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Effect of Immediate Postoperative Physical Therapy on Length of Stay for Total Joint Arthroplasty Patients
The Journal of Arthroplasty Vol. 27 No. 6 2012
Effect of Immediate Postoperative Physical Therapy on Length of Stay for Total Joint Arthroplasty Patients Antonia F. Chen, MD, MBA,* Melissa K. Stewart, MD,y Alma E. Heyl, LAS, RTR, CCRC,* and Brian A. Klatt, MD*
Abstract: The isolated effect of physical therapy (PT) on total joint arthroplasty hospital length of stay (LOS) has not been studied. A prospective cohort study was conducted on 136 primary total joint arthroplasties (58 hips, 78 knees). The LOS was determined by the operative start time until the time of discharge. On postoperative day (POD) 0, 60 joints remained in bed, 51 moved to a chair, and 25 received PT (22 ambulated, 3 moved to a chair). Length of stay differed for patients receiving PT on POD 0 (2.8 ± 0.8 days) compared with POD 1 (3.7 ± 1.8 days) (P = .02). There was no difference in PT treatment based on nausea/vomiting, pain levels, or discharge location. Isolated PT intervention on POD 0 shortened hospital LOS, regardless of the intervention performed. Keywords: physical therapy, day of surgery, total joint arthroplasty, length of stay, rehabilitation. © 2012 Elsevier Inc. All rights reserved.
The number of total joint arthroplasties (TJAs) performed each year in the United States is steadily increasing [1,2]. Given the prevalence of arthroplasties performed, many measures have been implemented to improve patient outcomes by increasing functionality, improving range of motion (ROM), decreasing pain, and decreasing the duration of hospital stay. A previous study demonstrated that instituting earlier inpatient rehabilitation after total knee arthroplasty (TKA) or total hip arthroplasty (THA) resulted in shorter hospital length of stay (LOS), improved short-term functional outcomes, and decreased costs [3]. Decreasing the LOS has also been shown to increase quality of life and reduce costs [4]. Thus, it is desirable to implement programs that prepare patients for earlier discharges. Studies have shown improved patient outcomes and reduced LOS using a multimodality approach, also called
From the *Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and yUniversity of Pittsburgh Medical School, Pittsburgh, Pennsylvania. Submitted June 8, 2011; accepted January 15, 2012. None of the authors listed above have a financial interest in this study. All authors have full control of all primary data, and the journal may review our data if requested. The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2012.01.011. Reprint requests: Brian A. Klatt, MD, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 5230 Centre Avenue, Suite 415, Pittsburgh, PA 15232. © 2012 Elsevier Inc. All rights reserved. 0883-5403/2706-0005$36.00/0 doi:10.1016/j.arth.2012.01.011
rapid recovery protocols or accelerated perioperative care. These approaches include the use of preoperative consultation and intervention, multiple modalities of perioperative analgesia, and aggressive rehabilitation protocols [5,6]. Many of these studies have created entire centers specifically for the care of arthroplasty patients, with specially trained staff and therapists [7-9]. Although these pathways are very effective at reducing hospital LOS, many hospitals do not have the resources to implement all recommended modalities. Furthermore, this approach does not isolate each specific protocol and makes research into the impact of reducing hospital LOS within each modality impossible. There is interest to study the protocols individually so that the protocols with the greatest impact can be used to optimize patient outcomes. In a cost-aware system, hospitals may not wish to allocate resources to immediate physical therapy (PT) because this increases expenses to the day of surgery costs. Some work has been done to study the effect of specific rehabilitation protocols on patient outcomes. A recent randomized controlled trial from Spain demonstrated that PT performed within 24 hours of primary TKAs resulted in a shorter hospital stay, less rehabilitation sessions, less pain, greater ROM, improved quadriceps and hamstring strength, and improved gait and balance [10]. Aggressive preoperative rehabilitation, perioperative PT and continuous passive motion, and postoperative home exercises have also been shown to shorten recovery, increase ROM, and decrease hospital stay in TKA and THA [11].
851
852 The Journal of Arthroplasty Vol. 27 No. 6 June 2012 There have been few studies exclusively dedicated to studying PT interventions on the day of surgery. Implementing a total joint initiative is expensive, and we desired to show that instituting rehabilitation on the day of surgery would be beneficial so that hospitals with limited funding could concentrate their efforts on funding immediate PT sessions. In this study, we measured the effect of rehabilitation in the early postoperative period on hospital LOS. Our hypothesis was that early rehabilitation alone on the day of surgery could shorten the hospital LOS, regardless of other interventions.
