent surgery on Monday, Wednesday or Friday depending on their orthopaedic surgeon. Clinical pathways were used by the ward physiotherapists to co-ordinate physiotherapy services and a case manager co-
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ordinated the overall patient care. The project was approved by the Ethics and Research Committee of Wentworth Area Health Service. Physiotherapy The orthopaedic ward included the equivalent of two full-time physiotherapists who worked from Monday to Friday. If possible, patients were seen on the day of surgery to start deep breathing exercises, bed mobility and ankle dorsiflexion/plantarflexion exercises for circulation. Patients were then seen on the day after surgery for more bed exercises and, if the post-operative radiograph was satisfactory, they were helped to sit out of bed on this day. Patients were seen twice daily to perform their exercises, to walk and to practise using stairs. Hip arthroplasty exercises included: ■ Ankle dorsiflexion and plantarflexion ■ Isometric quadriceps ■ Isometric gluteals ■ Inner range quadriceps ■ Hip flexion and extension in supine ■ Knee flexion and extension in supine ■ Hip abduction in supine This progressed to hip flexion, extension and abduction in standing. Knee arthroplasty exercises included: Ankle dorsiflexion and plantarflexion Isometric quadriceps Isometric gluteals Inner range quadriceps Knee flexion and extension in sitting Hamstring stretches All patients also practised walking, stairs, transfers and correct weight bearing status. Depending on the surgeon, some patients were required not to walk with all their weight through their limb for up to six weeks. No weekend physiotherapy was provided and patients were deemed safe when they satisfied the discharge criteria of walking steadily safe with an aid and being able to use stairs safely. Each day a physiotherapist completed and signed the patient clinical pathway as to what the patient had achieved. Joint range was recorded, along with walking aid used and exercises per formed for the day. Any variations in exercise performance or ■ ■ ■ ■ ■ ■
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mobilisation were noted on the pathway. This enabled all staff to follow each patient’s progress, and co-ordinate their care. For example, nurses could view the pathway and observe for that day what aid the patient was using. The nursing staff could then reinforce the use of the aid when a patient walked to the bathroom or toilet. At day of discharge, final measures of range of movement, any walking aid required, timed walk over ten metres and an exercise programme were recorded on the individual patient record sheet that had been started in the pre-admission clinic. Following discharge, a physiotherapist attached to an outreach service reviewed patients daily or every other day for a period of two weeks. The outreach physiotherapist reviewed and progressed exercises, continued training of transfers and weight-bearing status, and helped the patients to practise walking and using stairs. At the end of these two weeks patients were then referred for outpatient physiotherapy with ongoing reviews at six weeks and three and six months. Data collected over this review period included joint range of motion (hip flexion, extension, abduction; knee extension active and passive, knee flexion), use of walking aid and a timed ten-metre walk. Data were again added to the individual patient record sheets. In conjunction with home visits by a physiotherapist after discharge, patients were seen daily for two weeks by nursing staff to assess and clean the wound as necessary. If required, patients were also provided with home care help for meals and self-care which was arranged before the patient was discharged from hospital. Data Analysis Data were analysed using the Statistical Package for Social Sciences (SPSS) version 10 for Windows. Analysis of variance was used to examine the effects of day of surgery on length of stay, and also the effects of day of surgery on patient outcomes (range of movement, walking aid, timed ten-metre walk) over the entire six-month period. Independent t-tests examined the effect of gender on all outcomes for all arthroplasties over the six-month data collection period. Independent t-tests were used to show further differences between the sexes at baseline for all outcome measures, for all
Author Kelly Thomas BMedSc BAppSc(physiotherapy) is a physiotherapist in private practice in Sydney, Australia. This study was conducted at the Nepean Hospital, Sydney, while she was employed as an orthopaedic outreach physiotherapist. Preliminary data were presented at the fifth annual Case Management Conference ‘Cohesion and Diversity?’ (New South Wales, Australia, February 2002). Final results were presented at the 13th Annual Australasian Association for Quality in Health Care (Queensland, Australia, June 2002). The project was funded by the National Demonstration Hospitals Project Phase 3 (Australia). Address for Correspondence Physiotherapy Department, Nepean Hospital, PO Box 63 Penrith, Sydney, Australia 2751. E-mail [email protected]
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Acknowledgements Thanks are due to the staff of the physiotherapy department at Nepean Hospital who helped with the data collection, particularly the outpatient staff and senior orthopaedic physiotherapist Anne Cavagnino; and also to Susan Patterson, Jennifer Smith and Ravy Thavaravy for their contributions to the project. Special appreciation is acknowledged to Michelle Moulds for her support and encouragement in the writing of this paper and help with the data analysis.
arthroplasties. Statistical significance for these tests was set at 5% (p < 0.05). Analysis of variance was also used to determine if any significant improvements were obtained in patient outcomes between the collection periods. Statistical significance was set again at 5% (p < 0.05) and Bonferroni correction was applied to post hoc analyses when primary analyses were significant. Only available data were entered into the analysis (ie not by intention to treat) and this is recognised as a limitation.
Results Patient Satisfaction A patient satisfaction survey was randomly distributed to 83 patients following discharge and was completed by 55 (response rate 66%), with 94% of patients happy with their episode of care, information they received throughout their hospital stay, and staff professionalism. Furthermore, 81% of patients indicated that at the time they were discharged they were ready to go home, with another 4% indicating they could have been discharged sooner, although a further 13% of patients would have preferred to stay longer in hospital – reasons given included that they enjoyed the rest and service being provided.
