HSS Journal

, Volume 7, Issue 1, pp 9–15

A Multimodal Clinical Pathway Can Reduce Length of Stay After Total Knee Arthroplasty

  • Omri Ayalon
  • Spencer Liu
  • Susan Flics
  • Janet Cahill
  • Karen Juliano
  • Charles N. Cornell
Original Article

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.

Keywords

clinical pathways pre-emptive pain management total knee replacement 

References

  1. 1.
    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: 180–186CrossRefPubMedGoogle Scholar
  2. 2.
    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: 1463–1467CrossRefPubMedGoogle Scholar
  3. 3.
    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: 2411–2418CrossRefPubMedGoogle Scholar
  4. 4.
    Choi PT, Bhandari M, Scott J, Douketis J, Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003; 3: CD003071PubMedGoogle Scholar
  5. 5.
    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): 167CrossRefPubMedGoogle Scholar
  6. 6.
    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: 510–517PubMedGoogle Scholar
  7. 7.
    Husted H, Holm G, Jacobsen S, Predictors of length of stay and patient satisfaction after hip and knee replacement surgery. Acta. Orthopedica. 2008; 79: 168–173CrossRefGoogle Scholar
  8. 8.
    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): 495–502CrossRefPubMedGoogle Scholar
  9. 9.
    Kardash KJ, Sarrazin F, Tessler MJ, Velly AM, Single dose dexamethasone reduces dynamic pain after total hip arthroplasty. Anesth Analg. 2008; 106: 1253–1257CrossRefPubMedGoogle Scholar
  10. 10.
    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: CD004957Google Scholar
  11. 11.
    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: 780–5CrossRefGoogle Scholar
  12. 12.
    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 CrossRefPubMedGoogle Scholar
  13. 13.
    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): 149–59CrossRefPubMedGoogle Scholar
  14. 14.
    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: 761–772CrossRefGoogle Scholar
  15. 15.
    McDonald S, Hetrick S, Green S, Pre-operative education for hip or knee replacement. Cochrane Database Syst. Rev. 2004; (1): CD003526Google Scholar
  16. 16.
    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: 160–167CrossRefGoogle Scholar
  17. 17.
    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: 1258–1264CrossRefGoogle Scholar
  18. 18.
    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: 133–7PubMedGoogle Scholar
  19. 19.
    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]Google Scholar

Copyright information

© Hospital for Special Surgery 2010

Authors and Affiliations

  • Omri Ayalon
    • 1
  • Spencer Liu
    • 2
    • 3
  • Susan Flics
    • 2
  • Janet Cahill
    • 2
  • Karen Juliano
    • 2
  • Charles N. Cornell
    • 2
    • 3
  1. 1.Darmouth Medical CollegeHanoverUSA
  2. 2.Hospital for Special SurgeryNew YorkUSA
  3. 3.Weill Cornell Medical College of Cornell UniversityNew YorkUSA

Personalised recommendations