Rapid Recovery Total Joint Programs: Interdisciplinary Collaboration

Transcription

1 Rapid Recovery Total Joint Programs: Interdisciplinary Collaboration Alisa L. Curry, PT, DPT CJR Program Manager Physical Therapy Clinical Coordinator

2 Center for Joint Replacement Mission Statement since 1998 to provide state-of-the-art joint replacement in an efficient yet highly personal way.

3 Keys to Developing a Successful Program Understand the surgical component Understand factors that impact patient progress Identify how the rapid recovery program correlates with patient satisfaction Collect, record and report outcomes

4 Surgical Procedures

5 Total Knee Arthroplasty / Unicompartmental Knee

6 Surgical Technique Medial Parapatellar Midvastus Subvastus Quad Sparing

7 Total Hip Arthroplasty

8 Surgical Technique Anterior Photo courtesy of DePuy Orthopedic Modified Watson Jones technique (2003)

9 Surgical Technique 2-incision Minimally invasive

10 Components of a Successful Program Understand the surgical component Understand factors that impact patient progress Identify how the rapid recovery program correlates with patient satisfaction Collect, record and report outcomes

11 Anesthesia and Analgesia Types being used Regional techniques Spinal Epidural Continuous Patient controlled continuous Nerve block techniques Femoral General

12 Femoral Nerve Block The choice of the type and concentration of local anesthetic is based on whether the block is planned for surgical anesthesia or pain management. Long-acting local anesthetic should be avoided in ambulatory patients undergoing relatively minor procedures as ambulation is affected by prolonged motor block of the quadriceps muscle.

13 Modified Bromage Scale Modified Bromage score as used by Breen 1993 Can be used to help determine a patient s ability to control the affected extremity during ambulation Helpful to use in preventing falls while regional anesthesia is being administered Score Criteria 1 Complete block (unable to move feet or knees) 2 Almost complete block (able to move feet only) 3 Partial block (just able to move knees) 4 Detectable weakness of hip flexion while supine 5 No detectable weakness of hip flexion while supine 6 Able to perform partial knee bend (full flexion of knees)

14 Medications The focus on multimodal pain control, mobilization, use of intravenous and oral opioids requires a multidisciplinary approach by the disciplines to effectively manage this type of orthopedic patient (Pasero 2006) Need adequate pain control for patients to participate in a rapid recovery program Fears of addiction Consider the patient s pre-op opioid use (infrequent and regular)

16 Why have a Rapid Recovery Program for Joint Replacement? Improve staffing ratios Increase patient satisfaction Improve cost containment Increase patient referrals Improve outcomes Minimize Surgeon s variability Facilitate continuity of care

17 The Patient Perspective What does the elective joint replacement patient want? Hands-on care Proven results Outcomes-based relationship Navigation of surgical process Marketing of a good program

18 Clinical Pathway Pathways give direction and a process for care Standardized orders agreed on by all surgeons Patient s goals delineated (to care team and patient) Patient becomes a participant in the care team Norms and outcomes identified, deviations studied to improve processes Provides consistency for staff and patients It gives everyone a focused end goal

19 Clinical Pathway Patient empowerment is the underestimated component in integrating a clinical pathway Deber (1994) most patients prefer to have experts perform the problem-solving tasks but wish to take an active role in decision making.

20 Patient Education

21 Patient Education Opportunities Classes Pre-Op class provided three times a week by RNs, PTs and OTs who also provide clinical care on the unit PT group exercise class THA and TKA patients OT group class THA patients Individualized treatments also given (not an assembly line)

22 Patient Education Investing in education is economically beneficial and cost effective (average of 90 min/patient) Surgeons strongly insist patients attend Surgeon and unit staff s expectations of care and progress reinforced Emphasizes the patient and family (coach) roles Pays for itself on the hospital stay side We have built in a non-monetary charge to account for meeting times

23 Pre-Op Assessment

24 Rehabilitation Unit-based team

25 Rehabilitation Ratios / Schedule 2 full time Physical Therapists daily 1 per diem Physical Therapy Assistant (3/5 or more) 2+ Physical Therapists for 4 to 5 days of surgery 1 PT Aide per 3 therapists We work PM shifts to accommodate the later cases that have day of surgery PT evaluations Occupational Therapists handle 2-3 patients each (not unit based)

26 Rehabilitation Integrated role with other disciplines Attend all meetings regarding the Unit Directly involved with program planning Accountable for anything related to functional abilities of the patient Specific interaction with the patient s family and/or caregivers to include them in all activities Encouraged to attend all classes, exercise sessions and to be present at hospital discharge for Nursing instructions

27 Functional Range of Motion Walker (2001) examined normal range of motion for patients with OA vs. control group for minimum and maximum joint angle activities Activity Min Max Excursion Range Walking Stairs Up/down to low chair In/out to tub