Table 1: Average length of stay for hip and knee arthroplasties Site of arthroplasty
Length of Stay With the implementation of this project, all patients undergoing arthroplasty attended the pre-admission clinic. One to two weeks later patients were admitted to the ward on their day of surgery and length of stay was calculated from this day until discharge. The average lengths of
Length of stay (days) Before clinical pathways
With clinical pathways
Knee
10
6
Hip
12
7
Table 2: Outcomes for hip arthroplasty: Mean (SD) range of hip movement, use of walking aid and time taken to walk 10 metres Function measured
Pre-admission (n = 89)
Discharge (n = 89)
6 weeks (n = 69)
After surgery 3 months (n = 65)
6 months (n = 56)
Flexion (°)
75 (18)
Abduction (°)
16 (10)
60 (16)
77 (13)
82 (11)
83 (11)
17
(9)
28
(8)
31 (10)
Extension (°)
–3
34 (8)
–5
(8)
4 (11)
8 (10)
10 (10)
Time to walk 10 metres (sec)
12 (11)
33 (20)
13 (11)
9 (4)
8 (3)
Walking aid (%) None Frame Crutches Walking stick
41 8 7 44
45 55
32 18 20 30
(9)
62 3 3 32
70
30
Table 3: Outcomes for knee arthroplasty: Mean (SD) range of knee movement, use of walking aid and time taken to walk 10 metres Function measured
Pre-admission (n = 126)
Flexion (°)
109 (17)
Active extension (°)
Discharge (n = 124)
77 (13) (8)
–8
(5)
After surgery 3 months (n = 86)
6 months (n = 70)
77 (13)
82 (11)
83 (11)
28
(8)
31 (10)
34 (8)
4 (11)
8 (10)
10 (10)
9 (3)
8 (3)
–8
(8)
Passive extension (°)
–4
(5)
Time to walk 10 metres (sec)
11 (11)
38 (25)
11
Walking aid (%) None Frame Crutches Walking stick
60 4 4 32
57 38 5
41 9 11 39
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–18
6 weeks (n = 103)
(7)
74 1 4 21
78 4 2 16
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stay for knee and hip arthroplasty are shown in table 1 and are compared to the sample before implementation of the project (n = 31, average age for knee arthroplasty 68 years, hip arthroplasty 67 years). Analysis of variance revealed no significant differences between length of stay and day of surgery for all arthroplasties (p > 0.05). That is, regardless of day of operation (or surgical team), length of stay was comparable. Outcome Measures Tables 2 and 3 summarise the average range of movement, walking aid usage and timed ten-metre walk over the data collection period. Analysis of variance showed significant improvements between each time-frame of data collection from discharge to six months for all patients across all variables (p < 0.05). That is, from discharge to six weeks, to three and six months after surgery, significant improvements in the measured variables were obtained. Effects of Day of Surgery Statistical analyses showed that outcomes at any particular review period were not significantly different whatever the day of operation (p > 0.05). For example, those undergoing surgery on Monday had no significantly better outcomes than those who had operations on a Wednesday or Friday. This was true for hip and knee arthroplasty and for any time period. Gender Effects Independent t-tests showed no significant differences at baseline on any outcome measures for hip arthroplasties (p > 0.05). However, by discharge until six months post-operatively, a significant difference was observed, with men performing the ten-metre walk on average two seconds faster than women (p < 0.05). For knee arthroplasty patients, independent t-tests indicated significant differences between males and females for the timed walk test at baseline (p < 0.05). There were no significant differences between the sexes at baseline for any other measures (p > 0.05). To account for the sex difference at baseline for the timed walk test for knee arthroplasty, further analysis of covariance was performed. Results showed that the men still walked significantly faster over the ten
607
metres than women only at discharge (p < 0.05). No significant difference was observed between sex and length of stay for hip arthroplasty (p > 0.05); however, men undergoing knee arthroplasty were discharged significantly sooner than women (p < 0.05). Discussion Through the integration of services and the implementation of clinical pathways, a number of outcomes were achieved for patients undergoing a hip or knee arthroplasty in Nepean Hospital. Physiotherapy in conjunction with other services enabled a four-day reduction in length of stay after implementation of the project for knee arthroplasty, and five days for hip arthroplasty. This in turn equated to an increased turnover of patients through the hospital system and as such reduced waiting times and costs per patient. Interestingly, average lengths of stay in England for 2001/02 were 12 days for hip arthroplasty (average age 68 years) and 11 days for knee arthroplasty (average age 70 years) (DoH website), equivalent to the baseline values in this study. However, although patients were discharged sooner, with a more intense exercise programme during their hospital stay, patient satisfaction with overall care was good. The reductions in length of stay were achieved through co-ordinating patient care, particularly improving upon the physiotherapy service, which did not require an increase in provision across weekends as suggested by other authors who reduced length of stay by providing weekend physiotherapy (Hughes et al, 1993; Mahoney et al, 1985). Pearson et al (2000) found similar results to the present study with a reduced length of stay following implementation of clinical pathways. Day of surgery (and hence surgical team) did not appear to affect the outcome. Patients whose operations were on a Friday were discharged at similar times to those operated on earlier in the week. This may have been due to the use of the clinical pathways, whereby over the weekend when no physiotherapy was provided, nursing staff could refer to the physiotherapy comments on the pathway and continue to encourage functional independence in an appropriate way, Physiotherapy October 2003/vol 89/no 10
