Critical Pathway for Hip and Knee Arthroplasty: Faster Home due to Multidisciplinary Cooperation

Introduction

In the next decade, a significant increase in total hip and knee replacements is expected. Until the year 2020, an increase of 50 per cent can be expected. ¹ This prognosis can be made based upon the ageing of the population and the implantation of prostheses in younger patients, ¹ whereas the number of hospital beds will decrease to fulfil the clinical capacity norm set by the government. ² If no adjustments are made, waiting lists will increase. On the other hand, intense pressure to reduce health-care costs have led many health-care organizations to seek strategies that reduce resource utilization while maintaining the quality of care. ³ One of these initiatives was the development of critical pathways, also known as clinical pathways or care pathways. Critical pathways are management plans that display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency. ³ They are designed to minimize delays and resource utilization and to maximize quality of care. ⁴ The approach and goals of critical pathways are consistent with those of total quality management (TQM) and can be an important part of an organization's TQM process. ⁴ Also, the introduction of diagnosis-related groups (DRGs) in many countries has intensified the process of cost reduction.

Method

In 1998, we started to search for a way to reduce length of stay (LOS) for our hip and knee replacements without reducing quality of care, overloading the (para-)medical staff or shifting care to the general practitioners. Finally, in February 2000, we started with our first patients treated in a critical pathway for total hip and knee replacement. The programme was introduced by an industrial partner and launched under the name ‘Joint Care^® Orbis’. Following other hospitals proceeding Sittard, the project was carried out with two major goals: improving quality of patient care for patients awaiting hip or knee replacement surgery, and realizing a more efficient level of cooperation in and outside the boundaries of the hospital setting.

First, we describe the concept of the critical pathway we used. Secondly, a short presentation of the medical outcomes over the first four years is given. Finally, we discuss the gains and future aspects.

New aspects of this health-care concept were:

From the beginning of the project, all hospital partners like ‘home care nurses’ and general practitioners were involved in the project. Through this a solid base for cooperation was established. Education and collective treatment were the corner stones of this new treatment approach. After the decision about hip or knee replacement was made, the patient was optimally informed. This process started when patients left the consulting room and received an information chart. After this, the preoperative visit was scheduled. During this consultation, patients saw the orthopaedic surgeon, the anaesthesiologist, a physical therapist and a nurse. In addition, once every month a collective information meeting was held. During this meeting, patients saw an instruction video, presentations of the previous-mentioned specialties and a patient with his coach. In this meeting, patients were able to ask questions and saw a patient who had just had hip or knee replacement surgery.

At the night of admission, all patients were admitted jointly. This started with an information video about the clinic, routine check up and blood sampling. After surgery, patients received written instructions with the daily programme each day. This information was also available in their info chart. Active rehabilitation started the day after surgery and the day before discharge the patients were briefed by the ward doctor, physical therapist and the nurse about the time after hospitalization. This session was ended with a video about the situation at home.

Maximum effort of the patient in arranging front care was the starting point in transmural health-care planning (defined as the interface between primary and secondary health care). Wherever needed, assistance was given. After discharge, a shift of hospital care towards home nursing care was prevented. During the pre-clinical visit estimation was made about the care needed after discharge. The official government organization estimated home care neediness before admission instead of during admission. Clear criteria were present to make the judgement about the provided care. By doing so, a better capacity planning of the home care institution was possible. After the total care programme was taken care of, the operation date was confirmed.

The patients started their rehabilitation the day after surgery, when they all walked to a living room. This room was patient friendly, without beds and patients stayed there all day in specially designed chairs. The chairs were designed in a way that patients could change their position to a supine one by themselves. In this room all activities took place like physical therapy, lunch and also resting.

Early involvement of the relatives had two advantages. Firstly, the hospitalization was less of a threat to the patient due to the presence of a coach. This coach could relieve the nurser from some tasks like handing coffee while walking with the patient to the toilet. These things provided a confident return home for the patient and his relatives. Secondly, the nurse could shift her task during the hospitalization from care to guiding tasks. The time won in this process could be used to answer the phone calls at the helpdesk or perform the telephonic interviews after discharge. In daily practice, most patients were able to provide their own coach, if this was not possible other coaches of the group took over this role. In the daily process, coaches made arrangements with each other about their presence. At discharge, no other measures than those in the old situation were taken.

One of the goals of the project was to prevent a shift of care towards the first line due to the shortening of LOS. Therefore, the following measures were taken: two days after discharge, the home nurse service provided wound care. They received thorough instructions from the hospital. The coach took part in the communication with the care providers. A telephonic helpdesk was available 24-hours a day. Two weeks after surgery, the stitches were removed at home.

Results

The first consecutive series of patients were evaluated. ⁷ These patients were operated on from February 2000 to February 2004. Because the Joint Care programme had limited capacity, only 45% of all hips were treated in this critical pathway. Of these total hip replacements (THRs), 92% were discharged at the fifth postoperative morning. Half of all patients who were not discharged had wound-related problems; most of these patients were discharged two days later. Readmission rate was 6.4% of all patients. Half of these patients were readmitted because they dislocated their hip prosthesis. Some of these dislocations were years after the operation. ⁷ Surgical debridement was needed in 1.2% of all cases. None of these patients had an extraction of their prosthesis. Serious complications like infection, luxation and pulmonary embolism were comparable with the literature.^8–10

Because initially only ASA I and II patients were treated in Joint Care, we choose not to compare them with the patients treated outside the programme. The selection bias can be a large confounder, especially for LOS. However, we believe that compromised patients would benefit more from an accelerated stay programme than the relatively fit patients, because patients with very low physical conditions are more prone to serious complications and after hip replacement surgery patients showed a major setback in physical condition, on average 23%. ¹² In regular treatment, these compromised patients might suffer most from the tranquil period present during the first days after surgery. Whereas in accelerated stay programmes, this problem might be less.

Future

Critical pathways are management plans to achieve goals with optimal efficiency ³ and to maximize quality of care. ⁴ Maybe a more extensive approach of the CP was made by Kehlet and Wilmore ¹³ who synthesized, integrated and applied research information in a comprehensive programme, now commonly referred to as ‘fast-track surgery’. The success of a fast-track surgery programme requires a multidisciplinary approach involving anaesthesiologists, surgeons, nurses and physical therapists. ¹³ The thrust of this fast-track approach was to reduce the physiological and psychological stresses associated with operations, thereby reducing potential complications. In optimizing perioperative care, many intraoperative and postoperative outcomes have to be influenced pre-operatively. ¹⁴ Fast-track surgery evolved as a coordinated effort, combining modern concepts of patient education with newer anaesthetic and analgesic methods and minimally invasive surgical techniques; the intention was to reduce the stress response, and minimize pain and discomfort. The key pathogenic factor in postoperative morbidity, excluding failures of surgical and anaesthetic technique, is the surgical stress response with subsequent increased demands on organ function. ¹⁴ Therefore preoperative optimization, improved perioperative monitoring, early resuscitation, more responsive fluid therapy (i.e. avoidance of hypovolemia and hypervolemia), maintenance of normothermia, and prevention of postoperative nausea and vomiting^15,16 are the challenges.

Conclusion

In summary, if we evaluated the first four years of total hip and knee replacement in a critical pathway, a continuum of the care chain was made. A reduction in the LOS without compromising the quality of care or reducing the self-supportiveness of the patients was established. Patients treated outside the critical pathway are currently treated in almost the same way, except for the group treatment and the use of a coach. All other aspects are the same. For further reduction in LOS, without compromising the quality of care, reducing the surgical stress response might be the most logical step.