Rapid Recovery in Total Joint ReplacementA Rural Hospital Experience
Adam English, RN, DNP-S
Minnesota Center for Orthopaedics
Cuyuna Regional Medical Center, Crosby, MN
aenglish@cuyunamed.org
Disclosure
No financial disclosures to report.
Objectives
• Identify current trends in total joint replacement.
• Describe the rapid recovery protocol for total
joint replacement.
• Explain the difference in patient outcomes
between standard recovery and rapid recovery
protocols.
Trends in Total Joint Replacement
• Projected increases by 2030:
– THA- will increase by 174%
– Hip revision- will increase by 137%
– TKA- will increase by 673% (3.48 million)
– Knee revision- will increase by 601%
• Knee revisions will double by 2015
Trends-Cost
• Half of patients receiving total joint replacement are
under 65, and still in workforce1.
• Job-related knee pain cost $3.4-$13.2 billion in lost wages
for patients1.
• After a surgery, societal savings averaged between
$10,000 and $30,000/joint from increased earnings and a
decrease in fewer work days and disability payments1.
J Bone Joint Surg Am. 2013.
Critical Access Hospitals (CAH)
• No more than 25 inpatient beds.
• Average length of stay no more than 96 hours.
• Must offer 24/7 emergency access.
• Must be in a rural area.
• Allows CAH to receive cost-based reimbursement from
Medicare instead of standard fixed rates.
Cuyuna Regional Medical Center (CRMC)
• Critical-access hospital located in north-central, rural
MN.
• Currently employs over 1000 people in a town of 1300.
• Total joint replacement increased by 25% last year.
• Over $2 million in surgical cases diverted away in 2012
because of no hospital bed available.
Total Joint Replacement-Standard
• General anesthesia with femoral nerve block
for postoperative pain.
• Physical therapy initiated on post-op day 2.
• Average hospital stay: 3-5 days.
CRMC-Rapid Recovery Protocol
• Multimodal analgesia before, during, and after surgery.
• Treat and eliminate potential complications (blood loss,
nausea, urinary retention).
• Use less narcotic pain medication throughout inpatient
stay.
• Get patient up and walking the day they have surgery.
Preoperative Care
• Medications (Pain):
• Medications (Nausea):
– Lyrica 150mg
– ASA 325mg
– Oxycontin 10mg
– Scopolamine Patch
behind ear.
Potentially Flomax 0.4mg at HS based on AUA BPH scale (started 7-10 days preoperatively).
Intra-operative Care
• Anesthesia: General
• Transexemic Acid: 1 gram IV before incision and 1
gram IV at closure.
• Acetaminophen 1000mg IV: Q8 hours x 3 doses
(started after implants in).
• Toradol: 15mg IV Q6 hours x 4 doses (started at end of
operation).
Postoperative Care
• Continue the scheduled non-narcotic pain
medications (Acetaminophen and Toradol).
• Narcotic Stratification: different pain meds
based on level of patient pain.
• DVT Prophylaxis: ASA 325mg PO BID x 4
weeks unless previously on warfarin.
Orthopaedic Joint Coordinator
• 24/7 total joint hotline that patients are instructed to
call if any issues (before ER).
• Handles all preoperative education, hospital rounds,
and discharge instructions.
• 100% clinic-based to be there to answer
questions/concerns.
• “Open-door” policy where total joint patients can
come to the clinic to check incision/reassure patients.
CRMC Rapid Recovery Outcomes
• Knee Replacement data published in American
Academy of Orthopaedic Surgeons (AAOS)
(presentation at national conference in 2015).
• Hip Replacement data published in American
Academy of Hip and Knee Surgeons (AAHKS)
with poster presentation at conference.
Methods
• Last 100 total joints using standard protocol compared to
first 100 total joints using rapid recovery.
• All surgeries performed by a fellowship-trained orthopaedic
surgeon using the same approach for all patients.
• Measured length of stay, pain levels, narcotic usage, need
for skilled nursing facilities, readmissions, complications.
• No patients excluded from data set.