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ie using correct aid and weight bearing status. This emphasises the continuum of care provided to patients across all multidisciplinary areas. Physiotherapy care was co-ordinated from pre-admission to six months after surgery for all patients. Initially, patients were provided with information on their pending operation, post-operative care including home visits by a physiotherapist following discharge, and outpatient physiotherapy treatments and reviews over the six-month period. Studies have shown that single pre-operative education sessions may have a more beneficial cost/benefit ratio than prolonged programmes (D’Lima et al, 1996; Weidenhielm et al, 1993). Ward and outpatient physiotherapists communicated regularly after patient discharge to ensure optimal care. A panel consisting of 16 physical therapists, one physician and two nurses all with expertise on hip and knee arthroplasty (Enloe et al, 1996) recommended physiotherapy twice a day postoperatively, five days a week; and daily for two weeks after discharge. Early mobilisation of patients was encouraged. These authors also endorsed the exercises and other training as provided in this project. These findings overall are in accordance with the results of our present study. Results shown in tables 2 and 3 show maximal gains are achieved and maintained in the first six months after surgery with average range of movements tending to plateau by three to six months, with hip flexion within the safe allowable range. By six months 100% of hip arthroplasty and 94% of knee arthroplasty patients were walking unaided or using only a stick. Anouchi et al (1996) found that no significant range of movement improvements occur in knee arthroplasty beyond the first year. They also found that range of movement of knee arthroplasty is an important measurement of outcome with a finding of a functional range of around 100° to 110°. This range is adequate for most activities of daily living and was achieved in the present study. Interestingly, significant gender effects were noted from this study. After hip arthroplasty from discharge to six months after surgery, and at discharge only after knee arthroplasty, men walked two seconds faster than women over ten Physiotherapy October 2003/vol 89/no 10
metres. Kreibich et al (1996) believe some patients tend to over-perform when postoperative functional tests such as walking are carried out. Bohannon (1997) found that gait speed reduces in older, shorter people with less lower extremity muscle strength. This may explain the gender results in walking outcomes, with men possibly still having stronger leg muscles than women even at an older age. With regard to length of stay no differences were observed between the sexes for hip arthroplasty, but with knee arthroplasty men were discharged one day earlier than women. Hughes et al (1993) similarly found that males tended to have a shorter post-operative length of stay. Since length of stay in acute hospitals has progressively shortened, more emphasis is placed on pre-admission educational and assessment programmes, appropriate and co-ordinated physiotherapy care, and rehabilitation both during and after in-patient care (NIHCC, 1995). Some patients could not be followedup due to difficulty encountered in contacting them at each review period, particularly at six months. Some also declined to attend or had moved out of the area, or had difficulty in keeping an appointment, for example because of transport problems. A further limitation of the present study included the lack of quality of life outcome measures. This study was conducted in conjunction with one undertaken by nursing staff that did address some quality of life issues and pain measures before and after surgery. However, at the time of writing, conclusive data were not available. The influence of age, as well as presurgical status of patients, may impact on length of stay as well as long-term outcomes. Further work on these variables and the role of a pre-operative programme on long-term outcomes is indicated. This study used clinical pathways and physiotherapy during the working week to reduce length of stay while aiming to provide optimal patient care. Further study is needed to determine whether the introduction of physiotherapy over weekends would provide further benefit. In sum, this research offers a preliminary indication of the effectiveness of the clinical pathways approach to the management of orthopaedic patients. It is
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acknowledged that conclusions about the relative efficacy of this model of care as compared to standard treatment procedures can be only tentative. Conclusion This project enabled current services to be improved so that a significant reduction in length of patient stay was References Anouchi, Y S, McShane, M, Kelly, F, Elting, J and Stiehl, J (1996). ‘Range of motion in total knee replacement’, Clinical Orthopaedics and Related Research, 331, 87-92. Bohannon, R W (1997). ‘Comfortable and maximum walking speed of adults aged 20-79 years: Reference values and determinants’, Age and Ageing, 26, 15-19. Brosseau, L, Touisignant, M, Budd, J, Chartier, N, Duciaume, L, Plamondon, S, O’Sullivan, J P, O’Donoghue, S and Balmer, S (1997). ‘Intra-tester and inter-tester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects’, Physiotherapy Research International, 2, 150-166. Brosseau, L, Balmer, S, Touisignant, M, O’Sullivan, J P, Goudreault, C, Goudreault, M and Gringras, S (2001). ‘Intra- and inter-tester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with knee restrictions’, Archives of Physical Medicine and Rehabilitation, 82, 396-402. Department of Health website www.doh.gov.uk/hes D’Lima, D D, Colwell, C W, Morris, B A, Hardwick, M E and Kozin, F (1996). ‘The effect of pre-operative exercise on total knee replacement outcomes’, Clinical Orthopaedics and Related Research, 326, 174-182. Enloe, L J, Shields, R K, Smith, K, Leo, K and Miller, B (1996). ‘Total hip and knee replacement treatment programmes: A report using consensus’, Journal of Orthopaedic and Sports Physical Therapy, 23, 3-11. Hale, C (1995). ‘Case management and managed care’, Nursing Standard, 9, 33-35.
