Rapid Mobilization Decreases Length-of-Stay in Joint Replacement Patients

222 Rapid Mobilization Decreases Length-of-Stay in Joint Replacement Patients Gregory Tayrose, M.D., Debbie Newman, B.S., James Slover, M.D., M.S., Fredrick Jaffe, M.D., Tracey Hunter, B.S., and Joseph Bosco III, M.D. Gregory Tayrose, M.D., Debbie Newman, B.S., James Slover, M.D., M.S., Fredrick Jaffe, M.D., Tracey Hunter, B.S., and Joseph Bosco III, M.D., are in the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Correspondence: Joseph Bosco III, M.D., NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, New York 10003; Joseph.Bosco@nyumc.org. Abstract Background: Physiotherapy after total joint replacement enhances postoperative recovery. Implementing a pathway to include earlier postoperative mobilization can reduce the hospital length-of-stay as well as cost. Questions: Does a rapid rehabilitation program consisting of physical therapy on the day of surgery affect the hospital length-of-stay on patients undergoing either total hip or total knee replacements? Is there a difference in the effectiveness of rapid rehabilitation between patients undergoing Total Hip and Total Knee Replacements? Can these patients tolerate day of surgery physical therapy sessions? Patients and Methods: Nine-hundred hip and knee arthroplasty patients were divided into two groups for analysis. Group 1 participated in a rapid rehabilitation physical therapy program that began with physical therapists in the recovery room. Group 2 received a standard physical therapy protocol starting the day after surgery. Progression with rehabilitation was followed, and length of hospital stay between the two groups was compared. Results: Total length-of-stay was 3.9 days for the rapid rehabilitation group and was 4.4 days (p < 0.001) for the standard therapy group. We found the rapid rehabilitation group had a significantly shorter length-of-stay than patients who began therapy on postoperative day one. In addition to decreased length-of-stay, rapid rehabilitation also resulted in direct savings considering fewer hospital resources were utilized over the decreased time in-house. Conclusions: Rapid mobilization of total joint replacement patients in the recovery room can be accomplished safely and reduces the overall length of hospital stay for over 70 % of patients. Physiotherapy after total joint replacement enhances postoperative recovery by promoting faster rehabilitation and improving functional outcomes. Although the intensity and frequency of the ideal rehab protocol is unknown, early multidisciplinary rehabilitation improves outcomes. 1 Different protocols have been implemented attempting to reduce the length of inpatient hospital stay following total joint arthroplasty. These protocols have had varied roles in multimodal intervention protocols, care maps, accelerated intervention, fast track, and clinical pathways. However, these protocols all focus on utilizing a specialized orthopaedic care team with regular staff for continuity of care and consistency. 2 Previous attempts of early mobilization have demonstrated reductions in hospital length-of-stay 3,4 and are also thought to improve patient outcomes following joint arthroplasty. 5 Some studies of accelerated perioperative care have demonstrated cost savings while not adversely affecting patient outcomes. 6 In addition, clinical pathways have also been shown to reduce readmission rates. 7 However, it is still unclear if early mobilization that starts in the recovery room will lead to a reduction in hospital length-of-stay while maintaining patient outcomes. Our study aimed to address the impact of rapid rehabilitation beginning in the recovery room on length-of-stay after primary hip and knee arthroplasty. The questions we hoped to address were as follows: Does a rapid rehabilitation program consisting of physical therapy on the day of surgery affect the hospital length-of-stay on patients undergoing either total hip or total knee replacements? Is there a difference in the effectiveness of rapid rehabilitation between patients undergoing total hip and total knee replacements? Tayrose G Newman D, Slover J, Jaffe F, Hunter T, Bosco J III. Rapid mobilization decreases length-of-stay in joint replacement patients. Bull Hosp Jt Dis. 2013;71(3):222-6.

