Hip precautions following total hip replacement: to implement or not implement?

Transcription

1 Hip precautions following total hip replacement: to implement or not implement? Lauren Porter Senior Occupational Therapist, Abergele Hospital, Wales Jade Cope Clinical Specialist Occupational Therapist, Orthopaedic Dept. Guys and St Thomas NHS Foundation Trust, London 1

2 Learning Outcomes 1. Understand variations in practice in relation to hip precautions. 2. Be aware of current practice guideline recommendations and literature relating to hip precautions, including advice on how to effect service change. 2

3 What are hip precautions?? Post-operative restrictions in movement following THR, which vary throughout UK. Generally not to flex hip past 90-degrees, twist or cross legs. From 6-12 weeks. NWB to FWB. Variation exists. 3

4 Q Who uses hip precautions? 4

5 Why are they important? Believed to minimise the risk of dislocation for a post-operative period of 12 weeks. National Joint Registry 2011 report 17% of single stage revisions completed due to dislocation. Blom et al (2008) Large multi-surgeon audit found 3.4% dislocation following primary THR. 5

6 What is happening in the UK? Drummond et al (2012) National postal survey across UK n=236 sent out. Review of OT practice in advising hip precautions following THR. Period of time observed 6-12 weeks. 174 included in analysis across 65 counties in the UK. Did not include those without precautions (1) or private hospitals (1). 6

7 What is happening in the UK? Drummond et al (2012) cont. Findings: National agreement on precaution use and instructions: flexion, adduction & external/internal rotation Highlighted areas of variation in reasoning behind use of precautions and need for more evidenced based intervention. 7

8 Case study - Hospital 1 Abergele Hospital, North Wales. FWB, but enforce other hip precautions for 3 months. Attend hip Joint School pre-operatively for education and receive initial assessment following. Bring completed furniture heights sheet, and this is compared to recommended sitting height. 8

9 Case study - Hospital 1 (Cont.) If equipment needs identified for hip precautions or functional reasons, trialled and ordered same day if possible. Can complete outreach HV pre-op if indicated (complex, adaptations). Ensure home environment set up prior to admission. LHA also issued pre-op and practice encouraged. 9

10 Case study - Hospital 1 (Cont.) Post-op washing and dressing practice to ensure managing with LHA, functional mobility and transfer practice. LOS 3-4 days. Q Who else is implementing hip precautions? Q How do others find this practice? 10

11 Case study - Hospital 2 Guys & St Thomas (GSTT) Hospital, London. No precautions since March 2011 for all hip surgeries unless specifically indicated in post op notes. Last 12 months THR/Revisions at GSTT & 214 #NOF s. Average LOS #NOF s 11 days, THR 3.4 days (12 month plan to see majority d/c day 2). 11

12 Case study - Hospital 2 (Cont.) Seen by OT pre-op for functional Ax, furniture heights gained and equipment prescribed according to predicted functional needs only (clinical reasoning). Furniture heights used to practice post-op to ensure can transfer safely from those heights unless identified equipment is essential to allow this. Compulsory attendance at Hip School prior to admission. OT or Tech visit pre-op if required. Less patient anxiety around dislocation. 12

13 Case study - Hospital 2 (Cont.) Since removing Precautions: No noted increased in dislocation rates. Patients rehabilitation improved, achieving greater independence in shorter time, and reduced costs of equipment prescription per patient. OT role extended to ADL areas previously not ready to address in short acute stay. Positive experience of patients and OT s in comparison of previous surgery experience. Trust has decreased LOS and reduced waitlist time from 9 months to 2 weeks NB other pathway changes along side. 13

14 Case study - Hospital 2 (Cont.) Q Who doesn t use hip precautions, or has partial precautions? Q How have you found it? 14

15 What does the Guideline say? 18. It is recommended that occupational therapists consult with the surgical team regarding any specific precautions to be followed post-operatively. 19. It is recommended that occupational therapists advise service users, where protocol includes precautions, on appropriate position behaviours for those daily activities applicable to the individual s needs, ranging from getting in/out of a car to answering the telephone. 20. It is suggested that due to the uncertainty surrounding the need for hip precautions, and the potential for an increase in satisfaction and early functional independence when hip precautions are relaxed or discontinued, occupational therapists engage in local discussion/review of the emerging evidence with their surgical and multidisciplinary teams. 15

16 Evidence behind the recommendations Peak et al (2005) Randomized prospective study of 265 THR patients split into 2 groups (303 hips) Uncemented THR with antereolateral approach Both groups restricted with standard hip precautions (hip flexion 90 degrees, 45 degrees of internal/external rotation and no adduction) 6 weeks. 16

17 Evidence behind the recommendations Peak et al (2005) cont. Restricted group had additional precautions abduction wedge in theatre, pillows to maintain abduction in bed, no side lying or car travel and had raised toilet, chair and bed throughout their precaution period. Results: 1 dislocation in whole cohort in restricted group. Findings: Removal of several precautions didn t increase dislocation rates, lowered costs and improved patient satisfaction. 17

18 Evidence behind the recommendations Ververeli et al (2009) Randomised prospective study of 81 THR patients, split into two groups. Standard Rehabilitation Group had hip precautions in place. Early Rehabilitation Group only restriction was not to cross legs at thigh. 18

19 Evidence behind the recommendations Ververeli et al (2009) cont. Patients in the Early group, were faster to ambulate with a stick, and then faster to ambulate unaided. They walked without a limp sooner and returned to driving sooner. No incidents of dislocation in study cohort. 19

20 How can we affect change? O Donnell et al (2006) Canadian study examining process of removing hip precautions. In order to make a clinical decision in the absence of scientific evidence, a formal consensus process based on a nominal group technique was used. Lead and coordinated by rehab team OT / PT. 20

21 How can we affect change? O Donnell et al (2006) cont. Sent out survey to surgeons results collated into those that had achieved consensus and those requiring further discussion. Consensus meeting held all surgeons and key members of rehab team. Consensus met on most items. Summarised and sent for verification following. New guidelines then developed. 21

22 How can we affect change? At GSTT. Use of precautions discussed for many years between therapists and surgeons Enhanced Recovery program. Long term inconsistency of hip precaution use was discussed. Outcome: Ceased immediately. Surgeons have the final say. 22

23 How can we affect change? Q Has anyone present successfully influenced change in hip precaution practice? How? Q Who is motivated to influence change??!! 23

24 References and web links College of Occupational Therapists (2012) Occupational therapy for adults undergoing total hip replacement. Practice Guideline. London: COT. /files/general/public/p171-total- Hip-Replacement.pdf 24

25 COT Practice guidelines development process NICE has accredited the process used by the College of Occupational Therapists to produce its practice guidelines. Accreditation is valid for five years from January 2013 and is applicable to guidance produced using the processes described in the Practice guidelines development manual 2 nd edition (2011). More information on accreditation can be viewed at 25

26 Contact Us: Lauren Porter Jade Cope 26