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achieved, without any detrimental effect on joint range and functional ability by six months after surgery. The use of the preadmission clinic, day of surgery admission, co-ordinated physiotherapy care on the ward via clinical pathways, and post-acute physiotherapy care at home upon discharge enabled these clinical outcomes to be achieved. Kreibich, D N, Bourne, R B, Rorabeck, C H, Kim, P, Hardie, R, Kramer, J and Kirkley, A (1996). ‘What is the best way of assessing outcome after total knee replacement?’ Clinical Orthopaedics and Related Research, 331, 221-225. Mabrey, J D, Toohey, J S, Armstrong, D A, Lavery, L and Wammack, L A (1997). ‘Clinical pathway management of total knee arthroplasty’, Clinical Orthopaedics and Related Research, 345, 125-133. Mahoney, P, Dinnan, E and Zeleznik, R (1985). ‘The impact of prospective payment on clinical practice: Total hip replacement’, Physical Therapy, 65, 711-713.
Key Messages ■ Clinical pathways facilitate earlier patient discharge following arthroplasty. ■ Reduction in length of stay does not necessarily result in a poorer outcome. ■ If hospital stay is shortened, more emphasis needs to be placed on education and care before admission and after discharge. ■ Further research is indicated in this area.
Martin, S C, Scott, R D and Thornhill, T S (1998). ‘Current concepts of total knee arthroplasty’, Journal of Orthopaedic and Sports Physical Therapy, 28, 252- 261. National Institute of Health Consensus Conference (NIHCC) (1995). ‘Total hip replacement’, Journal of the American Medical Association, 273, 1950-56. Norkin, C C and White, D J (1995). Measurement of Joint Motion: A guide to goniometry, F A Davis, Philadelphia, 2nd edn, pages 76-79, 88-91. Pearson, S, Moraw, I and Maddern, G J (2000). ‘Clinical pathway management of total knee arthroplasty: A retrospective comparative study’, Australian and New Zealand Journal of Surgery, 70, 351-354. Potter, D (1998). ‘Managed care: A view from down under’, Nursing Management, 4, 11-13. Weidenhielm, L, Mattson, E, Brostrom, L A and Wersall-Robertsson, E (1993). ‘Effect of pre-operative physiotherapy in unicompartmental prosthetic knee replacement’, Scandinavian Journal of Rehabilitation Medicine, 25, 33-39.
Hughes, K, Kuffner, L and Dean, B (1993). ‘Effect of weekend physical therapy treatment on post-operative length of stay following total hip and total knee arthroplasty’, Physiotherapy Canada, 45, 245-249.
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Clinical Pathway for Hip and Knee Arthroplasty Summary The objective of this study was to evaluate the implementation of an early discharge programme for patients undergoing hip or knee arthroplasties. This paper examines outcomes pertinent to physiotherapy, and looks at patient movement and function for up to six months after surgery. A case management model of care using clinical pathways provided a means for physiotherapists working on an orthopaedic ward to optimise services and facilitate early patient discharge. Data were collected over a two-year period, with follow-up of 215 patients conducted at six weeks and three and six months after surgery. Data collected looked at length of stay based on day of surgery, range of movement and a timed ten-metre walk test. Results after implementation of the clinical pathway, in comparison to baseline measures, showed that length of stay was reduced, the day that surgery was performed did not affect length of stay, and all patients improved their range of movement and walking capabilities up to six months following surgery. It was concluded from this project that the implementation of clinical pathways enabled the orthopaedic ward to reduce elective joint replacement length of stay with the current physiotherapy service, without any detrimental long-term effects on patient function or movement.
Thomas, K (2003). ‘Clinical pathway for hip and knee arthroplasty’, Physiotherapy, 89, 10, 603-609.
Background and Purpose Osteo-arthritis commonly affects people over 65 years of age and is a major cause of pain and debility of hip and knee joints. Hip and knee arthroplasties are common elective joint procedures to reduce pain and improve function (Enloe et al, 1996; Martin et al, 1998). Hip arthroplasty may also be indicated in rheumatoid arthritis, avascular necrosis, hip fractures and arthritis associated with Paget’s disease (NIHCC, 1995). In Australia as well as the United Kingdom, managed care is in its infancy, with the main focus of healthcare delivery shifting from process to outcomes and ensuring a measurable quality of care is given to consumers (Hale, 1995; Potter, 1998). Organisations therefore recognise
