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Integrated Systems to Reduce Length of Stay for Knee and Hip Joint Replacement Surgeries
Integrated Systems to Reduce Length of Stay for Knee and Hip Joint Replacement Surgeries bY Tina Woo, Marion Bramwell, Beverley Greenwood, Shirley Gow, Rosemary Ackerman-Rainville, Patricia Corradetti, Susan Wood, and Julie Moreland
Abstract To reduce length of stay while
maintaining quality of care, St. Joseph’s Hospital, Hamilton, ON implemented a care path with three discharge options. Two of these discharge options were early discharge to integrated community services. Patients meeting early discharge criteria are discharged home five days post-operatively with follow-up by home care nursing and physiotherapy. Otherwise, patients are discharged
on day four to a multi-disciplinary rehabilitation unit at a separate facility. Patients requiring acute medical services for complications or co-morbidity stay in the acute care hospital. A prospective cohort evaluation showed no difference in complications and similar functional outcomes for the three discharge options.
T
he goal to reduce the length of stay for patients having knee and hip arthroplasty - while maintaining quality of care - was undertaken at St. Joseph’s Hospital, Hamilton, ON by developing an evidence-based care path and integrating care with community services.
able to achieve discharge between four and seven days post-operatively to alternate institutions such as skilled nursing facilities.
At the time of this project, the structural system did not allow patients to move in a timely manner from our acute care hospital to another venue for patients who were medically stable. This barrier Many facilities have successfully used to discharge created the opportunity care paths to reduce the length of to forge partnerships with two stay for joint replacement s~rgery.’,~,~,~ community organizations. It was Using a care path, hospitals have hypothesized that implementation decreased the cost for hip or knee of an evidence-based care path and arthroplasty by 20?404and by 11%’ early discharge to community with quality of care not compromised. partners would decrease the length With a care path, Ireson3showed of stay without compromising care. an improvement in self-care ability, To establish effective partnerships, all ambulation and psychological players who could contribute to this attitude. Gregor and colleagues2 pfoject were invited to the discussion reported improved utilization of table. Vertical integration with St. perioperative antibiotics and Elizabeth Visiting Nurses Association anticoagulants and decreased (SEN) was arranged to provide a safe number of lab tests without an discharge home with support on the increase in complications. fifth post-operative day. Criteria Partnerships between acute care were established for early discharge: hospitals and community agencies caregiver available at home; patient may allow for more efficient and having adequate cognitive functioning; effective delivery of care. According absence of drug or alcohol abuse; to A l ~ h i na, ~paradigm shift from no multiple comorbidity or major in-patient to out-patient and from a medical problems and patient living focus on an admission to a continuum within the SEN catchment area. On of care must occur through alliances. four occasions during the continuum, For hip and knee joint arthroplasty, the criteria are checked (surgeon’s Weingarten et a16”and Carlisle*were office, pre-operative class, pre-
Healthcare Management Forum Gestion des soins de sant6
60
admission assessment unit, and during their admission). Those not meeting the criteria for discharge home on the fifth day were transferred on the fourth postoperative day to a multi-disciplinary rehabilitation unit at St. Peter’s Hospital, a chronic care hospital. Patients who experience complications post-operatively remain at the acute care hospital. Family physicians have been integrated by becoming involved in anti-coagulation therapy and suture removal following discharge from hospital. To ensure high quality of care, extensive crosstraining and visits between organizations and disciplines occurred, and the nurse educator assembled a reference binder as a resource for staff. In order to prepare patients, education and empowerment begin in a pre-op education class taught by a nurse, physiotherapist and occupational therapist. A n Environmental Assessment Form was introduced, which is used to gather detailed information regarding the patient’s physical home environment, level of function, and social supports. The occupational therapist reviews the form with the patient and identifies and resolves barriers to safe discharge. The care path is presented in layman’s terms so that the patient can anticipate what is to occur each day. and written material is provided to patients for review at home.