28 Functional Range of Motion Kolber and Brueilly (2006) reported normal functional range of motion for patients activities of daily living Activity Standing Stairs Flexed leg Stairs Lead leg Tying shoe Squatting Bathtub use ROM 0 extension flexion 0 extension 106 flexion 117 flexion 135 flexion

29 Functional Return Pathophysiology - Kolber (2006) Slightly flexed loose packed position initially post op Leads to fluid accumulation due to a available space Dense, fibrous scar tissue has not formed and ROM is attainable Granulation tissue begins to form, is highly vascularized and leads to stiffness Weeks to months later, granulation tissue matures and become Type I collagen Emphasizes the importance of early aggressive intervention

30 Rapid Recovery Protocol TKA Group therapy classes Continuous epidural catheters with Bupivicaine and Fentynyl Begin POD 1 with AM eval, PM group exercise class and ambulation Patients are transported via recliner to the Exercise area Exceptions for severe pain (9+), active vomiting, low BP, acute medical distress All exercises are those that can be done in supine or sitting so no reason why patients cannot attend 2 nd day forward: 10:30AM and 2PM Occupational therapy treats patients with B TKA and some TKA before PT class

31 Rapid Recovery Protocol Expectations: 0-90 degrees by hospital DC degrees by 2 weeks (first MD post op visit) degrees by second MD post op visit Transition on assistive device as patient becomes more steady Cover transfers beyond traditional (car, outdoors, stairs, etc.)

32 Post Operative Expectations Focus on flexibility in the first 6 weeks post op due to collagen maturation High potential for less than optimal ROM if strengthening exercises initiated too early

33 Post Operative Expectations NO short arc quad exercises until full ROM achieved reinforces quad strengthening Interferes with hamstring extension until fully achieved Encourage quad setting, LAQ and SLR instead Minimal strengthening until ROM is achieved Stationary bike with no resistance ok

34 THA Rehabilitation THA Group therapy classes Occupational Therapy does POD 1 evaluation and then a group session at 10AM Physical Therapy follows at 10:30AM for seated and then standing exercises and stretches Patients are ambulated to the Exercise area Exceptions for severe pain (9+), active vomiting, low BP, acute medical distress Afternoon session is one on one for specific training

35 Collaboration with Nursing Goals and expectations: Level of commitment to collaborative practice necessary for successful team

36 Nursing Improving Orthopedic clinical expertise 9 nurses have returned to achieve their Orthopedic Nurse certification 1 nurse presently pursuing a Master s degree for Clinical Nurse Specialist advanced practice Improving Pain Management expertise 1 nurse gained her Pain Resource Nurse certification

37 Interdisciplinary Meetings Case Review Conference Attendees Process Benefits Each discipline can extract pertinent information

38 Community Relationships Physicians Offices Outpatient Therapy Offices Home Care Agencies Investing the time into bringing consistent community entities into your program creates consistency of message and continuity of care Skilled Nursing Agencies Durable Medical Equipment Community Resources

40 Why collect data? Tracking trends in key performance categories over time has assisted in providing quality reports, making clinical judgments and providing evidence for clinical change Financial reports, in addition to the above assist senior level executives and board members in seeing that the program is meeting hospital s overall strategic goals

41 Tools THA TKA B TKA

42 Physical Therapy Process Improvement: CPM data % 90 9% 80 8% # Degrees % 6% 5% 4% 3% 2% % Closed Manipulations Done 10 1% 0 CPM Used = 105 knees CPM Not Used = 535 knees 0% Average Knee Flexion on Discharge Average Knee Extension on Discharge % of Closed Manipulations Done By collecting data, we were able to show that patients using CPMs did not do as well as patients following rapid recovery protocol It allowed the Therapy staff to show that a directed rehabilitation program gave the patients better outcomes

43 Tests/Measures Knee Society Scores Harris Hip Scores Timed Up and Go WOMAC SF 12 / 36 6 Minute Walk Test Other Modified Bromage Scale (Anesthesia) Schmid Fall Risk Tool (Nursing)

44 Tools Self-built Database Info collected Using data Findings

45 Tools: Example of TKA data extrapolated

46 Tools: Example of THA data extrapolated

47 Report Example Indicator Title : Goal = less than 2% VTE Number of VTE's over number of Joint Replacements done per quarter

48 Sample Articles from Research Comparison of PCEA vs. CEA in Total Knee Arthroplasty Patients Early Closed Knee Manipulation for Arthrofibrosis After Primary TKA Bilateral Simultaneous vs. Unilateral TKA within a Comprehensive Perioperative Joint Program Efficacy of a Non-selective Multimodal Thromboembolic Prophylactic Protocol

49 Patient Satisfaction HCAHPS Press Ganey Professional Resource Consultants (PRC) Healthgrades This is a underestimated component of program success!