603 Key Words Arthroplasty, clinical pathways, length of stay, physical therapy.
by Kelly Thomas
the need for restructuring the way care is delivered to their patients. In particular, with increasing economic constraints in health organisations, Nepean Hospital in Sydney, Australia, was looking for ways of reducing costs and using resources efficiently while still providing optimal patient care. A pilot project was conducted between July and October 1999 on people needing hip and knee arthroplasty. This study established that the current cost for hip arthroplasty at this hospital was $1,149 per day and for knee arthroplasty $1,080 per day, with average lengths of stay of 10 days for knee arthroplasty and 12 days for hip arthroplasty. Therefore, in October 1999 an early discharge project incorporating clinical pathways was implemented. The project targeted patients undergoing elective hip or knee arthroplasty, aiming to reduce length of stay without compromising patient outcomes. It was important after such an implementation that its effectiveness was evaluated. Before implementation of the early discharge programme and clinical pathways, patients were assessed ad hoc pre-operatively, often attending for tests on more than one occasion. Furthermore, there was no agreed order of or time interval between elements of care, and there was no structured system of physiotherapy intervention. Although patients were followed-up, they were not visited at home, but given outpatient appointments about two weeks after discharge. They were however instructed to continue with their exercises until reviewed at an outpatient appointment. A study by Mabrey et al (1997) examined the effect of introducing clinical pathways for total knee replacements and the effect on length of stay over a two-year period. Such an implementation resulted Physiotherapy October 2003/vol 89/no 10
604
in a reduction of length of stay from 11 ± 5 days to 5 ± 1 day which equated to hospital savings of 11% of the total cost of an episode of care. Similarly, a study by Pearson et al (2000) evaluated the implementation of clinical pathways for patients undergoing total knee arthroplasty. Their results showed that such an implementation significantly reduced length of stay from nine to seven days and improved streamlining of services, all without detrimental effects on patient outcomes. In contrast, Hughes et al (1993) and Mahoney et al (1985) found that to achieve a reduction in length of stay following arthroplasty, physiotherapy services had to include weekends. Hughes et al (1993) recognised a concern for patients undergoing their replacement on a Wednesday or Thursday who might therefore not receive consecutive physiotherapy due to the weekend interruption. By providing a weekend physiotherapy service they did reduce length of stay. However, these authors did not examine the use of clinical pathways as an alternative. The present study therefore sought to evaluate patient outcomes following hip and knee arthroplasty with emphasis on the examination of the role of physiotherapy. From the outset, it was recognised that the design did not permit inferences to be drawn about the efficacy of the clinical pathways relative to previous approaches to patient care. Rather, it was the primary objective of this study to carry out an initial empirical examination of this alternative management approach. In view of the paucity of such studies in the literature, this research sought to clarify the potential utility of clinical pathways. Methods Selection of Subjects The study ran from October 1999 to October 2001 and included 215 patients undergoing elective joint replacement. Patients were included if they lived in the local government area to ensure they received post-acute care – from the nursing and physiotherapy outreach ser vice. Thirty-three patients living outside this area were excluded from the study, although they were still casemanaged on a clinical pathway. Patients were also excluded if they had complications after surgery that required Physiotherapy October 2003/vol 89/no 10
a longer hospital stay, for example patients with low haemoglobin, wound ooze, constipation or nausea. The average age of patients undergoing a knee arthroplasty was 69 (SD 10) years, and for hip arthroplasty 67 (SD 12) years. Procedure Patients undergoing elective joint replacements were seen in the preadmission clinic for a full day of assessments before surgery. This included nursing, occupational therapy and specific physiotherapy assessments. Physiotherapy pre-admission data collected included joint range of motion, type of aid used to walk (if any) and time to walk ten metres. Range of movement was measured using universal goniometers, with all therapists standardising measurements as described by Norkin and White (1995). Knee movements were performed with the patients in sitting, and hip movements with the patients in supine (flexion and abduction) or sidelying (extension). Although in this study error attributable to differences between observers was not calculated, studies by Brosseau et al (1997, 2001) found good reliability when measurements were made by one observer on two or more occasions, and when different therapists measured joint angles using the universal goniometer. Pre-operatively patients were taught exercises by a physiotherapist and instructed in the use of walking aids. Patients were provided with information on early exercises and mobility training, and told that a physiotherapist would be involved with their care twice daily on the ward and once daily at home upon discharge. They were also asked to attend the outpatient physiotherapy department for regular appointments until their functional ability had been maximised. Pre-admission physiotherapy data were collected on an individual patient record sheet to be used later for further data collection. Patients were then admitted on their day of surgery and length of stay was calculated from day of surgery to discharge from the ward. Patients underwent surgery on Monday, Wednesday or Friday depending on their orthopaedic surgeon. Clinical pathways were used by the ward physiotherapists to co-ordinate physiotherapy services and a case manager co-
