Abstract
Clinical pathways reduce length of stay which is critical for hospitals to remain financially sound. We sought to determine if a multimodal pathway focusing on pre-op discharge planning and pre-emptive pain and nausea management lead to reduced length of stay, better pain management, and more rapid functional gains without an increase in post-op complications. A multimodal pathway incorporating pre-op discharge planning and pre-emptive pain and nausea management was initiated in August of 2007. Physical therapy began the day of surgery. Two hundred eleven patients treated over a 3-month period with the new pathway were compared to 192 patients treated in the last 3 months of an older pathway. Length of stay, VAS scores for pain, and the incidence of nausea were compared. Length of time to achieve functional milestones while in hospital and the incidence of complications out to 6 months were compared. Average length of stay was reduced by 0.26 days. VAS scores for pain were lower. Several functional milestones were achieved earlier and complications were not increased. Efforts to control nausea were not successful and severe nausea was experienced in 40% of patients in both groups. This enhanced pathway can lead to an important reduction in length of stay. Although this reduction seems small, it can significantly increase patient throughput and increase hospital capacity. Post-op nausea continues to be an impediment in patient care after TKR.
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Andersen KV, Pfeiffer-Jensen M, Haralstadt V, Soballe K, Reduced hospital stay and narcotic consumption and improved mobilization with local and intrarticular infiltration after total hip arthroplasty: a randomized clinical trial of an intraarticular technique versus epidural infusion in 80 patients. Acta. Orthop. 2007; 78: 180–186
Bergeron SG, Kardash KJ, Huk OL, Zukor DJ, Antoniou J, Perioperative Dexamethasone does not affect functional outcome in total hip arthroplasty. Clin. Orthop. Relat. Res. 2009; 467: 1463–1467
Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG, Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial. JAMA. 2003; 290: 2411–2418
Choi PT, Bhandari M, Scott J, Douketis J, Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003; 3: CD003071
Duellman TJ, Gaffigan C, Milbrandt JC, Allan DG, Multi-modal, pre-emptive analgesia decreases the length of hospital stay following total joint arthroplasty. Orthopedics. 2009; 32(3): 167
Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT, A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg. Anesth. Pain Med. 2008; 33: 510–517
Husted H, Holm G, Jacobsen S, Predictors of length of stay and patient satisfaction after hip and knee replacement surgery. Acta. Orthopedica. 2008; 79: 168–173
Iyengar KP, Nadkarni JB, Ivanovic N, Mahale A, Targeted early rehabilitation at home after total hip and knee joint replacement: Does it work?. Disabil. Rehabil. 2007; 29(6): 495–502
Kardash KJ, Sarrazin F, Tessler MJ, Velly AM, Single dose dexamethasone reduces dynamic pain after total hip arthroplasty. Anesth Analg. 2008; 106: 1253–1257
Khan F, Ng L, Gonzalez S, Hale T, Turner-Stockes L, Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst. Rev. 2008; 16: CD004957
Kurtz S, Ong K, Lau E, Mowat F, Halpern M, Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J. Bone Jt. Surg. Am. 2007; 89: 780–5
Larsen K, Hvass KE, Hansen TB, Thomsen PB, Søballe K, Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskelet. Disord. 2008; 9: 59, doi:10.1186/1471-2474-9-59
Larsen K, Sørensen OG, Hansen TB, Thomsen PB, Søballe K, Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up. Acta. Orthop. 2008; 79(2): 149–59
Larsen K, Hansen TB, Thomsen PB, Christainsen T, Soballe K, Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J. Bone Jt. Surg. 2009; 91: 761–772
McDonald S, Hetrick S, Green S, Pre-operative education for hip or knee replacement. Cochrane Database Syst. Rev. 2004; (1): CD003526
Petersen MK, Andersen NT, Soballe K, Self-reported functional outcome after primary total hip replacement treated with two different perioperative regimes. Acta. Orthopedica. 2008; 79: 160–167
Reuben SS, Buvenandran A, Katz B, Kroin JS, A prospective randomized trial on the role of perioperative celecoxib administration for total knee arthoplasty: improving clinical outcomes. Anesth. Anal. 2008; 106: 1258–1264
Walter FL, Bass N, Bock G, Markel DC, Success of clinical pathways for total joint arthroplasty in a community hospital. Clin. Orthop. Relat. Res. 2007; 457: 133–7
Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W, Patient Education Before Hip or Knee Arthroplasty Lowers Length of Stay. J. Arthroplasty. 2009 May 6. [Epub ahead of print]
Acknowledgments
The authors express their thanks to Peter Cornell, B.A., Karen Juliano, PT for their assistance in data collection. We also wish to thank Stephen Lyman, PhD for his help with the statistical analysis.
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Level of Evidence: Level III: therapeutic study. See the guidelines online for a complete description of level of evidence.
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Ayalon, O., Liu, S., Flics, S. et al. A Multimodal Clinical Pathway Can Reduce Length of Stay After Total Knee Arthroplasty. HSS Jrnl 7, 9–15 (2011). https://doi.org/10.1007/s11420-010-9164-1
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DOI: https://doi.org/10.1007/s11420-010-9164-1