Standardized teaching and care are big time-savers

Routine is key in total joint replacement surgery

Standardizing care for joint replacement patients became a priority at Provena Mercy Center in Aurora, IL. The goal was to become a "Center of Excellence" for total knee and total hip replacement surgery and garner more referrals. Yet management did not go to a hospital committee to design a program. Instead, they purchased a package that includes software and videos. The program, JointVentures, is produced by Televisual Communications in Clearwater, FL. (For more information on JointVentures, please refer to source box, p. 51.)

"The prepackaged version was more economical. It came with the videos already made, and patient teaching videos can be expensive to make," says Glenda Sinkora, RN, MS, orthopedic clinical nurse specialist at the medical center.

The software package includes patient handouts such as brochures, an inpatient newsletter, and a caremap that can be printed from the computer and taken to a print shop to produce in large quantities. Each written handout can be tailored to fit the institution that is using the JointVentures program. Provena Mercy changed some of the descriptions of physical therapy because aqua therapy isn't as readily available in the midwest as it is in Florida. Also, the knee surgeries at the medical center that created the program took 28 minutes; at Provena Mercy they take one hour.

The products, techniques, and systems in JointVentures were developed over a 12-year period by orthopedic surgeons at the Florida Knee and Orthopedic Centers in Clearwater, FL. Today, the practice performs 600 total joint procedures annually.

The program has not only saved time upfront in design, but it is also saving time on the floor, says Sinkora, because the patient education is standardized. All joint replacement surgeries are scheduled on Monday; therefore, teaching is the same for all patients on each day of their hospital stay. For example, all the patients receive instruction on their medications on Wednesday.

"We go down the line, from patient to patient, so nothing is forgotten. We get more done because of the routine," says Sinkora.

Another advantage to standardization is that appropriate staffing is easier to schedule when the hospital stay for all the joint replacement patients is synchronized. Additional staff are scheduled on Tuesday, the first day post-op, because the patients need more education and care. For convenience, all joint replacement patients are kept on the same floor.

^{Pre-packaged program shaped to institution}

While JointVentures has formed the foundation for the joint replacement program at Provena Mercy Center, management has deleted some parts and added others to help the program meet the needs of the institution. For example, the discharge video is not used because a lot of the information is not pertinent to patients at the medical center.

Certain amenities were added to the program to increase patient satisfaction. For example, the first day in the hospital, each patient is given a flower and a card from his or her physician. Also, patients can have their hair washed and styled by a beautician the day before discharge.

The education components of the program have been shaped to fit the health care facility as well. They include:

· Community outreach seminars on joint pain.

About twice a month, Provena Mercy Center offers a community outreach class on knee and hip pain. Instructors discuss the anatomy of the joint and different diagnoses that could be causing pain. Those who attend the class are encouraged to obtain the correct diagnosis for their problem so it can be adequately treated.

· Education on joint replacement surgery.

A video on joint replacement surgery is part of the program. Physicians show the video to patients who need the surgery before discussing the procedure with them. It saves valuable time in patient education, says Sinkora. The film is 10 minutes.

· Attendance at a joint class.

Patients who decide to have the joint replacement procedure and are scheduled for surgery at Provena Mercy Center are automatically enrolled in a pre-operative class that takes place within two weeks of surgery. At the class, patients learn what will happen during their hospital stay and what staff will expect from them.

A physical therapist reviews the exercises the patient will need to do to aid recovery. The education is reinforced with an exercise booklet, so the patient can practice at home.

Occupational therapy discusses what patients need to do to prepare their home for after the surgery and what equipment they might need.

· Daily inpatient teaching.

Patients are given a copy of a caremap that explains what education and care will take place each day of their hospital stay. For example, on Wednesday patients are given instructions on the anticoagulant their physicians prescribed. If the medication is Coumadin, a pharmacist does the teaching. If the patient is prescribed an anticoagulant that requires self-injections, a nurse demonstrates the procedure and asks the patient to demonstrate it back.

Discharge instruction is also one-on-one, with the nurse going over information such as how to get up out of a chair without dislocating the hip, reviewing medication teaching, and discussing signs of infection.

The program, which was implemented in October 1997, has boosted patient satisfaction scores for joint replacement surgery based on initial survey responses. Actual results won't be complete for several weeks, Sinkora says. Yet it took a while to convince physicians that the concept of "cookbook medicine," a recipe or formula, would work.

"We would hear, 'People are individuals. Why practice cookbook medicine?' But it can be individualized. From a cookbook standpoint, we say everyone is taught about anticoagulants, but we individualize teaching according to the patient's medication," says Sinkora.