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ordinated the overall patient care. The project was approved by the Ethics and Research Committee of Wentworth Area Health Service. Physiotherapy The orthopaedic ward included the equivalent of two full-time physiotherapists who worked from Monday to Friday. If possible, patients were seen on the day of surgery to start deep breathing exercises, bed mobility and ankle dorsiflexion/plantarflexion exercises for circulation. Patients were then seen on the day after surgery for more bed exercises and, if the post-operative radiograph was satisfactory, they were helped to sit out of bed on this day. Patients were seen twice daily to perform their exercises, to walk and to practise using stairs. Hip arthroplasty exercises included: ■ Ankle dorsiflexion and plantarflexion ■ Isometric quadriceps ■ Isometric gluteals ■ Inner range quadriceps ■ Hip flexion and extension in supine ■ Knee flexion and extension in supine ■ Hip abduction in supine This progressed to hip flexion, extension and abduction in standing. Knee arthroplasty exercises included: Ankle dorsiflexion and plantarflexion Isometric quadriceps Isometric gluteals Inner range quadriceps Knee flexion and extension in sitting Hamstring stretches All patients also practised walking, stairs, transfers and correct weight bearing status. Depending on the surgeon, some patients were required not to walk with all their weight through their limb for up to six weeks. No weekend physiotherapy was provided and patients were deemed safe when they satisfied the discharge criteria of walking steadily safe with an aid and being able to use stairs safely. Each day a physiotherapist completed and signed the patient clinical pathway as to what the patient had achieved. Joint range was recorded, along with walking aid used and exercises per formed for the day. Any variations in exercise performance or ■ ■ ■ ■ ■ ■
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mobilisation were noted on the pathway. This enabled all staff to follow each patient’s progress, and co-ordinate their care. For example, nurses could view the pathway and observe for that day what aid the patient was using. The nursing staff could then reinforce the use of the aid when a patient walked to the bathroom or toilet. At day of discharge, final measures of range of movement, any walking aid required, timed walk over ten metres and an exercise programme were recorded on the individual patient record sheet that had been started in the pre-admission clinic. Following discharge, a physiotherapist attached to an outreach service reviewed patients daily or every other day for a period of two weeks. The outreach physiotherapist reviewed and progressed exercises, continued training of transfers and weight-bearing status, and helped the patients to practise walking and using stairs. At the end of these two weeks patients were then referred for outpatient physiotherapy with ongoing reviews at six weeks and three and six months. Data collected over this review period included joint range of motion (hip flexion, extension, abduction; knee extension active and passive, knee flexion), use of walking aid and a timed ten-metre walk. Data were again added to the individual patient record sheets. In conjunction with home visits by a physiotherapist after discharge, patients were seen daily for two weeks by nursing staff to assess and clean the wound as necessary. If required, patients were also provided with home care help for meals and self-care which was arranged before the patient was discharged from hospital. Data Analysis Data were analysed using the Statistical Package for Social Sciences (SPSS) version 10 for Windows. Analysis of variance was used to examine the effects of day of surgery on length of stay, and also the effects of day of surgery on patient outcomes (range of movement, walking aid, timed ten-metre walk) over the entire six-month period. Independent t-tests examined the effect of gender on all outcomes for all arthroplasties over the six-month data collection period. Independent t-tests were used to show further differences between the sexes at baseline for all outcome measures, for all
Author Kelly Thomas BMedSc BAppSc(physiotherapy) is a physiotherapist in private practice in Sydney, Australia. This study was conducted at the Nepean Hospital, Sydney, while she was employed as an orthopaedic outreach physiotherapist. Preliminary data were presented at the fifth annual Case Management Conference ‘Cohesion and Diversity?’ (New South Wales, Australia, February 2002). Final results were presented at the 13th Annual Australasian Association for Quality in Health Care (Queensland, Australia, June 2002). The project was funded by the National Demonstration Hospitals Project Phase 3 (Australia). Address for Correspondence Physiotherapy Department, Nepean Hospital, PO Box 63 Penrith, Sydney, Australia 2751. E-mail [email protected]
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Acknowledgements Thanks are due to the staff of the physiotherapy department at Nepean Hospital who helped with the data collection, particularly the outpatient staff and senior orthopaedic physiotherapist Anne Cavagnino; and also to Susan Patterson, Jennifer Smith and Ravy Thavaravy for their contributions to the project. Special appreciation is acknowledged to Michelle Moulds for her support and encouragement in the writing of this paper and help with the data analysis.
arthroplasties. Statistical significance for these tests was set at 5% (p < 0.05). Analysis of variance was also used to determine if any significant improvements were obtained in patient outcomes between the collection periods. Statistical significance was set again at 5% (p < 0.05) and Bonferroni correction was applied to post hoc analyses when primary analyses were significant. Only available data were entered into the analysis (ie not by intention to treat) and this is recognised as a limitation.
Results Patient Satisfaction A patient satisfaction survey was randomly distributed to 83 patients following discharge and was completed by 55 (response rate 66%), with 94% of patients happy with their episode of care, information they received throughout their hospital stay, and staff professionalism. Furthermore, 81% of patients indicated that at the time they were discharged they were ready to go home, with another 4% indicating they could have been discharged sooner, although a further 13% of patients would have preferred to stay longer in hospital – reasons given included that they enjoyed the rest and service being provided.
Table 1: Average length of stay for hip and knee arthroplasties Site of arthroplasty
Length of Stay With the implementation of this project, all patients undergoing arthroplasty attended the pre-admission clinic. One to two weeks later patients were admitted to the ward on their day of surgery and length of stay was calculated from this day until discharge. The average lengths of
Length of stay (days) Before clinical pathways
With clinical pathways
Knee
10
6
Hip
12
7
Table 2: Outcomes for hip arthroplasty: Mean (SD) range of hip movement, use of walking aid and time taken to walk 10 metres Function measured
Pre-admission (n = 89)
Discharge (n = 89)
6 weeks (n = 69)
After surgery 3 months (n = 65)
6 months (n = 56)
Flexion (°)
75 (18)
Abduction (°)
16 (10)
60 (16)
77 (13)
82 (11)
83 (11)
17
(9)
28
(8)
31 (10)
Extension (°)
–3
34 (8)
–5
(8)
4 (11)
8 (10)
10 (10)
Time to walk 10 metres (sec)
12 (11)
33 (20)
13 (11)
9 (4)
8 (3)
Walking aid (%) None Frame Crutches Walking stick