Methods and Materials A prospective cohort study was conducted on 128 consecutive patients who underwent 136 primary and elective TJAs performed by a single surgeon (BK). Data were gathered on all patients who underwent operative management from September 2008 to September 2009. There was 1 death in the study population. All revisions and infections were excluded from this study. Institutional review board approval was obtained before performing this study. Sample Size Sample size was determined by assuming a type I error rate set at 5% and the power of detecting a true difference set at 80%. The calculation was adjusted based on Bonferroni correction for 2 comparisons. Assuming that outcome measurements could be obtained on all patients and assuming that patients were equally allocated to each group, there needed to be a minimum of 25 patients in each group to detect a difference of 1 day LOS in at least 2 groups. Patient Data Patient demographic and surgical data were collected for all patients, including age, gender, body mass index (BMI), diagnosis, joint (hip or knee), side (left or right), American Society of Anesthesiology (ASA) score, comorbidities, home status, and the use of assistive devices before surgery. The patient population consisted of 53 men (41.4%) and 75 women (58.6%), with an average age of 62.3 years (range, 30-95 years). There were 58 THAs (42.6%) and 78 TKAs (57.4%). There were an equal number of right and left prostheses
(68 right, 68 left). All patients lived at home by themselves and were ambulatory before surgery, with 41 (30.1%) patients who ambulated without assistive devices and 95 (69.9%) who required assistive devices, including crutches, canes, and walkers. There were no statistically significant differences between patients who did and did not receive PT with regard to demographic, medical, and surgical data, including gender, age, BMI, procedure performed, laterality, ASA, and the use of assistive devices before surgery (Table 1). All patients were admitted to the hospital on the day of surgery. There was no special preoperative education session that instructed patients about postoperative rehabilitation, but all patients were told that they would be ambulating before discharge. There was no preselection of younger patients or patients with less comorbidities. Patients were not permitted to select the time of day that their case was performed. Patients who underwent a THA received a modified anterolateral gluteus medius–splitting approach to the hip in the supine position [12], where the abductor muscles were reattached at the end of each surgery. Patients who underwent TKAs received quadriceps-splitting medial parapatellar approaches; there were no quadricepssparing approaches performed. The operative times were recorded; the admission time was recorded for when the patient entered the operating room, and a late operative time was defined as an end time after 15:00. Anesthesia was also recorded as spinal anesthesia or general endotracheal anesthesia. After surgery, all patients were first transferred to the postanesthesia care unit (PACU) and secondly to the floor for inpatient care. The time in PACU and the time of discharge from the PACU were recorded for each patient. Postoperative day (POD) 0 was defined as the same day of surgery. There were no standardized criteria by which patients were selected for participation in rehabilitation with physical therapists. Patient selection for POD 0 rehabilitation was dependent on timing and staff availability. No rehabilitation protocol was adjusted based on surgical approach, and all patients were weight bearing as tolerated. Total hip arthroplasty patients had no precautions or restrictions for rehabilitation. Total knee arthroplasty patients started continuous passive
Table 1. Demographic, Medical, and Surgical Data Did Not Differ Between Patients Who Received PT on POD 0 Compared With Patients Who Received Their First Therapy Session on POD 1
Age (y)
BMI (kg/m2)
Assistive Device Used Before Surgery
ASA Sore
THA
TKA
64.1 ± 11.0 62.3 ± 11.1 58.0 ± 9.4 .15
31.4 ± 6.6 33.1 ± 7.3 31.1 ± 6.8 .38
40 37 18 .77
2.7 ± 0.6 2.7 ± 0.5 2.6 ± 0.6 .85
19 25 14
41 26 11
Gender
POD 1—in bed POD 1—out of bed POD 0 PT P value
No. of Patients
No. of Joints
Male
Female
57 47 24
60 51 25
24 19 10
33 28 14 .81
Joint
.06
Immediate Physical Therapy Reduces LOS After TJA Chen et al
853
Elective Total Joint Arthroplasties (N = 136)
Post-operative Day 0 Physical Therapy (n = 25)
No Post-operative Day 0 Physical Therapy (n = 111)
Remained in Bed (n = 60)
Out of Bed to Chair (n = 51)
Out of Bed and Ambulating (n = 22)
Out of Bed to Chair (n = 3)
Fig. 1. Study design examining the isolated effect of immediate postoperative PT on hospital LOS in elective TJAs.
Discharge Criteria Patients were discharged when they had met all the following discharge criteria, regardless of rehabilitation intervention: (1) out of bed and ambulating a minimum of 100 ft, (2) could walk up and down stairs, (3) minimal drainage from the incision site, (4) adequate pain control
using oral pain medications, (5) tolerating a regular diet without nausea and vomiting, and (6) approval from PT with an understanding of the home exercise program. Patients were discharged either to home, to a skilled nursing facility (SNF), or to a rehabilitation facility. The LOS was determined as the length of time in the hospital from admission (operative start time) to the actual time of discharge. A second LOS was calculated from the time of discharge from the PACU to the actual time of discharge. These were measured in hours and were calculated to prevent overestimating of the LOS if a patient was a later operative case. Statistical Methods Statistical analysis for categorical variables was performed by χ 2 tests. Continuous variables were analyzed using 1-way analysis of variance. Statistical significance was defined as a P value of less than .05. All statistical analysis was performed using Predictive Analytics Software Statistics (PASW) version 18.0 (SPSS, Chicago, Ill).
Results Patients who received PT on POD 0 were compared with patients who received PT on POD 1 (Fig. 2). Using the operative start time to determine LOS, patients who received therapy on POD 0 stayed an average of 2.81 ± 0.77 days, and those who received therapy on POD 1
P = .02
POD 0 PT No POD 0 PT
6 Length of Stay (Days)
motion on the day of surgery from 0° to 90°, and they did not use knee immobilizers. Rehabilitation for hips and knees included isometric gluteus, quadriceps, hamstring, and hip adduction muscle sets. Active and active assisted ROM exercises were also initiated, including short-arc quadriceps ROM, long-arc quadriceps ROM, straight leg rises, hip abduction, ankle pumps, and heel slides. Finally, transfers, gait training, and activities of daily living exercises were implemented. Rehabilitation data were collected from the first therapy session, either on POD 0 or 1. The following data points were recorded: activity performed and the distance covered if the patient was able to ambulate. The primary end point of PT on the first session was to encourage patients to get out of bed and ambulate. Strengthening exercises were initiated on POD 1. However, if the patient was unable to ambulate, the patient received limited PT and was moved from bed to chair. Patients who received POD 0 PT were compared with patients who received PT on POD 1. The study design is depicted in Fig. 1, depicting that patients either ambulated, got out of bed to a chair, or remained in bed. On POD 0, 60 joints remained in bed, 51 joints got out of bed to a chair without PT, and 25 joints received PT. Of the 25 joints that received PT, 22 joints ambulated and 3 joints got out of bed to a chair. The 111 joints that remained in bed or got out of bed to a chair on POD 0 received PT on POD 1. Fourteen hip (24%) and 11 knee (14%) arthroplasties received POD 0 PT, and 44 THAs (76%) and 67 TKAs (67%) received PT on POD 1. Factors that could affect PT intervention were recorded. Antiemetic and analgesia regimens were recorded. Pain scores were recorded based on the 0 to 10 visual analog scale, where 0 was no pain and 10 was maximum pain. Hemoglobin, hematocrit, and tolerance of a regular diet were also recorded upon inpatient admission.
