Hospital improves joint replacement discharges
Preoperative patient education, assessment are key
Several years ago, administrators at Sutter Medical Center Sacramento (SMCS) in California realized that only 2% of patients undergoing elective joint replacement were being discharged home.
Today, that number stands at 60%. The greatest single factor on improving that number is preoperative assessment, education, and training, says Patrick Blair, OTR, MPA, the program’s rehabilitation services areawide director.
According to Blair, SMCS has focused on length of stay (LOS). But an even greater focus has been on discharge destination. Back in the mid-1990s, 98% of these patients were discharged to Sutter’s hospital-based skilled nursing facility.
"When we started benchmarking ourselves against other providers, we found that we were way too high," he reports. "Our goal was to send more patients home." SMCS had an average LOS of about 3.5 days and sent only 2% of its patients home. Today, Sutter sends close to 60% of its patients home, and the average LOS is about five days.
"We actually increased our LOS," Blair says. But he notes that the costs for the end-of-stay days are the least expensive. "Most of your costs are upfront," he asserts.
"We think we can shave our LOS in the future," Blair says. Some programs send an even larger percentage of their patients home and have an average LOS of roughly four days, he notes. "That is our target from an LOS standpoint."
SMCS also tracks the number of readmissions and how many complications occur. "We have not seen any real change in those areas," Blair says.
Changing cultural mindsets
Sutter tested its preoperative education program using a pilot program in 1997 and launched the program the following year. Its managed care patients now are required to participate in the program before surgery is authorized.
Blair says the first task was to work on changing the culture in its care unit. "We wanted to change the mindset first," he says. Instead of keeping patients for three days and then transferring them to the transitional care unit, SMCS’s case management team and orthopedic surgeons started assessing what these patients require preoperatively and then educating and training them and sending them home without dramatically increasing the LOS.
"You want the patients and their families ready to go before they have their surgery," Blair says. "That way, once they have their surgery and are recovering from the initial postoperative period, they are ready to get going right away."
In order to operationalize its effort, SMCS hired a full-time nurse with the sole responsibility of working with these patients once they are hospitalized and before the surgery takes place. The nurse also monitors the patients after they are discharged to make sure there are no gaps or delays in care.
"This person is not the case manager," says Blair. "We still have the traditional case manager on the unit who does hospital case management." Rather, the nurse hired for these patients acts as the continuum care coordinator, he says.
Preoperative procedures emphasized
According to Blair, the greatest emphasis is placed on preoperative education. To facilitate that education, Sutter uses a variety of tools. As soon as the surgeon’s office notifies the hospital that a procedure is being scheduled, patients receive a custom-developed handbook. SMCS also offers a three-hour class once a week that includes both an education and a physical therapy training component.
In addition, Sutter is considering developing a video. "For those people who are able to access all of these tools, you are hitting all modes of education," Blair says. While repetition is important for any patient population, it is especially important for these patients, who generally are older, he says.
According to Blair, many of SMCS’s treatments, such as ACL repairs, ligament repairs, and rotator cuff repairs have moved largely to an outpatient basis. On the inpatient side, the facility does fracture repairs and some major reconstructive surgery. Patients with a high acuity also may be admitted for a one-day stay.
Overall, SMCS is focused on joint replacements, predominantly knee and hip, which represent 60% to 70% of its inpatient cases. Sutter is on pace this year to perform 900 joint replacements, Blair says. However, smaller organizations that perform fewer of these procedures can employ the same processes, he adds.
"The model is a little bit different, but the concepts are all the same," he says. In fact, Sutter has smaller facilities that perform only 60 joint replacements a year but still perform preoperative education and assessments.
Appropriate assessment should include talking to patients and their families about their home environment and whether they have had a similar procedure in the past, Blair says.
Many of these patients may have had a knee replacement prior to a hip replacement or a knee replacement that failed 10 years later, he notes. They also frequently have other comorbid conditions and various medical conditions that will affect their recovery.
Allowing flexibility
Regardless of how much work is done in advance, programs must allow a significant degree of flexibility, Blair says. "Someone that you think is going to do very well after the surgery may not, due to complications or side effects," he warns.
In addition to its emphasis on patient education, SMCS revised its clinical pathway, including formal pre-op and post-op physician order sets, and formalized its rehabilitation protocols, including specific objectives and measures, Blair says.
SMCS relies on a group that includes orthopedic surgeons, nursing, rehab therapy, physical therapy and occupational therapy, case managers, home health, and others.
Most patients who go to rehab simply progress more slowly, says Debbie Zakerski, RN, the total joint care coordinator. "They need to be able to get in and out of bed by themselves and be independent," she explains. "They may need to work on those things."
In any given week, there are 20 patients coming in, 20 in the hospital, and 20 at home, Zakerski says. "I don’t manage each one of them by myself." While she speaks to each one prior to surgery, once they are in-house, the discharge planning team makes all of the arrangements. "I communicate with them and put notes in the chart and then communicate with them when they go home," she says.
"We have a whole group that is a formalized committee that works on the joint program," Blair explains. That program now is being developed into a more formal organization — Sutter Joint Replacement Center — to make sure that all of these groups are pursuing the same goals and objectives for this patient population. Blair adds that a medical director will be added to that team soon.
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