Total knee pathway weds acute care, rehab
Early mobilization, aggressive PT keys to success
With its cross-continuum pathway for total knee replacement, St. David's Medical Center in Austin, TX, has improved care coordination between acute care and rehab while slashing length of stay by four days and cutting costs per day by as much as $300.
The pathway, which formed the basis for the facility's Progressive Orthopedic Program, is geared toward patients who can bear an accelerated regimen of physical therapy - sometimes as much as six hours a day, says Laura Halliday, LMSW/ACP, supervisor of the orthopedic program in rehabilitation at St. David's.
Before the pathway was developed, patients stayed in acute care alone for an average of seven days, while the average cost per day for rehab was $1,300. The pathway calls for four days in acute care, followed by three to five in rehab. The actual average length of stay is 5.9 days, while rehab costs have been cut to $1,000 per day.
Halliday attributes the success of the pathway to its emphasis on mobilizing the patient as quickly as possible following surgery. For example, on the first day following surgery, clinicians apply continuous passive motion to the patients. "Many times, a number of days can go by before physical therapy really starts," she says. "So we get physical therapy and occupational therapy involved very early in the acute care phase. That helps because as patients start moving around and doing things for themselves, they become mentally ready to come over to rehab sooner."
St. David's began developing the pathway two years ago as a way of streamlining medical management of its 250 annual total knee replacement patients. Through chart reviews and data analysis, case managers concluded that too many laboratory tests were being ordered, and that there was too much variation in physician practice patterns.
Armed with statistical data, they approached the physicians for input about how best to standardize the medical management of knee replacement patients. They also worked with clinical nurse specialists and program supervisors to come to some consensus. "It's taken a really long time to get all the doctors, different staff, and nursing all together under some common guidelines through the pathway," Halliday says.
In particular, it was difficult to come up with a best practice that all the surgeons felt comfortable with. The end result is a flexible document that "is somewhat vague and allows them the ability to individualize, because they felt that they needed to be able to customize patient care to some degree," Halliday says. "But we wanted a general framework to drive the patients through in a consistent manner, except of course when there were legitimate variances for medical reasons to have them fall off the pathway."
Later in the development process, the pathway team devised the Progressive Orthopedic Program (POP), which adds to the pathway by strengthening ties between acute care and St. David's orthopedic rehabilitation program. The POP was created, Halliday says, after staff observed that a number of orthopedic patients reported on follow-up visits that they were having difficulties with tub transfers and other activities of daily living.
The program includes basic rehabilitation services such as physical therapy, occupational therapy, and therapeutic recreation, but at an accelerated rate. "For some patients, it can be four or five or more hours per day [of physical therapy], depending on what they're able to handle," Halliday says.
In addition, patients go on outings, take the bus to a local grocery store, and practice getting around in the community. The hospital has a large volume of patients from rural areas who don't have access to services such as home-delivered meals. Instead, these patients have to be able to run their own errands and prepare their own means when they return home.
These services, as well as aquatic therapy, are available on weekends as well as weekdays, Halliday says, "So there's really no lost time." She adds that the driving force behind cost containment and the reduction in length of stay is the intensity of rehabilitation and the early introduction of therapies in acute care.
Since the program was initiated in October 1997, about 50% of St. David's total knee replacement patients have been placed on the pathway, a percentage that's likely to hold constant in the future. The reason is that not all patients are appropriate candidates for POP's accelerated regimen of physical therapy. "Some patients may be a bit older, or they weren't particularly independent prior to coming in," Halliday says. "We're looking for that healthy older adult who's going to have few medical complications, is cognitively intact, and was somewhat active beforehand."
Streamlining program through collaboration
Because of the pathway and the program constructed around it, acute care clinicians have strengthened ties with their counterparts in rehabilitation, Halliday says. "In the past, I think it was more fragmented. Acute did their thing, rehab did their thing, and each operated independently," she says. "Both did a good job, but by not working together, it was difficult to streamline the program the way we have since we started collaborating."
One collaborative initiative was to train acute care nurses to more effectively screen patients for their appropriateness for rehabilitation. Nurse liaisons from rehab also go to acute care during the discharge planning process to evaluate the patient.
"It helps that we're all in one medical center," Halliday says. "Some facilities might have to transfer off their campus, and that certainly inhibits how quickly they can secure [rehab] bed space and get the admission coordinated. What helped us was really trying to coordinate writing orders, making sure that information was available and that we were reserving bed space for someone that we knew was coming in couple of days."
For more information, contact Laura Halliday, LMSW/ ACP supervisor of the orthopedic program in rehabilitation at St. David's Medical Center, 919 E. 32nd St., Austin, TX 78705. Telephone: (515) 476-7111.
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