223 Can these patients tolerate day of surgery physical therapy sessions? Patients and Methods In this study, we retrospectively reviewed 900 consecutive hip and knee arthroplasty patients at our institution. Cases were either placed into the rapid rehabilitation group (Group 1 331 patients) or the standard rehabilitation group (Group 2 569 patients). The rapid rehabilitation patients started as part of a pilot program in which the first two cases of the day were mobilized in the recovery room. The remainder of the cases received the standard rehabilitation protocol, which included working with physiotherapists starting on the morning of postoperative day one. Patients considered not stable for immediate intervention, as determined by the anesthesiologist, surgeon, and the intensive care unit medical doctor, were not mobilized in the recovery room, even if they were one of the first two cases of the day. The PACU nurse monitored all patients for hypotension, tachycardia, or decreased oxygen saturation as routinely performed on all postoperative patients. The therapy program implemented for the patients was the same, differing only in the time initiated and location implemented. The therapist would start with having patients hang their legs over the side of the bed. would then progress with transferring to a chair, ambulation, and climbing stairs. The expectation for a patient was to ambulate 100 feet or greater, and climb six stairs, prior to discharge. To qualify for discharge home, patients must demonstrate the ability to perform safe transfers, bed mobility, and the ability to ambulate, including navigating stairs. When the patient is determined to be medically stable for discharge but unable to meet the appropriate therapy goals, the patient was discharged to an inpatient rehabilitation center for further care. Progression with rehabilitation was followed, and length of hospital stay was compared. In addition, ASA class, anesthesia type, comorbidities, procedure length, estimated blood loss (EBL), and estimated time of physical therapy were followed. Univariate analysis was performed with a significance set at p = 0.05. A subgroup analysis was performed comparing the total hip and total knee patients respectively in each group. Factors leading to unsuccessful completion of the early mobilization protocol were followed. Internal Review Board approval was obtained. Results Table 1 demonstrates the study groups had no differences in sex, age, ASA class, anesthesia type, comorbidity groups, and estimated time of physical therapy. Procedure length and estimated blood loss (EBL) were noted to be statistically Table 1 Combined Arthroplasty Groups Participants 331 569 125 206 216 353 0.99 Age (years) 63.7 64.3 0.47 13 225 90 2 0 26 335 200 5 1 0.96 55 276 114 455 0.21 Comorbility w/o CC/MCC and w/cc and W CC/ W MCC w/o CC/MCC and w/cc and W CC/ W MCC Groups 312 9 10 520 32 17 0.15 Procedure Length 109 124 < 0.001* Estimated Blood 227 319 < 0.001* Time pf Physical 231 (60-660)** 233 (90-1,110)** 0.74 *Statistically significant (p < 0.05); ** mean and range of time in therapy. Extended definitions of comorbidity and complication groups: 1. Without

224 Table 2 Hip Arthroplasty Subgroup Participants 170 291 74 96 126 165 0.99 Age (years) 64.1 62.4 0.15 7 122 39 1 0 16 178 92 2 1 0.22 Comorbility Groups Procedure Length 36 134 74 217 0.36 w/o CC/MCC and w/cc and W CC/ W MCC w/o CC/MCC and w/cc and W CC/ W MCC 161 4 5 257 23 11 0.042* 111 134 < 0.001* Estimated Blood 326 464 < 0.001* Time pf Physical 228 (60-600)** 248 (90-870)** 0.74 * Statistically significant (p < 0.05); ** mean and range of time in therapy. Extended definitions of comorbidity and complication groups: 1. Without Table 3 Knee Arthroplasty Subgroup Participants 161 278 51 110 90 188 0.92 Age (years) 65.0 64.4 0.55 6 103 51 1 0 10 157 108 3 0 0.48 18 143 40 238 0.46 Comorbility w/o CC/MCC and w/cc and W CC/ W MCC w/o CC/MCC and w/cc and W CC/ W MCC Groups 151 5 5 264 8 6 0.83 Procedure Length 107 114 0.07 Estimated Blood 120 167 < 0.002* Time pf Physical 234 (60-660)** 218 (90-1,110)** 0.12 * Statistically significant (p < 0.05); ** mean and range of time in therapy. Extended definitions of comorbidity and complication groups: 1. Without