Those identified for acute care discharge on the fifth post-operative day must achieve both medical and functional goals. Medical objectives are normal haemoglobin, INR in therapeutic range and no sign of infection or deep vein thrombosis. Functional goals include the ability to do transfers, and ambulate and do stairs safely with a gait aid. To achieve this, patients receive both weekend and regular weekday
physiotherapy treatment. If the patient is not independent, caregivers are educated on how to safely assist them, and in the event that the caregiver cannot manage, discharge is withheld until goals are adequately met. Upon discharge, SEN provides inhome nursing on days five to seven and physiotherapy on day six and, if needed, on day seven. In order to promote high quality, SEN extended the care path to community care and developed a risk management plan, which outlines potential complications, prevention strategies, signs and symptoms and nursing interventions. Additional nursing or physiotherapy is available if needed, although to date no patients have required this. St. Joseph’s Hospital pays a fee to SEN for each visit.
questionnaire designed for patients with osteoarthritis, that has evidence of reliability, validity and responsiv e n e ~ sQuestionnaires .~ were repeated at six-week follow-up in the Fracture Clinic to gather data on complications after returning home, preparedness to go home and the WOMAC.
Results
Evaluation Method
A total of 117 patients were admitted for hip or knee arthroplasty during this time period. Ninety-four percent of the patients were admitted from their own home and 86% were scheduled for surgery due to osteoarthritis. Eighty-nine percent completed pre-op questionnaires and 58% completed follow-up questionnaires. There was a larger proportion of women and widows in the group that did not complete the follow-up questionnaires; however, there were no statistically significant differences between those who completed the follow-up and those who did not. Demographic, clinical and outcome data are presented in Table 1.
To examine the results of the integrated systems, an evaluation was carried out. Patients remaining at St. Joseph’s who did not meet early discharge criteria were compared to those discharged home with SEN on day five and those discharged to St. Peter’s on day four. The evaluation was carried out for surgeries occurring between October 1997 and June 1998. Information was gathered by chart review and by prospective questionnaires, which were given at the pre-operative class to gather data on age, gender, education, marital status, previous hip or knee surgery and function as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The WOMAC is a
As expected, those who were discharged to home on day five with SEN follow-up were slightly younger and had slightly better initial function (according to the WOMAC), than those who remained in St. Joseph’s Hospital. The St. Peter’s Hospital population consisted of more widowed women, indicating the lack of a caregiver for home discharge. Postdischarge complications were similar across the three discharge plans and functional gains on the WOMAC were similar and not statistically significantly different. Preparedness for discharge was lowest in those patients who had rehabilitation for three days at St. Peter’s Hospital (pc.05).
Patients discharged to St. Peter’s Hospital receive comprehensive rehabilitation for three days. St. Joseph’s Hospital pays St. Peter’s Hospital to reserve two beds year round for this purpose.
Healthcare Management Forum Gestion des soins de sant6
61
References
Table 1
N Age mean (range) Gender
Male Female
Education < grade 9 high school post-secondary Marital Status married/equivalent separated/divorced single widow Surgery
hip knee
Previous hip/knee surgery Complications in hospital Deep vein thrombosis lncisional complication Blood transfusion Transfer to ICU Other
37
46
65 (31-82)
71 (42-88)
51% 49%
36% 64%
29% 52% 19%
41% 41% 18%
90% 3%
67%
0
7%
0 28%
61% 39%
44% 56%
5%
38%
47%
0 8%
3% 12% 34% 3% 37%
16% 0
4%
Reason not discharged to SEN No caregiver Bilateral surgery Co-morbidities Complications Outside SEN catchment Dementia/drug/alcohol Length of stay days mean (range) Prepared to go home Post-discharge complications WOMAC mean (sd) Pre Post Difference Follow-up questionnaires received
26% 12% 17% 33% 12% 0 5.2 (4-8)
9.5 (6-20)
100%
88%
14%
13%
2.1 1 (.93) n=32 1.12 (31) n=28 1.OO (.94) n=24
2.49 (.81) n=45 1.31 (.76) n=24 1.14 (.69) n=23
73%
46%
Discussion Since this was not a randomized controlled trial, systematic bias was expected between the three discharge plans. Our concern was that patients not be disadvantaged if discharged early. The evaluation suggests that those discharged do as well with respect to function and complications as those who are kept in the acute care hospital. Subjective preparedness to go home needs to be studied further in those transferred to St.
1. Mabrey JD, Toohey JS, Armstrong DA, Lavery L, Wamrnadt LA. Clinical pathway management of total knee arthroplasty. Clinical Orthopaedics and Related Research. 1997;345:125-133. 2. Gregor C, Pope S, Werry D, Dodek P. Reduced length
of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty. Journal on Quality Improvement. 1996;22:617-627. 3. lreson CL. Critical pathways: Effectiveness in achieving patient outcomes. JONA. 1997;27(6):16-23. 4.
