Patient education speeds joint replacement recovery
Multidisciplinary team developed teaching plan
A Florida hospital has developed a clinical path for total joint replacement that resulted in a reduction in average length of stay (LOS) of almost three days and a reduction in charges by $700 per patient. The path includes extensive preoperative patient teaching as a way to improve care.
Carol Raymond, RN, BSN, MS, assistant administrator of quality at Halifax Medical Center in Daytona Beach, FL, says chart review of patients undergoing hip or knee replacement surgery was conducted in early 1994.
"A subgroup of the care path committee was formed to discuss the formulation of a care path," says Raymond.
The group included representatives from the following departments:
• nursing;
• case management;
• pharmacy;
• physical therapy;
• dietary;
• preoperative testing;
• respiratory therapy;
• same-day surgery.
Based on the findings of the chart review and suggestions from committee members, a rough draft of the total hip and total knee care paths was developed in October 1994.
"The group agreed a solid preop teaching program was crucial to quality patient care, to reduced length of stay, and to improved patient satisfaction through preparedness," Raymond notes.
A preoperative teaching plan then was developed by the case manager, respiratory therapist, physical therapist, and anesthesiologist Expected outcomes at discharge included the following:
• the ability to transfer from bed to chair with minimal assistance;
• having knowledge about discharge instructions, precautions, and medications;
• having knowledge concerning the use of equipment, such as walkers or crutches;
• having stable vital signs.
In addition, preprinted preoperative and postoperative orders were submitted to an orthopedic surgeon, Thurman Gillespy, MD, for review. (See sample preoperative orders, pp. 25-26, 31.) He approved the orders and garnered the support of the hospital’s orthopedic surgeons for them as well. The physicians also agreed to have their patients participate in the preoperative teaching program, which can include as many as eight patients, says Raymond. All the disciplines involved in caring for the patient postoperatively participate in patient teaching.
Some problems had to be ironed out, however. She says the preoperative teaching originally was scheduled to take place in the physical therapy department because of the available space there, and because the department had all the necessary equipment to demonstrate exercises and transfers to patients. However, physical therapy was located "some distance" from the preoperative testing center and anesthesiologists, which made it difficult for patients to get from one location to another. After negotiation with the educational services department, Raymond says space was found in the same building as preoperative testing.
"Problems in developing and implementing the care paths have been addressed and solved through cooperation between the disciplines involved," she adds.
Another problem was duplication of orders, Raymond explains. There was one set of orders for preoperative testing, and another set that was sent with the patient on the day of surgery. By working with the physicians’ office managers, she says the committee was able to consolidate orders into one set used by all surgeons.
The average length of stay for total hip/knee replacement patients was 7.3 days from April 1994 through June 1994; by May 1995, that LOS had dropped to 4.4 days, says Raymond. In addition, although no firm data are available yet on cost reductions, she estimates there has been roughly a $700 savings per patient on the new path, mainly related to reduced LOS and standardization of implants.
"The most successful result of the care paths and the teaching program has been the satisfaction [expressed] by patients and their families," Raymond says. "They feel better prepared for what to expect after surgery, and they are able to make arrangements for home care or a rehab facility before surgery. The total joint care paths also have been helpful to the staff , allowing them to deliver appropriate and timely care."
Sequence of testing, PT instruction
This is an outline of the total joint replacement preoperative teaching program Halifax developed:
1. Preoperative testing will be performed in the preoperative testing center. Preoperative teaching will be done on Tuesdays and Thursdays at 10 a.m. Patients will be scheduled for both types of teaching through the centralized scheduling department by their physicians’ offices. Testing and teaching will be done approximately two weeks before surgery.
2. A folder containing brochures, precautions, and other instructional materials will be given to each patient during the teaching session.
3. The original preoperative order sheet will be sent to the preoperative testing center by the physician’s office. The office also will inform patients to expect to spend several hours going through the teaching program.
4. The sequence of testing and teaching will be as follows:
• preoperative testing (lab work, radiology, electrocardiogram, etc.);
• teaching video (approximately 15 minutes);
• anesthesiologist’s evaluation;
• interview and evaluation by the case manager;
• physical therapist instruction/return demonstration of exercises, transfers, equipment, etc., specific to the type of surgery the patient is having;
• respiratory therapist instruction/return demonstration of spirometry and breathing exercises.
The above procedures may be done concurrently to minimize the amount of time each patient must spend completing the program.
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