Objectives
 Discuss why the orthopedic joint program was initiated
 Describe the Surgical Education Center (SEC)
 Demonstrate a total knee and total hip patient’s typical hospital stay
 Discuss outcome data since initiation of joint program
 Review areas for growth
 Discuss new trends in joint replacement

(Network Distributing, 2010)

Orthopedic Joint Program
 Several staff went on a site visit at Missouri Baptist
Medical Center in St. Louis in the Fall of 2014
 Determined that the program should be trialed at
NMH due to the positive results with patient outcomes

Orthopedic Joint Program
 Bundled Payment for Care Improvement (BPCI) Initiative
 Organizations may enter into payment arrangements that include financial and performance accountability for episodes of care
 May lead to higher quality and more coordinated care at a lower cost to Medicare
 Align incentives for providers –hospitals, post-acute care providers, and physicians – allowing them to work closely together across all settings
(CMS, n.d.)

Orthopedic Joint Program
 The orthopedic joint program was initiated at
Nebraska Methodist Hospital in January 2015
 Program includes Surgical Education Center (SEC), home evaluation, initiating activity POD #0, change in pain management, joint aide, group therapy, earlier discharge planning

Surgical Education Center (SEC)
 Pre-surgery education for total hip and total knee patients
 Located at the Healthwest building on 156 th and Dodge
 Education is provided by an orthopedic RN and a
Physical Therapy Assistant (PTA)

 Involve health care partner if available – family member or friend who is present for SEC, at hospital and involved in discharge
 Helps to improve continuity of care pre-surgery to discharge

SEC- RN’s Role
 Review what to bring to hospital including a list of current medications, adaptive equipment, personal belongings


Adaptive equipment such as walker, leg lifter, reacher, sock aid
Personal belongings including personal care items, CPAP, appropriate clothing and shoes

SEC- RN’s Role
 Preparation for surgery
 What to expect during surgery

 What to expect after surgery
 Pain management


0-10 scale
Patient will set pain goal
 Blood clot prevention

 Fall Prevention
 Call for assistance
 Wear nonskid footwear
 Use walker or appropriate assistive device
 Chair and bed alarms

SEC- RN’s Role
 Infection Prevention
 IV antibiotics
 Foley removed morning after surgery to prevent UTI
(standardized to POD#1 at 6 am)
 Proper hand hygiene by staff and visitors

SEC- RN’s Role
 Pneumonia Prevention
 Oral care every 4 hours
 Incentive spirometer 10 times/hour while awake
 Cough and deep breathe every hour
 Be as active as possible
 Treatment
 Ice Therapy

SEC- RN’s Role
 Skin breakdown prevention
 Be as active as possible
 Change positions frequently
 Constipation
 Be as active as possible
 Drink plenty of fluids
 Take stool softeners as prescribed



SEC- PTA’s Role
 Preparing the home


Remove throw rugs and cords
Rearrange furniture


Firm chair with back and arm rests
Foot stool same height as chair for total knee replacement patients
 Review adaptive equipment needs and purchasing equipment

SEC- PTA’s Role
 Review hip precautions
 Provide home exercise program

H
I
P

TOTAL
K
N
E
E

SEC- PTA’s Role
 Risk Assessment and Prediction Tool (RAPT)
 Developed by Dr. Leonie Oldmeadow in Victoria in 2001 to predict the discharge destination of patients undergoing elective hip and knee surgeries
 Purpose is to indicate before total knee or total hip surgery, the most likely discharge destination after surgery

P
T
R
A

 Overall predictive accuracy of the RAPT was 78%
 Accuracy was lowest for scores between 7-10 (65.2%)
 The intermediate group (7-10) has been seen as a possible group to target for interventions, such as a home evaluation, to facilitate discharge home instead of skilled care
(Hansen et al., 2015)

Pre-Operative Home Evaluation
 Initiated Nov. 2015 to help improve percentage of patients able to return home versus needing skilled care following surgery
 May decrease length of stay
 Anticipate it will improve confidence level of patient to return home following surgery