Fisher S, Trimble S, Clapp B, DorsetI K. Effect of a patient management system on outcomes of total hip and knee arthroplasty. Clinical Orthopaedin and Related Research. 1997;345:155-160.
5.
Alphin J. Looking beyond the walls. Nursing Administration Quarterly. 1998;22(3):66-70.
6. Weingarten SR, Conner L, Riedinger M, Alter A, Brien W, Ellrodt G. Total knee replacement: A guideline to reduce postoperative length of stay. West J Med.
1995;163:26-30. 7. Weingarten S, Riedinger M, Conner L, Siebens H, Varis G, Alter A, Ellrodt G. Hip replacement and hip
hemiarthroplastysurgery: Potential opportunities to shorten lengths of hospital stay. The American Journal of Medicine. 1994;97:208-213.
8. Carlisle D. Fresh look at rehabilitation of hip replacement patients. Nursing Times. 1996;30:32-33. 9. Bellamy N, Buchanan W,Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in pattents with osteoarthritisof the hip or knee. The Joumal of Rheumatology. 1988;15:1833-1840.
Tina Woo BSc(OT), is an Occupational Therapist, St. Joseph's Hospital. M y i o n Bramwell, RN, BA, MHSc, CHE, is the Director, Clinical Integration, St. Joseph's Hospital. Beverley Greenwood, RN, is Charge Nurse, Fracture Clinic, St. Joseph's Hospital.
Peter's Hospital, since these patients are less likely to have home support. Shirley Gow, BHSc(PT), is a Physiotherapist, Another opportunity for improvement St. Joseph's Hospital. is with patients who stay in acute Rosemary Ackerman-Rainville, RN, Educator, St. Joseph's Hospital. care but are classified as having no caregiver or living outside the SEN Patricia Corradetti RN, BScN, is Director of catchment area. Continued evaluation Nursing, St. Elizabeth Visiting Nurses Association. of the program and care plans is warranted. Overall, early discharge Susan Wood RN, CRRN, is Case Manager, St. incorporating the use of a care path Peter's Hospital. and partnering for an integrated Julie Moreland. BHSc(PT), MSc, is Research system has been very successful. Coordinator, St. Ioseph's Hospital.
Healthcare Management Forum Gestion des soins de sand
62
Abstract To reduce length of stay while
maintaining quality of care, St. Joseph’s Hospital, Hamilton, ON implemented a care path with three discharge options. Two of these discharge options were early discharge to integrated community services. Patients meeting early discharge criteria are discharged home five days post-operatively with follow-up by home care nursing and physiotherapy. Otherwise, patients are discharged
on day four to a multi-disciplinary rehabilitation unit at a separate facility. Patients requiring acute medical services for complications or co-morbidity stay in the acute care hospital. A prospective cohort evaluation showed no difference in complications and similar functional outcomes for the three discharge options.
T
he goal to reduce the length of stay for patients having knee and hip arthroplasty - while maintaining quality of care - was undertaken at St. Joseph’s Hospital, Hamilton, ON by developing an evidence-based care path and integrating care with community services.
able to achieve discharge between four and seven days post-operatively to alternate institutions such as skilled nursing facilities.