225 Table 4 Hospital Length-of-Stay (Days) All Cases (p < 0.001) Knee Replacement (p = 0.16) Hip Replacement (p < 0.001) Rapid Rehabilitation 3.85 3.89 3.80 Routine Rehabilitation 4.39 4.13 4.63 different. Tables 2 and 3 demonstrate subgroup analysis of the same data for hip and knee arthroplasty groups separated. Regarding length-of-stay, we found that the rapid rehabilitation group (Group1) had significantly less length-ofstay than patients who began therapy on postoperative day one (Group 2). As seen in Table 4, Group 1 had an average length-of-stay of 3.9 days, and Group 2 had an average length-of-stay of 4.4 days (p < 0.001). Our subgroup analysis for hip arthroplasty patients demonstrated that Group 1 patients had an average length-of-stay of 3.8 days, and Group 2 had an average length-of stay of 4.6 days (p < 0.001). The subgroup analysis for knee arthroplasty patients demonstrated that Group 1 patients had an average length-of-stay of 3.9 days, and Group 2 had an average length-of-stay of 4.1 days (p = 0.16). As seen in Table 5, of the hip arthroplasty patients enrolled in the rapid rehabilitation protocol, 74% completed the regimen, and of the knee arthroplasty patients who started, 70 % completed the regimen. Reasons for not completing the regimen included hypotension, dizziness, and weakness. The body mass index (BMI) of the hip arthroplasty patients was 29 for both the rapid and standard groups (p = 0.062), and 32 for the knee arthroplasty rapid and standard therapy groups (p = 0.74). Discussion Previously described clinical pathways outline different elements believed to positively influence recovery and hospital length-of-stay. These elements include preoperative education, perioperative nutrition, preemptive analgesia, and optimal postoperative rehabilitation. 8,9 Clinical pathways also appear successful in reducing costs and length-of-stay in the acute care hospital, with no compromise in patient outcomes, 9 but the ideal protocol remains to be delineated. We found a decrease in length-of-stay for patients in the rapid rehabilitation program, which began in the recovery room. This corresponds to results reported by Husted and colleagues, 4 who demonstrated that mobilization on the day of surgery was associated with decreases in length-of-stay following hip and knee arthroplasty, although total time spent with a physiotherapist during hospitalization did not correspond to length-of-stay. Our analysis of knee arthroplasty patients alone also corresponds to results reported by Table 5 Percent Completion of the Rapid Rehabilitation Program Rapid Knees 70% Rapid Hips 74% Renkawitz and associates, 3 who implemented physiotherapy the same day of unilateral total knee arthroplasty patients in the afternoon of morning operating room cases and did not observe any decrease in length of hospital stay. Chen and coworkers 7 demonstrated that isolated physical therapy given on the day of surgery decreases length-of-stay, although their analysis did not perform a subgroup analysis differentiating between hip and knee arthroplasty. We observed a difference in the effectiveness of our program between patients undergoing hip or knee replacements. The program resulted in a greater decrease on LOS for hip compared to knee replacements. Differences in effectiveness of our program for knee and hip arthroplasty patients may be related to the baseline length-of-stay after hip and knee replacement, which was a half of a day less for the knee patients compared to the hip patients, with routine therapy, leaving less time for improvement. The rapid hip arthroplasty and rapid knee arthroplasty subgroups were both discharged after similar length-of-stays after participating in the program. The subgroup analysis also reveals a significant difference in comorbidity groups and procedure length, with regards to the hip arthroplasty group, and not the knee arthroplasty group. These findings, in addition to the difference noted in EBL, are potential confounding factors to the results noted. It is possible, that the reduced length-of-stay was due to a decrease in EBL, although the knee arthroplasty group demonstrated a significant difference in EBL with no subsequent reduction in length-of-stay. This provides evidence that EBL alone does not explain the findings noted of decreased length-of-stay. The rapid rehabilitation program was equally well tolerated by our hip and knee arthroplasty patients, as 70% and 74% of hip and knee replacement patients, respectively, were able to complete the entire course of therapy. We did not preselect for morning patients. Some previous studies may have preselected early mobilization for the more infirmed patients, who tend to have their surgeries earlier in the day, leading to a selection bias towards sicker patients for early rehabilitation. The ASA class and comorbidity groups were not overall significantly different. Our goal was to implement safe early physiotherapy in a controlled environment. The pathway was implemented in an organized multidisciplinary fashion, with education and participation of all members of the care team including anesthesia, surgery, nursing, and physical therapy. Weaknesses of this study include the retrospective study design and potential selection bias caused by surgeon selection of patients designated to be one of the first two cases of the day. At our hospital, the operative case order