Pre-Operative Home Evaluation
 Free service offered to our joint patients who attend SEC
 Focuses on patients who score between 6-9 on the RAPT and those who score >9 and indicate they intend to go to
SNF
 Home evaluations consist of:




Removing clutter, throw rugs and furniture
Reviewing adaptive equipment needs
Assessing bathroom setup
Addressing support system

Pre-Operative Home Evaluation
 Initial feedback is positive from the patient perspective
 Therapists report that patients seem to have increased confidence regarding home safety, equipment needs and potential discharge home
 Internal research study to determine the efficacy of preoperative home evaluation on discharge location
(December 14, 2015-March 14, 2016)

Hospital Stay
 Activity Schedule
 Patient will get out of bed the day of surgery
 Morning routine begins at 5:30 a.m.
 Meals pre-ordered and delivered at set times, in order to reduce interference with therapy schedule
 Majority of day is spent out of bed to help promote successful recovery

Hospital Stay
 Joint Aide



Joint aide and night staff assist with bathing, dressing, and transfer to chair
Joint aide is assigned to all elective total hip and knee patients to help with their daily cares, update therapy schedule, and hourly rounding
Joint aide is available M-F

Hospital Stay
 Physical Therapy twice per day
 Occupational Therapy once per day

•
Group Therapy
Offered W-F

Physical Therapy

Occupational Therapy

Therapy Goals for Going Home
 Get in and out of bed
 Walk at least 50 feet with your walking device
 Bathe and dress using assistive tools
 Transfer on/off toilet
 Stand for 5 minutes at counter/sink to do simple tasks
 Be able to get in and out of the bathtub or shower safely based on your home set-up
 Negotiate stairs if needed for home
 Get in/out of car



Total Joint Program Outcomes
 Total Knee:
 Overall length of stay: 9% reduction


MPC (Methodist Physician Clinic) surgeons: 13% reduction

Decreased from 3.0 to 2.7 days
Non-MPC surgeons: 3% reduction
 Patients discharged home: 5% increase


MPC surgeons: 7% increase
Non-MPC surgeons: 3% reduction
(*small sample size of only 10% of TKR surgeries)

Total Joint Program Outcomes
 Total Hip:
 Overall length of stay: 8% reduction
 MPC surgeons: 8% reduction

Decreased from 2.5 to 2.2 days
 Patients discharged home: 4% increase
 MPC surgeons: 3% increase
(*Do not have specific data for non-MPC surgeons)

Total Joint Program Outcomes
 Analysis by Payer:


Medicare Total Knee patients discharged home: 8% increase
Medicare Total Hip patients discharged home: 14% increase
 Readmission Rates:


2014: 1.57% knee, 2.69% hip
2015: 1.12% knee, 1.72% hip

Total Joint Program Outcomes
 Data was analyzed for 50 patients following total knee in the Fall of 2014 and early Winter of 2015
 Pain
 ROM POD#3
 Ambulation POD#1 (a.m. and p.m.)
 Length of stay

Outcomes for 1 MPC Surgeon
MD
PRE SEC
Fall 2014
(5 Patients)
POST SEC
Group #1
Feb-Mar ‘15
(5 Patients)
POST SEC
Group #2
May-Jun ‘15
(7 Patients)
Avg Pain at
Rest
(Out of 10)
6.5
Avg Pain with Activity
(Out of 10)
8
Average ROM
(POD #3)
Avg Ambulation
POD #1 a.m. (ft)
Avg Ambulation
POD #1 p.m. (ft)
Avg LOS
4-79 6.8
19 4.6
2.7
1.9
2.8
6.1
3-99
3-96
82
50
110
96
(29% Stairs)
3
2.7
D/C
Destination
HHC: 80%
SNF: 20%
HHC: 60%
SNF: 40%
HHC: 57%
SNF: 43%

Areas for Growth
 Improved education on pain management and control pre and post surgery
 Therapeutic Neuroscience Education (TNE):
 Current best-evidence research indicates that when a patient better understands their pain, and what pain truly is, they experience less pain, have less fear, move better, exercise more and can regain hope
(Network Distributing, 2010)