5 4 3 2 1 0 Overall Out of bed Ambulating Overall no Out of bed Remain in bed POD 0 PT to chair with POD 0 PT to chair with PT nurse
Fig. 2. Hospital LOS was shorter for patients who receive PT on POD 0 compared with patients who did not receive therapy on POD 0.
854 The Journal of Arthroplasty Vol. 27 No. 6 June 2012 Table 2. Factors Associated With PT Timing Physical Therapy LOS Comorbidities Anesthesia Spinal General endotracheal anesthesia Operative time Late operative end time Pain level Antiemetics Analgesia Hemoglobin level Hematocrit Regular diet Physical therapy distance ambulated first session
POD 0
POD 1
P
2.81 d 4.36 comorbidities
3.79 d 4.09 comorbidities
.019 * .761 .578
20 joints (80.0%) 5 joints (20.0%) 1 h and 25 min 0 joints (0%) 4.64 / 10 0.64 medications 4.96 medications 11.3 g/dL 33.1% 20 joints (80.0%) 18.7 ft
97 joints (87.4%) 14 joints (12.6%) 1 h and 32 min 21 joints (18.9%) 4.75 / 10 0.81 medications 4.7 medications 11.1 g/dL 32.6% 93 joints (83.8%) 37.4 ft
.398 .001 * .949 .470 .573 .788 .871 .608 .012 *
Postoperative day 0 PT intervention demonstrated significantly lower LOS. Postoperative day 1 PT had later operative times and ambulated longer distances during the first PT session. * Statistically significant.
stayed an average of 3.79 ± 1.74q days. The LOS was statistically significantly different between groups (P = .02). The statistical significance remained the same for hospital LOS when calculated from the time of discharge from the PACU (POD 0, 2.57 ± 0.77 days; POD 1, 3.52 ± 1.78 days; P = .02). Patients who received PT on POD 0 and were out of bed to a chair stayed an average 2.86 ± 0.58 days, and those who were ambulating with physical therapists on POD 0 stayed an average of 2.80 ± 0.81 days. Patients who did not receive POD 0 PT and remained in bed stayed an average of 3.76 ± 1.76 days. For patients who were out of bed to a chair on POD 0 without PT intervention, the average LOS was 3.56 ± 1.66 days. All patients who received PT on POD 0 got out of bed, whereas none of the remaining patients ambulated on POD 0. As for timing, all patients who received therapy on POD 0 were out of the operating room by 15:00, whereas 90 (81.1%) of 111 joints that received POD 1 PT were out of the operating room by 15:00. No patients who received POD 0 PT were out of the operating room later than 15:00, whereas 21 (18.9%) of 111 joints that received therapy on POD 1 were out of the operating room after 15:00. This difference was statistically significant (P = .02). The time in the PACU was not significantly different between groups (POD 0 PT, 254.3 ± 81.2 minutes; POD 1 PT, 265.8 ± 109.9 minutes; P = .62). The distance ambulated during the first PT session was statistically significantly higher for those who received PT on POD 1 (37.7 ft) compared with POD 0 (18.7 ft) (P = .02). However, patients who had worked with PT on POD 0 ambulated an average of 62.9 ft on POD 1 during their second session of PT. The remainder of factors, including preoperative narcotic medication, number of comorbidities, anesthesia, operative time, pain level on POD 0, number of
antiemetics used, amount of postoperative analgesia medication used, hemoglobin, hematocrit, and regular diet, were not significantly associated with PT on POD 0 (Table 2). There was no significant difference between discharge location and the timing of PT (P = .19). Of the patients who receive POD 0 therapy, 22 (88.0%) were discharged to home, 2 (8.0%) were discharge to a SNF, and 1 (4.0%) was discharged to a rehabilitation facility. For patients who received POD 1 therapy, 78 (70.3%) were discharged to home, 22 (19.8%) were discharged to an SNF, and 11 (9.9%) were discharged to a rehabilitation facility.
