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Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6
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.
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 replaceGregory 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.
ment patients in the recovery room can be accomplished
safely and reduces the overall length of hospital stay for
over 70 % of patients.
P
hysiotherapy 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-stay3,4 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.
Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6
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.
Therapy would then progress with transferring to a chair,
223
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
Rapid Rehabilitation
Standard Rehabiliation
P Value
Participants
331
Sex
Male
Female
569
Male
Female
125
206
216
353
Age (years)
63.7
ASA Class
1
2
3
4
5
1
2
3
13
225
90
2
0
26
335
200
0.99
64.3
0.47
4
5
5
1
Anaethesia Type
General
Neuroaxial
General
Neuroaxial
55
276
114
455
Comorbility
Groups
w/o CC/MCC and w/CC and W CC/
w/o MCC
MCC
W MCC w/o CC/MCC and w/CC and W CC/
w/o MCC
MCC
W MCC
312
10
17
9
520
32
0.96
0.21
0.15
Procedure Length 109
(minutes)
124
< 0.001*
Estimated Blood
Loss (mL)
227
319
< 0.001*
Time pf Physical
Therapy
(minutes)
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
Comorbidities & Complications/ Major Comorbidities & Complications (W/O CC/MCC); 2. With Comorbidities & Complications (W CC)—“minor”
comorbidities and complications; 3. With Major Comorbidities & Complications (W MCC); 4. With Comorbidities & Complications/ Major Comorbidities
(W CC/MCC), we cannot distinguish whether the comorbidities and complications were minor or major; 5. Without Major Comorbidities & Complications
(W/O MCC), we do not know whether there were any minor comorbidities and complications; Considering the ambiguity of groups 4 and 5, groups 1
& 5 and 2 & 4 have been recombined for the purposes of statistical analysis.
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Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6
Table 2 Hip Arthroplasty Subgroup
Rapid Rehabilitation
Standard Rehabiliation
P Value
Participants
170
Sex
Male
Female
Male
Female
74
96
126
165
Age (years)
64.1
ASA Class
1
2
3
4
5
1
2
3
4
5
7
122
39
1
0
16
178
92
2
1
Anaethesia Type
Comorbility
Groups
291
0.99
62.4
0.15
General
Neuroaxial
General
Neuroaxial
36
134
74
217
0.36
w/o CC/MCC and w/CC and W CC/
w/o MCC
MCC
W MCC w/o CC/MCC and w/CC and W CC/
w/o MCC
MCC
W MCC
161
5
11
4
257
23
0.22
0.042*
Procedure Length 111
(minutes)
134
< 0.001*
Estimated Blood
Loss (mL)
326
464
< 0.001*
Time pf Physical
Therapy
(minutes)
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
Comorbidities & Complications/ Major Comorbidities & Complications (W/O CC/MCC); 2. With Comorbidities & Complications (W CC)—“minor”
comorbidities and complications; 3. With Major Comorbidities & Complications (W MCC); 4. With Comorbidities & Complications/ Major Comorbidities
(W CC/MCC), we cannot distinguish whether the comorbidities and complications were minor or major; 5. Without Major Comorbidities & Complications
(W/O MCC), we do not know whether there were any minor comorbidities and complications; Considering the ambiguity of groups 4 and 5, groups 1
& 5 and 2 & 4 have been recombined for the purposes of statistical analysis.
Table 3 Knee Arthroplasty Subgroup
Rapid Rehabilitation
Standard Rehabiliation
P Value
Participants
161
Sex
Male
Female
278
Male
Female
51
110
90
188
Age (years)
65.0
ASA Class
1
2
3
4
5
1
2
3
6
103
51
1
0
10
157
108
0.92
64.4
0.55
4
5
3
0
Anaethesia Type
General
Neuroaxial
General
Neuroaxial
18
143
40
238
Comorbility
Groups
w/o CC/MCC and w/CC and W CC/
w/o MCC
MCC
W MCC w/o CC/MCC and w/CC and W CC/
w/o MCC
MCC
W MCC
151
5
6
5
264
8
0.48
0.46
0.83
Procedure Length 107
(minutes)
114
0.07
Estimated Blood
Loss (mL)
120
167
< 0.002*
Time pf Physical
Therapy
(minutes)
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
Comorbidities & Complications/ Major Comorbidities & Complications (W/O CC/MCC); 2. With Comorbidities & Complications (W CC)—“minor”
comorbidities and complications; 3. With Major Comorbidities & Complications (W MCC); 4. With Comorbidities & Complications/ Major Comorbidities
(W CC/MCC), we cannot distinguish whether the comorbidities and complications were minor or major; 5. Without Major Comorbidities & Complications
(W/O MCC), we do not know whether there were any minor comorbidities and complications; Considering the ambiguity of groups 4 and 5, groups 1
& 5 and 2 & 4 have been recombined for the purposes of statistical analysis.
Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6
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 coworkers7 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
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Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6
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
colleagues5 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 associates2 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.
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