 Current assumption is there is a direct link between amount of tissue damage and the level of pain
 Patients believe all pain is caused by injury and more damage means increased pain
 We need to work with patients to change their beliefs about this pain model and change how we as professionals explain pain to patients

(MedBridge, 2015)

Stress Responses to Pain

Stress Responses to Pain

Stress Responses to Pain

Stress Responses to Pain

Areas for Growth
 Weight loss
 Each pound of body weight lost, there is a 4 pound decrease in joint stress to the knee and a 6 pound decrease in the hip
(Malecha, 2016) and (Warner, 2005)

Areas for Growth
 Anti-inflammatory lifestyle habits
 Moderate exercise throughout the day
 Sleep hygiene
 Avoid chronic stress
 Mind-body interventions

Areas for Growth
 Anti-inflammatory dietary changes
 Avoid unhealthy substances including inflammatory foods such as sugars, processed starches, meat, fat, modern vegetable oils, fried foods

Trends
 Mesenchymal Cells (MSC)
 Stem cell implantation is a promising approach for cartilage repair in the knee and is already in clinical use for focal defects and generalized osteoarthritis.
 MSC offer a potential regenerative solution given their ability to differentiate to all tissues within a joint and modulate the local inflammatory response.
 The clinical outcomes of the ongoing and available trials in patients are encouraging.
(Wyles et al., 2015) and (Orth et al., 2014)

Trends
 Platelet-rich plasma (PRP) therapy for arthritis
 PRP therapy attempts to take advantage of the blood’s natural healing properties to repair damaged cartilage, tendons, ligaments, muscles, or even bone
 Not a standard practice, but a growing number of people are turning to PRP injections to treat an expanding list of orthopedic conditions, including osteoarthritis
(Wilson, n.d.)

Summary
 The orthopedic program has improved outcomes, decreased length of stay, and encouraged patients to take a more active role in their health care.
 Staff feel that patients are more motivated, empowered, and prepared for their post operative recovery.
 Knowledge is power.
 There are several opportunities for growth to continue on our path for improved patient satisfaction and outcomes.

References
Centers for Medicare & Medicaid Services. (n.d.). Bundled payments for care improvement (BPCI) initiative: General
information. Retrieved from https://innovation.cms.gov/initiatives/bundled-payments/
Hansen, V. J., Gromov, K., Lebrun, L. M., Rubash, H. E., Malchau, H., & Freiberg, A. A. (2015, November). Does the risk assessment and predication tool predict discharge disposition after joint replacement? Clinical Orthopedics and
Related Research, 473, 597-601. doi: 10.1007/s11999-014-3851-z
Malecha, Shane. (2016). Therapeutic Strategies for Degenerative Joint Disease. Eau Claire, WI: PESI, Inc.
MedBridge. (2015, February 17). Teaching people about pain video: Adriaan Louw. [Video file]. Retrieved from https://www.youtube.com/watch?v=LO1hg2ya3Js
Network Distributing. (2010, June 24). Weekend at Bernie’s. [Video file]. Retrieved from https://www.youtube.com/watch?v=YXhfv4UYv2I&app=desktop
Orth, P., Rey-Rico, A., Venkatesan, J. K., Madry, H., & Cucchiarini, M. (2014). Current perspectives in stem cell research for knee cartilage repair. Stem Cells Cloning, 7, 1-17. doi: 10.2147/SCCAA.S42880
Warner, J. (2005, June 29). Small weight loss takes big pressure off knee. Retrieved from http://www.webmd.com/osteoarthritis/news/20050629/small-weight-loss-takes-pressure-off-knee
Wilson, J. J. (n.d.). Platelet-rich plasma (PRP) therapy for arthritis. Retrieved from http://www.arthritishealth.com/treatment/injections/platelet-rich-plasma-prp-therapy-arthritis
Wyles, C. C., Houdek, M. T., Behfar, A., & Sierra, R. J. (2015). Mesenchymal stem cell therapy for osteoarthritis: Current perspectives. Stem Cells Cloning, 8, 117-124. doi: 10.2147/SCCAA.S68073