Discussion Perioperative rehabilitation, in combination with multimodality analgesia regimens and perioperative education, has been shown to decrease the hospital LOS for patients who undergo TJAs. However, few studies have isolated the effect of early postoperative rehabilitation on hospital LOS. The purpose of our study was to determine if immediate PT intervention on the operative day decreased hospital stay and if any factors affected early rehabilitation. Our study confirms our hypothesis and demonstrates that patients who receive PT on postoperative 0 have statistically significantly shorter hospital stays. Our study indicates that PT intervention alone decreases hospital LOS, regardless of the intervention performed. Patients who are out of bed to a chair with the assistance of PT have shorter stays than those who are out of bed to a chair with floor nurses who do not receive immediate PT. However, no statistical analysis could be performed between these groups given the small sample size. This may be because physical therapists motivate patients and affirm that patients should expect to ambulate with full weight immediately after surgery. After achieving 1
Immediate Physical Therapy Reduces LOS After TJA Chen et al
goal of getting patients out of bed to a chair, physical therapists return the next day with the next goal of ambulating with the patient. Patients who receive PT on the day after surgery may not have the same expectation because they did not work with a physical therapist on the day of surgery. Our study also found that patients are more likely to receive PT on the day of surgery if they complete surgery before 15:00, which indicates that adjusting surgical and PT schedules may be beneficial for decreasing hospital LOS. However, not all patients who were operated on before 15:00 received PT on the day of surgery. In addition, our results demonstrate that patients ambulated shorter distances at their first PT session on the day of surgery, but they were discharged earlier than the comparison group that received therapy on POD 1. This finding highlights the importance of instituting immediate postoperative PT because the distance ambulated during the first PT session did not correlate with the discharge date. In addition, instituting POD 0 rehabilitation resulted in a significant improvement in ambulation distance during their second PT session conducted on POD 1. Decreasing the hospital LOS also decreases hospital costs. The historical cost savings of discharging a patient on hospital day 3 (POD 2) instead of hospital day 4 (POD 3) is $454 [13].Our institution regularly performs over 1000 TJAs annually for an estimated cost savings of $454 000 per year. The results of this study correlate with other studies that have demonstrated that TJA patients benefit from rehabilitation immediately after surgery [10]. Although this finding is not surprising, our study did note that the act of receiving PT regardless of activity performed may shorten the hospital LOS. Previous studies have demonstrated that the hospital LOS may be increased by increased age, ASA class, incision length, and operative time [14]. Our study demonstrated that PT intervention was not dependent on other factors, such as comorbidities, age, BMI, or ASA. Our study also demonstrated that other factors, such as pain or nausea/vomiting, did not affect PT intervention. The main strength of this study is that it isolates the single factor of rehabilitation in the immediate postoperative period as a method of decreasing LOS. Although multimodality approaches should be implemented in conjunction with rehabilitation intervention, rehabilitation alone may shorten the duration of hospital stay. This study highlights the benefit of PT and the potential cost savings of earlier discharges. Assuming 2 sessions of daily PT, implementing 1 earlier session of PT on the day of surgery may decrease the overall number of PT sessions, as was demonstrated by Labraca et al [10]. Implementing these changes may save on resources and allow for PT sessions for other patients. Another strength of this study is that data were collected during the same
855
period, which ensured that all patients were treated equally with regard to other modalities. Finally, patients were not preselected or targeted to receive immediate postoperative PT. There are some limitations to this study. First, the study would have been strengthened if hip and knee patients were separated into different patient cohorts. Second, although this was a prospective study, true randomization of POD 0 rehabilitation would have strengthened the results of this study. Third, measuring hospital LOS as a primary outcome is informative, but it would have been beneficial to also assess the results of patient outcomes, including function and ROM. Fourth, there are multiple confounding factors besides PT that can affect hospital LOS. We attempted to control for these other factors, as we looked at age, gender, medical comorbidities, pain, hemoglobin/hematocrit, and diet. However, patients who ambulated with PT on POD 0 may have been more motivated than other patients, which may have resulted in shorter hospital stays. Physical therapists also have different personalities, and a more positive physical therapist may have a greater effect on motivating patients. Fifth, some patients may have selected an operative date specifically so that their case would be earlier in the day, which would result in a higher likelihood of getting PT on the operative day. These patients may have been more motivated and may have resulted in shorter hospital LOS. Finally, adverse events caused by early discharge were not studied. Future work will involve tracking complications and readmissions of this patient population after discharge from our facility and evaluating the improvement in patient care from specific rehabilitation methods. Overall, this study suggests that early rehabilitation and patient mobilization on the date of surgery is important to decrease the time of hospital admission. This study further demonstrated that limited PT may be of value because patients who were only out of bed to a chair with PT had shorter hospital stays than those who were out of bed to a chair without PT intervention. If resources are available, rehabilitation protocols should be initiated on the day of surgery regardless of when the patient comes out of the operating room. This emphasizes the need for faster and earlier patient recovery so that they may receive immediate postoperative PT to facilitate earlier discharges. Future longitudinal studies are needed to assess if limited PT affect patients' longterm outcomes and functionality.
Acknowledgments The authors wish to thank Alvaro Sanchez-Ortiz for assistance with statistical analysis. We would also like to thank Brooke Gilliland, Gina Rose, and Courtney Dube for physical and occupational therapy assistance. We
856 The Journal of Arthroplasty Vol. 27 No. 6 June 2012 truly appreciate the hard work and effort of the PT staff, the nursing staff, and the hospital staff.
References 1. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg [Am] 2007;89:780. 2. Fehring TK, Odum SM, Troyer JL, et al. Joint Replacement Access in 2016: a supply side crisis. J Arthroplasty 2010 [Epub ahead of print]. 3. Munin MC, Rudy TE, Glynn NW, et al. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA 1998;279:847. 4. Larsen K, Hansen TB, Thomsen PB, et al. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg [Am] 2009;91:761. 5. Berend KR, Lombardi Jr AV, Mallory TH. Rapid recovery protocol forperi-operative care of total hip and total knee arthroplasty patients. Surg Technol Int 2004;13:239. 6. Berger RA, Sanders SA, Thill ES, et al. Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients. Clin Orthop Relat Res 2009;467:1424. 7. Larsen K, Sørensen OG, Hansen TB, et al. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up. Acta Orthop 2008;79:149.