41 8 7 44
45 55
32 18 20 30
(9)
62 3 3 32
70
30
Table 3: Outcomes for knee arthroplasty: Mean (SD) range of knee movement, use of walking aid and time taken to walk 10 metres Function measured
Pre-admission (n = 126)
Flexion (°)
109 (17)
Active extension (°)
Discharge (n = 124)
77 (13) (8)
–8
(5)
After surgery 3 months (n = 86)
6 months (n = 70)
77 (13)
82 (11)
83 (11)
28
(8)
31 (10)
34 (8)
4 (11)
8 (10)
10 (10)
9 (3)
8 (3)
–8
(8)
Passive extension (°)
–4
(5)
Time to walk 10 metres (sec)
11 (11)
38 (25)
11
Walking aid (%) None Frame Crutches Walking stick
60 4 4 32
57 38 5
41 9 11 39
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–18
6 weeks (n = 103)
(7)
74 1 4 21
78 4 2 16
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stay for knee and hip arthroplasty are shown in table 1 and are compared to the sample before implementation of the project (n = 31, average age for knee arthroplasty 68 years, hip arthroplasty 67 years). Analysis of variance revealed no significant differences between length of stay and day of surgery for all arthroplasties (p > 0.05). That is, regardless of day of operation (or surgical team), length of stay was comparable. Outcome Measures Tables 2 and 3 summarise the average range of movement, walking aid usage and timed ten-metre walk over the data collection period. Analysis of variance showed significant improvements between each time-frame of data collection from discharge to six months for all patients across all variables (p < 0.05). That is, from discharge to six weeks, to three and six months after surgery, significant improvements in the measured variables were obtained. Effects of Day of Surgery Statistical analyses showed that outcomes at any particular review period were not significantly different whatever the day of operation (p > 0.05). For example, those undergoing surgery on Monday had no significantly better outcomes than those who had operations on a Wednesday or Friday. This was true for hip and knee arthroplasty and for any time period. Gender Effects Independent t-tests showed no significant differences at baseline on any outcome measures for hip arthroplasties (p > 0.05). However, by discharge until six months post-operatively, a significant difference was observed, with men performing the ten-metre walk on average two seconds faster than women (p < 0.05). For knee arthroplasty patients, independent t-tests indicated significant differences between males and females for the timed walk test at baseline (p < 0.05). There were no significant differences between the sexes at baseline for any other measures (p > 0.05). To account for the sex difference at baseline for the timed walk test for knee arthroplasty, further analysis of covariance was performed. Results showed that the men still walked significantly faster over the ten
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metres than women only at discharge (p < 0.05). No significant difference was observed between sex and length of stay for hip arthroplasty (p > 0.05); however, men undergoing knee arthroplasty were discharged significantly sooner than women (p < 0.05). Discussion Through the integration of services and the implementation of clinical pathways, a number of outcomes were achieved for patients undergoing a hip or knee arthroplasty in Nepean Hospital. Physiotherapy in conjunction with other services enabled a four-day reduction in length of stay after implementation of the project for knee arthroplasty, and five days for hip arthroplasty. This in turn equated to an increased turnover of patients through the hospital system and as such reduced waiting times and costs per patient. Interestingly, average lengths of stay in England for 2001/02 were 12 days for hip arthroplasty (average age 68 years) and 11 days for knee arthroplasty (average age 70 years) (DoH website), equivalent to the baseline values in this study. However, although patients were discharged sooner, with a more intense exercise programme during their hospital stay, patient satisfaction with overall care was good. The reductions in length of stay were achieved through co-ordinating patient care, particularly improving upon the physiotherapy service, which did not require an increase in provision across weekends as suggested by other authors who reduced length of stay by providing weekend physiotherapy (Hughes et al, 1993; Mahoney et al, 1985). Pearson et al (2000) found similar results to the present study with a reduced length of stay following implementation of clinical pathways. Day of surgery (and hence surgical team) did not appear to affect the outcome. Patients whose operations were on a Friday were discharged at similar times to those operated on earlier in the week. This may have been due to the use of the clinical pathways, whereby over the weekend when no physiotherapy was provided, nursing staff could refer to the physiotherapy comments on the pathway and continue to encourage functional independence in an appropriate way, Physiotherapy October 2003/vol 89/no 10
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ie using correct aid and weight bearing status. This emphasises the continuum of care provided to patients across all multidisciplinary areas. Physiotherapy care was co-ordinated from pre-admission to six months after surgery for all patients. Initially, patients were provided with information on their pending operation, post-operative care including home visits by a physiotherapist following discharge, and outpatient physiotherapy treatments and reviews over the six-month period. Studies have shown that single pre-operative education sessions may have a more beneficial cost/benefit ratio than prolonged programmes (D’Lima et al, 1996; Weidenhielm et al, 1993). Ward and outpatient physiotherapists communicated regularly after patient discharge to ensure optimal care. A panel consisting of 16 physical therapists, one physician and two nurses all with expertise on hip and knee arthroplasty (Enloe et al, 1996) recommended physiotherapy twice a day postoperatively, five days a week; and daily for two weeks after discharge. Early mobilisation of patients was encouraged. These authors also endorsed the exercises and other training as provided in this project. These findings overall are in accordance with the results of our present study. Results shown in tables 2 and 3 show maximal gains are achieved and maintained in the first six months after surgery with average range of movements tending to plateau by three to six months, with hip flexion within the safe allowable range. By six months 100% of hip arthroplasty and 94% of knee arthroplasty patients were walking unaided or using only a stick. Anouchi et al (1996) found that no significant range of movement improvements occur in knee arthroplasty beyond the first year. They also found that range of movement of knee arthroplasty is an important measurement of outcome with a finding of a functional range of around 100° to 110°. This range is adequate for most activities of daily living and was achieved in the present study. Interestingly, significant gender effects were noted from this study. After hip arthroplasty from discharge to six months after surgery, and at discharge only after knee arthroplasty, men walked two seconds faster than women over ten Physiotherapy October 2003/vol 89/no 10