At the time of this project, the structural system did not allow patients to move in a timely manner from our acute care hospital to another venue for patients who were medically stable. This barrier Many facilities have successfully used to discharge created the opportunity care paths to reduce the length of to forge partnerships with two stay for joint replacement s~rgery.’,~,~,~ community organizations. It was Using a care path, hospitals have hypothesized that implementation decreased the cost for hip or knee of an evidence-based care path and arthroplasty by 20?404and by 11%’ early discharge to community with quality of care not compromised. partners would decrease the length With a care path, Ireson3showed of stay without compromising care. an improvement in self-care ability, To establish effective partnerships, all ambulation and psychological players who could contribute to this attitude. Gregor and colleagues2 pfoject were invited to the discussion reported improved utilization of table. Vertical integration with St. perioperative antibiotics and Elizabeth Visiting Nurses Association anticoagulants and decreased (SEN) was arranged to provide a safe number of lab tests without an discharge home with support on the increase in complications. fifth post-operative day. Criteria Partnerships between acute care were established for early discharge: hospitals and community agencies caregiver available at home; patient may allow for more efficient and having adequate cognitive functioning; effective delivery of care. According absence of drug or alcohol abuse; to A l ~ h i na, ~paradigm shift from no multiple comorbidity or major in-patient to out-patient and from a medical problems and patient living focus on an admission to a continuum within the SEN catchment area. On of care must occur through alliances. four occasions during the continuum, For hip and knee joint arthroplasty, the criteria are checked (surgeon’s Weingarten et a16”and Carlisle*were office, pre-operative class, pre-
Healthcare Management Forum Gestion des soins de sant6
60
admission assessment unit, and during their admission). Those not meeting the criteria for discharge home on the fifth day were transferred on the fourth postoperative day to a multi-disciplinary rehabilitation unit at St. Peter’s Hospital, a chronic care hospital. Patients who experience complications post-operatively remain at the acute care hospital. Family physicians have been integrated by becoming involved in anti-coagulation therapy and suture removal following discharge from hospital. To ensure high quality of care, extensive crosstraining and visits between organizations and disciplines occurred, and the nurse educator assembled a reference binder as a resource for staff. In order to prepare patients, education and empowerment begin in a pre-op education class taught by a nurse, physiotherapist and occupational therapist. A n Environmental Assessment Form was introduced, which is used to gather detailed information regarding the patient’s physical home environment, level of function, and social supports. The occupational therapist reviews the form with the patient and identifies and resolves barriers to safe discharge. The care path is presented in layman’s terms so that the patient can anticipate what is to occur each day. and written material is provided to patients for review at home.
Those identified for acute care discharge on the fifth post-operative day must achieve both medical and functional goals. Medical objectives are normal haemoglobin, INR in therapeutic range and no sign of infection or deep vein thrombosis. Functional goals include the ability to do transfers, and ambulate and do stairs safely with a gait aid. To achieve this, patients receive both weekend and regular weekday
physiotherapy treatment. If the patient is not independent, caregivers are educated on how to safely assist them, and in the event that the caregiver cannot manage, discharge is withheld until goals are adequately met. Upon discharge, SEN provides inhome nursing on days five to seven and physiotherapy on day six and, if needed, on day seven. In order to promote high quality, SEN extended the care path to community care and developed a risk management plan, which outlines potential complications, prevention strategies, signs and symptoms and nursing interventions. Additional nursing or physiotherapy is available if needed, although to date no patients have required this. St. Joseph’s Hospital pays a fee to SEN for each visit.
questionnaire designed for patients with osteoarthritis, that has evidence of reliability, validity and responsiv e n e ~ sQuestionnaires .~ were repeated at six-week follow-up in the Fracture Clinic to gather data on complications after returning home, preparedness to go home and the WOMAC.
Results
Evaluation Method
A total of 117 patients were admitted for hip or knee arthroplasty during this time period. Ninety-four percent of the patients were admitted from their own home and 86% were scheduled for surgery due to osteoarthritis. Eighty-nine percent completed pre-op questionnaires and 58% completed follow-up questionnaires. There was a larger proportion of women and widows in the group that did not complete the follow-up questionnaires; however, there were no statistically significant differences between those who completed the follow-up and those who did not. Demographic, clinical and outcome data are presented in Table 1.
To examine the results of the integrated systems, an evaluation was carried out. Patients remaining at St. Joseph’s who did not meet early discharge criteria were compared to those discharged home with SEN on day five and those discharged to St. Peter’s on day four. The evaluation was carried out for surgeries occurring between October 1997 and June 1998. Information was gathered by chart review and by prospective questionnaires, which were given at the pre-operative class to gather data on age, gender, education, marital status, previous hip or knee surgery and function as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The WOMAC is a
As expected, those who were discharged to home on day five with SEN follow-up were slightly younger and had slightly better initial function (according to the WOMAC), than those who remained in St. Joseph’s Hospital. The St. Peter’s Hospital population consisted of more widowed women, indicating the lack of a caregiver for home discharge. Postdischarge complications were similar across the three discharge plans and functional gains on the WOMAC were similar and not statistically significantly different. Preparedness for discharge was lowest in those patients who had rehabilitation for three days at St. Peter’s Hospital (pc.05).
Patients discharged to St. Peter’s Hospital receive comprehensive rehabilitation for three days. St. Joseph’s Hospital pays St. Peter’s Hospital to reserve two beds year round for this purpose.