8. Larsen K, Hvass KE, Hansen TB, et al. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247patients with a 3-month follow-up. BMC Musculoskelet Disord 2008;9:59. 9. Husted H, Hansen HC, Holm G, et al. What determines length of stay after total hip and knee arthroplasty? A nationwide study in Denmark. Arch Orthop Trauma Surg 2010;130:263. 10. Labraca NS, Castro-Sánchez AM, Matarán-Peñarrocha GA, et al. Benefits of starting rehabilitation within 24 hours of primary total knee arthroplasty: randomized clinical trial. Clin Rehabil 2011 [Epub ahead of print]. 11. Lenssen AF, de Bie RA. Role of physiotherapy in perioperative management intotal knee and hip surgery. Injury 2006;37(Suppl 5):S41. 12. Klatt BA, Sharkey PF. Mini lateral approach THA—the anterolateral approach—(modified Hardinge). In: Brown TE, Cui Q, Mihalko WM, Saleh K, editors. Arthritis and Arthroplasty: The Hip. Philadelphia: Saunders; 2009. p. 211. 13. Healy WL, Iorio R, Richards JA, et al. Opportunities for control of hospital costs for total joint arthroplasty after initial cost containment. J Arthroplasty 1998;13: 504. 14. Foote J, Panchoo K, Blair P, et al. Length of stay following primary total hip replacement. Ann R Coll Surg Engl 2009; 91:500.
Effect of Immediate Postoperative Physical Therapy on Length of Stay for Total Joint Arthroplasty Patients Antonia F. Chen, MD, MBA,* Melissa K. Stewart, MD,y Alma E. Heyl, LAS, RTR, CCRC,* and Brian A. Klatt, MD*
Abstract: The isolated effect of physical therapy (PT) on total joint arthroplasty hospital length of stay (LOS) has not been studied. A prospective cohort study was conducted on 136 primary total joint arthroplasties (58 hips, 78 knees). The LOS was determined by the operative start time until the time of discharge. On postoperative day (POD) 0, 60 joints remained in bed, 51 moved to a chair, and 25 received PT (22 ambulated, 3 moved to a chair). Length of stay differed for patients receiving PT on POD 0 (2.8 ± 0.8 days) compared with POD 1 (3.7 ± 1.8 days) (P = .02). There was no difference in PT treatment based on nausea/vomiting, pain levels, or discharge location. Isolated PT intervention on POD 0 shortened hospital LOS, regardless of the intervention performed. Keywords: physical therapy, day of surgery, total joint arthroplasty, length of stay, rehabilitation. © 2012 Elsevier Inc. All rights reserved.
The number of total joint arthroplasties (TJAs) performed each year in the United States is steadily increasing [1,2]. Given the prevalence of arthroplasties performed, many measures have been implemented to improve patient outcomes by increasing functionality, improving range of motion (ROM), decreasing pain, and decreasing the duration of hospital stay. A previous study demonstrated that instituting earlier inpatient rehabilitation after total knee arthroplasty (TKA) or total hip arthroplasty (THA) resulted in shorter hospital length of stay (LOS), improved short-term functional outcomes, and decreased costs [3]. Decreasing the LOS has also been shown to increase quality of life and reduce costs [4]. Thus, it is desirable to implement programs that prepare patients for earlier discharges. Studies have shown improved patient outcomes and reduced LOS using a multimodality approach, also called
From the *Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and yUniversity of Pittsburgh Medical School, Pittsburgh, Pennsylvania. Submitted June 8, 2011; accepted January 15, 2012. None of the authors listed above have a financial interest in this study. All authors have full control of all primary data, and the journal may review our data if requested. The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2012.01.011. Reprint requests: Brian A. Klatt, MD, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 5230 Centre Avenue, Suite 415, Pittsburgh, PA 15232. © 2012 Elsevier Inc. All rights reserved. 0883-5403/2706-0005$36.00/0 doi:10.1016/j.arth.2012.01.011
rapid recovery protocols or accelerated perioperative care. These approaches include the use of preoperative consultation and intervention, multiple modalities of perioperative analgesia, and aggressive rehabilitation protocols [5,6]. Many of these studies have created entire centers specifically for the care of arthroplasty patients, with specially trained staff and therapists [7-9]. Although these pathways are very effective at reducing hospital LOS, many hospitals do not have the resources to implement all recommended modalities. Furthermore, this approach does not isolate each specific protocol and makes research into the impact of reducing hospital LOS within each modality impossible. There is interest to study the protocols individually so that the protocols with the greatest impact can be used to optimize patient outcomes. In a cost-aware system, hospitals may not wish to allocate resources to immediate physical therapy (PT) because this increases expenses to the day of surgery costs. Some work has been done to study the effect of specific rehabilitation protocols on patient outcomes. A recent randomized controlled trial from Spain demonstrated that PT performed within 24 hours of primary TKAs resulted in a shorter hospital stay, less rehabilitation sessions, less pain, greater ROM, improved quadriceps and hamstring strength, and improved gait and balance [10]. Aggressive preoperative rehabilitation, perioperative PT and continuous passive motion, and postoperative home exercises have also been shown to shorten recovery, increase ROM, and decrease hospital stay in TKA and THA [11].
851
852 The Journal of Arthroplasty Vol. 27 No. 6 June 2012 There have been few studies exclusively dedicated to studying PT interventions on the day of surgery. Implementing a total joint initiative is expensive, and we desired to show that instituting rehabilitation on the day of surgery would be beneficial so that hospitals with limited funding could concentrate their efforts on funding immediate PT sessions. In this study, we measured the effect of rehabilitation in the early postoperative period on hospital LOS. Our hypothesis was that early rehabilitation alone on the day of surgery could shorten the hospital LOS, regardless of other interventions.
