Joint camp improves quality, patient satisfaction
Everyone follows best practices protocol
Several years ago, rehab and hospital administrators at Genesys Regional Medical Center in Grand Blanc, MI, decided to revamp their hip and knee replacement programs from start to finish.
"We got physicians together and looked at best practices across the country for everything they did, the operating room [OR], post-op, you name it," says Sonia Nesbitt, RN, MS, an orthopedic clinical nurse specialist and orthopedic program manager for the Hip and Knee Replacement Program at Genesys Regional.
The hospital, including rehab staff and physicians, implemented a new program that patients call the joint camp, and the outcomes have been very positive, Nesbitt says.
Since 1994, hospital clinicians have done assessments of each joint patient to see how they’ve improved after surgery and rehabilitation. They’ve found some significant improvements in a variety of measurements, including these:
- Prior to the new program, 52% of patients could ambulate 100 feet after hip surgery; since the new program, 99% of patients can do so.
- Before the new program, 57% of knee patients could walk 100 feet; after the program, 94% of knee patients could do so.
- Previously, 84% of joint patients could achieve a 65-degree flexion; after the program, 100% of patients could achieve this.
- Likewise, before the program, only 22% of patients could achieve a 90-degree flexion; afterward, 88% of patients reached that level of flexion.
Another benefit is that the hospital has reduced its length of stay by an entire day for both hip and knee patients, Nesbitt says.
"Patient satisfaction has been amazing," Nesbitt adds. "We haven’t done a lot of marketing about the program, but we have patients telling other patients, and that’s the greatest marketing tool."
As a result, the hospital’s total number of hip and knee replacement surgeries has increased within the past three years from 400 to 700 annually, Nesbitt says.
Here’s how the hospital started the program:
1. Research best practices.
A group, consisting of Nesbitt, three orthopedic surgeons who each represented a different orthopedic practice, a nurse administrator, a surgical technician, an operating room nurse manager, and a floor nurse manager, traveled to two hospitals to observe their hip and knee programs.
They visited Anne Arundel Medical Center of Annapolis, MD, and Grant Medical Center of Columbus, OH. Grant Hospital had an efficient OR process, and Anne Arundel Medical Center had a special joint program in place, Nesbitt says.
After seeing the other hospitals’ programs, the team continued to research joint replacement best practices before coming up with a suggestion for the new program.
2. Write a business proposal for hospital top brass.
Nesbitt and others wrote and then presented the business proposal for Genesys Regional to change its joint program to a more efficient and systematic process.
To simplify the process, they decided it would work best if the hospital purchased a prepackaged replacement program called Joint Ventures, marketed by TeleVisual Communications of Clearwater, FL, Nesbitt says.
"They give you a basic framework, and you work with your physicians and say this is how you’ll standardize your protocol," Nesbitt says. "It’s a template, a how-to manual, and it cuts down on start-up time."
After hearing the business proposal, hospital administrators and the board agreed to the purchase, Nesbitt says.
3. Physicians and other staff adjusted the program to fit hospital’s needs.
"We had physicians and each member of the task force take different components of the OR piece, the post-op piece, exercise, and pain protocol and work with these to come up with a best practices idea," Nesbitt says.
Physicians eager to implement program
Because physicians from each orthopedic group were represented, there was better communication and input about what various surgeons did and didn’t want to see changed.
"We meet monthly with all orthopedic surgeons and give them an update on where we are," Nesbitt says. "We also have a physician coordinator for the program."
Physicians very quickly became excited about the changes and were eager to see the efficiencies put in place, she says.
4. Implement new protocol for joint patients.
After several months of writing and improving the program, the hospital was ready to begin. The protocol basically works this way:
• It begins in the physician’s office when a patient has decided to have surgery. The patient is given a knee or hip replacement booklet that discusses the process from its beginning to what happens two months after surgery, Nesbitt says.
"The doctor reinforces the message that the patient has to go to a pre-op class and tells the patient more about the joint program," Nesbitt explains. Then the patient is told to take pre-op vitamins.
• The physician sends the patient’s information to the hospital, where a secretary sends the patient a letter inviting the patient to a pre-op class, which is held once a week. Nesbitt, an occupational therapist, and a physical therapist lead the classes, teaching patients about what they have to do prior to surgery and what to expect.
"I call it expectation setting: Here’s what they have to do to be successful," Nesbitt says.
Patients are encouraged to bring a family member/coach to the pre-op classes and to any hospital therapy sessions.
"It’s very important for a family member to be here while we go through all the typical things, including pain management, IVs, catheters, and how long they’ll be in the hospital," Nesbitt says.
• On the day of surgery, the patient is encouraged to relax, but physical therapy begins aggressively on the very next day, Nesbitt says.
"We have all the patients bring in their own clothing, and most dress in shorts or T-shirts," Nesbitt says. "They do group therapy twice a day, and then they walk a lot and are encouraged to go to the bathroom on their own."
Therapists also encourage patients to walk to the group room for a lunch buffet.
• Therapy continues on the remaining days the patient is in the hospital. Patients are encouraged to visit the rehab center and practice getting in and out of a car, walking down steps, and getting in and out of a shower.
On their last day, patients are given group therapy in the morning, and they have a graduation ceremony at which they are given certificates and pins.
"And we have a putting tournament on a roll-up putting green," Nesbitt says. "If they get a hole-in-one they win, and the nurses give them little model cars of Ferraris and Corvettes."
The ending event is meant to be fun and the patients’ families are encouraged to be involved, Nesbitt says.
• Most patients are sent home after four days, and they’re expected to continue their exercises for the next few weeks before they are scheduled to return to their physician’s office.
"Our hip replacement patients will continue with the exercise protocol using notebooks from the pre-op visit," Nesbitt says.
They are supposed to exercise three times a day, doing typical hip replacement exercises, she says.
While in the hospital, the patient may have started at 10 repetitions of quad sets, straight leg raises, and short arc quad sets, but by the time they return home, they may do 40 repetitions, Nesbitt says.
"We had exercises weekly, and have about 20 different exercises," she says.
"Knee replacement patients do the same thing, but they also go to outpatient therapy three times a week for three to six weeks, because they need to improve flexion and extension," Nesbitt says. "These patients need the expertise of a physical therapist involved in those cases."
Only about 2% of these joint patients are referred to home care services.
Most of the patients are encouraged to return to their normal daily routines and to walk in a mall or wherever they’re comfortable.
To treat patients’ pain, physicians may ask them to try oral narcotics with Tylenol and cold therapies on the knee or hip, Nesbitt says.
Need More Information?
- Sonia Nesbitt, RN, MS, Orthopedic Clinical Nurse Specialist, Orthopedic Program Manager, Hip and Knee Replacement Program, Genesys Regional Medical Center, One Genesys Parkway, Grand Blanc, MI 48439. Telephone: (810) 606-6517. E-mail: [email protected].
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