50 Program Certifications Blue Cross Blue Shield Blue Distinction Center for Knee and Hip Replacement ANCC Magnet Recognition Awarded September 2011 JCAHO Disease Specific Certification Pending

51 National Association of Orthopaedic Nurses (NAON) Total Joint Replacement Special Interest Group (TJR SIG) SIG group forum online SIG groups meet annually at Congress AAOS and NAON Collaboration Nursing and Allied Health program developed for annual Academy meeting Orthopaedic Nursing Journal

52 American Physical Therapy Association (APTA) Acute Care Section Total Joint Therapists Group Currently over 400 members Goal is to change clinical rehabilitation practice in the acute care setting to reflect the advancements in orthopedic practice SIG group forum online SIG groups meet annually at CSM First article published in JACPT Vol. 2 Gorman SL, Curry A. A pilot study exploring the variability of physical therapy practices of members of the total joint replacement listserv. J Acute Care Phys Ther. 2010:1(2);46-53.

53 Patient Listserve Total_Joint_Replacement listserve started in 2002 Moderate a group of over 2200 members People who are considering surgery, having surgery or have already had surgery Gives insight to what is being done in the field from the patient perspective

54 Tying it all together Roos (2003) Early mobilization is the gold standard for achieving functional mobility, including sufficient range of motion Cochrane Review Summaries Continuous passive motion has no impact on length of stay Patient education has been shown to be beneficial for patients with anxiety Multidisciplinary rehabilitation programs have been shown to improve patient outcomes, decrease length of stay and have fewer postoperative complications

55 Tying it all together Assess your current system Assemble key players Understand current process Determine roadblocks Make unit-based changes Change / modify your language Set defined expectations and explanations Reassess regularly Collect and report outcomes

56 Contact Information Alisa Curry PT DPT Washington Hospital Fremont CA Center for Joint Replacement

57 References Activity after Total Joint - Healy WL, et al.: Athletic Activity After Total Joint Arthroplasty. The Journal of Bone and Joint Surgery (American). 2008;90: Swanson EA, Schmalzried TP and Dorey FJ. Activity Recommendations After Total Hip and Knee Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons. Journal of Arthroplasty. 2009; 6(1): (Graph) Coordinated Program / Clinical Pathways Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD Roos EM. Effectiveness and practice variation of rehabilitation after joint replacement. Journal of Bone and Joint Surgery British. 2003; 89B(3): General NIH consensus statement on total knee replacement. Journal of Bone and Joint Surgery. 2004;86: Interdisciplinary Relationships Cohn, R. Professional Case Management. Making Sense of Physical Therapy The Leader in EBP. Physical Therapy. 2000; 5(6): Medical Interventions - Patterson C. Orthopaedic Service Lines-Revisited. Orthopaedic Nursing. 2008; 27(1): Pain Management Breen TW, Shapiro T, Glass B et al: Epidural anesthesia for labor in an ambulatory patient. Anesth Analg 1993; 77: Pasero C and Belden J. Evidence-Based Perianesthesia Care: Accelerated Postoperative Recovery Programs. Journal of PeriAnesthesia Nursing. 2006; 21(3):

58 References Patient Satisfaction Deber RB. Physicians in health care management: 8. The patient-physician partnership: decision making, problem solving and the desire to participate. Journal of the Canadian Medical Association. 1994; 151(4): Physical Therapy Intervention Lavernia C, D'Apuzzo M, Rossi MD and Lee D. Is Post Operative Function After Hip of Knee Arthroplasty Influenced by Preoperative Functional Levels? Journal of Arthroplasty. 2009; 7: Rowe PJ and Nutton R. The Effect of Total Knee Arthroplasty on Joint Movement During Functional Activities and Joint Range of Motion With Particular Regard to Higher Flexion Users. Journal of Orthopedic Surgery. 2005; 13(2): Preoperative Education (Benefits) McDonald S, Hetrick SE, Green S. Pre-operative education for hip or knee replacement. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD Prouty A. Cooper M. Thomas P. Christensen J. Strong C. Bowie L. Oermann MH. Multidisciplinary patient education for total joint replacement surgery patients. Orthopaedic Nursing. 2006; 25(4): Stensdotter, AK, Hodges PW, Mellor R, Sundelin G, and Hager-Ross C. Quadriceps Activation in Closed and in Open Kinetic Chain Exercise. Med. Sci. Sports Exerc. 2003; 35 (12): pp ROM for functional ADLs - Kolber MJ and Brueilly K. Artthrofibrosis following total knee arthroplasty: considerations for the acute care physical therapist. Acute Care Perspectives. 2006; Winter: Walker CRC, Myles C, Nutton, R and Rowe P. Movement of the knee in oseteoarthritis. Journal of Bone and Joint Surgery. 2001; 83: Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004260