Methods and Materials A prospective cohort study was conducted on 128 consecutive patients who underwent 136 primary and elective TJAs performed by a single surgeon (BK). Data were gathered on all patients who underwent operative management from September 2008 to September 2009. There was 1 death in the study population. All revisions and infections were excluded from this study. Institutional review board approval was obtained before performing this study. Sample Size Sample size was determined by assuming a type I error rate set at 5% and the power of detecting a true difference set at 80%. The calculation was adjusted based on Bonferroni correction for 2 comparisons. Assuming that outcome measurements could be obtained on all patients and assuming that patients were equally allocated to each group, there needed to be a minimum of 25 patients in each group to detect a difference of 1 day LOS in at least 2 groups. Patient Data Patient demographic and surgical data were collected for all patients, including age, gender, body mass index (BMI), diagnosis, joint (hip or knee), side (left or right), American Society of Anesthesiology (ASA) score, comorbidities, home status, and the use of assistive devices before surgery. The patient population consisted of 53 men (41.4%) and 75 women (58.6%), with an average age of 62.3 years (range, 30-95 years). There were 58 THAs (42.6%) and 78 TKAs (57.4%). There were an equal number of right and left prostheses
(68 right, 68 left). All patients lived at home by themselves and were ambulatory before surgery, with 41 (30.1%) patients who ambulated without assistive devices and 95 (69.9%) who required assistive devices, including crutches, canes, and walkers. There were no statistically significant differences between patients who did and did not receive PT with regard to demographic, medical, and surgical data, including gender, age, BMI, procedure performed, laterality, ASA, and the use of assistive devices before surgery (Table 1). All patients were admitted to the hospital on the day of surgery. There was no special preoperative education session that instructed patients about postoperative rehabilitation, but all patients were told that they would be ambulating before discharge. There was no preselection of younger patients or patients with less comorbidities. Patients were not permitted to select the time of day that their case was performed. Patients who underwent a THA received a modified anterolateral gluteus medius–splitting approach to the hip in the supine position [12], where the abductor muscles were reattached at the end of each surgery. Patients who underwent TKAs received quadriceps-splitting medial parapatellar approaches; there were no quadricepssparing approaches performed. The operative times were recorded; the admission time was recorded for when the patient entered the operating room, and a late operative time was defined as an end time after 15:00. Anesthesia was also recorded as spinal anesthesia or general endotracheal anesthesia. After surgery, all patients were first transferred to the postanesthesia care unit (PACU) and secondly to the floor for inpatient care. The time in PACU and the time of discharge from the PACU were recorded for each patient. Postoperative day (POD) 0 was defined as the same day of surgery. There were no standardized criteria by which patients were selected for participation in rehabilitation with physical therapists. Patient selection for POD 0 rehabilitation was dependent on timing and staff availability. No rehabilitation protocol was adjusted based on surgical approach, and all patients were weight bearing as tolerated. Total hip arthroplasty patients had no precautions or restrictions for rehabilitation. Total knee arthroplasty patients started continuous passive
Table 1. Demographic, Medical, and Surgical Data Did Not Differ Between Patients Who Received PT on POD 0 Compared With Patients Who Received Their First Therapy Session on POD 1
Age (y)
BMI (kg/m2)
Assistive Device Used Before Surgery
ASA Sore
THA
TKA
64.1 ± 11.0 62.3 ± 11.1 58.0 ± 9.4 .15
31.4 ± 6.6 33.1 ± 7.3 31.1 ± 6.8 .38
40 37 18 .77
2.7 ± 0.6 2.7 ± 0.5 2.6 ± 0.6 .85
19 25 14
41 26 11
Gender
POD 1—in bed POD 1—out of bed POD 0 PT P value
No. of Patients
No. of Joints
Male
Female
57 47 24
60 51 25
24 19 10
33 28 14 .81
Joint
.06
Immediate Physical Therapy Reduces LOS After TJA Chen et al
853
Elective Total Joint Arthroplasties (N = 136)
Post-operative Day 0 Physical Therapy (n = 25)
No Post-operative Day 0 Physical Therapy (n = 111)
Remained in Bed (n = 60)
Out of Bed to Chair (n = 51)
Out of Bed and Ambulating (n = 22)
Out of Bed to Chair (n = 3)
Fig. 1. Study design examining the isolated effect of immediate postoperative PT on hospital LOS in elective TJAs.
Discharge Criteria Patients were discharged when they had met all the following discharge criteria, regardless of rehabilitation intervention: (1) out of bed and ambulating a minimum of 100 ft, (2) could walk up and down stairs, (3) minimal drainage from the incision site, (4) adequate pain control
using oral pain medications, (5) tolerating a regular diet without nausea and vomiting, and (6) approval from PT with an understanding of the home exercise program. Patients were discharged either to home, to a skilled nursing facility (SNF), or to a rehabilitation facility. The LOS was determined as the length of time in the hospital from admission (operative start time) to the actual time of discharge. A second LOS was calculated from the time of discharge from the PACU to the actual time of discharge. These were measured in hours and were calculated to prevent overestimating of the LOS if a patient was a later operative case. Statistical Methods Statistical analysis for categorical variables was performed by χ 2 tests. Continuous variables were analyzed using 1-way analysis of variance. Statistical significance was defined as a P value of less than .05. All statistical analysis was performed using Predictive Analytics Software Statistics (PASW) version 18.0 (SPSS, Chicago, Ill).
