Clinical pathway for hip and knee arthroplasty

Physiotherapy October 2003/vol 89/no 10 Summary:

dy was to eval ate the i!ple!entation of an early dischar"e pro"ra!!e for patient nder"oin" hip or knee arthroplasties his paper e#a!ines o tco!es pertinent to physiotherapy$ and looks at patient !ove!ent and f nction for p to si# !onths after s r"ery% ata collected& looked at len"th of stay based on day of s r"ery $ran"e of !ove!ent and a ti!ed ten'!etre walk test% es lts: after i!ple!entation of the clinical pathway$ in co!parison to baseline !eas res$ showed that len"th of stay was red ced$ the day that s r"ery was perfor!ed did not affect len"th of stay$ and all patients i!proved their ran"e of !ove!ent and walkin" capabilities p to si# !onths followin" s r"ery%

he objective of this st

Background and purpose

Osteo'arthritis co!!only affects people over () years of a"e and is a !ajor ca se of pain and debility of hip and knee joints% *ip arthroplasty !ay also be indicated in rhe !atoid arthritis$ vasc lar necrosis$ hip fract res and arthritis associated with pa"ets disease. Nepean Hospital in Sydney, Australia, was looking for wavs o reducing costs and using resources efficiently while still providing optimal patient care. July and October !!! on people needing hip and knee arthroplasty. "urrent cost for hip arthroplasty at this hospital was # , $! per day and for knee arthroplasty # ,%&% per day , average lengths of stay of % days for knee arthroplasty and ' days for hip arthroplasty. October !!! an early discharge pro(ect incorporating clinical pathwars was implemented. aiming to reduce length of stay without compromising patient outcomes. )efore implementation of the early discharge programme and clinical pathwarys, patients were assessed ad hoc pre*operatively. Although patients were followed*up, they were not visited at home, but give outpatient appointments about two weeks after discharge. +hey were however instructed to continue with their e,ercise until reviewed at an outpatient appointment. -abery et al . !!/0 e,amined the effect of introducing clinical pathways

for total knee replacements and the effect on length of stay over a two*year period. Similarly, a study by pearson et al.'%%%0 results showed that such an implementation significantly reduced length of stay from nine to seven days and improved streamlining of services. Hughes et al . !!10 and -ahoney et al . !&20 found that to achieve a reduction in length of stay following arthroplasty, physiotherapy service had to include weekends. Hughes on a 3ednesday or +hursday who might therefore not receive consecutive physiotherapy due to the weekend interruption.

Methods
Selection of subject +he study ran from October !!! to October '%% and included ' 2 patients undergoing elective (oint replacement. +hey received post*acute care 4 from the nursing and physiotherapy outreach service. +hirty*three patients living outside e,cluded. 5atients were also e,cluded if complications after surgery that re6uired a longer hospital stay, for e,ample patients with low haemoglobin, wound oo7e, constipation or nausea. +he average arthroplaty was 8! .S9 %0 years, and for hip arthroplasty 8/ .S9 ' 0

Procedure
5re*admission clinical for a full day of assessment before surgery. :ncluded nursing, occupational therapy, specific physiotherapy assessments. 5hysiotheyapy data collected incuded (oint range of motion, type of aid used to work .if any0 and time to walk ten meters. ;nee movements were performed with the patients in sitting, and hip movements with the patients in supine .fle,ion and abduction0 or side lying .e,tension0. 5re*operatively patients were taught e,ercise by a physiotherapy and instructed in the use of walking aids. early e,ercise and mobility training. +hey were also asking to attend the outpatient physiotherapy department for regular appointment until their functional ability had been ma,imi7ed. Sheet to Admitted on their day of surgery and length of stay was calculated from the day of surgery to discharge from the ward. "linical pathways were used by the ward physiotherapists to co*ordinate physiotherapy services and a case manager coordinated the overall patient care.

Physiotherapy
5atient were seen on the day of surgery to start deep breathing e,ercises, bed mobility and ankle dorsifle,ion<plantarfle,tion e,ercise for circulation. :f 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 e,ercises, to walk and to practice using stairs. Hip arthroplasty e,ercises included= Ankle dorsife,ion and plantarfe,ion :sometric 6uadriceps :sometric gluteals :nner range 6uadriceps Hip fle,ion and e,tension in supine ;nee abduction in supine +his progressed to hip fle,ion, e,tension and abduction in standing. ;nee arthroplasty e,ercises included= Ankle dorsife,ion and plantarfe,ion :sometric 6uadriceps :sometric gluteals :nner range 6uadriceps ;nee fle,ion and e,tension in sitting Hamstring stretches

Data Analysis
9ata were analysis using the Statistical 5ackage for Social Sciences .S5SS0 version % for 3indows. :ndependent t*test were using to show further differences between the se,es at baseline for all outcome measures. statistical significance for these test was set at 2> .5 ? %.%2 0

RESULTS
Patient Satisfaction Survey was randomly distributed to &1 patients following discharge and was completed by 22 , with !$> of patients happy with their episode of care, & > of patients indicated that at the time they were discharge they were ready to go home, $> indicating they could have been discharge sooner, 1> of patients would have to stay longer in hospital. Length of Stay +heir day of surgery and length of stay was calculated form this day until discharge. Analysis of variance revealed no significant differences between length of

stay and day of surgery for all arthroplasties . p@%.%20. Outco e Measure +able ' and 1 summarise the average range of movement, walking aids usage and timed ten*metre. Analysis of variance showed significant improvements discharge to si, months for all patients across all variables .p ? %.%20. Effects of Day of Surgery 3ere not significantly different whatever the day of operation .p @ %.%20. !ender effects 3ith men performing the ten*metre walk average two seconds faster than women .p ? %.%20. ;nee arthroplasty patients, independent t*test indicated significant differences between males and females for the times walk test at baseline .p ? %.%20 . Aesult showed that the men still walked significantly faster over the ten metres that women only at discharge .p ? %.%20. No significant difference was observed between se, and length of stay for hip arthroplasty .p ? %.%2 0 B men undergoing knee arthroplasty were discharge significantly sooner than women .p ? %.%20.

Discussion
:nterestingly, average lengths of stay in Cngland for '%% < %' were ' days for hip arthroplasty .average age 8& years 0 and days for knee arthroplasty .average age /% years 0. Aesults shown tables ' and 1 )y si, months %%> of hip arthroplasty and !$> of knee arthroplasty patients were walking unaided or using only a stick. +hey also found that range of movement of knee arthroplasty is an important measurement of outcome with a finding of a functional range of around %% to %. After hip arthroplasty from discharge to si, months after surgery, and at discharge only after knee arthroplasty, men walked two second than women over ten metres. )ohannon . !!/0 found that gait speed reduces in older, shorter people with less lower e,tremity muscle strength. Some patient could not be followed*up due to difficult

"onclusion#
+he pro(ect enable current services to be improved to that a significant reduction in length of patient stay was achieved.

+he use of the preadmission clinic, day of surgery admission, co*ordinated physiotherapy care on word via clinical pathway, and post*acute physiotherapy care At home upon discharge enabled these clinical outcome to be achieved.