226 is determined by the operating surgeon. Healthier or sicker patient could potentially be selected as the first cases as per surgeon preference, although there was no statistical difference noted in ASA class or comorbidity groups. This may have led to a healthier population in the rapid rehabilitation program, as only the first two cases of the day were eligible. This could potentially lead to shorter hospital stays. In addition, our hospital has implemented other programs designed to shorten hospital length-ofstay during the study period, which may confound results. These additional programs, involving social workers, are designed to plan the patients discharge prior to admission. Specifically, the average length-of-stay for our arthroplasty patients, in the 2 years preceding this study, were 4.8 and 4.7 days. Although the length-of-stay was similar for the total hip patients, the total knee patients undergoing routine physical therapy had over one half day shorter length-ofstay than the years prior. Therefore, factors other than the rapid rehabilitation program have likely impacted lengthof-stay during the study period. Previous studies of rapid rehabilitation protocols did not result in increased readmission rates. 10 Schnieder and colleagues 5 reported that without preselecting patients for fast track rehabilitation following joint replacement neither comorbidities or obesity influenced rehabilitation time, and perioperative complication rates fell within published norms. In fact, Dowsey and associates 2 stated that joint arthroplasty patients with comorbidities may be better served having clinical pathways with rapid mobilization. Additionally, early mobilization may decrease the need for services or care, including elements such as blood transfusion, which have been shown to increase with lack of mobilization on the day of surgery. 11 Rapid rehabilitation also likely resulted in a direct savings, considering fewer hospital resources were utilized over the decreased time in-house. The additional cost to the hospital was the price of a single therapy session per patient. Some of the potential expenses patients generate while in-house include additional therapy sessions, as well as the retention of other necessary ancillary hospital staff. Also, the risk of postoperative complications, such as hospital acquired infections, continues while postoperative patients remain hospitalized, which taxes the health care system. The subsequent available hospital resources due to reduced length-of-stay, such as increased bed availability, could be utilized by additional patients who might then undergo joint arthroplasty procedures leading to further indirect financial gain for the hospital. Disclosure Statement None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony. References 1. Khan F, Ng L, Gonzalez S, et al. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004957. 2. Dowsey MM, Kilgour ML, Santamaria NM, Choong PF. Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. Med J Aust.1999 Jan 18;170(2):59-62. 3. Renkawitz T, Rieder T, Handel M, et al. Comparison of two accelerated clinical pathways after total knee replacement how fast can we really go? Clin Rehabil. 2010 Mar;24(3):230-9. 4. Husted H, Hansen HC, Holm G. What determines length-ofstay after total hip and knee arthroplasty? A nationwide study in Denmark. Arch Orthop Trauma Surg. 2010 Feb;130(2):263-8. 5. Schneider M, Kawahara I, Ballantyne G, et al. Predictive factors influencing fast track rehabilitation following primary total hip and knee arthroplasty. Arch Orthop Trauma Surg. 2009 Dec;129(12):1585-91. 6. Minns Lowe CJ, Barker KL, Dewey ME, Sackley CM. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. BMC Musculoskelet Disord. 2009 Aug 4;10:98. 7. Chen AF, Stewart MK, Heyl AE, Klatt BA. Effect of immediate postoperative physical therapy on length-of-stay for total joint arthroplasty patients. J Arthroplasty. 2012 Jun;27(6):851-6. 8. Berend KR, Lombardi AV Jr, Mallory TH. Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients. Surg Technol Int. 2004;13:239-47. 9. Larsen K, Hansen TB, Thomsen PB, et al. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg Am. 2009 Apr;91(4):761-72. 10. Kehlet H, Sballe K. Fast-track hip and knee replacement--what are the issues? Acta Orthop. 2010 Jun;81(3):271-2. 11. Petersen MK, Madsen C, Andersen NT, Soballe K. Efficacy of multimodal optimization of mobilization and nutrition in patients undergoing hip replacement: a randomized clinical trial. Acta Anaesthesiol Scand. 2006 Jul;50(6):712-7.