Results Patients who received PT on POD 0 were compared with patients who received PT on POD 1 (Fig. 2). Using the operative start time to determine LOS, patients who received therapy on POD 0 stayed an average of 2.81 ± 0.77 days, and those who received therapy on POD 1
P = .02
POD 0 PT No POD 0 PT
6 Length of Stay (Days)
motion on the day of surgery from 0° to 90°, and they did not use knee immobilizers. Rehabilitation for hips and knees included isometric gluteus, quadriceps, hamstring, and hip adduction muscle sets. Active and active assisted ROM exercises were also initiated, including short-arc quadriceps ROM, long-arc quadriceps ROM, straight leg rises, hip abduction, ankle pumps, and heel slides. Finally, transfers, gait training, and activities of daily living exercises were implemented. Rehabilitation data were collected from the first therapy session, either on POD 0 or 1. The following data points were recorded: activity performed and the distance covered if the patient was able to ambulate. The primary end point of PT on the first session was to encourage patients to get out of bed and ambulate. Strengthening exercises were initiated on POD 1. However, if the patient was unable to ambulate, the patient received limited PT and was moved from bed to chair. Patients who received POD 0 PT were compared with patients who received PT on POD 1. The study design is depicted in Fig. 1, depicting that patients either ambulated, got out of bed to a chair, or remained in bed. On POD 0, 60 joints remained in bed, 51 joints got out of bed to a chair without PT, and 25 joints received PT. Of the 25 joints that received PT, 22 joints ambulated and 3 joints got out of bed to a chair. The 111 joints that remained in bed or got out of bed to a chair on POD 0 received PT on POD 1. Fourteen hip (24%) and 11 knee (14%) arthroplasties received POD 0 PT, and 44 THAs (76%) and 67 TKAs (67%) received PT on POD 1. Factors that could affect PT intervention were recorded. Antiemetic and analgesia regimens were recorded. Pain scores were recorded based on the 0 to 10 visual analog scale, where 0 was no pain and 10 was maximum pain. Hemoglobin, hematocrit, and tolerance of a regular diet were also recorded upon inpatient admission.
5 4 3 2 1 0 Overall Out of bed Ambulating Overall no Out of bed Remain in bed POD 0 PT to chair with POD 0 PT to chair with PT nurse
Fig. 2. Hospital LOS was shorter for patients who receive PT on POD 0 compared with patients who did not receive therapy on POD 0.
854 The Journal of Arthroplasty Vol. 27 No. 6 June 2012 Table 2. Factors Associated With PT Timing Physical Therapy LOS Comorbidities Anesthesia Spinal General endotracheal anesthesia Operative time Late operative end time Pain level Antiemetics Analgesia Hemoglobin level Hematocrit Regular diet Physical therapy distance ambulated first session
POD 0
POD 1
P
2.81 d 4.36 comorbidities
3.79 d 4.09 comorbidities
.019 * .761 .578
20 joints (80.0%) 5 joints (20.0%) 1 h and 25 min 0 joints (0%) 4.64 / 10 0.64 medications 4.96 medications 11.3 g/dL 33.1% 20 joints (80.0%) 18.7 ft
97 joints (87.4%) 14 joints (12.6%) 1 h and 32 min 21 joints (18.9%) 4.75 / 10 0.81 medications 4.7 medications 11.1 g/dL 32.6% 93 joints (83.8%) 37.4 ft
.398 .001 * .949 .470 .573 .788 .871 .608 .012 *
Postoperative day 0 PT intervention demonstrated significantly lower LOS. Postoperative day 1 PT had later operative times and ambulated longer distances during the first PT session. * Statistically significant.
stayed an average of 3.79 ± 1.74q days. The LOS was statistically significantly different between groups (P = .02). The statistical significance remained the same for hospital LOS when calculated from the time of discharge from the PACU (POD 0, 2.57 ± 0.77 days; POD 1, 3.52 ± 1.78 days; P = .02). Patients who received PT on POD 0 and were out of bed to a chair stayed an average 2.86 ± 0.58 days, and those who were ambulating with physical therapists on POD 0 stayed an average of 2.80 ± 0.81 days. Patients who did not receive POD 0 PT and remained in bed stayed an average of 3.76 ± 1.76 days. For patients who were out of bed to a chair on POD 0 without PT intervention, the average LOS was 3.56 ± 1.66 days. All patients who received PT on POD 0 got out of bed, whereas none of the remaining patients ambulated on POD 0. As for timing, all patients who received therapy on POD 0 were out of the operating room by 15:00, whereas 90 (81.1%) of 111 joints that received POD 1 PT were out of the operating room by 15:00. No patients who received POD 0 PT were out of the operating room later than 15:00, whereas 21 (18.9%) of 111 joints that received therapy on POD 1 were out of the operating room after 15:00. This difference was statistically significant (P = .02). The time in the PACU was not significantly different between groups (POD 0 PT, 254.3 ± 81.2 minutes; POD 1 PT, 265.8 ± 109.9 minutes; P = .62). The distance ambulated during the first PT session was statistically significantly higher for those who received PT on POD 1 (37.7 ft) compared with POD 0 (18.7 ft) (P = .02). However, patients who had worked with PT on POD 0 ambulated an average of 62.9 ft on POD 1 during their second session of PT. The remainder of factors, including preoperative narcotic medication, number of comorbidities, anesthesia, operative time, pain level on POD 0, number of
antiemetics used, amount of postoperative analgesia medication used, hemoglobin, hematocrit, and regular diet, were not significantly associated with PT on POD 0 (Table 2). There was no significant difference between discharge location and the timing of PT (P = .19). Of the patients who receive POD 0 therapy, 22 (88.0%) were discharged to home, 2 (8.0%) were discharge to a SNF, and 1 (4.0%) was discharged to a rehabilitation facility. For patients who received POD 1 therapy, 78 (70.3%) were discharged to home, 22 (19.8%) were discharged to an SNF, and 11 (9.9%) were discharged to a rehabilitation facility.