Healthcare Management Forum Gestion des soins de sant6
61
References
Table 1
N Age mean (range) Gender
Male Female
Education < grade 9 high school post-secondary Marital Status married/equivalent separated/divorced single widow Surgery
hip knee
Previous hip/knee surgery Complications in hospital Deep vein thrombosis lncisional complication Blood transfusion Transfer to ICU Other
37
46
65 (31-82)
71 (42-88)
51% 49%
36% 64%
29% 52% 19%
41% 41% 18%
90% 3%
67%
0
7%
0 28%
61% 39%
44% 56%
5%
38%
47%
0 8%
3% 12% 34% 3% 37%
16% 0
4%
Reason not discharged to SEN No caregiver Bilateral surgery Co-morbidities Complications Outside SEN catchment Dementia/drug/alcohol Length of stay days mean (range) Prepared to go home Post-discharge complications WOMAC mean (sd) Pre Post Difference Follow-up questionnaires received
26% 12% 17% 33% 12% 0 5.2 (4-8)
9.5 (6-20)
100%
88%
14%
13%
2.1 1 (.93) n=32 1.12 (31) n=28 1.OO (.94) n=24
2.49 (.81) n=45 1.31 (.76) n=24 1.14 (.69) n=23
73%
46%
Discussion Since this was not a randomized controlled trial, systematic bias was expected between the three discharge plans. Our concern was that patients not be disadvantaged if discharged early. The evaluation suggests that those discharged do as well with respect to function and complications as those who are kept in the acute care hospital. Subjective preparedness to go home needs to be studied further in those transferred to St.
1. Mabrey JD, Toohey JS, Armstrong DA, Lavery L, Wamrnadt LA. Clinical pathway management of total knee arthroplasty. Clinical Orthopaedics and Related Research. 1997;345:125-133. 2. Gregor C, Pope S, Werry D, Dodek P. Reduced length
of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty. Journal on Quality Improvement. 1996;22:617-627. 3. lreson CL. Critical pathways: Effectiveness in achieving patient outcomes. JONA. 1997;27(6):16-23. 4.
Fisher S, Trimble S, Clapp B, DorsetI K. Effect of a patient management system on outcomes of total hip and knee arthroplasty. Clinical Orthopaedin and Related Research. 1997;345:155-160.
5.
Alphin J. Looking beyond the walls. Nursing Administration Quarterly. 1998;22(3):66-70.
6. Weingarten SR, Conner L, Riedinger M, Alter A, Brien W, Ellrodt G. Total knee replacement: A guideline to reduce postoperative length of stay. West J Med.
1995;163:26-30. 7. Weingarten S, Riedinger M, Conner L, Siebens H, Varis G, Alter A, Ellrodt G. Hip replacement and hip
hemiarthroplastysurgery: Potential opportunities to shorten lengths of hospital stay. The American Journal of Medicine. 1994;97:208-213.
8. Carlisle D. Fresh look at rehabilitation of hip replacement patients. Nursing Times. 1996;30:32-33. 9. Bellamy N, Buchanan W,Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in pattents with osteoarthritisof the hip or knee. The Joumal of Rheumatology. 1988;15:1833-1840.
Tina Woo BSc(OT), is an Occupational Therapist, St. Joseph's Hospital. M y i o n Bramwell, RN, BA, MHSc, CHE, is the Director, Clinical Integration, St. Joseph's Hospital. Beverley Greenwood, RN, is Charge Nurse, Fracture Clinic, St. Joseph's Hospital.
Peter's Hospital, since these patients are less likely to have home support. Shirley Gow, BHSc(PT), is a Physiotherapist, Another opportunity for improvement St. Joseph's Hospital. is with patients who stay in acute Rosemary Ackerman-Rainville, RN, Educator, St. Joseph's Hospital. care but are classified as having no caregiver or living outside the SEN Patricia Corradetti RN, BScN, is Director of catchment area. Continued evaluation Nursing, St. Elizabeth Visiting Nurses Association. of the program and care plans is warranted. Overall, early discharge Susan Wood RN, CRRN, is Case Manager, St. incorporating the use of a care path Peter's Hospital. and partnering for an integrated Julie Moreland. BHSc(PT), MSc, is Research system has been very successful. Coordinator, St. Ioseph's Hospital.
Healthcare Management Forum Gestion des soins de sand
62