Patient Demographics
Patient Characteristics
Pre-Rapid Recovery
Post-Rapid Recovery
p value
Gender (% Male-Female)
50.0-50.0
54.0-46.0
0.693
Mean Age (Years)
69.24
67.14
0.247
Mean ASA Classification
2.56
2.5
0.552
Mean BMI
35.75
34.57
0.421
No significant difference in gender, age, ASA, BMI
Total Hip Replacement
• Patients in rapid recovery
protocol had a mean discharge
day of 1.5 compared to 2.75 days
in the pre-rapid recovery group
(p<0.0001).
• Pain scores were significantly
better in the rapid recovery group
with a postoperative day one
average of 2.8/10 compared t0
4.1/10 before (p=0.002).
3
5
2.5
4
2
Before Rapid
Recovery
1.5
1
After Rapid
Recovery
0.5
Before Rapid
Recovery
3
After Rapid
Recovery
2
1
0
0
Length of Hospital
Stay(Days) (p<0.0001)
Postoperative Day #1 Pain
(out of 10) (p=0.002)
Total Hip Replacement
• Skilled Nursing Facilities (SNF): In
the pre-rapid recovery dataset,
34% of patients required a SNF
stay. In the post-rapid recovery
dataset, only 7% were sent to
SNF.
SNF (%)
35
30
25
20
SNF (%)
15
10
5
0
Pre-Rapid
Recovery
Post-Rapid
Recovery
• Readmissions: In the pre-rapid
recovery dataset, there 1 readmission (constipation) within
the first 30 days postoperatively.
This compares to 1 re-admission
(wound dehiscence) in the postrapid recovery dataset.
Total Knee Replacement
• Patients in the rapid recovery
group had a mean discharge day
of 1.7 compared to 3.2 days in
the pre-rapid recovery group
(p<0.001).
• Patients in the rapid recovery
group had mean pain scores that
were significantly better in the
rapid recovery group (3.2/10)
compared to the pre-rapid
recovery group (4.8/10).
Total Knee Replacement
• Narcotic consumption was
significantly less (11.21mg) in the
rapid recovery group than in the
pre-rapid recovery
group(21.76mg).
• In the pre-rapid recovery group,
34% of patients discharged to
skilled nursing facilities compared
to 7% in the rapid recovery group.
SNF (%)
35
30
25
20
SNF (%)
15
10
5
0
Pre-Rapid
Recovery
Post-Rapid
Recovery
Discussion
• Data demonstrates the positive impact and
advantages of an easily translatable rapid
recovery protocol using non-narcotic medicines.
• Patients are able to discharge on Day 1, pain
scores are markedly better, and the overall health
care costs are diminished, due to shorter length
of hospitalization and less need for skilled nursing
facilities.
Discussion
• Forecast is for dramatic increase in patient
volume.
• Health care reform is going to place more
emphasis on outcomes and value.
• Facilities must prepare for increase in volume
and prove their outcomes.
References
1.
2.
3.
4.
5.
Ruiz, D., Koenig, L., Dall, T., Gallo, P., Narzikul, A., Parvizi, J., Tongue, J. (2013). The direct and indirect costs to society of
treatment for end-stage knee osteoarthritis. The Journal of Bone and Joint Surgery. 95:1473-80.
Tayrose G, Newman D, Slover J, Jaffe F, Hunter T, Bosco III J. Rapid Mobilization Decreases Length of Stay in Joint
Replacement Patients. Bulletin of the Hospital for Joint Disease. January 2013; 71(3):222-226.
Malviya A, Martin K, Harper I, Muller S, Emmerson K, Parlington P, Reed M. Enhanced Recovery Program for Hip and Knee
Replacement Reduces Death Rate. Acta Othopaedica. October 2011;82(5):577-581.
Lombardi A, Berend K, Adams J. A Rapid Recovery Program: Early Home and Pain Free. Orthopaedics. September
2010;33(9):656.
Doman D, Gerlinger T. Total Joint Arthroplasty Cost Savings with a Rapid Recovery Protocol in a Military Medical Center.
Military Medicine. January 2012; 177 (1):64-69.