Discussion Perioperative rehabilitation, in combination with multimodality analgesia regimens and perioperative education, has been shown to decrease the hospital LOS for patients who undergo TJAs. However, few studies have isolated the effect of early postoperative rehabilitation on hospital LOS. The purpose of our study was to determine if immediate PT intervention on the operative day decreased hospital stay and if any factors affected early rehabilitation. Our study confirms our hypothesis and demonstrates that patients who receive PT on postoperative 0 have statistically significantly shorter hospital stays. Our study indicates that PT intervention alone decreases hospital LOS, regardless of the intervention performed. Patients who are out of bed to a chair with the assistance of PT have shorter stays than those who are out of bed to a chair with floor nurses who do not receive immediate PT. However, no statistical analysis could be performed between these groups given the small sample size. This may be because physical therapists motivate patients and affirm that patients should expect to ambulate with full weight immediately after surgery. After achieving 1
Immediate Physical Therapy Reduces LOS After TJA Chen et al
goal of getting patients out of bed to a chair, physical therapists return the next day with the next goal of ambulating with the patient. Patients who receive PT on the day after surgery may not have the same expectation because they did not work with a physical therapist on the day of surgery. Our study also found that patients are more likely to receive PT on the day of surgery if they complete surgery before 15:00, which indicates that adjusting surgical and PT schedules may be beneficial for decreasing hospital LOS. However, not all patients who were operated on before 15:00 received PT on the day of surgery. In addition, our results demonstrate that patients ambulated shorter distances at their first PT session on the day of surgery, but they were discharged earlier than the comparison group that received therapy on POD 1. This finding highlights the importance of instituting immediate postoperative PT because the distance ambulated during the first PT session did not correlate with the discharge date. In addition, instituting POD 0 rehabilitation resulted in a significant improvement in ambulation distance during their second PT session conducted on POD 1. Decreasing the hospital LOS also decreases hospital costs. The historical cost savings of discharging a patient on hospital day 3 (POD 2) instead of hospital day 4 (POD 3) is $454 [13].Our institution regularly performs over 1000 TJAs annually for an estimated cost savings of $454 000 per year. The results of this study correlate with other studies that have demonstrated that TJA patients benefit from rehabilitation immediately after surgery [10]. Although this finding is not surprising, our study did note that the act of receiving PT regardless of activity performed may shorten the hospital LOS. Previous studies have demonstrated that the hospital LOS may be increased by increased age, ASA class, incision length, and operative time [14]. Our study demonstrated that PT intervention was not dependent on other factors, such as comorbidities, age, BMI, or ASA. Our study also demonstrated that other factors, such as pain or nausea/vomiting, did not affect PT intervention. The main strength of this study is that it isolates the single factor of rehabilitation in the immediate postoperative period as a method of decreasing LOS. Although multimodality approaches should be implemented in conjunction with rehabilitation intervention, rehabilitation alone may shorten the duration of hospital stay. This study highlights the benefit of PT and the potential cost savings of earlier discharges. Assuming 2 sessions of daily PT, implementing 1 earlier session of PT on the day of surgery may decrease the overall number of PT sessions, as was demonstrated by Labraca et al [10]. Implementing these changes may save on resources and allow for PT sessions for other patients. Another strength of this study is that data were collected during the same
855
period, which ensured that all patients were treated equally with regard to other modalities. Finally, patients were not preselected or targeted to receive immediate postoperative PT. There are some limitations to this study. First, the study would have been strengthened if hip and knee patients were separated into different patient cohorts. Second, although this was a prospective study, true randomization of POD 0 rehabilitation would have strengthened the results of this study. Third, measuring hospital LOS as a primary outcome is informative, but it would have been beneficial to also assess the results of patient outcomes, including function and ROM. Fourth, there are multiple confounding factors besides PT that can affect hospital LOS. We attempted to control for these other factors, as we looked at age, gender, medical comorbidities, pain, hemoglobin/hematocrit, and diet. However, patients who ambulated with PT on POD 0 may have been more motivated than other patients, which may have resulted in shorter hospital stays. Physical therapists also have different personalities, and a more positive physical therapist may have a greater effect on motivating patients. Fifth, some patients may have selected an operative date specifically so that their case would be earlier in the day, which would result in a higher likelihood of getting PT on the operative day. These patients may have been more motivated and may have resulted in shorter hospital LOS. Finally, adverse events caused by early discharge were not studied. Future work will involve tracking complications and readmissions of this patient population after discharge from our facility and evaluating the improvement in patient care from specific rehabilitation methods. Overall, this study suggests that early rehabilitation and patient mobilization on the date of surgery is important to decrease the time of hospital admission. This study further demonstrated that limited PT may be of value because patients who were only out of bed to a chair with PT had shorter hospital stays than those who were out of bed to a chair without PT intervention. If resources are available, rehabilitation protocols should be initiated on the day of surgery regardless of when the patient comes out of the operating room. This emphasizes the need for faster and earlier patient recovery so that they may receive immediate postoperative PT to facilitate earlier discharges. Future longitudinal studies are needed to assess if limited PT affect patients' longterm outcomes and functionality.
Acknowledgments The authors wish to thank Alvaro Sanchez-Ortiz for assistance with statistical analysis. We would also like to thank Brooke Gilliland, Gina Rose, and Courtney Dube for physical and occupational therapy assistance. We
856 The Journal of Arthroplasty Vol. 27 No. 6 June 2012 truly appreciate the hard work and effort of the PT staff, the nursing staff, and the hospital staff.
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