metres. Kreibich et al (1996) believe some patients tend to over-perform when postoperative functional tests such as walking are carried out. Bohannon (1997) found that gait speed reduces in older, shorter people with less lower extremity muscle strength. This may explain the gender results in walking outcomes, with men possibly still having stronger leg muscles than women even at an older age. With regard to length of stay no differences were observed between the sexes for hip arthroplasty, but with knee arthroplasty men were discharged one day earlier than women. Hughes et al (1993) similarly found that males tended to have a shorter post-operative length of stay. Since length of stay in acute hospitals has progressively shortened, more emphasis is placed on pre-admission educational and assessment programmes, appropriate and co-ordinated physiotherapy care, and rehabilitation both during and after in-patient care (NIHCC, 1995). Some patients could not be followedup due to difficulty encountered in contacting them at each review period, particularly at six months. Some also declined to attend or had moved out of the area, or had difficulty in keeping an appointment, for example because of transport problems. A further limitation of the present study included the lack of quality of life outcome measures. This study was conducted in conjunction with one undertaken by nursing staff that did address some quality of life issues and pain measures before and after surgery. However, at the time of writing, conclusive data were not available. The influence of age, as well as presurgical status of patients, may impact on length of stay as well as long-term outcomes. Further work on these variables and the role of a pre-operative programme on long-term outcomes is indicated. This study used clinical pathways and physiotherapy during the working week to reduce length of stay while aiming to provide optimal patient care. Further study is needed to determine whether the introduction of physiotherapy over weekends would provide further benefit. In sum, this research offers a preliminary indication of the effectiveness of the clinical pathways approach to the management of orthopaedic patients. It is
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acknowledged that conclusions about the relative efficacy of this model of care as compared to standard treatment procedures can be only tentative. Conclusion This project enabled current services to be improved so that a significant reduction in length of patient stay was References Anouchi, Y S, McShane, M, Kelly, F, Elting, J and Stiehl, J (1996). ‘Range of motion in total knee replacement’, Clinical Orthopaedics and Related Research, 331, 87-92. Bohannon, R W (1997). ‘Comfortable and maximum walking speed of adults aged 20-79 years: Reference values and determinants’, Age and Ageing, 26, 15-19. Brosseau, L, Touisignant, M, Budd, J, Chartier, N, Duciaume, L, Plamondon, S, O’Sullivan, J P, O’Donoghue, S and Balmer, S (1997). ‘Intra-tester and inter-tester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects’, Physiotherapy Research International, 2, 150-166. Brosseau, L, Balmer, S, Touisignant, M, O’Sullivan, J P, Goudreault, C, Goudreault, M and Gringras, S (2001). ‘Intra- and inter-tester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with knee restrictions’, Archives of Physical Medicine and Rehabilitation, 82, 396-402. Department of Health website www.doh.gov.uk/hes D’Lima, D D, Colwell, C W, Morris, B A, Hardwick, M E and Kozin, F (1996). ‘The effect of pre-operative exercise on total knee replacement outcomes’, Clinical Orthopaedics and Related Research, 326, 174-182. Enloe, L J, Shields, R K, Smith, K, Leo, K and Miller, B (1996). ‘Total hip and knee replacement treatment programmes: A report using consensus’, Journal of Orthopaedic and Sports Physical Therapy, 23, 3-11. Hale, C (1995). ‘Case management and managed care’, Nursing Standard, 9, 33-35.
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achieved, without any detrimental effect on joint range and functional ability by six months after surgery. The use of the preadmission clinic, day of surgery admission, co-ordinated physiotherapy care on the ward via clinical pathways, and post-acute physiotherapy care at home upon discharge enabled these clinical outcomes to be achieved. Kreibich, D N, Bourne, R B, Rorabeck, C H, Kim, P, Hardie, R, Kramer, J and Kirkley, A (1996). ‘What is the best way of assessing outcome after total knee replacement?’ Clinical Orthopaedics and Related Research, 331, 221-225. Mabrey, J D, Toohey, J S, Armstrong, D A, Lavery, L and Wammack, L A (1997). ‘Clinical pathway management of total knee arthroplasty’, Clinical Orthopaedics and Related Research, 345, 125-133. Mahoney, P, Dinnan, E and Zeleznik, R (1985). ‘The impact of prospective payment on clinical practice: Total hip replacement’, Physical Therapy, 65, 711-713.
Key Messages ■ Clinical pathways facilitate earlier patient discharge following arthroplasty. ■ Reduction in length of stay does not necessarily result in a poorer outcome. ■ If hospital stay is shortened, more emphasis needs to be placed on education and care before admission and after discharge. ■ Further research is indicated in this area.
Martin, S C, Scott, R D and Thornhill, T S (1998). ‘Current concepts of total knee arthroplasty’, Journal of Orthopaedic and Sports Physical Therapy, 28, 252- 261. National Institute of Health Consensus Conference (NIHCC) (1995). ‘Total hip replacement’, Journal of the American Medical Association, 273, 1950-56. Norkin, C C and White, D J (1995). Measurement of Joint Motion: A guide to goniometry, F A Davis, Philadelphia, 2nd edn, pages 76-79, 88-91. Pearson, S, Moraw, I and Maddern, G J (2000). ‘Clinical pathway management of total knee arthroplasty: A retrospective comparative study’, Australian and New Zealand Journal of Surgery, 70, 351-354. Potter, D (1998). ‘Managed care: A view from down under’, Nursing Management, 4, 11-13. Weidenhielm, L, Mattson, E, Brostrom, L A and Wersall-Robertsson, E (1993). ‘Effect of pre-operative physiotherapy in unicompartmental prosthetic knee replacement’, Scandinavian Journal of Rehabilitation Medicine, 25, 33-39.
Hughes, K, Kuffner, L and Dean, B (1993). ‘Effect of weekend physical therapy treatment on post-operative length of stay following total hip and total knee arthroplasty’, Physiotherapy Canada, 45, 245-249.
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